S02 - Attachment 14 - Financial Disclosure.pdf
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FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104
Indefinite Delivery Indefinite Quantity -
ATTACHMENT 14
FINANCIAL QUESTIONNAIRE
OFFEROR INSTRUCTIONS: Please complete below and return as per instructions no later than: July 26, 2022.
Prospective Contractor for which information is being requested:
Firm Name: ___________________________________________
Address: ___________________________________________
Point of Contact: ___________________________________________
Phone Number: ___________________________________________
Name & Signature of the Person Authorized to request financial information:
Please complete below and return as per instructions no later than:
FINANCIAL INSTITUTION INSTRUCTIONS: The Department of Veterans affairs, Network
Contracting Office 10 is considering the firm listed below for award of a VA contract. In order to be responsive to VA’s needs, it is requested that you complete this questionnaire and place it in a sealed envelope showing return address of the financial institution and forward it to the above-mentioned firm no later July 26, 2022 or you may email as an attachment to apolinar.vargas@va.gov. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal
Acquisition Regulation (15.506) prohibits the release of the names of individuals providing reference information about Offeror’s financial status.
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: ___________________ mailto:yvonne.demorest@va.gov
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