IEE Representation Form.pdf
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Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form
This is a self-certification form issued by the Department of Health & Human Services Indian Health Service (IHS), Office of Management Services, Division of Acquisition Policy. The form is used in response to Sources Sought Notices, Requests for Information (RFI), or Solicitations to certify that an offeror meets the definition of an "Indian Economic Enterprise" (IEE) under the authority of the Buy Indian Act (25 U.S.C. 47) and HHSAR 326.601.
An offeror must maintain Indian Economic Enterprise status with Indian Ownership at three critical junctures: at the time an offer is submitted, at the time of contract award, and throughout the entire contract performance period. Any changes to eligibility status during these periods require immediate written notification to the Contracting Officer. The form requires the offeror to provide the name of the Federally Recognized Tribal Entity, the business name, the name of the 51% owner, the UEI SAM registration number, and a certifying signature from an authorized representative. Individual Contracting Officers may request documentation of eligibility before awarding set-aside or sole source contracts, and awards may be subject to protest if the successful offeror's eligibility is questioned. Submission of false or misleading information is punishable under 18 U.S.C. 1001, and false claims submitted during contract performance are subject to penalties under 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.
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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
UEI SAM Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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