CRHC21-24.pdf

REOUEST FOR OUOTES (RFO):

OUOTE DUE DATE:

RETURN RFO TO:

NOTICE TO QUOTERS

CRHC2I.2d

Quotes are due l\larch 23,2021 @ 1:00 PM MST

Cheyenne River Service Unit Attn: Stephanie Charger PO Box 1012 Eagle Butte, SD 57625 Telephone: 605-964-7724 Ext. 0507 Fax: 605-964-1140

GENERAL DESCRIPTION:

Firm Fixed Price, Purchase Order, various furnace parts for the Maintenance Department at the Cheyenne River

Health Center located in Eagle Butte, SD. 30day after ARO. The quoted "unit price" shall be an all inclusive price.

This ppQ is issued as a 100% Small Business Set Aside and the associated NAICS code is 333415 with a small business size standard of 500 employees.

BASIS FORAWARD:

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

1. Quality of Product

2. Meet Delivery Schedule

Indian Economic Enterprise Small Businesses will be given preference if in competitive range. Fill out and submit Indian Firm Represenation Form if claiming Indian Preference'

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

\\'\\'\\r. sal1l . gov

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

I . Complete and sign SF- 1 8 - Request for Quotation (Signature required)

2. Complete Taxpayer Identification Form (FAR Part 52.204-3 - Taxpayer Identilication)

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

ATTACHMENTS:

l. SF-18 Request lbr Quotations

2. Notice to Quoters

3. Specification Sheet

4. Clauses incorporated by reference

5. Clauses incorporated in full text

6. Representations and Certifications

7. Indian Firm Representation Form

NO CONTRACT AWARD SHALL BE MADE TO ANY VENDOR OR PROVIDER LISTED ON '|I'IE

OIG EXI.USION LIST http://exlusions.oig.hhs.gov THROUGIIOUT THE DURATION OF- THE CONTRT\CT. lT SFIALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO NOTII'-Y THE ACQUISITION OFFICIAL IF TFIERE IS A CHANGE IN l'}ltOVIDLllt.

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 fbr Quotation (ifpe), and be returned no later than the date referenced in Block #10 ofthe Request for Quotation form SF-18.

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

REQUEST FOR QUOTATIONS

(THIS IS NOT AN ORDER)

THIS RFQ IS SMALL BUSINESS SET-ASIDE

PACE OF PAGES

1of 2

I REQUEST NO

9RHC21-24

2 DATE ISSUED

03t12t2021

3. REQUISITION/PURCHASE REQUEST NO,

1Hs1423462

4, CERI',FOR NAT, DEF,

UNDER BDSA REC,2

AND/OR DMS REC I

RAIING

Eagle Butte Indian Health Service, Cheyenne River Service Unit 24276 16dn St. PO Box 1012. Eaqle Butte. SD 57625

6. DELIVER BY (Date)

See schedule

5b. FOR ? DELIVERY OTTIER

X Fos orslNorrcN Z &" *n"*u,", NAME

Stephanie Charger

.IUMBER 9 DESTINATION

AREA CODE

NUMBER

964-0507

a. NAME OF CONSICNEE

Cheyenne River Service Unit b, STREET ADDRESS

24276 1661n St , PO Box 1012 A b COMPANY c CITY

Eagle Butte

0, c STATE I i ZIP CODE d. STATE

SD

e. ZIP CODE

57625 PLEASE FURNTSH QUOt'A', ONS tO

THE ISSUING OF'FICE IN BLOCK

5a ON OR IIY I r00 PM MST ON (Dar€./

March 23,2021

IMPORTANTT This is areques! for informalion, and quotations fumished are not omerc. lfyou are u@ble lo quotc. plc6sc so indicrte on ftis fom and rclum it to the address in Block 5a. This requ€sl does not commil the Covcrnmcnt to pay arly costs nlcuded in the prepaBtion ofthe submission ofthis quotarion or to contracl for supplies or services Slpplics arc ol-domesticorigtn unless otherwise indicated by quoter. Any rcpresentarions and/or certifications anached lothis Rcquest for Ouotations must be corrDleted bv thequoter.

I I. SCHEDULE FI Sl e tnd local

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

tel

AMOTJNT

(f)

Firm Fixed Price Purchase Order for various Air Fumace Parts, Maintenance Department, Cheyenne River Health Center, Eagle Bufte, SD. Price is all inclusive. 30 Days ARO.

See attached Spec Sheet t2 PROMPT PAYMEN I %o

IO CALENDAR DAYS b. 20

CAI ENDAR

DAYSTo

c. l0 CAI-ENDAR DAYS o/o d, CALF]NDAR DAYS

NUMBER PERCLNl'ACE ional orovisions and reDresentations Ll are arc nol atlached.

