4-4. 26-R-475186 Reps Certifications.pdf

REPRESENTATIONS AND CERTIFICATIONS OF BIDDER/OFFEROR

ANTHC 25-R-475186

1. Type of Business Organization The Bidder/Offeror, by checking the applicable box, represents that --

(a) It operates as

[__] a corporation incorporated under the laws of the State of [__] an individual, [__] a partnership, [__] a nonprofit organization, or [__] a joint venture; or

(b) If the Bidder/Offeror is a foreign entity, it operates as

[__] an individual, [__] a partnership, [__] a nonprofit organization, [__] a joint venture, or [__] a corporation registered for business in the Country of

(c) The Bidder/Offeror is not

[__] on the List of Parties Excluded from Federal Procurement and Non-Procurement Programs, compiled, maintained, and distributed by the General Services Administration; and [__] barred from bidding or contracting with the State of Alaska.

2. Parent Company Information The Bidder/Offeror by checking the applicable box represents that --

[__] It is independently owned and operated and it is not owned or controlled by a parent company or parent organization.

[__] It is not independently owned and operated; it is owned or controlled by a parent company or parent organization; and the full name and address of the Bidder/Offeror's parent company or parent organization is: _______________________________ [__] If not independently owned and operated, the parent company or parent organization's Taxpayer Identification Number (TIN) or Employer Identification Number (E.I. No.) is

3. Taxpayer Identification

(a) Definitions.

"Common parent," as used in this solicitation provision, means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member.

"Corporate status," as used in this solicitation provision, means a designation as to whether the offeror is a corporate entity, an unincorporated entity (e.g., sole proprietorship or partnership), or a corporation providing medical and health care services.

"Taxpayer Identification Number (TIN)," as used in this solicitation provision, means the number required by the IRS to be used by the offeror in reporting income tax and other returns.

(b) All offerors are required to submit the information required in paragraphs (c) through (e) of this solicitation provision in order to comply with reporting requirements of 26 U.S.C. 6041, 6041A, and 6050M and implementing regulations issued by the Internal Revenue Service (IRS). If the resulting contract is subject to the reporting requirements described in FAR 4.903, the failure or refusal by the offeror to furnish the information may result in a 31 percent reduction of payments otherwise due under the contract.

(c) Taxpayer Identification Number (TIN). TIN:

[__] TIN has been applied for.

[__] TIN is not required because:

[__] Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the U.S.

and does not have an office or place of business or a fiscal paying agent in the U.S.;

[__] Offeror is an agency or instrumentality of a foreign government;

[__] Offeror is an agency or instrumentality of a Federal, state, or local government;

[__] Other. State basis for no TIN

ANTHC 26-R-475186

(d) Corporate Status.

[__] Corporation providing medical and health care services, or engaged in the billing and collecting of payments for such services;

[__] Other corporate entity;

[__] Not a corporate entity:

[__] Sole proprietorship [__] Partnership [__] Hospital or extended care facility described in 26 CFR 501(c)(3) that is exempt from taxation under 26 CFR 501(a).

(e) Common Parent.

[__] Offeror is not owned or controlled by a common parent as defined in paragraph (a) of this provision. Name and TIN of common parent:

Name TIN

4. Contingent Fee Representation and Agreement (Note: The offeror must check the appropriate boxes. For interpretation of the representation, including the term "bona fide employee," see the General Provision of this contract entitled, COVENANT AGAINST

CONTINGENT FEES.)

(a) Representation. The offeror represents that, except for full-time bona-fide employees working solely for the offeror, the offeror:

(1) [__] has, [__] has not employed or retained any person or company to solicit or obtain this contract; and

(2) [__] has, [__] has not paid or agreed to pay to any person or company employed or retained to solicit or obtain this contract any commission, percentage, brokerage, or other fee contingent upon or resulting from the award of this contract.

