IHS IEE Representation Form_Jan 2022_508 Compliant.pdf
PDF 852 KB Posted
- Attached to
- Kayenta Health Center: Non-Personal Service Contract - Pediatric Physician Services (Amendment 02)
- Solicitation number
- 75H71025Q00030
About this file
This is a representation form template for the Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise certification requirement. The form is used in conjunction with Sources Sought Notices, Requests for Information (RFI), or formal solicitations issued by the IHS Division of Acquisition Policy.
Offerors must self-certify their status as an Indian Economic Enterprise (IEE) with Indian ownership in accordance with 25 U.S.C. 47 and HHSAR 326.601. The certification requirement applies at three critical junctures: at the time of offer submission, at contract award, and throughout the entire contract performance period. Contractors must maintain eligibility continuously and provide immediate written notification to the Contracting Officer if eligibility status changes at any point. The form requires disclosure of the federally recognized tribal entity affiliation, the 51% owner name, business name, DUNS number, and a certified signature. Successful offerors must also register with the System of Award Management (SAM). The form warns that false or misleading information constitutes a violation under 18 U.S.C. 1001, and false claims during contract performance are subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287. Contracting Officers may require supporting documentation of eligibility before award, and awards are subject to protest if the successful offeror's IEE status is questioned.
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Other files
| File | Type | Posted |
|---|---|---|
| Performance Work Statement.pdf | ||
| 75H71025Q00030_Amd_0002.pdf | ||
| Sol_75H71025Q00030_Amd_0001.pdf | ||
| IHS IEE Representation Form_Jan 2022_508 Compliant.pdf | ||
| Performance Work Statement.pdf | ||
| PWS.pdf | ||
| Sol_75H71025Q00030.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 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
Attachment C
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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