S02 SOL 0004 AttD Financial Disclosure 585-21-115.pdf
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- Solicitation number
- 36C25225R0004
About this file
This is a Financial Disclosure Questionnaire form (Attachment D) for Solicitation 36C25225R0004, Project 58521-115 Replace Boiler Plant, issued by the Department of Veterans Affairs Network Contracting Office 12. The form is designed to gather financial information about prospective contractors being considered for VA contract award.
The two-section form requires the offeror to complete Section A with their company information and authorized contact details, then submit it to their financial institution. The bank must complete Section B, providing details about the contractor's account type, average balance, line of credit information, relationship status with the bank, length of client relationship, and most recent credit rating. The completed form must be returned to the Contracting Officer (Kristi.Kluck3@va.gov) as part of the RFP submission. The information is considered Source Selection Sensitive and protected under FAR 15.506 regarding the confidentiality of reference providers.
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Text version
Solicitation 36C25225R0004 Project 58521-115 Replace Boiler Plant Attachment D – Financial Disclosure 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: __________________________________________________________
Name & Signature of the Person
Authorized to request financial information: ______________________________________________
Phone Number: __________________________________________________________ e-mail: __________________________________________________________
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.
SECTION B - FINANCIAL INSTITUTION INSTRUCTIONS:
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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