Enclosure B - AMS Form 050 Reps and Certs.pdf
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- MB476094
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Department of Energy Office of Science
About this file
This is an Annual Representations & Certifications form (AMS-FORM-050, Rev. 1.0, September 2023) used by Brookhaven National Laboratory (BNL/BSA) to gather and maintain registration data and certifications from all offerors seeking to provide goods or services in support of U.S. Government contracts. The form serves as a standardized template rather than a specific solicitation document.
The form requires all offerors to complete Section A.1 (Business Information) and Section C (Authorized Signature), with additional requirements based on business classification. Small Business Offerors must also complete Section A.2, which includes representations regarding small business status, disadvantaged business ownership, women-owned small business (WOSB) eligibility, economically disadvantaged women-owned small business (EDWOSB) status, veteran-owned status, and HUBZone certification. Section B contains additional certifications required for U.S. Government prime contract work, including FAR clauses addressing lobbying activities (52.203-11), executive compensation reporting (52.204-10), responsibility matters (52.209-5 and 52.209-7), previous contracts compliance (52.222-22), affirmative action (52.222-25), government property accountability, and Buy American provisions (52.225-1 and 52.225-9). The form requires submission of business address, remittance information, NAICS codes, physical location details, and information regarding principals and executives, along with authorized signature certifying the accuracy of all representations 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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