AND UOTER I5, SICNATURE OF PERSON AUTHORIZEDTO

SICN QUOTATION

15 DATE OF

QUOTATION

b. srRF€T-

CCXJNI t6. stcNER a.NAME (Type olNint) LI F:PHONI

AREA CODE

e STATE f. zlP coDE c. TITLE (type or print) NUMBIR

ST l8lnc edition not usable Prescribed by CSA'FAR (4E CFR) 53-215-l(a)

ITEM

NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

I.JNtT PRICE (e)

AMOUNT

(f)

DUNS & Bradstreet Number:

(The Duns & Bradstreet number is required.

Provided you do not have it, you may call 866-705- 57 | I and obtain one.) You will need a DUNS & Brodstrcel NUMBER lo he owarded the purchase

The quoter is hereby 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 .qov 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 OIG Exclusion List (htto://exlusions.oi g.hhs. gov) throughout the duration of the contract.

Federal Tax tD Number:

Email Address:

Net Terms:

SPECIFICATIONS

The IHS/Cheyenne River Health Center (CRHC) Good River Housin8 Community has a requirement for various HVAC/furnace part to repair the current water furnaces in the government quarter. The following part are for 3.5, 4, and 5 ton water furnaces.

Water fu rnace model numbers:

3.5 ton-RJSV042TL000CAN N24SSA

4 ton-RJSV048TR000CANN24SSA 5 ton-RJSV060TL000CAN N24SSA

Item #1 THERMOSTAT

TP32U03

Quantity - 3 x

Total:

Itern#Z I PRINTED CIRCUIT BOARD

Quantity - 3 x r7Ps73-o7

Total:

Item #3

Quantity - 5 x

PLASTIC CONSENDATE TRAY

49P513C03

Total:

cRHC-20-26 Page 1of 4

Item #4

Quantity - 5 x

Total:

4 TON FILTER DRYER

36P500801

Item #5

Quantity - 3 x

4 TON COIL

61S606-02

Total:

Item #6

Quantity - 5 x

5 TON COIL

515701-02

Total:

Item #7

Quantity - 5 x

5 TON FILTER DRYER

35P500802

Total:

cRHC-20-26

Item #8

Quanti ty-6x

T

10 uf 370v CAPACITOR

16P008D06CK

Item #9

Quantity- 5 x

T

45 uf 370 v CAPACITOR

16P008D21CK

Item #10

Quantity- 5 x

T

70 uf 370v CAPACITOR cRHC-20-26 Page 3 of 4

List any warranties, what it covers and any Warranty I additional wananties you provide.

Shippingltrreight I No shipping costs, pricing is all inclusive.

Aggregate Total: $ cRHC-20-26 Page 4 ot 4

3.5 Ton

Serial Number: 110700209

3- Thermostats - TP32U03 -52,505.25

3- PCB - 17P513-07 control board- S1,712.78

5- 10 uf 370v capacitor - 16P008D05CK - 574.70 5- 45 uf 370v capacitor - 16P008D2lCK -5229.82

5- 70 uf 370v capacitor - $255.30 5- plastic condensate drain tray - 49P513C03 - S587.40

4 Ton

Serial Number: 111q)0209

2- 4 ton coil - 515506-02 - s4,597.14 5- 4 ton filter dryer - 36P500801- S331.33

5 Ton

Serial Number: 101q)1785

5- 5 ton coifs - 61570l-02 - 5L6,437.34

5- 5 ton filter drvers - 36P500802 - 5331.33

CLAUSES INCORPORATED BY REFERf,NCE (Firm Fixed-Price -Corn:nercial Items)

FAR CITATION: 52.252-l: Solicitation Provision Incorporated by Reference. (FEB f998) & 52.252-2 Clauses Incorporated by Reference (FEB 1998) This solicitation & contract incorporates one or more solicitation provisions & clauses by reference, with the sanre force and effect as ifthey were given in full text. Upon request, the Contracting Officer will make their full text available. The offeror is cautioned that the listed provisions rnay include blocks that must be completed by the offeror and submitted with its quotation or offer. ln lieu of submitting the full text ofthose provisions, the offeror rnay identifu the provision by paragraph identifier and provide the appropriate infonnation with its quotation or off'er. Also, the full text ofa solicitation provision & clauses may be accessed electronically at this/these address(es): httpgth4ury.acgtrililiqlr=gav/&f

I.

No. FAR Citation Clause Title Clause Date

14.

