CRHC20-38.pdf

REQUEST FOR QUOTATIONS

(THIS IS NOT AN ORDER)

THIS RFQ!S SMALL BUSINESS SET.ASIDE

PAGE OF PAGES

1of 2

I, REQUEST NO

cRHC20-38

2, DATE ISSUED

08t17t2020

3, REQUISITION,/PURCHASE REQUEST NO

tHs1409786

4. CERT FOR NAT. DEF

UNDER BDSA REG,2

AND/OR DMS REG. I

RATINC

5A ISSUED BY

Eagle Butte Indian Health Service, Cheyenne River Service Unit 24276 166th St, PO Box 1012, Eagle Butte, SD 57625

6 DELIVER BY (Date)

See schedule

5b FOR INFORMATION C ALL (NO COLLECTCALLS) ?. DELIVERY OTHER

X ros oesrll.rarrcx 16"" s,n"ou,")

NAME

Stephanie Charger stephanie.redelk@ihs.sov

TELEPHONT ER 9 DEST

AREA CODE

NUMBER

964-0507 a NAME OF CONSIGNEE

Cheyenne River Service Unit

8. TOI b. S.TREET ADDRESS

24276 166th St . PO Box 1012 a NAME b COMPANY c CITY

Eagle Butte c STREET ADDRESS

d. CITY e STATE If.ZIPCODE d STATE le ZIPCODE sD | 57625

IO PLEASE FURNISH QUOTATIONS 1O

THE ISSUING OFFICE IN BLOCK

5a ON OR BY l:00 PM MST ON (Ddte, August 27, 2020

IMPORTANT: This is a request for informatton, and quotations fumished are not offiers lfyouareuMbletoquote,please so indicate on lhis form and retum it to the address in Block 5a This request does nol commit the Covemment to pay any costs incurred tn the Dreoamtion ofth€ submission ofthis quolation or to contract for supplies or services grpplrcs are of domestic oflgin unless otherwise indicated by quoter Any representations and/or cenifications attached to this Request for

Ouotations rnust bo cornpleted by thequoter l l. SCHEDULE /zclude spplicqble Federul, Slale on

ITEM NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

TNIT

(d)

UNII'PRICE

{e)

AMOLINT

(o

Firm Fixed Price Purchase Order for various Air Filters, Maintenance Department, Cheyenne River Health Center, Eagle Butte, SD. Price is all inclusive. POP: I year ARO, with Deliver of 25% of each size quarterly to be shipped.

See attached Spec Sheet

I2. DISCOI.'NT FOR PROMPT

PAYMENT

a.

vo

IO CALENDAR DAYS b.20

CALENDAR

DAYS%

c. 30 CALENDAR DAYS o/" d CALENDAR DAYS

NUMBER PERCENTAGE

NOfg,,qOO,t.""t pro"'.tdls aJ)d rcpres(nlations are E arc not aftached n". NrfrElNd noonEss oe Quorsa I5, SICNATURE OF PERSON AU I HOKIZbU IU

SICN QUOTATION QUO'TATION

a NAME OF QUOTER b STREET ADDRESS c COUNI'Y

16 SIGNER

a NAME (-lype olPrint) b TELEPHONE

AREA CODE

d. CITY e STATE f ZIP CODE c TITLE (type ot Ptint) NUMtsEK

ST

FOR

edition not usable Prescribed by CSA-FAR (4E CFR) 53'215-l(a)

ITEM

NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

TJNIT

(d)

UNIT PRICE

(e)

AMOUNT

(f)

DLJNS & Bradstreet Number:

(The Duns & Bradstreet number is required.

Provided you do not have i! you may call 86G705- 571 I and obtain one.) You will need a DUNS & Bradstreet NUMBER lo be ax'arded lhe ourchase

Tbe quoter is bereby notilied that they must be registered in the System for Award Management (SAM) before the Government will issue an award. You may do this by going to www.sam .sov to register and you are required to update this registration every year prior to the expiration date.

No contract award shall be made to a vendor listed on the OIC Exclusion List (htto://exlusions.oi g.hhs.gov) throughout the duration of the contract.

Federal Tax ID Number:

Email Address:

Net Terms:

NOTICE TO QUOTERS

REOUEST FOR QUOTES RFO): CRHC20-38

OUOTE DUE DATE: Quotes are due August 27,2020 @ l:00 PM MST

RETURN RFO TO: Cheyenne River Service Unit Attn: Stephanie Charger PO Box 1012 Eagle Butte, SD 57625 Telephone: 605-964-1724 Ext. 0507 Fax: 605-964-1140

GENERAL DESCRIPTION:

Firm Fixed Price, Purchase Order, various filters for the Maintenance Department at the Cheyenne River Health

Center located in Eagle Butte, SD. Delivery: 25%o of each size quarterly will be shipped to reduce storage space needed onsite. ARO. The quoted "unit price" shall be an all inclusive price.

This RFQ is issued as a 100% Small Business Set Aside and the associated NAICS code is 333415 with a small business size standard of 1,250 employees.

BASIS FOR AWARD:

Lowest Price Technically Acceptable (LPTA). LPTA factors in determining the successful contractor:

l. Meet Delivery Schedule

2. Quality of Product

Contractor must be registered with the System for Award Management. The website to register is at:

\4'\tw.sam.qov

INSTRUCTION TO OUOTERS:

To be considered an acceptable quote, the following items 4g! be completed and returned by the due date stated above.

l. Complete and sign SF-l8 - Request for Quotation (Signature required)

2. Complete Ta.rpayer Identification Form (FAR Part 52.204-3 - Taxpayer ldentification)

3. Complete Annual Representations & Certifications form (FAR 52'212-5)

ATTACHMENTS:

l. SF-t8 Request for Quotations

2. Notice to Quoters

3. Specification Sheet

4. Clauses incorporated by reference

5. Clauses incorporated in full text

6. Representations and Certifications

NO CONTILA.CT AWAI].D SIIALL BE MADE TO ANY VENDOR OIt PROVIDER LISTtrD ON'fHE OIG EXLUSION LIST T}IROUGHOUT THtr DURA,TION OF-IIIE CONTR{CT, IT SHALL BE THE RESPONSIBILI-|Y OF THE CONTRACTOIT'fO NOTIFY TIIE ACQUISITION OFFICIAL IF THERE IS A CHANGE IN PRO\TII)IiIi.

SECURITY CLEARANCE

Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (l.H.S.). Before starting work requiring routine access to l.H.S. facilities or systems each person must complete a FBI National Criminal History Check (Fingerprint Check) adjudicated by an l.H.S. employee using the Office of Personnel Management Personnel Investigations Processing System. Contractors shall allow five business days for l.H.S. processing of fingerprints taken electronically at an l.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of l.H.S. sites with electronic fingerprint capability is available from the Contracting Officer.

Quotation must set forth full, accurate, and complete information as required by this Request for Quotation (RFQ), and be retumed no later than the date referenced in Block #10 of the Request fbr Quotation form SF-18.

All required information must be submitted in order to be considered responsive and eligible for award.

SCOPE OF WORIVSPECIFICATIONS

The Vendor shall ship 25% of each size quarterly to reduce the amount of storage space needed onsite. The

Vendor shall not send any items until contacted by the Facility Manager. Quantities of each size will be fina lized during bidding process, Item #1

Quantity - 12 x otal:

Type: Pleated

Dimensions: 16" x25" x4"

Media: Synthetic, Mechanical

Frame: 100% reclaimed fiber moisture resistant die-cut

Final Resistance: 0.19" WG

Efficiency: MERVS or greater

Equal to Tri-Pleat Ultra

T

Item#3 | Type: Pleated

Quantity-648r I Dimensions:20"x25"x2"

$- = | Media: Synthetic, Mechanical

Itern#2

Quantity - 600 x

Total:

Type: Pleated

Dimensions: 20" x2 4" x2"

Media: Synthetic, Mechanical

Frame: 100% reclaimed fiber moisture resistant die-cut

Final Resistance: 0.21" WG

Efficiency: MERVS or greater

Equal to Tri-Pleat Ultra

Total: Frame: 100% reclaimed fiber moisture resistant die-cut

Final Resistance: 0.21" WG

Efficiency: MERVS or greater

Equal to Tri-Pleat Ultra

Itern#4

Quantity - 24 x

Total:

Type: Pleated

Dime nsions: 20" x25" x4"

Media: Synthetic, Mechanical

Frame: 100% reclaimed frber moisture resistant die-cut

Final Resistance: 0.19" WG

Efficiency: MERV8 or greater

Equal to Tri-Pleat Ultra

Item#5 | Type: Box

Quantity -252x I Dimensions:12"x24"x4"

$ = I Media: Glass microfiber

Total: I Frame: Plastic box with single header

$ | Final Resistance: 1.5" WG

Efficiency: MERVl5 or greater

Equal to Tri-Cell fV X

Item #6

Quantity - 12 x

Type: Pleated

Dimensions: 12" x2 4" x2"

Page 2 ol 4

$ - | Media: Synthetic, Mechanical

Total: I Frame: 100% reclaimed fiber moisture resistant die-cut

Final Resistance: 0.21" WG

Efficiency: MERVS or greater

Equal to Tri-Pleat Ultra

Item#7 | Type: Box

Quantity - 780 x I Dimensions:24"x24"x4"

$ = Media: Glass microfiber

Total: I Frame: Plastic box with single header

I Final Resistance: 1.5" WG

Efficiency: MERV15 or greater

Equal to Tri-Cell fVX

Item#8 | Type: Pleated

Quantity - 12 x ' Dimensions:24"x24"x2" g = | Media: Synthetic, Mechanical

Total: Frame: 100% reclaimed fiber moisture resistant die-cut

Final Resistance: 0.21" WG

Efficiency: MERV8 or greater

Warranty Standard warranty. Damaged/unusable filters will not be accepted at time of delivery. Vendor shall send usable filters as replacements at no cost to the Government.

Page 3 of4

Shipping/Freight I No shipping costs, pricing is all inclusive.

CLAUSf,S INCORPORATED BY REFERENCE (Firm Fixed-Price -Commercial Items)

FAR CITATION: 52.252-l: Solicitation Provision Incorporated by Reference. (FEB 1998) & 52.252-2 Clauses Incorporated by Reference @EB 1998) This solicitation & contract incorporates one or more solicitation provisions & clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officerwill maketheirfull text available. The offeror is cautioned that the listed provisions may include blocks that must be completed by the offeror and submitted with its quotation or offer. In Iieu of submitting the full text ofthose provisions, the offeror may identi! the provision by paragraph identifier and provide the appropriate information with its quotation or offer. Also, the full text ofa solicitation provision & clauses may be accessed electronically at this/these address(es): https:/,/u..r,vw.acquisition.qov/fhr

I.

No. FAR Citation Clause Title Clause Date

2.

3.

4.

t.

5.

6.

7.

8.

9.

10.

11.

t2.

13.

14.

15.

16.

17.

18.

19, 52.204-'7 System for Award Management (P)

52.204-13 System for Award Management Maintenance

52.204-16 Commercial and Govemment Entity Code Reporting

52.204-18 Commercial and Government Entity Code Maintenance

52.204-19 Incorporation by Reference of Representations and Certifications

52.211-6 Brand Name or Equal

52.211-17 Delivery of Excess Quantities

52.212-l Instructions to Offerors - Commercial Items

52.212-4 Contract Terms and Conditions - Commercial Items

52.215-5 FacsimileProposals

52.232-1 Payments

52.232-8 Discounts for Prompt Payment

52.232-11 Extras

52.232-39 Unenforceability of Unauthorized Obligations

52.232-40 Providing Accelerated Payments to Small Business subcontractors

52.233-l Disputes

52.243-l Changes-Fixed-Price

52.244-6 Subcontracts for Commercial ltems

52.246-16 ResponsibilityforSupplies

Oct 2018

Oct 2018

Jul 2016

Jul 2016

Dec 2014

Aug I 999

Sep 1989

Mar 2020

Oct 201 8

Oct 1997

Apr 1984

Feb 2002

Apr 1984

Jun 2013

Dec 201 3

May 2014

Aug 1987

Aug 20l 9

Apr 1984

Page I of2l

20. 52.247-34 F.o.b. - Destination Nov l99l

21. 52.249-l Termination for Convenience of the Govemment Apr 1984 (Fixed-Price)(Short Form)

22. 52.249-8 Default (Fixed-Price Supply and Service) Apr 1984

23. 52.253-l Computer Generated Forms Jan l99l

II. Federal Acquisition Regulations (FAR) (48 CFR Chapter l) Clauses in Full Text

No. FAR Citation Clause Title Clause Date

l. 52.204-l Approval ofcontract Dec 1989

2. 52.204-3 Taxpayer ldentification (P) Oct 1998

3. 52.212-3 Offeror Reoresentation and Certifications Mar 2020

- Commercial Iterns

4. 52.212-5 Contract Terms and Condition Required to Implement Mar 2020 Statutes or Executive Orders - Commercial Items

52.204-l ApproYal of Contract This contract is subject to the written approval ofContracting Officer and shall not be finding until so approved.

52.204-3 Taxpayer Identifi cation

TAXPAYER IDENTIFICATION (OCT I998)

(a) Definitions.

"Common parent," as used in this position, means that corporate entity that owns or controls an affiliated group of corporations that files its Federal income tax returns on a consolidated basis, and of which the offeror is a member.

"Taxpayer Identification Number (TIN)," as used in this provision, means the number required by the Internal Revenue Service (lRS) to be used by the offeror in reporting income tax and other retums. The TIN may be either a

Social Security Number or an Employer Identification Number.

(b) All offerors must submit the information required in paragraphs (d) through (f) ofthis provision to comply with debtcollectionrequirementsof3lU.S.C.TT0l(c)and3325(d),reportingrequirementsof26U.S.C.604l,405lA, and 6050M, and implementing regulations issued by the IRS. lf the resulting contract is subject to the payment reporting requirements described in Federal Acquisition Regulation (FAR) 4.904, the failure or refusal by the offeror to fum ish the information may result in a 3 I percent reduction of payments otherwise due under the contract.

(c) The TIN may be used by the Government to collect and report on any delinquent amounts arising out ofthe offeror's relationship with the Government (3 I U.S.C. 7701O(3). lf the resulting contract is subject to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder may be matched with IRS records to verifo the accuracy ofthe offeror's TlN.

(d) Taxpayer ldentification Number (TIN)

! ttN:

! tlN has been applied for.

n rtN is not required because:

Page 2 ol2l

! Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States;

! Offeror is an agency or instrumentality of a foreign Govemment;

I Offeror is an agency or instrumentality of the Federal Covemment.

(e) Type of organization.

n Sole proprietorship;

n Partnership;

t] Corporate entity (not tax-exempt);

n Corporate entity (tax-exempt);

n Government entity (Federal, State, or local);

n Foreign govemment;

n lnternational organization per 26 CFR 1.6049-4;

n other

(l) Common parent.

! Offeror is not owned or controlled by a common parent as defined in paragraph (a) of this provision.

n Name and TIN of common parent:

Name

(End of provision)

52,212-3 -- Offeror Representations and Certifications -- Commercial Items.

The Offeror shall complete only paragraph (b) ofthis provision ifthe Offeror has completed the annual representations and certification electronically in the System for Award Management (SAM) accessed through https://www.sam.gov. If the Offeror has not completed the annual representations and cenifications electronically, the Offeror shall complete only paragraphs (c) through (v )) of this provision.

{a) Definitions. As used in this orovision- ''Covered telecommunications equipment or services" has the meaning provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

Economically disadvantaged women-owned small business (EDWOSB) concem means a small business concern that is at least 5l percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States and who are economically disadvantaged in accordance with l3 CFR part 127. It automatically qualifies as a women-owned small business eligible under the WOSB Program.

Forced or indentured child labor means all work or service-

( l) Exacted from any person under the age of I 8 under the menace ofany penalty for its nonperformance and for which the worker does not offer himself voluntarily: or

TIN

Page 3 of2l

(2) Performed by any person under the age of I 8 pursuant to a contract the enforcement of which can be accomplished by process or penalties.

Highest-level owner means the entity that owns or controls an immediate owner ofthe offeror, or that owns or controls one or more entities that control an immediate owner of the offeror. No entity owns or exercises control of the highest level owner.

Immediate owner means an entity, other than the offeror, that has direct control of the offeror. Indicators of control include, but are not limited to, one or more ofthe following: ownership or interlocking management, identity of interests among family members, shared facilities and equipment, and the common use of employees.

Inverted domestic corporation, means a foreign incorporated entity that meets the definition ofan inverted domestic corporation under 6 U.S.C. 395(b), applied in accordance with the rules and definitions of 6 U.S.C, 395(c).

Manufactured end product means any end product in product and service codes (PSCs) 1000-9999, except-

( l) PSC 55 I 0, Lumber and Related Basic Wood Materials;

(2) Product or Service Group (PSG) 87, Agricultural Supplies,

(3) PSG 88, Live Animals;

(4) PSG 89, Subsistence;

(5) PSC 941 0, Crude Grades of Plant Materials;

(6) PSC 9430, Miscellaneous Crude Aninal Products, Inedible;

(7) PSC 9440, Miscellaneous Crude Agricultural and Forestry Products;

(8) PSC 96 10, Ores;

(9) PSC 9620, Minerals, Natural and Synthetic; and ( I 0) PSC 9630, Additive Metal Materials.

Place of manufacture means the place where an end product is assembled out of components, or otherwise made or processed from raw materials into the finished product that is to be provided to the Government. If a product is disassembled and reassembled, the place of reassembly is not the place of manufacture.

Predecessor means an entity that is replaced by a successor and includes any predecessors ofthe predecessor.

Restricted business operations means business operations in Sudan that include power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, as those terms are defined in the Sudan Accountability and Divestment A ct of 2007 (pub. L. I I0- I 74).

Restricted business operations do not include business operations that the person (as that term is defined in Section 2 ofthe Sudan Accountability and Divestment Act of2007) conducting the business can demonstrate-

(l) Are conducted under contract directly and exclusively with the regional govemment ofsouthern Sudan;

(2) Are conducted pursuant to specific authorization from the Office of Foreign Assets Control in the Department ofthe Treasury, or are expressly exempted under Federal law fiom the requirement to be conducted under such authorization;

(3) Consist ofproviding goods or services to marginalized populations ofsudan;

(4) Consist ofproviding goods or services to an internationally recognized peacekeeping force or humanitarian organization;

(5) consist of providing goods or selices that are used only to promote health or education; or

(6) Have been voluntarily suspended."Sensitive technology,'-

Sensitive technology ( l) Means hardware, software, telecommunications equipment, or any other technology that is to be used specifically-

(i) To restrict the free flow of unbiased infomation in Iran; or

(ii) To disrupt, monitor, or otherwise restrict speech of the people of Iran; and

(2) Does not include information or informational materials the export of which the President does not have the authority to regulate or prohibit pursuant to section 203(b)(3)of the lnternational Emergency Economic Powers Act (s0 U.S.C. 1702(bX3).

Service-disabled veteran-owned small business concem- ( I ) Means a small business conccrn-

(i) Not less than 5 I percent of wh ich is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 5l percent ofthe stock of which is owned by one or more service-disabled veterans; ano

(ii) The management and daily business operations of which are controlled by one or more service- Page 4 ol 2l disabled veteransor, in the case ofa service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver ofsuch veteran.

(2) Service-disabled veteran means a veteran, as defined in 3E U.S.C. l0l(2), with a disability that is service connected, as defined in 38 U.S.C. l0l(16).

Small business concem means a concern, including its affiliates, that is independently owned and operated, not dominant in the field ofoperation in which it is bidding on Covemment contracts, and qualified as a small business under the criteria in l3 CFR Part I 2l and size standards in this solicitation.

Small disadvantaged business concem, consistent with I 3 CFR 124. I 002, means a small business concern under the size standard applicable to the acquisition, tha

( I ) Is at least 5 I percent unconditionally and directly owned (as defined at 13 CFR 124. I 05) by-

(i) One or more socially disadvantaged (as defined atl3 CFR 124.103) and economically disadvantaged (as defined at l3 CFR 124.104) individuals who are citizens ofthe United States; and

(ii) Each individual claiming economic disadvantage has a net worth not exceeding $750,000 after taking into account the applicable exclusions set forth at I 3 CFR 124.104(c)(2); and

(2) The management and daily business operations of which are controlled (as defined at l3.CFR 124.106) by individuals, who meet the criteria in paragraphs (l)(i) and (ii) of this definition.

Subsidiary means an entity in which more than 50 percent ofthe entity is owned-

(l) Directly by a parent corporation; or

(2) Through another subsidiary of a parent corporation

Successor means an entity that has replaced a predecessor by acquiring the assets and carrying out the affairs ofthe predecessor under a new name (often through acquisition or merger). The term "successor" does not include new offices/divisions of the same company or a company that only changes its name. The extent ofthe responsibility ofthe successor for the liabilities ofthe predecessor may vary, depending on State law and specific circumstances.

Veteran-owned small business concern means a small business consem- ( l) Not less than 5l percent of which is owned by one or more veterans (as defined at 38 U.S.C. l0l(2)) or, in the case ofany publicly owned business, not less than 5l percent ofthe stock of which is owned by one or more veterans; and

(2) The management and daily business operations of which are controlled by one or more veterans.

Women-owned small business (WOSB) concern eligible under the WOSB Program (in accordance with 13

CFR part I27), means a small business concern that is at least 5 I percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States.

Women-owned small business concern means a small business concem-

(l) That is at least 5l percent owned by one or more women; or, in the case ofany publicly owned business, at leastsl percent ofthe stock of which is owned by one or more women; and

(2) Whose management and daily business operations are controlled by one or more women.

