B11 - IEE Representation.pdf
PDF 130 KB Posted
- Attached to
- Crow Service Unit: Mobile Mammography Services
- Solicitation number
- 75H709-CR25Q-002
About this file
The document is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise Representation Form for a Sources Sought Notice related to mobile mammography services. The form requires self-certification by an Indian Economic Enterprise (IEE) that meets specific ownership and operational criteria, including at least 51% Indian ownership, earnings, and management control. The associated Sources Sought Notice seeks to identify Indian Small Business Economic Enterprises (ISBEEs) capable of providing mobile mammography services for the Crow Service Unit, with a one-year base contract and four optional years. The requirement involves operating two mobile clinics per month, using licensed radiographic technicians to perform digital mammograms and DEXA scans, with NAICS code 621512 and a size standard of $19 million.
Interested ISBEEs must submit a detailed capability statement demonstrating experience in mobile mammography services, including years of experience, past contract references, and how they meet the IEE definition. Responses should be emailed to Tanya.azure@ihs.gov, including the Buy Indian Act representation form, with the Sources Sought ID SS-75H709-CR25Q-002 recommended in the subject line. The government will use the responses to determine the acquisition strategy, with the requirement potentially set aside 100% for Indian Small Business Economic Enterprises under the Buy Indian Act.
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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
UEI SAM Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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