Attachment 4_IEE Representation.pdf
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- Solicitation number
- 75H70926BAO_084RFQ
About this file
This is an Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form used by the Department of Health & Human Services to certify offeror eligibility for set-aside or sole source contracts under the Buy Indian Act authority.
The form requires offerors to self-certify that they meet the definition of an "Indian Economic Enterprise" with Indian Ownership as defined in HHSAR 326.601. Certification must be maintained throughout three critical periods: at the time of offer submission, at contract award, and during the full contract performance period. Offerors must immediately notify the Contracting Officer in writing if they cease to meet eligibility requirements at any point. The form mandates that successful offerors register with the System of Award Management (SAM). Contracting Officers may request documentation of eligibility before awarding contracts, and awards are subject to protest if offeror eligibility is questioned. The form includes a representation section where offerors indicate whether they do or do not meet the Indian Economic Enterprise definition, and requires submission of the Federally Recognized Tribal Entity name, 51% owner name, business name, certifying signature, printed name, and UEI SAM number. False or misleading information submitted with an offer violates 18 U.S.C. 1001, while false claims during contract performance are subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287.
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Other files
| File | Type | Posted |
|---|---|---|
| 75H70926BAO_084.pdf | ||
| Attachment 1_Statement of Work.pdf | ||
| Attachment 3_SCA WD 2015_5397.pdf | ||
| Attachment 2_RFQ Price_Schedule.xlsx | XLSX spreadsheet |
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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
UEI SAM Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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