A10 Attachment 1 IHS IEE Representation Form_Jan 2022.pdf
PDF 141 KB Posted
- Attached to
- Cheyenne Quarters French Door Replacement
- Solicitation number
- 75H70124R00053
About this file
This document is an Indian Economic Enterprise (IEE) Representation Form related to a federal contract opportunity for the Cheyenne River Quarters French Door Replacement project.
The form outlines the requirements for an offeror to self-certify that it meets the definition of an "Indian Economic Enterprise" under the Buy Indian Act in order to be eligible for award of a set-aside or sole source contract. The offeror must meet the IEE definition at the time of offer, award, and throughout contract performance. Successful offerors must also be registered in SAM. The form includes details on penalties for false or misleading information. The related federal contract opportunity is for the removal and replacement of doors for 113 quarters at the Cheyenne River Health Center, with an anticipated project value between $500,000 and $1,000,000. The agency is conducting market research to identify capable businesses, especially small, disadvantaged, and Native American-owned firms, that may be interested in submitting a proposal if the opportunity is solicited.
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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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