(b) Agreement. The offeror agrees to provide information relating to the above Representation as requested by the ANTHC and, when subparagraph (a) (1) or (a) (2) is answered affirmatively, to promptly submit to the Contracting Officer:

(1) A complete Standard Form 119, Statement of Contingent or Other Fees, (SF 119); or

(2) A signed statement indicating that the SF 119 was previously submitted to the same procurement officer, including the date and applicable solicitation or contract number, and representing that the prior SF 119 applies to this bid or offer.

5. Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions (This provision is applicable only if the amount of the bid exceeds $100,000.)

(a) The definitions and prohibitions contained in the clause, at General Provisions 8 (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, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any Federal contract, grant, loan, or cooperative agreement;

(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 the Contracting Officer; 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 an 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.

6. Certification of Non-segregated Facilities

(a) "Segregated facilities", as used in this provision, means any waiting rooms, work areas, rest rooms and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees, that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin because of habit, local custom, or otherwise.

(b) By submission of this offer, the Bidder/Offeror certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform their services at any location under its control where segregated facilities are maintained. The Bidder/Offeror agrees that a breach of this certification is a violation of the Equal Opportunity clause in the contract.

(c) The Bidder/Offeror further agrees that (except where it has obtained identical certifications from proposed subcontractors for specific time periods) it will --

(1) Obtain identical certifications from proposed subcontractors before the award of subcontracts under which the subcontractor will be subject to the Equal Opportunity clause;

(2) Retain the certifications in the files; and

(3) Forward the following notice to the proposed subcontractors (except if the proposed subcontractors have submitted identical certifications for specific time periods):

NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR CERTIFICATIONS OF

NONSEGREGATED FACILITIES.

A Certification of Non-segregated Facilities must be submitted before the award of a subcontract under which the subcontractor will be subject to the Equal Opportunity clause. The certification may be submitted either for each subcontract or for all subcontracts during a period (i.e., quarterly, semi-annually, or annually).

7. Certification Regarding Debarment, Suspension, Proposed Debarment, and Other Responsibility Matters

(a) (1) The Offeror certifies, to the best of its knowledge and belief, that--

(i) Neither the Offeror nor any of its Principals--

(A) Are presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any federal, state, or local governmental agency;

(B) Have, 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 presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subdivision (a)(1)(i)(B) of this provision.

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

(2) "Principals," for the purposes 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).

(b) The Offeror shall provide immediate written notice to the Contracting Officer if, at any time prior to contract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

(c) Failure of the Offeror to furnish a certification or provide such additional information as requested by the Contracting Officer 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 ANTHC, the Contracting Officer may terminate the contract resulting from this solicitation for default.

8. Clean Air and Water Certification The Offeror certifies that--

(a) Any facility to be used in the performance of this proposed contract is [__] is not [__] listed on the Environmental Protection Agency (EPA) List of Violating Facilities;

(b) The Offeror will immediately notify the Contracting Officer, before award, of the receipt of any communication from the Administrator, or a designee, of the EPA, indicating that any facility that the Offeror proposes to use for the performance of the contract is under consideration to be listed on the EPA List of Violating Facilities; and

(c) The Offeror will include a certification substantially the same as this certification, including this paragraph (c), in every nonexempt subcontract.

9. Anti-Kickback Provisions

(a) The Contractor assures that regarding this contract, neither the Contractor, nor any of its employees, agents, or representatives has violated the provisions of the "Anti-Kickback" Act of 1986 (41 USC 51-58) or the Copland Anti-Kickback Act clause (18 USC 874, as supplemented by Department of Labor regulations at 29 CFR Pt. 3), which are incorporated by reference and made a part of this contract.

(b) The Contractor warrants that neither the Contractor nor any of its representatives has been required, directly or indirectly as an express or implied condition in obtaining or carrying out this contract, to employ or retain, any organization or person or to make a contribution, donation or consideration of any kind.

10. Certificate of Independent Price Determination

(a) The offeror certifies that--

(1) The prices in this offer have been arrived at independently, without, for the purpose of restricting competition, any consultation, communication, or agreement with any other offeror or competitor relating to--

(i) Those prices;

(ii) The intention to submit an offer; or

(iii) The methods or factors used to calculate the prices offered.

