OMB No.: 3064-0072
Expiration Date: 03/31/2019
FDIC 3700/57 (1-10)
Federal Deposit Insurance Corporation
PAST PERFORMANCE QUESTIONNAIRE
ESTIMATED REPORTING BURDEN
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for
reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Paperwork Reduction Act Officer, Legal Division, Federal Deposit Insurance Corporation,
550 17
th
Street, N.W., and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C.
20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a
currently valid OBM control number.
TO: Government agency or commercial organization (i.e., customer) with knowledge on offeror's past
performance.
1. Please complete this questionnaire, which concerns the past performance of a contractor or
subcontractor who is doing business (or has done business) with you, and is interested in doing business
with the Federal Deposit Insurance Corporation (FDIC). Handwritten responses are sufficient. If you need
more space than that provided, please attach additional pages. Responses will be treated as source
selection sensitive information. The contractor who provided FDIC with your name as a reference was
informed, via a solicitation provision, that by listing you as a reference and requesting your submission of
the questionnaire, they are authorizing you to release information to FDIC relative to their past
performance, whether it is positive or negative information.
Fax or email the completed questionnaire to the attention of the responsible FDIC Contracting Officer.
The offeror must either
fill in below the solicitation number, fax number, email address, and name of
Contracting Officer prior to providing you with the questionnaire, or
provide you with the information to
fill in. Your completed questionnaire must be provided directly to the FDIC Contracting Officer from
you. FDIC will not accept completed questionnaires sent from the offeror.
FDIC Solicitation Number:
*ATTN: Contracting Officer:
*Fax:
*Email: @FDIC.gov
*Offeror must obtain this Information from paragraph (e) of FDIC solicitation provision 7.3.2-16
2. Please complete the following identifying information and past performance assessment:
A. Contractor:
B. Contract Number:
C. Period of Performance:
D. Total Contract Amount (Including any Options)
E. Describe product acquired:
