S02 - Sol - Att 5 - Financial Disclosure Questionnaire.pdf
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- Solicitation number
- 36C25220R0060
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Multiple Award Task Order Contract (MATOC) Solicitation 36C25220R0060
SOURCE SELECTION SENSITIVE Page 1 of 1 Attachment 3 FAR 2.101 and 3.104-5
Solicitation Attachment 5 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: ______________________________
| Solicitation Attachment 5 |
| Financial Disclosure Questionnaire |
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