15.

16.

17.

t8.

19.

52.204-7 System for Award Management (P)

52.204-13 System for Award Management Maintenance

52.204-16 Commercial and Government Entity Code Reporting

52.204-18 Commercial and Covernment Entity Code Maintenance

52.204-19 Incorporation by Reference of Representations and Certifications

52.211-6 Brand Narne or Equal

52.21l-17 Delivery of Excess Quantities

52.212-1 Instructions to Offerors - Commercial Items

52.212-4 Contract Terms and Conditions - Commercial Items

52.215-5 FacsimileProposals

52.232-l Payments

52.232-8 Discounts for Prompt Payment

52.232-ll Extras

52.232-39 Unenforceability of Unauthorized Obligations

52.232-40 Providing Accelerated Payments to Small Business subcontractors

52.233-l Disputes

52.243-1 Changes-Fixed-Price

52.244-6 Subcontracts for Comrnercial ltems

52.246-16 ResponsibilityforSupplies

Oct 2018

Oct 201 8

Jul 2016

Jul 2016

Dec 2014

Aug 1999

Sep 1989

Mar 2020

Oct 2018

Oct 1991

Apr 1 984

Feb 2002

Apr 1984

Jun 201 3

Dec 2013

May 2014

Aug 1 987

Aug 2019

Apr 1984

PaBe l ol2l

20. 52.247 -34

52.249-l

52.219 -8

52,253-l

F.o.b. - Destination

Termination for Convenience ofthe Govenrment (Fixed-Price)(Short Form)

Default (Fixed-Price Supply and Service)

Computer Generated Forms

Nov 1 99l

Apr 1984

Apr I 984

Jan 199I

2t.

22.

23.

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

No. FAR Citation Clause Title Clause Date

|. 52.204-l

2. 52.204-3

3. 52.2t2-3

Approval ofContract

Taxpayer Identifi cation (P)

Offeror Representation and Certifications

- Commercial Items

Contract Terms and Condition Required to Implement Statutes or Executive Orders - Commercial Items

Dec 1989

Oct I 998

Mar 2020

Mar 2020/1 ) l.z t l-)

52.204-l Approval 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 offerot is a metnber.

"Taxpayer Identification Nurnber (TIN)," as used in this provision, means the number required by the Internal

Reveiue Service (IRS) to be used by the offeror in reporting income tax and other returns. The TIN nray be either a

Social Security Number or an Employer Identification Number'

(b) All otferors must submit the inforrnation required in paragraphs (d) through (l) ofthis provision to cornply with debt collection requirements of3I U.S.C. 7701(c) and 3325(d), reporting requirements of26 U.S.C 604l.4051A.

and 6050M, and implementing regulations issued by the IRS. lfthe resulting contract is subject to the payment repofting requirements described in Federal Acquisition Regulation (FAR) 4.904, the failure ol Iefusal by the offeror to fLrmish the information may result in a 31 percent reduction of payments othefwise due under tlre contract.

(c) The TIN may be used by the Covernment to collect and report on any delinquent amounts arising out ofthe offeror'srelationshipwiththeGovemment(31U.S.C.7701O(3). If the resulting contract is subject to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder may be matched with IRS recolds to veriI the accuracy ofthe offeror's TIN

(d) Taxpayer ldentification Number (TIN)

! rrr:

TIN has been applied for.

TIN is not required because:

n n

Pasc 2 of 2l n Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not lrave income eff'ectively connected with the conduct ofa 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;

f Offeror is an agency or instrumentality of a foreign Government;

I Offeror is an agency or instrumentality ofthe Federal Government.

(e) Type of organization.

n Sole proprietorship;

n Partnership;

n Corporate entity (not tax-exempt);

! Corporate entity (tax-exempt);

D Govemment entitv (Federal, State, or local);

n Foreign government;

! International organization per 26 CFR 1.6049-4;

n other

(f) Corrmon parent.

n Offeror is not owned or controlled by a common parent as defined in paragraph (a) ofthis pror ision.

n Name and TIN of common parent:

Name

TtN

(End of Provision)

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

The Offeror shall cornplete only paragraph (b) ofthis provision if the Offeror has completed the annual representations and certification electronically inthe Syitem for Award Management (SAM) accessed through https://www.sam gov. If the Offeror has not cornpletei the annual representations and ceftifications electronically, the Offeror shall cornplete onll palagraphs (c) lhrough (v)) of this provision.