(2) The prices in this offer have not been and will not be knowingly disclosed by the offeror, directly or indirectly, to any other offeror or competitor before bid opening (in the case of a sealed bid solicitation) or contract award (in the case of a negotiated solicitation) unless otherwise required by law; and

(3) No attempt has been made or will be made by the offeror to induce any other concern to submit or not to submit an offer for the purpose of restricting competition.

(b) Each signature on the offer is considered to be a certification by the signatory that the signatory--

(1) Is the person in the offeror's organization responsible for determining the prices being offered in this bid or proposal, and that the signatory has not participated and will not participate in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision; or

(2) (i) Has been authorized, in writing, to act as agent for the following principals in certifying that those principals have not participated, and will not participate in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision _____

[insert full name of person(s) in the offeror's organization responsible for determining the prices offered in this bid or proposal, and the title of his or her position in the offeror's organization];

(ii) As an authorized agent, does certify that the principals named in subdivision (b)(2)(i) of this provision have not participated, and will not participate, in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision; and

(iii) As an agent, has not personally participated, and will not participate, in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision.

(c) If the offeror deletes or modifies subparagraph (a)(2) of this provision, the offeror must furnish with its offer a signed statement setting forth in detail the circumstances of the disclosure.

11. Drug Free Workplace To the extent that any facilities, equipment, vessel, or vehicle to be provided under this bid/offer is to be used as a place of work by Owner employees, the Bidder/Offeror certifies that it does and will maintain such place of work as a drug free workplace in compliance with the Drug Free Workplace Act of 1988 (P.L. 100-690) subject to all the sanctions and penalties in that Act. To this end the Bidder/Offeror represents that it is in compliance with the requirements of the clause prescribed by the Federal Acquisition Regulations (FAR) 52.223-5. (A copy of the FAR 52.223-5 clause is available from the office issuing this solicitation upon request.)

12. Cooperation for Required Determination of Responsible Prospective Contractor Prior to Award of Contract

(a) (This subparagraph applicable to Construction only) Signing of the bid shall be deemed to be a certification by the bidder that:

(1) Bidder is a construction contractor who owns, operates, or maintains a place of business, regularly engaged in construction, alteration or repair of buildings, structures, communication facilities, or other engineering projects, including furnishing and installing of necessary equipment; or

(2) If newly entering into a construction activity, bidder has made all necessary arrangements for personnel, construction equipment, and required licenses to perform construction work; and

(3) Upon request, prior to award, bidder will promptly furnish to ANTHC a statement of facts in detail as to bidder's previous experience (including recent and current contracts), organization (including company officers), technical qualifications, financial resources and facilities available to perform the contemplated work.

(b) The Bidder shall, upon request, promptly furnish ANTHC with a current certified statement of the Bidder's financial condition and such data as ANTHC may request with respect to the Bidder's operations.

ANTHC will use this information to determine the Bidder's financial responsibility and ability to perform under the contract.

(c) Failure of a Bidder to comply with a request for information may be cause for rejection of the bid on responsibility grounds.

(d) ANTHC may make such investigations as they deem necessary to determine the ability of the bidder to perform the work, and the bidder shall furnish to ANTHC all such information and data for this purpose as ANTHC may request. ANTHC reserves the right to reject any bid if the evidence submitted by, or investigation of such bidder fails to satisfy ANTHC that such bidder is properly qualified and responsible to carry out the obligations of the contract and to complete the work contemplated therein.

13. Native Preference Representation

(a) Representation: The offeror represents that [__] it is, [__] is not an Alaska Native/American

Indian or an Alaska Native / American Indian Entity as defined in this Section 13 below. An Offeror that represents he or she qualifies as an Alaska Native / American Indian must submit satisfactory evidence of his or her Native status.

An Offeror that represents as an Alaska Native/American Indian Entity must submit satisfactory evidence to demonstrate the specific degree of Alaska Native/American Indian primary ownership, control and management.

