PR-FRM-12_Representations_and_Certifications_Newest_Edition.doc

Enter Company Name Below:

ANNUAL COMMERCIAL ITEM ACQUISITION REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF OFFERORS

Usage: For All Commercial Item Subcontracts

Certain representations and certifications must be made by the Offeror and must be submitted as appropriate. The signature by an authorized agent of the Offeror on the last page of this document constitutes the execution of all applicable representations and certifications.

Please complete the following:

Offeror Name

Phone Number

Address

Solicitation/Purchase Order Number

Proposal Number (if applicable)

Federal Tax ID Number

DUNS Number:

NAICS Code:

TYPE OF BUSINESS ORGANIZATION

The offeror, by checking the applicable box, represents that -

It operates as FORMCHECKBOX a corporation incorporated under the laws of the state of

, FORMCHECKBOX

a partnership, FORMCHECKBOX a nonprofit organization, or FORMCHECKBOX a joint venture.

52.219-1 SMALL BUSINESS PROGRAM REPRESENTATIONS (May 2004) A.

General:

1.

The North American Industry Classification System (NAICS) code for this acquisition is . (insert code) 2.

The Small Business size standard is . (insert size standard) 3.

The Small Business size standard for a concern which submits an offer in its own name, other than on a construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is 500 employees.

B.

Representations:

1.

The offeror represents as part of its offer that it FORMCHECKBOX is, FORMCHECKBOX is not, a Small Business Concern.

2.

(Complete only if the offeror represented itself as a Small Business Concern in paragraph (b)(1) of this provision.) The offerer represents, for general statistical purposes, that it FORMCHECKBOX is, FORMCHECKBOX is not, a Small Disadvantaged Business Concern as defined in 13 CFR 124.1002.

Note: Attach disadvantaged status certification from the Small Business Administration or documentation verifying request for certification.

3.

(Complete only if the offerer represented itself as a Small Business Concern in paragraph (b)(1) of this provision.) The offerer represents as part of its offer that it FORMCHECKBOX is, FORMCHECKBOX is not, Women-Owned Small Business Concern.

4.

(Complete only if the offeror represented itself as a Small Business Concern in paragraph (b)(1) of this provision.) The offeror represents as part of its offer that it FORMCHECKBOX is, FORMCHECKBOX is not, a Veteran-Owned Small Business Concern.

5.

(Complete only if the offeror represented itself as a Veteran-Owned Small Business concern in paragraph (b)(4) of this provision.) The offeror represents as part of its offer that it FORMCHECKBOX is, FORMCHECKBOX is not, a Service-Disabled Veteran-Owned Small Business Concern.

6.

(Complete only if the offeror represented itself as a Small Business Concern in paragraph (b)(1) of this provision.) The offeror represents, as part of its offer, that:

(i) It FORMCHECKBOX is, FORMCHECKBOX is not, a HUBZone Small Business Concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration, and no material change in ownership and control, principal office, or HUBZone employee percentage has occurred since it was certified by the Small Business Administration in accordance with 13 CFR part 126; and (ii) It FORMCHECKBOX is, FORMCHECKBOX is not, a joint venture that complies with the requirements of 13 CFR part 125, and the representation in paragraph (b)(6)(i) of this provision is accurate for the HUBZone Small Business Concern or Concerns that are participating in the joint venture. (The offeror shall enter the name or names of the HUBZone Small Business Concern or Concerns that are participating in the joint venture .) Each HUBZone Small Business Concern participating in the joint venture shall submit a separate signed copy of the HUBZone representation.

C.

Definitions.

1.

"Service-Disabled Veteran-Owned Small Business Concern"-a.

Means a Small Business Concern-

(i) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and

(ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran.

b.

Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16).

2.

"Small Business Concern" means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a Small Business under the criteria in 13 CFR Part 121 and the size standard in paragraph (A) of this provision.

3.

"Veteran-Owned Small Business Concern" means a Small Business Concern-a.

Not less than 51 percent of which is owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and b.

The management and daily business operations of which are controlled by one or more veterans.

4.

"Women-Owned Small Business Concern." means a Small Business Concern:

a.

That is at least 51 percent owned by one or more women: or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and b.

Whose management and daily business operations are controlled by one or more women.

D.

Notice.

1.

If this solicitation is for supplies and has been set aside, in whole or in part, for Small Business Concerns, then the clause in this solicitation providing notice of the set-aside contains restrictions on the source of the end items to be furnished.

2.

Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a Small, HUBZone Small Business Concern, Small Disadvantaged, or Women-Owned Small Business Concern in order to obtain a contract to be awarded under the preference programs established pursuant to section 8(a), 8(d), 9, or 15 of the Small Business Act or any other provision of Federal law that specifically references section 8(d) for a definition of program eligibility, shall—

(i) Be punished by imposition of fine, imprisonment, or both;

(ii) Be subject to administrative remedies, including suspension and debarment; and (iii) Be ineligible for participation in programs conducted under the authority of the Act.