(a) Definitions. As used in this provision- .,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) concern 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 tlre WOSB Program

Forced or indentured child labor means all work or service- ( I ) Exacted from any person under the age of l8 under the menace ofany penalty for its nonperformance and for which tlie worker does not offer himself voluntarily; or

Pagc I ol21

(2) Performed by any person under the age of l8 pursuant to a contract the enforcement of which can be accomplished by process or penalties.

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

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

Inverted dornestic corporation, means a foreign incorporated entity that meets the definition ofan invefted domestic corporation under 6 U.S.C.395(b), applied in accordance with the rules and definitions of6 U.S.C, 395(c).

Manufactured end product means any end product in product and service codes (PSC$ 1000-9999, except-

( I ) PSC 55 10, Lumber and Related Basic Wood Materials;

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

(3) PSC 88, Live Animals;

(4) PSC 89, Subsistence;

(5) PSC 9410, Crude Grades ofPlant Materials;

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

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

(8) PSC 9610, Ores;

(9) PSC 9620, Minerals, Natural and Synthetic; and ( l0) PSC 9630, Additive Metal Materials, Place ofmanufacture means the place where an end product is assembled out ofcomponents, 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 preoecessor, 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 rhose rerms are defined in the Sudan Accountability and Divestment Act of2007 (Pub. L. I l0-174).

Restricted business operations do not include business operations that the person (as that term is defined irl

Section 2 ofthe Sudan Accountability and Divestment Act of2007) conducting the business can demonst|ate- ( I ) Are conducted under contract directly and exclusively with the regional government of southern Sudan;

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

(3 ) Consist of providing goods or services to marginalized populations of Sudan;

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

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

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

( I ) Means hardwari, software, telecommun ications equ ipment, or any other technology that is to be used specifically-

(i) To restrict the free flow ofunbiased information in Iran; or

(ii) To disrupt, monitor, or otherwise restrict speech ofthe people oflran; and

(2j Ooes not include information or informational materials the export of which the President does not have the uuit ority to rcgulate or prohibit pursuant to section 203(b)(3)ofthe Intemational Emergency Economic Powers

Act (50 U.S.C. 1702(bX3).

Service-disabled veteran-owned small business concern-

(l ) Means a stnall business concern- 1l; Not less than 5 I percent of which is owned by one or more service-disabled veterans or, in the case of any puUli.ty o*n"a business, not less than 5 I percent of the stock of wh ich is owned by one or more se.vice-disabled veterans; ano

(ii) The management and daily business operations of which are controlled by one oI more servlce-

Pase 4 of2l disabled veteransor, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran.

(2) Serwice-disabled veteran means a veteran, as defined in 38 U.S.C. l0l(2), with a disability that is service connected. as defined in 38 U.S.C. 101( l6).

Small business concern means a concern, including its affrliates, that is independently owned and operated, not dominant in the field ofoperation in which it is bidding on Govemment contracts, and qualified as a small business under the criteria in l3 CFR Part l2l and size standards in this solicitation.

Smaf l d isadvantaged business concern, consistent with I 3 CFR 124.1002, means a small business concern under the size standard applicable to the acquisition, that

( 1 ) ls at least 5 I percent unconditionally and directly owned (as defined at l3 CFR I 24. I05) 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 of the United States; and

(ii) Each individual claiming economic disadvarfage has a net worth not exceeding $750,000 after taking into account the applicable exclusions set forth at l3 CFR 124.104(c)(2); and

(2) The management and daily business operations of which are controlled (as defined at l3.CFR I 24. 106) by individuals, who meet the criteria in paragraphs ( I )(i) and (ii) of this definition.

Subsidiary means an entity in which more than 50 percent ofthe entity is o*ned- ( I ) 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 ofthe 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 concern- (l)Notlessthan5lpercentofwhichisownedbyoneormoreveterans(asdefinedat38U.S.C. I01(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 vetenns.

Women-owned small business (WOSB) concern eligible under the WOSB Program (in accordance with I 3

CFR part I27), means a small business concern that is at least 5l percent directly and uncondilionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens ofthe 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 leasts I percent of the 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) ( I ) Annual Representations and Certifications. Any changes provided by the Offeror in paragraph (b)(2) of this 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 olier tlrat the representations and cerlifications currently posted electronically at FAR 52.212-3, Offeror Representarions and Ce;tifications-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 the 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. 120 | ), except for paragraphs

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

These amended representation(s) and/or cerlification(s) are also incorporated in this oft'er and are cu|Tent. accurate, and complete as ofthe date of this offer, Any changes provided by the offeror are applicable to this solicitation only, and do uot result in an ttpdate to the representations and certifications posted electronically on SAM.

(c) Oft'erors must complete the following representations when the resulting contract rvill be performed in the tJnited

States or its outlying areas. Check all that apply.