(b) (1) Annual Representations and Ceftifications. Any changes provided by the Offeror in paragraph (b)(2) ofthis provision do not automatically change the representations and certifications in SAM

(2) The offeror has completed the annual representations and certifications electronically in SAM accessed through http://www.sam.gov. After reviewing SAM information, the Offeror verifies by submission of this offer that the representations and certifications currently posted electronically atF AR 52.212-3, Offeror Representations and Certifications-Commercial ltems, have been entered or updated in the last l2 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard(s) applicable to rhe NAICS code(s) referenced for this solicitation), at the time this offer is submitted and are incorporated in this offer by reference (see FAR 4.1201), except for paragraphs

[Offeror to identily the applicable paragraphs at (c) through (v) of this provision that the offeror has completed for the purposes ofthis solicitation only, if any.

These amended representation(s) and/or certification(s) are also incorporated in this offer and are current, accurate, and complete as ofthe date of this offer.

Any changes provided by the offeror are applicable to this solicitation only, and do not result in an update to the representations and cefiifications posted electronically on SAM.

(c) Offerors must complete the following representations when the resulting contract will be performed in the United States or its outlying areas. Check all that apply, ( l) Small business concem. The offeror represents as part of its offer that it a is, r is not a small business concern.

(2) Veteran-owned small business concern. [Comupleteronly if the offeror represented itselfas a small business concern in paragraph (c)(l) of this provision.] The offeror represents as paft of its offer that it r is, r is not a veteran-owned small business concern.

(3) Service-disabled veteran-owned small business concem. [Complete only if the offeror represented itself as a veteran-owned small business concern in paragraph (cX2) of this provision.] The offeror represents as part of its offer that it r is, n is not a service-disabled veteran-owned small business concem.

(4) Small disadvantaged business concem. [Complete only ifthe offeror represented itself as a small business concem in paragraph (c)( i ) of this provision.] The offeror represents, that it D is, a is not a small disadvantaged business concern as defined in 13 CFRl24.l002.

(5) Women-owned small business concern. [Complete only if the offeror represented itselfas a small business concern in paragraph (cXl) ofthis provision.] The offeror represents that it n is, n is not a women-owned small business concem.

(6) WOSB concern eligible under the WOSB Program. [Complete only if the offeror represented itself as a women-owned small business concem in paragraph (c)(5) ofthis provision.] The offeror represents that-

(i) It c is, - is not a WOSB concern eligible under the WOSB Program, has provided all the required documents to the WOSB Repository, and no change in circumstances or adverse decisions have been issued that affects its eligibility; and

(ii) It r is, tr is not ajoint venture that complies with the requirements of l3 CFR part 127, and the representation in paragraph (c)(6)(i) ofthis provision is accurate for each WOSB concern eligible under the WOSB Program participating in thejoint venture. [The offeror shall enter the name or names of the WOSB concem eligible under the WOSB Program and other small businesses that are participating in the joint venture: .] Each WOSB concem eligible under the WOSB Program participating in the joint venture shall submit a separate signed copy ofthe WOSB representation.

(7) Economically disadvantaged women-owned small business (EDWOSB) concern. [Complete only if the offeror represented itselfas a WOSB concem eligible underthe WOSB Program in (c)(6) ofthis provision.l The off€ror represents that-

(i) It a is, - is not an EDWOSB concem, has provided all the required documents to the WOSB Repository, and no change in circumstances or adverse decisions have been issued that affects its eligibility; and

(ii) It a is, - is not a joint venture that complies with the requirements of I 3 CFR part 127, and the representation in paragraph (c)(7)(i) of this provision is accurate for each EDWOSB concem participating in thejoint venture. [The offeror shall enter the name or names ofthe EDWOSB concern and other small businesses that are participating in thejoint venture: .] Each EDWOSB concern participating in the joint venture shall submit a separate signed copy ofthe EDWOSB representation.

Note: Complete paragraphs (c)(8) and (c)(9) only if this solicitation is expected to exceed the simplified acquisition threshold.

(8) Women-owned business concern (other than small business concern). [Complete only ifthe offeror is a women-owned business concern and did not represent itself as a smallbusiness concern in paragraph

(c)( I ) of this provision.] The offeror represents that it tr is a women-owned business concem.

(9) Tie bid priority for labor surplus area concems. If this is an invitation for bid, small business offerors may identif the labor surplus areas in which costs to be incurred on account of manufacturing or production (by offeror or first-tier subcontractors) amount to more than 50 percent of the contract pnce:

(10) HUBZone small business concem. [Complete only if the offeror represented itselfas a sma]l business concern in paragraph (c)(l) of this provision.] The offeror represents, as part of its offer, that-

(i) It o is, tr is not a HUBzone small business concem listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concems maintained by the Small Business Administration, and no material changes in ownership and control, principal office, or lIUBZone employee percentage have occurred since it was certified in accordance with l3 CFR Part 126: and

(ii) It r is, tr is not a HUBZone joint venture that complies with the requirements of l3 CFR Part 126, and the representation in paragraph (c)(10)(i) of this provision is accurate for each HUBZone small business concern parlicipating in the HUBZone joint venture. [The offeror shall enter the names ofeach ofthe HUBZone small business concerns participating in the HUBZonejoint venture: .] Each HUBZone small business concem participating in the HUBZonejoint venture shall submit a separate signed copy of the HUBZone representation.

(d) Representations required to implement provisions ofExecutive Orderl 1246- ( I ) Previous contracts and compliance. The offeror represents that-

Pase 6 ol 2l

(i) lt ! has, r has not pa(icipated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation; ano

(ii) It r has, r has not filed all required compliance repofts.

(2) Affirmative Action Compliance. The offeror represents that-

(i) It n has developed and has on file, a has not developed and does not have on file, at each establishment, affirmative action programs required by rules and regulations ofthe Secretary of Labor (41 CFR parts 60-l and 60-2), or

(ii) It n has not previously had contracts subject to the written affirmative action programs requirement ofthe rules and regulations ofthe Secretary ofLabor.

(e) Certification Regarding Payments to lnfluence Federal Transactions (3 I http://uscode.house.gov/ U.S.C.

l3 52). (Applies only if the contract is expected to exceed $ I 50,000.) By subm ission of its offer, the offeror certifies to the best of its knowledge and belief that no Federal appropriated funds have been paid or will be paid to any person for influencing or aftempting to influence an officer or employee ofany agency, a Member ofCongress, an officer or employee of Congress or an employee of a Member ofCongress on his or her behalf in connection with the award of any resultant contract. Ifany registrants under the Lobbying Disclosure Act of 1995 have made a lobbying contact on behalf ofthe offeror with respect to this contract, the offeror shall complete and submit, with its offer, OMB Standard Form LLL, Disclosure ofLobbying Activities, to provide the name ofthe registrants. The offeror need not repoft regularly employed officers or employees ofthe offeror to whom payments ofreasonable compensation were made.

(f) Buy American Certificate, (Applies only ifthe clause at Federal Acquisition Regulation (FAR) 52.225-1, Buy American-Supplies, is included in this solicitation.)

(l) The offeror certifies that each end ptoduct, except those listed in paragraph (f)(2) ofthis provision, is a domestic end product and that for other than COTS items, the offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The offeror shall list as foreign end products those end products manufactured in the United States that do not qualifo as domestic end products,i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) ofthe definition of "domestic end product." The terms "commercially available off-the-shelf (COTS) item" "component," "domestic end product," "end product," "foreign end product," and "United States" are defined in the clause of this solicitation entitled "Buy American-Supplies."

(2 ) Foreign End Products:

LINE ITEM NO. COUNTRY OF ORIGIN

IList as necessary]

(3) The Government will evaluate offers in accordance with the policies and procedures ofFAR part 25.

(l) Buy American-Free Trade Agreements-lsraeli Trade Act Certificate. (Applies only ifthe clause at FAR 52.225-3, Buy American-Free Trade Agreements-lsraeli Trade Act, is included in this solicitation.)

(i) The offeror certifies that each end product, except those listed in paragraph (gX I Xii) or (g)( | )(iii) of this provision, is a domestic end product and that for other than COTS items, the offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The terms "Bahrainian, Moroccan, Omani, Panamanian, or Peruvian end product," "commercially available off-the-shelf (COTS) item," "component," "domestic end product," "end product," "foreign end product," "Free Trade Agreement country," "Free Trade Agreement country end product," "lsraeli end product," and "United States" are defined in the clause ofthis solicitation entitled "Buy American-Free Trade Agreements-lsraeli Trade Act."

(ii) The offeror certifies that the following supplies are Free Trade Agreement country end products (other than Bahrainian, Moroccan, Omani, Panamanian, or Peruvian end products) or Israeli end products as defined in the clause of this solicitation entitled "Buv American-Free Trade Asreements-lsraeli Trade Act":

(gl

Pagc ? of2l

Free Trade Agreement Country End Products (Other than Bahrainian, Moroccan, Omani, Panamanian, or Peruvian End Products) or Israeli End Products:

'LINE ITEM NO. TCOUNTRY OF ORIGIN

IList as necessary]

(iii) The offeror shall list those supplies that are foreign end products (other than those listed in paragraph (gX lXii) ofthis provision) as defined in the clause ofthis solicitation entitled "Buy American-Free Trade Agreements-lsraeli Trade Act." The offeror shall list as other foreign end products those end products manufactured in the United States that do not qualii, as domestic end products, i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) of the definition of"domestic end product."

Other Foreign End Products:

COUNTRY OF ORIGIN;LINE ITEM NO.

IList as necessary]

(iv) The Government will evaluate offers in accordance with the policies and procedures of FAR pan 25.

(2) Buy American-Free Trade Agreements-lsraeliTrade Act Certificate, Altemate i. lf Alremate I to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (gXtXii) for paragraph (g)(lXii) ofthe basic provision:

(c) fl)

(ii) The offeror certifies that the following supplies are Canadian end products as defined in the clause ofthis solicitation entitled "Buy American-Free Trade Agreements-lsraeliTrade Act":

Canadian End Products:

,LINE ITEM NO. COLTNTRY OF ORIGIN

IList as necessary]

(3) Buy American-Free Trade Agreements-lsraeli Trade Act Certificate, Altemate II. If Alternate II to the clause at FAR 52 225-3 is included in this solicitation, substitute the following paragraph (gX l)(ii) for paragraph (g\ lXii) ofthe basic provision:

(gXlXii) The offeror certifies that the following supplies are Canadian end products or Israeli end products as defined in the clause of this solicitation entitled "Buy American-Free Trade Agreements-lsraeli Trade Act":

Canadian or Israeli End Products:

.LINE ITEM NO. COUNTRY OF ORIGIN

[List as necessary]

(4) Buy American-Free Trade Agreements-lsraeli Trade Act Certificate, Altemate III. If Altemate III to the clause at 52.225-3 is included in this solicitation, substitute the following paragraph (gXlXii) for paragraph (g)(l)(ii) of the basic orovision:

Pagc 8 of2l

(gXlXii) The offeror certifies that the following supplies are Free Trade Agreement country end products (other than Bahrainian, Korean, Moroccan, Omani, Panamanian, or Peruvian end products) or Israeli end products as defined in the clause ofthis solicitation entitled "Buy American-Free Trade Agreements-lsraeli Trade Act":

Free Trade Agreement Country End Products (Other than Bahrainian, Korean, Moroccan, Omani, Panamanian, or Peruvian End Products) or tsraeli End Products:

,COUNTRY OF ORIGIN

IList as necessary]

(5) Trade Agreements Certificate. (Applies only ifthe clause at F AR 52.225-5, Trade Agreements, is included in this solicitation.)