(End of provision) Alternate I (Apr 2002). As prescribed in 19.308(a)(2), add the following paragraph (b)(7) to the basic provision:

(7) (Complete if offeror represented itself as disadvantaged in paragraph (b)(2) of this provision.) The offeror shall check the category in which its ownership falls:

FORMCHECKBOX

Black American.

FORMCHECKBOX

Hispanic American.

FORMCHECKBOX

Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians).

FORMCHECKBOX

Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru).

FORMCHECKBOX

Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal).

FORMCHECKBOX

Individual/concern, other than one of the preceding.

(End of provision) 52.204-10 Reporting Executive Compensation and First-Tier Subcontract Awards

The Government Funding Transparency Act is applicable to this Subcontract and/or Purchase Order, in accordance with FAR clause at 52.204-10, Reporting Executive Compensation and First-Tier Subcontract Awards. FAR clause 52.204-10 requires the prime contractor to provide information on its first-tier Subcontractors/Sub-Awards and to disclose to the Subcontractor/Sub-Award that the information will be made available to the public as required by FAR 52.204-10. Based on this requirement, the Subcontractor certifies that:

(a) The Subcontractor FORMCHECKBOX is FORMCHECKBOX is not an individual. If ‘is’ is marked, do not complete the remainder of the certification. Sign and date it below and return to ASRC.

(b) The Subcontractor FORMCHECKBOX did FORMCHECKBOX did not have a gross income less than $300,000 in the previous tax year. If ‘did’ is marked, do not complete the following information. Sign and date it below and return it to ASRC. If “did” is marked, complete the remainder of the certification, then sign and date it below and return to ASRC.

1.

The subcontractor’s primary performance location, if different from above address is:

2.

The Subcontractor represents that, in its preceding fiscal year, the Subcontractor --a.

FORMCHECKBOX

did FORMCHECKBOX did not receive 80 percent or more of its annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants), cooperative agreements, and other forms of Federal financial assistance; and

$25,000,000 or more in annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants), cooperative agreements, and other forms of Federal financial assistance; and b.

FORMCHECKBOX

does FORMCHECKBOX does not provide public access to information about the compensation of the senior executives through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986. If ‘does not’ is marked, the Subcontractor shall provide the names and total compensation (as defined in FAR 52.204-10) of each of the Subcontractor’s five most highly compensated executives, for the completed fiscal year preceding the year the subcontract is awarded. If “does” is marked, do not complete the remainder of the certification, then sign and date it below and return to ASRC. Otherwise, complete the required information below for your preceding completed tax year, then sign, date, and return this certification to ASRC.

(End of provision)

52.203-11 CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS (SEP 2007) (APPLICABLE OVER $100,000) A.

The definitions and prohibitions contained in the clause at FAR 52.203-12, Limitation on Payments to Influence Certain Federal Transactions, included in this solicitation, are hereby incorporated by reference in paragraph (b) of this certification.

B.

The offeror, by signing its offer, hereby certifies to the best of his or her knowledge and belief that on or after December 23, 1989:

1. No Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on his or her behalf in connection with the awarding of any Federal contract;

2. If any funds other than Federal appropriated funds (including profit or fee received under a covered Federal transaction) have been paid, or will be paid, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on his or her behalf in connection with this solicitation, the offeror shall complete and submit with its offer, OMB standard form LLL, Disclosure of Lobbying Activities, to AFHC, and

3.

He or she will include the language of this certification in all subcontract awards at any tier and require that all recipients of subcontract awards in excess of $100,000 shall certify and disclose accordingly.

C.

Submission of this certification and disclosure is a prerequisite for making or entering into this contract imposed by section 1352, title 31, United States Code. Any person who makes expenditure prohibited under this provision or who fails to file or amend the disclosure form to be filed or amended by this provision, shall be subject to a civil penalty of not less than $10,000, and not more than $100,000, for each such failure.

52.209-5 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS (DEC 2001)

A.

The Offeror certifies, to the best of its knowledge and belief, that:

1.

The Offeror and/or any of its Principals-a.

Are FORMCHECKBOX , are not FORMCHECKBOX , presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

b.

Have FORMCHECKBOX , have not FORMCHECKBOX , within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; violation of Federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property; and c.

Are FORMCHECKBOX , are not FORMCHECKBOX , presently indicted for or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in paragraph A.1.b.of this provision.

2.

The Offeror has FORMCHECKBOX , has not FORMCHECKBOX , within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal agency.

3.

"Principals," for the purpose of this certification, means officers; directors; owners; partners; And, persons having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment, and similar positions).

This certification concerns a matter within the jurisdiction of any agency of the United States, and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under Section 1001, Title 18, United States Code.

B.

The Offeror shall provide immediate written notice to AFHC if, at any time prior to subcontract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reasons of changed circumstances.

C.

A certification that any of the items in paragraph (A) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Offeror's responsibility. Failure of the Offeror to furnish a certification or provide such additional information as requested by AFHC may render the Offeror non-responsible.