( l) Srnall business concem. The offeror represents as part of its offer that it r is, tr is not a small business concern.

(2) Veteran-owned small business concern, [Complet;r;1lV if the offeror represented itselfas a small business concern in paragraph (c)(1) ofthis provision.] The offeror represents as part of its offer that it - is, ! is not a veteran-owned small business concern.

(3) Service-disabled veteran-owned small business concern. [Complete only if the offeror represented itselfas a veteran-owned small business concern in paragraph (c)(2) of this provision.] The offeror represents as part of its offer that it ! is, ! is not a serv ice-d isabled veteran-owned srnall business concern.

(4) Small disadvantaged business concern. [Complete only ifthe offeror represented itselfas a small business concern in paragraph (c)(l) ofthis provision.] The offeror represents, that it ! is, - is not a small disadvantaged business concem as defined in I 3 CFR 124. I 002.

(5) Wornen-owned small business concern. [Courplete only if the offeror represented itselfas a srnall business concern in paragraph (c)(l) ofthis provision.] The offeror represents that it r is, r is not a women-owned small business concem.

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

(i) lt I 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 aff'ects its eligibility; and (ii)ltn is, I is not ajoint venture that complies with the requirements of l3 CFR part 127, and the representation in paragraph (c)(6)(i) of this provision is accurate for each WOSB concern eligible under the WOSB Program participating in the joint venture. [The offeror shall enter the nalne or names of the

WOSB concem eligible under the WOSB Program and other small businesses that are pallicipating in the

Jolnr venrure: .] Each WOSB concern eligible under the WOSB Program panicipating in the joint venture shall submit a separate signed copy ofthe WOSB representation.

(7) Economically disadvantaged women-owned smallbusiness (EDWOSB) concem. [Complete only if the offeror represented itself as a WOSB concern eligible under the WOSB Program in (cX6) ofthis provision.l The offeror represents that-

(i) lt . is, n is nor an EDWOSB concem, has provided allthe required documents to the WOSB Repository.

and no change in circumstances or adverse decisions have been issued that affects its eligibility: and

(ii) Ir - is, ! is not a joint venture that complies with the requirements of l3 CFR part 127, and the representation in paragraph (c)(7)(i) ofthis provision is accurate for each EDWOSB concern participating in thijoint venture. [The offeror shall enter the name or names of the 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 itselfas a smallbusiness concern in paragraph

(c)(l) ofthis provision.l The offeror represents that it c is a women-owned business concern.

(9) Tie bid priority for labor surplus area concerns. If this is an invitation for brd, srrall business ofl-erors rnay identify the labor surplus areas in which costs to be incurred on account of manufacturing or production (by offeror or first-tier subcontractofs) amount to more than 50 percent of the contract orice:

itO) HUSZon" small business concern. [Complete only if the offeror represented itself as a srtall business concern in paragraph (c)(l) of this provision.l The offeror represents, as part -of its offer, that-

(i) It I is, o is not a fUgZon" small business concern listed, on the date ofthis representation. on the List of

Qualified HUBZone Small Business Concems maintained by the Small Business Administration' and no rnaterial changes in ownership and control, principal office, or HUBZone employee percentage have occurred since it was certified in accordance with l3 CFR Part 126; and

(ii) It a is, I is not a HUBZone joint venture that complies with the requirements of l3 CFR Pan 126. and the representation in paragraph (c)(igxi) ofthis provision is accurate for each HUBZone small business concern participating in ttt. Hie2one.loint'venture. iThe s of each of the HUBZone small business concerns participatin! in the HUBZtnej Each HUBZone small busiuess concern participating in tire HlBZone joint ventu gned copy ofthe HUBZone rePresentation

(d) Represeniations required to implernent provisions o-f Executive Otderl1246-

( l) Previous contracts and compliance. tn" "*1",:J:?i:;ents tha!

(i) lt - has, D has not participated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation; ano

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

(2) Affir rrative Action Compliance. The offeror represents that-

(i) lt r has developed and has on file, o has not developed and does not have on file, at each establishment, affirmative action programs required by rules and regulations of the Secretary of Labor (41 CFR parts 60- I and 60-2), or

(ii) lt r has not previously had contracts subject to the written affirmative action prograrns requirement ofthe rules and regulations ofthe Secretary ofLabor.

