S02 SOL-Att-03 Financial Disclosure Questionnaire.pdf
PDF 106 KB Posted
- Attached to
- Z1DA--Multiple Award Task Order Contract 695-23-109 Clement J. Zablocki VA Medical Center
- Solicitation number
- 36C25223R0071
About this file
This document contains a financial disclosure questionnaire template for a Multiple Award Task Order Contract solicitation from the Department of Veterans Affairs Network Contracting Office 12. The solicitation is for Z1DA--Multiple Award Task Order Contract 695-23-109 to be awarded to Clement J. Zablocki VA Medical Center. Offerors are required to complete Section A of the attached questionnaire and submit it to their financial institution to verify account and credit information. The financial institution will then complete Section B providing details on the offeror's account types, balances, lines of credit, relationship and credit ratings to be included in the offeror's response by the solicitation closing date.
View the file
Other files
Show all 23
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Multiple Award Task Order Contract (MATOC) 36C25223R0071
SOURCE SELECTION SENSITIVE 36C25223R0071 Attachment 3 FAR 2.101 and 3.104-5
| 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: ______________________________
File details come from the government source that posted it. Updated .