S02 Att08 Financial Disclosure Questionnaire IDIQ Abatement 0020.pdf
PDF 117 KB Posted
- Attached to
- Z1DA--578-26-004: IDIQ ACM Abatement Base
- Solicitation number
- 36C25226B0020
About this file
This document is a Financial Disclosure Questionnaire template for Solicitation 36C25226B0020, a VA indefinite-delivery/indefinite-quantity (IDIQ) contract for abatement services. The questionnaire is designated as Source Selection Sensitive and serves as Attachment 08 to the solicitation.
Section A requires the prospective contractor to complete basic identification information including company name, address, phone number, email, and the name and signature of the person authorized to request financial information. Section B contains instructions for the financial institution to complete, requesting detailed financial information about the prospective contractor including banking institution details, account type and average balance, line of credit status and unused balance, relationship with the bank (rated as outstanding, satisfactory, or other), length of client relationship, most recent credit rating and the date it was prepared, and the name and signature of the provider or credit rater. The questionnaire explicitly notes that responses are Source Selection Sensitive and prohibits the release of names of individuals providing reference information about the offeror's financial status. The form is issued by the Department of Veterans Affairs, Network Contracting Office 12 for the 578-26-004 IDIQ Abatement Services contract.
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Text version
SOURCE SELECTION SENSITIVE
Solicitation 36C25226B0020 Page 1 of 1
578-26-004 IDIQ Abatement Services
Attachment 08 Financial Disclosure
Solicitation Attachment 8 Financial Disclosure Questionnaire
OFFEROR INSTRUCTIONS: Section A shall be completed by Offeror and submitted to Financial Institution requesting they complete and return to Offeror and included in the offer.
SECTION A:
Prospective Contractor for which information is being requested:
Contractor Name: __________________________________________________________________
Address: __________________________________________________________________
Phone Number: __________________________________________________________________ e-mail: __________________________________________________________________
Name & Signature of the Person ______________________________________________
Authorized to request financial information: ______________________________________________
FINANCIAL INSTITUTION INSTRUCTIONS: The Department of Veterans Affairs, Network Contracting Office
12 is considering the firm listed above for award of a VA contract. To be responsive to VA’s needs, it is requested that you complete this questionnaire and return it to the Offeror that it is included with their offer. Your comments are considered Source Selection Sensitive; the release of the names of individuals providing reference information about
Offeror’s financial status is prohibited
SECTION B:
Banking Institution: _________________________________________
Account number: ______________ Type of account:______________ Average balance:_____________
Do they have a Line of Credit? [ ] Yes [ ] No
What is their limitation: ________________________ Unused Balance: _________________
Relationship with the bank: [ ] Outstanding [ ] Satisfactory [ ] Other: __________________
How long have they been a client: ______________________________
What is their most recent credit rating: ______________________________
Date of most recent credit rating: ______________________________
Credit rating prepared by: ______________________________
Signature of Provider/Title: ______________________________
Date: ______________________________
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