(i) The offeror certifies that each end product, except those listed in paragraph (gx5xii) of this provision, is a U.S.-made or designated country end product, as defined in the clause ofthis solicitation entitled "Trade Agreements."

(ii) The offeror shall list as other end products those end products that are not U.S.-rnade or designated country end products.

Other End Products:

]LINE ITEM NO.

,LINE ITEM NO, Y OF ORIGIN

IList as necessary]

(iii) The Govemment will evaluate offers in accordance with the policies and procedures ofFAR part 25.

For line items covered by the WTO GPA, the Govemment will evaluate offers of U.S.-made or designated country end products without regard to the restrictions ofthe Buy American statute. The Govemment will consider for award only offers of U.S,-made or designated country end products unless the Contracting Officer determines that there are no offers for such products or that the offers for such products are insufficient to fulfill the requirements ofthe solicitation.

(h) Certification Regarding Responsibility Matters (Executive Order 12689). (Applies only ifthe contract value is expected to exceed the simplified acquisition threshold.) The offeror certifies, to the best of its knowledge and beliel, that the offeror and/or any of its principals-

( I ) c Are, - are not presently debaned, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

(2) o Have, I have not, within a three-year period preceding this offer, been convicted ofor had a civiljudgment rendered against them for: commission of fraud or a criminal ofense in connection with obtaining, attempting to obtain, or performing a Federal, state or local government contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiv ing slolen property:

(3) o Are, c are not presently indicted for, or otherwise criminally or civilly charged by a Government entity with, commission of any ofthese offenses enumerated in paragraph (h)(2) of this clause; and

(4) I Have, o have not, within a three-year period preceding this offer, been notified ofany delinquent Federal taxes in an amount that exceeds $3,500 for which the liability remains unsatisfied.

(i) Taxes are considered delinquent if both ofthe following criteria apply:

(A) The tax liability is finally determined. The liability is finally determined if it has been assessed. A liability is not finally determined ifthere is a pending administrative orjudicial challenge. In the case ofa judicial challenge to the liability, the liability is not finally determ ined until all jud icial appeal rights have been exhausted.

Page 9 ol 2l

(B) The taxpayer is delinquent in making payment. A taxpayer is delinquent if the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded.

(ii) Examples.

(A) The taxpayer has received a statutory notice ofdeficiency, under I.R.C. $6212, which entitles the taxpayer to seek Tax Court review of a proposed tax deficiency. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek Tax Coufi review, this will not be a final tax liability until the taxpayer has exercised alljudicial appeal rights.

(B) The IRS has filed a notice of Federal tax lien with respect to an assessed tax liability, and the taxpayer has been issued a notice under I.R.C. $6320 entitling the taxpayer to request a hearing with the IRS Office ofAppeals contesting the lien filing, and to funher appeal to the Tax Court ifthe IRS determines to sustain the lien filing. In the course ofthe hearing, the taxpayer is entitled to contest the underlying tax liability because the taxpayer has had no prior opportunity to contest the liability. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek tax court review, this will not be a final tax liability until the taxpayer has exercised alljudicial appeal rights.

(C) The taxpayer has entered into an installment agreement pursuant to I.R.C. $6159. The taxpayer is making timely payments and is in full compliance with the agreement terms. The tarpayer is not delinquent because the taxpayer is not currently required to make full payment.

(D) The taxpayer has filed for bankruptcy protection. The taxpayer is not delinquent because enforced collection action is stayed under I I U.S.C. $362 (the Bankruptcy Code).

(i) Certification Regarding Knowledge of Child Labor for Listed End Products (Executive Order 13126). [The Contracting Officer must list in paragraph (i)( l) any end products being acquired under this solicitation that are included in the List of Products Requiring Contractor Certification as to Forced or Indentured Child Labor, unless excluded at 22.1 503(b).1

( I ) Listed end products.

LINE ITEM NO. COUNTRY OF OzuCIN

(2) Certification. [fthe Contracting Officer has identified end products and countries oforigin in paragraph (i)( l) of this provision, then the offeror must certif to either (i)(2)(i) or (i)(2)(ii) by checking the appropriate block.l

(i) The offeror will not supply any end product listed in paragraph (i)( I ) of this prov ision that was mined, produced, or manufactured in the corresponding country as listed for that product.

(ii) The offeror may supply an end product listed in paragraph (iXl) ofthis provision that was mined, produced, or manufactured in the conesponding country as listed for that product, The offeror certifies that it has made a good faith effort to determine whether forced or indentured child labor was used to nrine, produce, or manufacture any such end product fumished under this contract. On the basis ofthose effons, the offeror certifies that it is not aware of any such use of child labor.

O Place ofmanufacture. (Does not apply unless the solicitation is predominantly for the acquisition of manufactured end products.) For statistical purposes only, the offeror shall indicate whether the place of manufacture of the end products it expects to provide in response to this solicitation is predominantly-

(1) I In the United States (Check this box if the total anticipated price of offered end products manufactured in the United States exceeds the total anticipated price of offered end products manufactured outside the United States); or

(2) r Outside the United States

(k) Certificates regarding exemptions from the application of the Service Contract Labor Standards (Certification by the offeror as to its compliance with respect to the contract also constitutes its certification as to compliance by its subcontractor if it subcontracts out the exempt services.) [The contracting officer is to check a box to indicate if paragraph (kX I ) or (k)(2) applies.l

( 1) Maintenance, calibration, or repair of certain equipment as described in FAR 22. I 003-4(c)( I ). The offeror I does c does not certiry that-

(i) The items ofequipment to be serviced under this contract are used regularly for other than Govemmental pur?oses and are sold or traded by the offeror (or subcontractor in the case ofan exempt subcontract) in substantial quantities to the general public in the course of normal business operarions;

Paee l0 of2l

(ii) The services will be fumished at prices which are, or are based on, established catalog or market prices (see

FAR 22.1003-4(c)(2)(ii)) for the maintenance, calibration, or repair ofsuch equipment; and

(iii) The compensation (wage and fringe benefits) plan for all service employees perform ing work under the contract will be the same as that used for these employees and equivalent employees servicing the same equipment of commercial customers.

