Atch H - IEE Representation Form.pdf
PDF 129 KB Posted
- Attached to
- Nurse Practitioner/Physician Services at Elko Southern Bands Federal contract opportunity
- Solicitation number
- RFP-22-PHX-05
About this file
This combined synopsis and solicitation from the Department of Health and Human Services Indian Health Service seeks firm fixed-price proposals to provide non-personal professional nurse practitioner/physician assistant services at the Elko Southern Bands Health Center in Elko, Nevada. The period of performance is from August 15, 2022 through August 14, 2023 with one option year. Offerors must complete the Indian Economic Enterprise Representation Form and be registered in the System for Award Management. Proposals are due by email no later than the response date of July 15, 2022. Award is set aside for Native American firms in accordance with the Buy Indian Act of 1910.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Atch D - Statement of Work Elko REV.pdf | ||
| Atch A - Rate Schedule NP.PA Services Elko 2 YR.xlsx | XLSX spreadsheet | |
| Atch G - Clauses.Terms and Instructions.pdf | ||
| Atch F - Wage Determination 2015-5601 dtd 14 Mar 2022.pdf | ||
| Atch E - Timesheet for Contract Service.xlsx | XLSX spreadsheet | |
| Atch C - 2022 Tax Exemption.pdf | ||
| Atch B - Business Associate Agreement.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
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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