S02 SOL 0026 AttE Financial Disclosure 578-17-027.docx
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- Solicitation number
- 36C25223R0026
About this file
This notice provides details for an upcoming construction solicitation for replacing steam pipes at the Edward Hines, Jr. VA Hospital in Hines, Illinois. The project includes replacing existing steam pipes between Vaults 9 and 7, and between Vault 9 and Pit 5. Additional work includes replacing sump pump controls, constructing new concrete box conduit steam tunnels and pipe racks, and performing the work with minimal disruption to hospital operations. The estimated value is between $10-20 million. The NAICS code is 238220 for plumbing, heating and air conditioning, with a small business size standard of $19.5 million. The solicitation posting date is estimated to be May 22, 2023 on SAM.gov, with a pre-bid conference to follow. The performance period is 730 calendar days from notice to proceed. This opportunity is 100% set aside for verified service-disabled veteran-owned small businesses. Interested firms must be registered in SAM and represent their eligibility at time of offer.
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SOL 36C25223R0026 Page 1 of 1
ATTACHMENT E
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: ______________________________
Project 578-17-027 Replace Steam Pipe – South Leg
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