(b) (This is applicable only if this is an Alaska Native/American Indian Entities preference or set-aside).

The specified degree of Alaska Native/American Indian ownership, control and management must be maintained during the period covered by this contract.

(c) Any Offeror that misrepresents itself as an Alaska Native/American Indian or as an Alaska Native/American Indian Entity in order to secure the award of a contract or purchase order shall be disqualified from being awarded the contract or, if the contract has already been awarded, shall be considered in material breach of the contract or purchase order and subject to the penalties specified in, the contract, purchase order or ANTHC policy, including immediate termination of the contract or purchase order.

DEFINITIONS

Alaska Native/American Indian:

Any of the following natural persons:

(1) Any citizen of the United States who is a person of one-fourth degree or more Alaska Native or

American Indian heritage or who is regarded as an Alaska Native by the Native village or Native group of which he or she claims to be a member and whose father or mother is (or, if deceased, was) regarded as Native by any village or group; or

(2) Any person of Indian or Alaska Native descent who is a member of, or eligible for membership in, any Federally recognized Indian Tribe, or an original ANCSA shareholder; or

(3) Any descendant of a person of American Indian or Alaska Native descent who is or was (if deceased) a member of, or eligible for membership in, any Federally recognized Indian Tribe or an original ANCSA shareholder.

Alaska Native / American Indian Entity.

An Alaska Native / American Indian (AN/AI) Entity includes an entity described in (1), (2) or (3) below:

(1) an Indian tribe, a tribal organization and intertribal consortium.

(2) any Alaska Native Claims Settlement Act Regional Corporation, Village Corporation, Urban

Corporation or Group Corporation whose Settlement and Common Stock and other stock held by holders of Settlement Common Stock and by Natives and descendants of Natives represent greater than 50% of both

(a) the total equity of the corporation, and

(b) the total voting power of the corporation for the purpose of electing directors

(3) a cooperative, enterprise, corporation, subsidiary, joint venture (JV), partnership, Limited Liability Partnership (LLP), Limited Liability Company (LLC), or other business association that meets the conditions of subsections (a) and (b) below.

(a) The entity is owned or controlled by AN/AI interests as demonstrated by at least one of the following:

(i) Greater than 50% of the total voting power of the governing board or its equivalent is AN/AI-controlled; or

(ii) Greater than 50% of the total equity of the enterprise is AN/AI- contributed, with “equity” for purposes of this subsection to include the market value of the enterprise’s stock and all other capital, and the market value of the enterprise’s real and personal property.

(b) The entity is primarily administered for the benefit of AN/AIs as demonstrated by one of the following:

(i) At least 51% of the enterprise’s service costs under the contract is expended on AN/AIs or AN/AI Entities, to include the cost of employee salaries and benefits, and the cost of service subcontractors during the term of a contract; or

(ii) Greater than 50% of the profits (if any) or revenue expenditures inure to AN/AI benefit.

Inter-Tribal Consortium: A coalition of two or more separate Indian Tribes or tribal organizations that join together for the purpose of participating in self-governance under the Indian Self-Determination Act.

Tribal Organization:

An entity that meets the definition of “tribal organization” under the Indian Self-Determination Act or the recognized governing body of any Indian tribe; any legally established organization of Indians which is controlled, sanctioned, or chartered by such governing body or which is democratically elected by the adult members of the Indian community to be served by such organization and which includes the maximum participation of Indians in all phases of its activities.

Indian Tribe. Any Indian Tribe, band, nation or other organized group or community, including any Alaska Native village or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.

14. Bidder/Offeror Certification and Representation Signature By signing below, the Bidder/Offeror represents that all of its statements, certifications, and representations, and other information supplied herein are true and correct as of the date of submittal of this bid/offer.

BIDDER/OFFEROR:

(Type or Print Company Name)

(Address of Bidder/Offeror)

AUTHORIZED SIGNATURE:

(Signature) (Date)

(Printed Name) (Email address)