Attachment 3 Representation Form.pdf
PDF 2 MB Posted
- Attached to
- Community Health Immunization Resources
- Solicitation number
- 75H70427Q00002
About this file
This is an Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form for solicitation 75H70427Q00002, Community Health Immunization Resources.
The form is a self-certification document that offerors must complete to represent their eligibility as an Indian Economic Enterprise (IEE) under 25 U.S.C. 47. Offerors must meet the IEE definition throughout three critical periods: at the time an offer is submitted in response to a solicitation, at the time of contract award, and during the full contract performance period. The form requires offerors to declare whether they do or do not meet the definition of an Indian Economic Enterprise with Indian Ownership. Documentation of eligibility may be required by the Contracting Officer before awarding set-aside or sole source contracts, and awards are subject to protest if the successful Offeror's eligibility is questioned. Successful offerors must also be registered with the System of Award Management (SAM). The form requires completion of fields identifying the name of the federally recognized tribal entity, business name, name of the 51% owner of the IEE firm, Unique Entity Identifier (UEI) number, certifying signature, and printed name. The form warns that false or misleading information constitutes a violation of law under 18 U.S.C. 1001, with false claims during contract performance subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287.
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Other files
| File | Type | Posted |
|---|---|---|
| 75H70427Q00002 00001.pdf | ||
| 75H70427Q00002 Questions and Answers.pdf | ||
| Attachment 2 Provisions and Clauses.pdf | ||
| Attachment 1 Statement of Work.pdf | ||
| 75H70427Q00002.pdf |
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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 enterprise 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 a 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 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
Unique Entity Identifier (UEI) Number
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: 75H70427Q00002 |
| PROJECT_TITLE: Community Health Immunization Resources |
| DoesNot: 0 |
| Does: Off |
| Date1_af_date: |
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