BLANK - IHS IEE Representation Form_Jan 2022_508 Compliant.pdf
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- Attached to
- AMENDMENT 001 - Four (4) Medical Assistants - Santa Fe Indian Health Center & Satellite Clinics
- Solicitation number
- 75H70726Q00020
About this file
This document is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise (IEE) Representation Form. The form requires self-certification for businesses seeking to qualify as an Indian Economic Enterprise under 25 U.S.C. 47, with specific eligibility requirements that must be maintained at the time of offer, contract award, and throughout the entire contract performance period.
The form emphasizes strict compliance with IEE definitions, mandating that businesses must be at least 51% owned by members of a Federally Recognized Tribal Entity. Offerors must disclose whether they meet IEE criteria and are required to immediately notify the Contracting Officer if they no longer qualify. Additional requirements include registration in the System of Award Management (SAM), and false representations can result in legal penalties under 18 U.S.C. 1001 and 31 U.S.C. 3729-3731. The form provides space for key information such as the business name, DUNS number, tribal entity name, and 51% owner details.
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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: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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