A10 IHS IEE Representation Form Jan 2022.pdf
PDF 129 KB Posted
- Solicitation number
- 75H701-22-R-00051
About this file
This document contains a sources sought notice for a construction project. The Department of Health and Human Services Indian Health Service is seeking information from contractors to renovate and expand an existing 27,195 square foot Mid-Atlantic Tribal Health Clinic located in Charles City, Virginia to provide primary care, dental, behavioral health, pharmacy, optometry, telehealth, diabetic care, and benefit coordination services. Interested prime contractors are invited to submit a capabilities statement no longer than ten pages by May 13th, 2022 with company information, confirmation of submitting a proposal if solicited, business type as Native American-owned, 8(a) certified, HUBZone, SDVOSB, WOSB or small business, bonding capacity, and experience on two to five similar past projects as a prime contractor or subcontractor between 2015-2022 including contract value, location, completion date, reference contacts, and whether the project was federal, state, tribal or other. The anticipated project value is over $10 million and the NAICS code is 236220 for commercial and institutional building construction.
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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
DUNS Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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