Attachment 3 Representation Form.pdf
PDF 2 MB Posted
- Solicitation number
- 75H70426Q00050
About this file
This document is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise Representation Form template used for federal contract opportunities.
The form serves as a self-certification mechanism for enterprises seeking to qualify as Indian Economic Enterprises (IEE) under the authority of the Buy Indian Act (25 U.S.C. 47) and HHSAR 326.601. Offerors must certify their eligibility status when responding to sources sought notices, Requests for Information (RFI), or solicitations issued by IHS. Enterprises must maintain their IEE status at three critical junctures: at the time an offer is submitted, at contract award, and throughout the full contract performance period. The contracting officer may require documentation of eligibility before awarding set-aside or sole source contracts under the Buy Indian Act, and awards are subject to protest if the successful offeror's eligibility is questioned. Successful offerors must also maintain current registration with the System of Award Management (SAM). The form requires identification of the 51% owner of the IEE firm and the associated federally recognized tribal entity. The document emphasizes that false or misleading information submitted during the offer process violates 18 U.S.C. 1001 and that false claims made during contract performance are subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287. Contractors must immediately notify the contracting officer in writing if they cease to meet eligibility requirements at any point during the contract timeline. The specific solicitation referenced is 75H70426Q00050 for VAERS Monitoring, Analytics, Reporting and Automation Enhancement.
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Other files
| File | Type | Posted |
|---|---|---|
| 75H70426Q00050 Questions and Answers.pdf | ||
| 75H70426Q00050 00002.pdf | ||
| 75H70426Q00050 00001.pdf | ||
| Attachment 2 Provisions and Clauses.pdf | ||
| 75H70426Q00050.pdf | ||
| Attachment 1 Statement of Work.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 enterprise 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 a 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 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
Unique Entity Identifier (UEI) Number
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: 75H70426Q00050 |
| PROJECT_TITLE: VAERS Monitoring, Analytics, Reporting and Automation Enhancement |
| DoesNot: 0 |
| Does: Off |
| Date1_af_date: |
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