B01 Attachment J06 IHS IEE Representation Form.pdf
PDF 959 KB Posted
- Attached to
- Stephenson-Taylor Water Line Extension
- Solicitation number
- 75H70125R00054
About this file
This document is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise (IEE) Representation Form for Solicitation 75H70125R00054 for the Stephenson-Taylor Water Line Extension project. The form requires self-certification that an offeror meets the definition of an "Indian Economic Enterprise" with Indian ownership, which must be maintained from offer submission through contract performance. The form emphasizes that false or misleading information is punishable under federal law.
The associated solicitation is for a construction project in Binger, Oklahoma, involving approximately 2,500 feet of 4-inch HDPE water line and 8,300 feet of 4-inch PVC water line for Caddo County Rural Water District No. 3. The project is valued between $250,000 and $500,000, with a 90-calendar day performance period. It will be awarded as a Firm Fixed Price contract using Lowest Price Technically Acceptable (LPTA) criteria and is 100% set aside for Indian Small Business Economic Enterprises under NAICS code 237110, with a size standard of $45 million. Mandatory requirements include SAM registration and compliance with Buy Indian Act provisions.
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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: 75H70125R00054 |
| PROJECT_TITLE: Stephenson-Taylor Water Line Ext |
| DoesNot: 0 |
| Does: Off |
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