Attachment 3 Representation Form.pdf
PDF 2 MB Posted
- Attached to
- Modernization of the Influenza-Like Illness (ILI) Surveillance Process and Algorithms Project
- Solicitation number
- 75H70427Q00001
About this file
This is an Indian Economic Enterprise Representation Form issued by the Indian Health Service (IHS), Department of Health & Human Services, for use in response to federal solicitations.
The form is a self-certification document required for solicitation 75H70427Q00001 titled "Modernization of the Influenza-Like Illness (ILI) Surveillance Process and Algorithm." Offerors must certify whether they meet the definition of an "Indian Economic Enterprise" with Indian ownership under the authority of the Buy Indian Act (25 U.S.C. 47) and HHSAR 326.601. The enterprise must maintain this eligibility status at three critical points: when submitting an offer, at contract award, and throughout the full contract performance period. Any loss of eligibility during these periods requires immediate written notification to the Contracting Officer. Successful offerors must also register with the System of Award Management (SAM). The form requires entries for the federally recognized tribal entity name, business name, unique entity identifier (UEI) number, name of the 51% owner, certifying signature, and printed name. False or misleading information is punishable 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. The Contracting Officer may require documentation of eligibility before awarding set-aside or sole source contracts, and awards are subject to protest if offeror eligibility is questionable.
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Other files
| File | Type | Posted |
|---|---|---|
| 75H70427Q00001 Questions and Answers.pdf | ||
| 75H70427Q00001.pdf | ||
| Attachment 2 Provisions Clauses.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: 75H70427Q00001 |
| PROJECT_TITLE: Modernization of the Influenza-Like Illness (ILI) Surveillance Process and Algorithms Process |
| DoesNot: 0 |
| Does: Off |
| Date1_af_date: |
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