(2) Certain services as described in FAR 22. 1003-4(dX I ). The offeror n does r does not certiry that-

(i) The services under the contract are offered and sold regularly to non-Governmental customers, and are provided by the offeror (or subcontractor in the case ofan exempt subcontract) to the general public in substantial quantities in the course ofnormal business operations;

(ii) The contract services will be furnished at prices that are, or are based on, established catalog or market prices (see FAR 22. 1003-+(d)(2)(iii));

(iii) Each service employee who will perform the services under the contract will spend only a small portion of his or her time (a month Iy average of less than 20 percent of the available hours on an annualized basis, or less than 20 percent ofavailable hours during the contract period if the contract period is less than a month) servicing the Govemment contract; and

(iv) The compensation (wage and fringe benefits) plan for all service employees performing work under the contract is the same as that used for these employees and equivalent employees servicing commercial customers.

(3) lf paragraph (k)( I ) or (k)(2) of this clause applies-

(i) If the offeror does not certii, to the conditions in paragraph (k)( I ) or (k)(2) and the Contracting Officer did not attach a Service Contract Labor Standards wage determination to the solicitation, the offeror shall notiry the Contracting Officer as soon as possible; and

(ii) The Contracting Officer may not make an award to the offeror ifthe offeror fails to execute the certification in paragraph (k)(l) or (k)(2) ofthis clause or to contact the Contracting Officer as required in paragraph (k)(3)(i) of this ctause.

(l) Taxpayer ldentification Number (TtN) ( 26 U. S.C. 6109, 3 I U.S.C. 7701). (Not applicable if the offeror is required to provide this information to the SAM to be eligible for award.)

( | ) All offerors must subm it the information required in paragraphs (lX3) through (l)(5) of this provision to comply with debt collection requirements of 3 I U.S.C. 7701 (c) and 3325(d), reporting requirements of 26

U.S.C. 6041, 6041A, and 6050M, and implementing regulations issued by the lnternal Revenue Service (lRS).

(2) The TIN may be used by the Government to collect and report on any delinquent amounls arising out ofthe offeror's relationship with the Government (3 I U.S.C. 7701(c)(3)). Ifthe resulting contracr is subjeci to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder may be matched with IRS recoidi to verifr the accuracy ofthe offeror's TIN.

(3) Taxpayer Identification Number (TIN).

TIN:

TIN has been applied for.

TIN is not required because:

Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States;

Offeror is an agency or instrumentality of a foreign government;

Offeror is an agency or instrumentality ofthe Federal Government.

(4) Type of organization.

Sole proprietorship;

Partnership;

Corporate entity (not tax-exempt);

Corporate entity (ta\-exem pt);

Govemment entity (Federal, State, or local);

Foreign govemment;

International organization per 26 CFR1.6049-4;

Other

(5) Common parent.

Offeror is not owned or controlled by a common parenq Name and TIN of common parent:

Page ll of2l

Name

TIN

(m) Restricted business operations in Sudan. By submission of its offer, the offeror certifies that the offeror does not conduct any restricted business operations in Sudan.

(n) Prohibition on Contracting with Inverted Domestic Corporations.

(1) Government agencies are not permitted to use appropriated (or otherwise made available) funds for contracts with either an inverted domestic corporation, or a subsidiary ofan inverted domestic corporation, unless the exception at 9. 108-2(b) applies or the requirement is waived in accordance with the procedures at 9. I 08-4.

(2) Representation. The Offeror represents that-

(i) It c is, o is not an inverted domestic corporation; and

(ii) It r is, r is not a subsidiary of an inverted domestic corporation.

(o) Prohibition on contracting with entities engaging in certain activities or transactions relating to Iran.

(l) The offeror shall e-mail questions concerning sensitive technology to the Department ofState at CISADA 106@state.gov.

(2) Representation and Certifications. Unless a waiver is granted or an exception applies as provided in paragraph (o)(3) of this provision, by submission of its offer, the offeror-

(i) Represents, to the best of its knowledge and belief, that the offeror does not export any sensitive technology to the government of Iran or any entities or individuals owned or controlled by, or acting on behalfor at the direction of, the government of [ran;

(ii) Ceftifies that the offeror, or any person owned or controlled by the offeror, does not engage in any activities for which sanctions may be imposed under section 5 of the Iran Sanctions Act; and

(iii) Certifies that the offeror, and any person owned or controlled by the offeror, does not knowingly engage in any transaction that exceeds $3,500 with lran's Revolutionary Guard Corps or any of its officials, agents, or affiliates, the property and interests in property of which are blocked pursuant to the Intemational Emergency Economic Powers Act (et seq.) (see OFAC's Specially Designated Nationals and Blocked Persons List at https://wvnv.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx).

(3) The representation and certification requirements of paragraph (o)(2) of this provision do not apply if-

(i) This solicitation includes a trade agreements certification (e.g., 52.212-3(g) or a comparable agency provision); and

(ii) The offeror has certified that all the offered products to be supplied are designated country end products.

(p) Ownership or Control of Offeror. (Applies in all solicitations when there is a requirement to be…