S02 SOL-Att-03 Financial Disclosure Questionnaire.docx
DOCX document 18 KB Posted
- Attached to
- Z1DA--Madison MATOC Federal contract opportunity
- Solicitation number
- 36C25221R0070
About this file
This document contains a pre-solicitation notice for a Multiple Award Task Order Contract (MATOC) for construction services. The Department of Veterans Affairs, Veterans Health Administration, Veterans Integrated Service Network 12 plans to award multiple Indefinite-Delivery Indefinite-Quantity contracts for maintenance, repair, alteration, and new construction projects ranging from $2,000 to $7,000,000. The total value of all task orders to a single contractor shall not exceed $40 million. The contract will have a five-year ordering period from the date of award. The VA anticipates awarding a minimum of two contracts and reserves the right to make additional awards. Work may include various construction disciplines such as HVAC, plumbing, electrical, communications, site work, and new facility construction. Task order solicitations will be competitively issued to all selected MATOC contractors. This 100% set-aside acquisition is reserved for Service-Disabled Veteran-Owned Small Businesses. Offerors must be verified as eligible in the VIP database and represent that they meet the size standard of $36.5 million for NAICS code 236220 at the time of proposal submission. The official solicitation number is 36C25221R0070 and will be issued on or around June 1, 2021.
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Text version
Multiple Award Task Order Contract (MATOC) 36C25221R0070 Solicitation Attachment 3 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 RFP 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. 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:
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: ______________________________
SOURCE SELECTION SENSITIVE Page 1 of 1 36C25221R0070 Attachment 3 FAR 2.101 and 3.104-5
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