A10 Attachment 1 IHS IEE Representation Form_Jan 2022.pdf
PDF 141 KB Posted
- Attached to
- Belcourt RTU & Cabinet Replacement CT Area
- Solicitation number
- 75H70124Q00025
About this file
This document is an Indian Health Service (IHS) Indian Economic Enterprise (IEE) Representation Form. The form is to be completed by offerors responding to the IHS sources sought notice for a project titled "Belcourt RTU & Cabinet Replacement CT Area" with Solicitation Number 75H70124Q00025. The form certifies that the offeror meets the definition of an "Indian Economic Enterprise" under the Buy Indian Act, which requires the enterprise to be at least 51% owned by a federally recognized tribe. The offeror must be registered in the System for Award Management (SAM) and provide documentation of their eligibility. False or misleading information is subject to legal penalties. The sources sought notice indicates the IHS is conducting market research to identify capable firms, including small businesses and Indian-owned firms, to potentially perform HVAC unit replacement and cabinet replacement work at a hospital in Belcourt, ND, with an anticipated contract value between $100,000 and $250,000. Respondents are requested to provide company information, bond capacity, and details on relevant past projects.
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
Indian Health Service
Office of Management Services Division of Acquisition Policy (DAP)
5600 Fishers Lane Rockville, MD 20857
INDIAN HEALTH SERVICE
BUY INDIAN ACT
INDIAN ECONOMIC ENTERPRISE
REPRESENTATION FORM
SOLICITATION/SOURCES SOUGHT/RFI #: _________________________________________________
PROJECT TITLE: ________________________________________________________
DATE: ___________________________________________________________________
In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.
The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:
(1) At the time an offer is made in response to this solicitation;
(2) At the time of contract award; and
(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.
Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).
Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.
False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.
REPRESENTATION
The Offeror represents as part of its offer that it does _____, does not _____ meet the definition of an “Indian Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.
Name of the 51% owner of IEE Firm
Certifying Signature
Print Name
Name of Federally Recognized Tribal Entity
Business Name
DUNS Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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