Enclosure B - AMS Form 050 Reps and Certs.pdf
PDF 3 MB Posted
- Solicitation number
- MB474724
- Issued by
-
Department of Energy Office of Science
About this file
This is a template form for Annual Representations and Certifications (AMS-Form-050 Rev. 1.0) issued by Brookhaven National Laboratory for use by offerors responding to U.S. Government contract opportunities. The form does not specify particular products, services, response dates, award dates, or pricing terms, as it serves as a standardized data collection instrument rather than a solicitation document.
The form requires all offerors to complete Section A.1 (Business Information) and Section C (Authorized Signature), which gather registration data including business name, address, contact information, NAICS codes, and physical location details. Small Business Offerors must additionally complete Section A.2, which includes representations regarding small business status, NAICS codes, and eligibility for various small business programs (women-owned, veteran-owned, service-disabled veteran-owned, HUBZone, and economically disadvantaged women-owned businesses). Section B addresses additional certifications required for work under U.S. Government prime contracts, including representations regarding lobbying activities (FAR 52.203-11), executive compensation and subcontract awards (FAR 52.204-10), responsibility matters (FAR 52.209-5 and 52.209-7), previous contracts and compliance (FAR 52.222-22 and 52.222-25), affirmative action compliance (FAR 52.222-5), Buy American requirements (FAR 52.225-1 and 52.225-9), and government property certification. The form requires an authorized representative's signature attesting to the accuracy of all representations and certifications provided.
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Text version
ANNUAL REPRESENTATIONS ERTIFICATIONS
Offeror: Offerors Offeror
All Offerors Section A.1. Section C all Small Business Offerors Section A.
Section A.1.:
A.1. Part I:
A.1. Part II:
Offeror
Offeror’s
AMS-Form-050 Rev. 1.0 - 09/2023
Offeror Yes No
Yes Offeror Offeror’s
Offeror
Section A. .: Applicable Only to Small Business Offerors
Offeror Offeror
Offeror
Offeror Offeror’s Section C, “Authorized Signature of Offeror ” Offeror Offeror Offeror
A. .1. Reference:
Offeror Offeror Offeror
Offeror
AND
Offeror Offeror
Offeror
Representations
NAICS Code : Small Business Concern ( Yes):
Offeror
Offeror
Offeror
Offeror
Offeror
Offeror
Offeror
Offeror
Offeror
Offeror and
Offeror
Offeror
Definitions and and and
Notice and
A. .2. Reference:
Offeror Offeror’s
Section B: Additional Representations and Certifications Required for Work Under U.S. Government Prime Contracts
B.1. FAR 52.203-11 (SEP 2007)
Offeror’s designated representative hereby certifies that he or she has read and understands (a) – (e), below.
Offeror
Offeror Offeror
Offeror Offeror
B.2 FAR 52.204-10 ( )
B. Offeror’s
Offeror Offeror
Offeror’s
Offeror’s Offeror
Yes No Yes
Offeror Offeror
Offeror
Yes No
Offeror’s Offeror
Yes No
Yes
No Offeror
Yes No
Yes Offeror
No
Offeror Offeror’s Offeror’s Offeror
Offeror Offeror’s
Executive Name: Executive Total Compensation:
Offeror Offeror
B. . FAR 52.209-5 ( )
Offeror:
Offeror
Offeror
This Certification Concerns a Matter Within the Jurisdiction of an Agency of the United States and the Making of a False, Fictitious, or Fraudulent Certification May Render the Maker Subject to Prosecution Pursuant to 18 U.S.C. 1001.
Offeror Offeror
Offeror’s Offeror Offeror
Offeror
Offeror
B. . FAR 52.209-7 ( ) —
Offeror
Definitions
Offeror Offeror
Offeror Offeror
Offeror Offeror
Offeror
B. . FAR 52.222-22 (FEB 1999)
Offeror
B. . FAR 52.222-25 (APR 1984)
Offeror
OR
B. . Government Property Certification
Offeror
Section C: Authorized Signature of Offeror
Certification of Offeror or Offeror’s Authorized Representative:
Offeror Offeror Offeror’s
Offeror
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