(e) Certification Regarding Payments to Influerice Federal Transactions (31 http://uscode.house.gov/ U.S.C.

l3 52). (Applies only if the contract is expected to exceed $ 150,000.) By subm ission of its offer, the offeror cefiifies to the best of its knowledge and beliefthat no Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress or an employee of a Member of Congress on his or her behalf in connection vvith the award of any resultant contract. If any registrants under the Lobbying Disclosure Act of I 995 have made a lobbying contact on behalf of the ofl'erol with respect to tlris contract, the offeror shall complete and submit, with its offer, OMB Standard Forrn

LLL. Disclosure ofLobbying Activities, to provide the name ofthe registrants. The offeror need not report regularly employed officers or employees of the offerol to whom payments ofreasonable compensation were made.

(f) Buy American Ceftificate. (Applies only if the clause at Federal Acquisition Regulation (FAR) 52.225- l, Buy American-Supplies, is included in this solicitation.)

(l) The otferor certifies that each end product, except those listed in paragraph (1)(2) of this provision. is a domestic end oroduct and that for other than COTS items. the offeror lras considered components of unknorvn origin to have been mined, produced, or manufactured outside the United States. The offeror shall list as fbreign end products those end products manufactured in the United States that do not qualify 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 deflnition of "domestic end product." The tems "commercially available off-the-shelf (COTS) iteln" "component," "domestic end product," "end product," "foreign end product," and "United States" are detlned in the clause of this solicitation entitled "Buv American-Supplies."

(2) Foreign End Products:

COUNTRY OF ORIGTN

IList as necessary]

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

( l) Buy American-Free Trade Agreements-lsraeli Trade Act Cerlificate. (Applies only ifthe clause at FAR

52.225-3, Buy Arnerican-Free Trade Agreements-l sraeli Trade Act, is included in this solicitation.)

(i) The ofieror certifies that each end product, except those listed in paragraph (g)( | )(ii) or (gX I )(iii) of th is provision, is a domestic end product and that for other than COTS items, the offeror has considered cotrponents ofunknown origin to have been mined, produced, or manufactured outside the United States. The terms ,'Bahrainial, Moroccan, Omani, Panamanian, or Peruvian end product," "commercially available off-the-shelf (coTS) item," "component," "domestic end product," "end ploduct," "foreign end product," "Free Tlade

Agreement coun6.y,",'Frei Trade Agreement country end product," "lsraeli end product." and "United States'' ar.! defined in the ilause of this solicitation entitted "I uy American-Free Trade Agreetnents IsraeliTrade

Act.''

(ii) The off'eror certifies that the following supplies are Free Trade Agleement country end products (other than bahrainian. Moroccan, Ornani, PanamanLn, or Peruvian end products) or Israeli end products as deflned in the clause ofthis solicitation entitled "Buy American-Free Trade Agreements-lsraeli Trade Act'':

LINE ITEM NO,

(g)

Pagc 7 of2l

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

LINE ITEM NO. COUNTRY OF ORIGIN

[List as necessary]

(iii) The offeror shall list those supplies that are foreign end products (other than those listed in paragraph

(gXlXii) 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 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) of the definition of "domestic end product."

Other Foreign End Products:

LINE ITEM NO. ]COUNTRY OF ORIGIN

lList as necessary]

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

(2) Buy American-Free Trade Agreements-lsraeli Trade Act Certificate, Alternate I. If Altemate I to the clause at FAR

52.225-3 is included in this solicitation, substitute the following paragraph (g)(l)(ii) for paragraph (gXlXii) ofthe basic prov ision:

(l)

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

Canadian End Products:

LINE ITEM NO. COUNTRY OF ORIGIN

IList as necessary]

(3) Buy American-Free Trade Agreements-l sraeli Trade Act Certificate, Alternate Il. If Alternate [l to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (gXlXii) fbr paragraph (g)( lXii) ofthe basic provision:' GXiXi,l-ifi" offeror certifies that the following supplies are Canadian end products or lsraeli end products as a.fined-in G "tuuse ofthis solicitation entitled "Buy American-Free Trade Agreements-lsraeli Trade Act":

I-INE ITEM NO.

Canadian or Israeli End Products:

COUNTRY OF ORIG]N

IList as necessarY]

(4) Buy Ainerican-Free Trade Agreements-l sraeli Trade Act cetificate, Alternate lll. If Alternate III to the clause at 52.225-3 is included in this soicitation' substitute the following paragraph (gXlXii) for paragraph (g)(l)(ii) of the basic Provision:

Pagc 8 of2l

(gX lXii) 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 Israeli End Products:

.LINE ITEM NO. Y OF ORIGIN

IList as necessary]

(5) Trade Agreeulents Certificate. (Applies only ifthe clause at FAR 52.225-5, Trade Agreements, is includcd in this solicitation.)

