A10 Attachment 1 IHS IEE Representation Form_Jan 2022.pdf
PDF 141 KB Posted
- Attached to
- Pine Ridge AH10 Replacement Federal contract opportunity
- Solicitation number
- 75H70125Q00023
About this file
This is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise (IEE) Representation Form for use in federal contract opportunities. The form requires self-certification by an Indian-owned enterprise that meets specific eligibility criteria for participation in IHS contract solicitations. Offerors must certify their status as an Indian Economic Enterprise at the time of offer, contract award, and throughout the entire contract performance period, with ongoing obligations to notify the Contracting Officer if eligibility changes.
The form is specifically linked to the Pine Ridge AH10 Replacement project (Solicitation Number 75H70125Q00023), a sources sought notice for replacing a supply fan in Air Handler 10 at Pine Ridge Hospital. The project is valued between $25,000 and $100,000, involves HVAC construction work, and is targeting Native American/Indian-Owned Businesses and other small business categories. Responses were due by 12:00 PM Pacific Time on April 10, 2025, and required detailed submissions including company information, business type, bond capacity, project experience, and the completed IEE Representation Form.
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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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