A02Attachment3FinancialReferenceQuestionnaire.pdf

FOR OFFICIAL USE ONLY

SOURCE SELECTION INFORMATION

ATTACHMENT 3

Financial References Questionnaire

TO BE FILLED OUT BY CONTRACTOR:

COMPANY’S NAME: ___________________________________________________

Point of Contact (POC) Name: _____________________________________________ POC Phone Number: ____________________________________________________

INSTITUTION NAME: __________________________________________________

POC Name: ____________________________________________________________ POC Title: _____________________________________________________________ POC phone number: _______________________ fax number: __________________

I give permission for the following information regarding my account(s) at your institution to be released to Angie Grimes, Contract Specialist of the USACE-St. Louis District, Missouri.

Name/Title Signature/Date

TO BE FILLED OUT BY FINANCIAL INSTITUTION:

Please give amounts as a range -- i.e. low four figures, mid six figures, etc.

Average monthly balance in checking: ______________________________ Average monthly balance in savings: _______________________________ Are there any outstanding loans: Yes/No Are payments on time: Yes/No Credit limit: _____________________________________ Are they a responsible customer: Yes/No Any late payments or NSF’s: _____________________________________ How long with this institution: _____________________________________ Credit rating with this institution: _____________________________________

Comments: ______________________________________________________________

I verify that the information provided above is current as of _____________________

Name/Title Signature/Date