(i) The offeror certifies that each end product, except those listed in paragraph (gx5)(ii) of this provision, is a U.S.-made or designated country end product, as defined in the clause of this solicitation entitled "Trade Agreements."

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

Other End Products:

LINE ITEM NO. COLINTRY OF ORIGIN

IList ai necessary]

(iii) The Government will evaluate offers in accordance with the policies and procedules of FAR pad 25

For line items covered by the WTO GPA, the Government willevaluate ofTers of U.S.-made or designated country end products without regard to the restrictions ofthe Buy Arnerican 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) Cerrificarion 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 belief. that the offeror and/ol any of its principals- ( I ) I Are, . are not presently debaned, suspended, proposed for debarment, or declared ineligible for the arvard of contracts by any Federal agencY;

(2) I Have, r have not, within a three-year period preceding this offer, been convicted ofor had a civiljudgment rendered against them for: comm ission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a Federal, state or local govemment contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, fbrgery, bribery, fhlsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws. or receiving stolen property:

(3) I Are, D are not presently indicted for, or otherwise crinrinally or civilly charged by a Government entity with, commission ofany ofthese offenses enurterated in paragraph (h)(2) ofthis clause; and

(4) I Have. I 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 iiu6itity ir not finally detennined ifthere is a pending administrative orjudicial challenge. In the case of a judicial challenge to the liabiliry, the liability is not finally determined until alljudicial appeal rights have been exhausted.

Page 9 of2l

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

( ii) Examples.

(A) The taxpayer has received a statutory notice ofdeficiency, under LR.C. $6212, which entitles the taxpayer to seek Tax Court review ofa 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 ofFederal tax lien rvith respect to an assessed tax liability, and tlre taxpayer has been issued a notice under l.R.C. $6320 entitling the ta-xpayer to request a hearing with the IRS Offlce ofAppeals contesting the lien filing, and to further appeal to the Tax Court if the IRS determines to sustain the lien filing. ln the course ofthe hearing. the taxpayer is entitled to contest the underlying tax liabilitl 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 couft r'eview, 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 LR.C. $61 59. The taxpayer is making timely palments and is in full compliance with the agreement tenns. The taKpayer is not delinquent because the taxpayer is not currently required to make full payment.

(D) The taxpayer has filed for bankruptcy prorection. The taxpayer is not delinquent because enforced collection action is stayed under l1 U.S.C. S362 (the Bankruptcy Code).

(i) Certification Regarding Knowledge of Child Labor for Listed End Products (Executive Order l3 126). [The Contracting Officer must list in paragraph (iX l) any end products being acquired under this solicitation that are included in the List ofProducts Requiring Contractor Certification as to Forced or Indentured Child Labor.

unless excluded at 22.1 503(b).1

( 1) Listed end products.

LINE ITEM NO. COUNTRY OF ORIGIN

(2) Certificatron. [f the Contracting Officer has identified end products and countries oforigin in paragraph (i)(l) ofthis provision, then the offeror must cefiiry to either (iX2Xi) or (i)(2)(ii) by checking the appropriate block.l

(i) The of'f'eror will not supply any end product listed in paragraph (i)(1) ofthis provision that was mined, produced, or manufactured in the corresponding country as listed for that product.

( ii) The off'eror may supply an end product listed in paragraph (i)( I ) of th is provision that rvas m ined, produced, or manufactured in the corresponding country as listed for that product. The off'eror certifies that it has made a good faith effort to detemine whether forced or indentured child labor was used to mine, produce-or manufacture any such end product furnished under this contract. On the basis of those effofts, the offelor certifies that it is not aware ofany such use of child labor'

O Place ofmanufacture. (Does not apply unless the solicitation is predominantly for the acquisition oftnanufactuted 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- (lj I In the United Stares (Check this box if the total anticipated price of offered end products manufactured in the

United States exceeds the total anticipated price ofoffered end products manufactured outside the United States)l oI

(2) r Outside the United States

(k) Certificates regarding exemptions from the application of the Service Contract Labor Standards (Cenification by the offeror as to its compliance with respect to the contract also constitutes its certification as to compliance bv its subcontractor if it subcontracts out the exempt services.) [The contracting officer is to check a box to indicate ifparagraph

(k)( l) or (kX2) applies.l (l ) Maintenanie, calibration, or repair of certain equipment as described in FAR 22. I 003-4(cX I ). The offetor I does I does not cefiify that

(i) The items ofequipment to be serviced under this contract are used regularly for other tharr Governmental pur.poses and are sold or traded by the offeror (or subcontractor in the case of an exempt subcontract) in substantial quantities to the general public in the course of normal business operations;

