buy indian compliance form.pdf
PDF 211 KB Posted
- Attached to
- Gallup NSSC Waste Disposal Sources Sought
- Solicitation number
- IHS1504492
About this file
This is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise Representation Form that must be completed by vendors responding to solicitation IHS1504492 for Medical Waste Disposal services at the Gallup NSSC facility. The form serves as a self-certification document for companies to declare whether they meet the definition of an "Indian Economic Enterprise" with Indian Ownership under the Buy Indian Act (25 U.S.C. 47).
The form requires vendors to maintain their Indian Economic Enterprise status throughout three key periods: when making the offer, at contract award, and during the full contract performance period. Vendors must provide immediate written notification if they lose eligibility. The form requires specific details including the name of the 51% owner of the IEE firm, federally recognized tribal entity, business name, UEI number, and certifying signature. False or misleading information is subject to penalties under 18 U.S.C. 1001 and other statutes. Successful offerors must also be registered in the System for Award Management (SAM).
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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 Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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