Attachment F - Eligibility Certification and Supplemental Information Form.pdf

Eligibility Certification and Supplemental Information Form

In accordance with Section 4.1 of the Appendix A (80GRC026R0008), a copy of this form shall be completed by the Offeror and each of the Offeror's partners listed in the proposal's Teaming Arrangement that will be supporting partner's research and technology development efforts.

1. Is your firm a for-profit organization, and if so, which type?1

Yes

No □

□ "S corporation" incorporated under Subchapter S of the Internal Revenue

Code

□ Corporation incorporated under another authority

□ Partnership

□ Limited liability corporation or partnership

□ Sole proprietorship

2. Is your firm organized under the laws of the United States or a State or Territory of the United States?

Yes

No □

If yes, please provide the State or Territory in which the organization is organized or incorporated, including the applicable reference number. Limit

250 characters.

If NO, your organization is ineligible to propose for this Appendix A.

See 2 CFR §25.425 for the applicable definition of "for-profit organization." Note that 2

CFR is otherwise inapplicable to this Appendix A or the Contract resulting from this Appendix A.

Attachment F

3. Is your organization more than 50% owned and controlled by United States nationals?

For purposes of this certification, ownership and control will be determined by whether U.S. nationals, either directly, or through a controlling intermediary, possess a controlling interest in the organization. A "controlling interest" is defined as

"ownership of an amount of equity in such entity sufficient to direct management of the entity or to void transactions entered into by the entity's management." A

"controlling intermediary'' is defined as another for-profit organization as defined in

Question 1. Ownership of more than 50% of the equity in an entity creates the presumption that such an interest is controlling.

Yes If yes, please provide the identification of any controlling intermediary for profit organizations and the citizenship status of the ownership interests in those controlling intermediary organizations. Limit 2,500 characters.

No □

4. If your organization checked "NO" in response to Question 3, is your organization a subsidiary of a foreign company that has evidenced a substantial commitment to the United States market, through:

a) Investments in the United States in long-term research, development, and manufacturing (including the manufacture of major components and subassemblies); and

Yes

No □

If yes, please describe how your organization has contributed to such investments in the United States, including years of corporate presence, manufacturing activities, and research and development activities in the

United States; locations and brief description of significant research and manufacturing facilities in the United States; and percentage of your firm's total revenue (in USD) attributable to research, development, and manufacturing conducted in the United States. Limit 10,000 characters

If NO, your organization is ineligible to propose for this Appendix A.

b) Significant contributions to employment in the United States?

Yes ☐

If yes, please describe your organization's significant contributions to employment in the United States, including the total number of employees worldwide, the total number of employees physically located in or otherwise substantially engaged in employment activities within the United States; the total number of employees physically located in or otherwise substantially engaged in employment activities in the United States. Limit 10,000 characters.

No ☐ If NO, your organization is ineligible to propose for this Appendix.

5. Please provide any additional information you believe is relevant to NASA's assessment of your organization's domestic eligibility in the space provided below. Limit 10,000 characters

CERTIFICATION

ON BEHALF OF [ ],

I HEREBY CERTIFY AND REPRESENT THAT TO THE BEST OF MY KNOWLEDGE, THE

RESPONSES AND INFORMATION PROVIDED IN THIS FORM ARE TRUE AND ACCURATE. I

ACKNOWLEDGE THAT MAKING, PRESENTING, OR SUBMITTING A FALSE, FICTITIOUS,

OR FRAUDULENT STATEMENT, REPRESENTATION, OR CERTIFICATION MAY

RESULT IN CRIMINAL, CIVIL, AND/OR ADMINISTRATIVE SANCTIONS, INCLUDING FINES,

PENALTIES, AND IMPRISONMENT.