S02 AttD Financial Disclosure 585-21-111 Upgrade Nurse Call.pdf
PDF 136 KB Posted
- Attached to
- Z1DA--585-21-111 Upgrade Nurse Call System at the Oscar G. Johnson VA Medical Center in Iron Mountain , MI
- Solicitation number
- 36C25223B0013
About this file
This document contains a financial disclosure questionnaire template for attachment to solicitation 36C25223B0013. The solicitation is for an upgrade to the nurse call system at the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan. Offerors are required to complete Section A of the questionnaire and submit it to their financial institution to complete Section B regarding the offeror's financial status and relationship with the bank. Section B responses will then be returned directly to the contracting officer at VA Network Contracting Office 12. The questionnaire seeks information on the offeror's account types and balances, line of credit limitations and balances, credit ratings and dates, and overall relationship with the financial institution.
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Text version
SOL 36C252230013, ATTACHMENT D
Project 585-21-111 Upgrade Nurse Call System Page 1 of 1
Financial Disclosure Questionnaire
OFFEROR INSTRUCTIONS: Section A shall be completed by Offeror and submitted to
Financial Institution requesting they complete and return to Contracting Officer
(Kristi.Kluck3@va.gov)
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:
SECTION B - FINANCIAL INSTITUTION INSTRUCTIONS: The Department of Veterans
Affairs, Network Contracting Office 12 is considering the firm listed above for award of a VA contract. In order to be responsive to VA’s needs, it is requested that you complete this questionnaire and return to the Offeror such that it is included with their RFP offer. Your comments are considered Source Selection Sensitive; therefore, you are advised that Federal
Acquisition Regulation FAR-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:Kristi.Kluck3@va.gov
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