D.

Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (A) of this provision. The knowledge and information of an Offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

E.

The certification in paragraph (A) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Government and AFHC, may terminate the subcontract resulting from this solicitation for default.

*52.222-21

PROHIBITION OF NONSEGREGATED FACILITIES (FEB 1999)

By execution of this document the offeror certifies that it is in full compliance with the provisions set forth in FAR 52.222-21.

*52.222-22

PREVIOUS CONTRACTS & COMPLIANCE REPORTS (FEB 1999)

By execution of this document the offeror certifies that it is in full compliance with the provisions set forth in FAR 52.222-22.

*52.222-25

AFFIRMATIVE ACTION COMPLIANCE (APR 1984)

The Offeror represents that (1) FORMCHECKBOX it has developed and has on file, FORMCHECKBOX has not developed and does not have on file, at each establishment, affirmative action programs required by the rules and regulations of the Secretary of Labor (41 CFR 60-1 and 60-2) or (2) FORMCHECKBOX it has not previously had contracts/subcontracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor.

This contractor and subcontractor shall abide by the requirements of 41 CFR §§ 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identification or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identification, national origin, protected veteran status or disability.

Please indicate, by checking the appropriate box(es), the states or districts which your company is authorized to collect sales tax:

FORMCHECKBOX

All

FORMCHECKBOX

Alabama

FORMCHECKBOX

Alaska

FORMCHECKBOX

Arizona

FORMCHECKBOX

Arkansas

FORMCHECKBOX

California

FORMCHECKBOX

Colorado

FORMCHECKBOX

Connecticut

FORMCHECKBOX

Delaware

FORMCHECKBOX

District of Columbia

FORMCHECKBOX

Florida

FORMCHECKBOX

Georgia

FORMCHECKBOX

Hawaii

FORMCHECKBOX

Idaho

FORMCHECKBOX

Illinois

FORMCHECKBOX

Indiana

FORMCHECKBOX

Iowa

FORMCHECKBOX

Kansas

FORMCHECKBOX

Kentucky

FORMCHECKBOX

Louisiana

FORMCHECKBOX

Maine

FORMCHECKBOX

Maryland

FORMCHECKBOX

Massachusetts

FORMCHECKBOX

Michigan

FORMCHECKBOX

Minnesota

FORMCHECKBOX

Mississippi

FORMCHECKBOX

Missouri

FORMCHECKBOX

None

FORMCHECKBOX

Montana

FORMCHECKBOX

Nebraska

FORMCHECKBOX

Nevada

FORMCHECKBOX

New Hampshire

FORMCHECKBOX

New Jersey

FORMCHECKBOX

New Mexico

FORMCHECKBOX

New York

FORMCHECKBOX

North Carolina

FORMCHECKBOX

North Dakota

FORMCHECKBOX

Ohio

FORMCHECKBOX

Oklahoma

FORMCHECKBOX

Oregon

FORMCHECKBOX

Pennsylvania

FORMCHECKBOX

Rhode Island

FORMCHECKBOX

South Carolina

FORMCHECKBOX

South Dakota

FORMCHECKBOX

Tennessee

FORMCHECKBOX

Texas

FORMCHECKBOX

Utah

FORMCHECKBOX

Vermont

FORMCHECKBOX

Virginia

FORMCHECKBOX

Washington

FORMCHECKBOX

West Virginia

FORMCHECKBOX

Wisconsin

FORMCHECKBOX

Wyoming

THE UNDERSIGNED OFFEROR CERTIFIES THAT THE INFORMATION CONTAINED WITHIN THIS DOCUMENT IS TRUE AND ACCURATE TO THE BEST OF ITS KNOWLEDGE.

BY THE EXECUTION OF THIS DOCUMENT, THE UNDERSIGNED OFFEROR AGREES TO PROVIDE IMMEDIATE WRITTEN NOTICE TO ASRC FEDERAL IF, AT ANY TIME DURING THE EFFECTIVE PERIOD OF THIS DOCUMENT, THE UNDERSIGNED OFFEROR LEARNS THAT THIS DOCUMENT WAS ERRONEOUS WHEN SUBMITTED OR HAS BECOME ERRONEOUS BY REASON OF CHANGED CIRCUMSTANCES.

**THE EFFECTIVE PERIOD OF THIS DOCUMENT IS ONE YEAR FROM THE DATE OF EXECUTION THROUGH DECEMBER 31ST OF THE SAME YEAR.

Signature

Printed Name of Signatory

Title of Signatory

Date

* Exempt if work is to be performed outside the U.S. by employees who were not recruited within the U.S.

**Annual certifications will be renewed during the last quarter of the year and will be effective beginning January 1 through December 31 of the next year. For certifications obtained during the year, the certification is considered effective from the date of execution to December 31 of the same year. The effective period of certifications will not exceed one year.

PR-FRM-12 Rev 01 PR-FRM-12 Rev 02