Page l0 of2l

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

FAR 22. I 003-4(c)(2)(ii)) for the maintenance, calibration, or repair of such equipment; and

(iii) The compensation (wage and fringe benefits) plan for all service employees performing 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) Cenain services as described in FAR 22.1003-4(d)( 1). The offeror r does r does not certify that-

(i) The services under the contract are offered and sold regularly to non-Governmental customers, and ate plovided by the otferor (or subcontractor in the case ofan exempt subcontract) to the general public in substantial quantities in the course of normal 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-a(d)(2Xiii));

(iii) Each service employee who will perform the services under the contract will spend only a small por-tion of his or her time (a monthly average of less than 20 percent ofthe 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 perfonning u'ork under the contract is the same as that used for these ernployees and equivalent employees servicing commercial customers.

(3) Ifparagraph (k)(l) or (k)(2) ofthis clause applies ( i) If the offeror does not certiry to the conditions in paragraph (k)( I ) or (k)(2) and the Contracting Officer did not attach a Senvice Contract Labor Standards wage determination to the solicitation, the off'elor shallnotifu the Contracting Officer as soon as possible; and

(ii) The Contracting Officer may not make an award to the offeror if the offerol fails to execute the cenification in paragraph (k)( I ) or (k)(2) of this clause or to contact the Contracting Officer as requiled in paragraph (k)(3)(i) of this clause.

(l)TaxpaverldentificationNumber(TIN)(26U.S.C.6109,31U.S.C.7701).(Notapplicableiftheofferor' is required to provide this infbrmation to the SAM to be eligible for award.)

( I ) All ofTerors must submit the inforrnation required in paragraphs (l)(3) through (lX5) ofthis provision to com pll n ith debt colleclion requ irements of 3 I U.S.C. 770 I (c) and 3325(d), reporting requ irernents of 26

U.S.C. 6041.6041A, and 6050M, and implementing regulations issued by the lntemal Revenue Service (lRS).

(2) 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. 770 I (cX3)). If 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 verify the accuracy ofthe offeror's TlN.

(3) Taxpayet Identification Number (TIN).

TIN:

TIN has been applied for.

TIN is not reouired becausc:

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

Offeror is an agency or instrumentality ofa foreign government;

Off'eror is an agency or instrumentality ofthe Federal Government.

(4) Type of organization.

Sole proprietorship;

Partnersh ip:

Corpo|ate entity (not tax-exempt);

Corporate entity (tax-exempt);

Government entity (Federal, State, or local);

Foreign government;

Intemational organization per 26 CFRl.6049-4;

Other

(5) Cornmon parent.

OfTeror is not owned or controlled by a common parenq

Name and TIN of common parent:

Page I I of2l

Name

TIN

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

(n) Prohibition on Contracting with Inverted Domestic Corporations.

( I ) 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 9.108-4.

(2) Representation. The Offeror represents that-

(i) lt a is, n is not an inverted dornestic corporation; and

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

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

( | ) The offeror shall e-rnail questions conceming sensitive technology to the Department of State at

C ISADA I 06@state.gov.

(2) Representation and Certifications. Unless a waiver is granted or an exception applies as provided in paragraph

(o)(3) ofthis provision, by submission of its offer, the offeror-

(i) Represents, to the best of its knowledge and beliei that the offeror does not expofi any sensitive technology to the government oflran or any entities or individuals owned or controlled by, or acting on behalfor at the direction o1, the government of Iran;

(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 International Enrergency Economic Powers Act (et seq.) (see OFAC's Specially Designated Nationals and Blocked Persons List at https://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx).

(3) The representation and certification requirements ofparagraph (o)(2) ofthis provision do not apply if-

(i) This solicitation includes a trade agreements certification (e.g., 52.212-3(9) 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 registered in SAM or a requirement to have a unique entity identifier in the solicitation).

( I ) The Offeror represents that it ! has or r does not lrave an immediate owner. If the Offeror has more than one irnmediate owner (such as ajoint venture), then the Offeror shall respond to paragraph (2) and ifapplicable.

paragraph (3) ofthis provision for each participant in thejoint venture.

(2) lf the Offeror indicates "has" in paragraph (p)(l) ofthis provision, enter the following inforrnation:

Immediate owner CAGE code:

Immediate owner legal name:

(Do not use a "doing business as" name) Is the immediate owner owned or controlled by another entity: n Yes or o No.

(3) If the Offeror indicates "yes" in paragraph (p)(2) ofthis provision, indicating that the immediate ownet is orvned or controlled by another entity, then enter the following information:

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