Revised_RFQ_-_Combo_-_FBO_-_Amendment_1.pdf

35th Contracting Squadron USAF Misawa Air Base, Japan

FA520518QMG01, Special Needs Coordinator (SNC)

REQUEST FOR QUOTATION:

This is a combined synopsis/solicitation for commercial items prepared in accordance with the format in FAR Subpart 12.6, as supplemented with additional information included in this notice. This announcement constitutes the only solicitation; proposals are being requested and a written solicitation will not be issued. The solicitation number is FA520518QMG01; this solicitation is a Request for Quotation (RFQ). This solicitation document and incorporated provisions and clauses are those in effect through FAC 2005-96, DPN 20161222, and AFAC 2017-1003. This acquisition will be full and open competition.

Offerors may use another format for submission of a response to this RFQ. All responses must contain the minimum information required as listed below.

Please provide the following information:

Company Name:

CAGE Code: DUNS No.: Quote Expiration:

Prompt payment discount terms:

Name of Offeror:

Offeror Email: Offeror Phone:

Signature: Date:

Requested Supplies and Services List Item No.

Description Qty Unit Unit Price Extended Price

Special Needs Coordinator Services In Accordance With (IAW) the terms and conditions of the Performance Work Statement (PWS).

Base Year: 1 Mar 18 – 30 Sep 18 (It may change due to contracting process)

7 Mo

Special Needs Coordinator Services In Accordance With (IAW) the terms and conditions of the Performance Work Statement (PWS).

Option Year One: 1 Oct 18 – 30 Sep 19

12 Mo

Special Needs Coordinator Services In Accordance With (IAW) the terms and conditions of the Performance Work Statement (PWS).

Option Year Two: 1 Oct 19 – 30 Sep 20

12 Mo

Total Amount:

Start Date: *Enter your first available date to begin work*

Government reserves the right to award for less that the quantity identified in the above table.

INSTRUCTIONS TO OFFERORS:

To assure timely and equitable evaluation of quotes, offerors must follow the instructions contained herein.

(a) Submit offeror information and the price as specified on page one of this RFQ.

(b) Prepare a resume and a copy of degree certificate, license, and PCS orders (if applicable) to demonstrate qualification requirements per section 4. of the PWS.

(c) Submit above items to below POC by 22 Dec 2017@ 13:00 JST by Email.

Primary point of contact is Shoko Suzuki, Contracting Specialist, Telephone 011-81-176-77-4895, Email shoko.suzuki.jp@us.af.mil.

Alternate POC is Ashley Grant, TSgt, Contracting Officer, Telephone 011-81-176-77-4895, Email ashley.grant.1@us.af.mil.

EVALUATION CRITERIA:

Evaluation of quotations will be completed in accordance with FAR 13.106-2. The Government will award the contract resulting from this solicitation to the responsible offeror whose offer conforms to the solicitation and represents the best value to the Government.

Evaluation Factors: (1) Technical and (2) Price.

(1) Technical:

Technical Acceptable/Unacceptable Rating Method Adjectival Rating Description Acceptable Proposal meets the requirements of the solicitation Unacceptable Proposal does not meet the requirements of the solicitation

(2) Price:

Price analysis will be used to ensure pricing is fair and reasonable. All offers with separately priced line items or subline items shall be analyzed to determine if the prices are unbalanced (FAR 15.404-1(g)).

Offers may be rejected if the PCO determines the lack of balance poses an unacceptable risk to the Government. Prices determined to be unbalanced shall be thoroughly documented during the evaluation process. Any quote submitted in a currency other than United States Dollar (USD) will be accessed based on the conversion using the current U.S. Treasury Rate.

The Government will evaluate your price based on the monthly rate provided as stated in FAR 52.212-2 of this solicitation.

Contractors must be actively registered with the System Award Management (SAM). Lack of registration in the SAM database will make an offeror ineligible for award. The Contractor is required to confirm on an annual basis that its information in the SAM database is accurate and complete at https://www.sam.gov/. (IAW FAR 52.232-33 Payment by Electronic Funds Transfer- System Award Management, Jul 13)

Contractors must be registered in Wide Area Work Flow (WAWF). The WAWF system is the method to electronically process vendor payment requests and receiving reports, at http://wawf.eb.mil/. (Authorized by DFARS 252.232-7003, Electronic Submission of Payment Requests and Receiving Reports)

RESPONSE TIME:

Please send any response NO LATER THAN 1300 on 22 Dec 17 (JST) or 2300 on 19 Dec 17 (EST).

Point of contact is Ms. Shoko Suzuki, Contracting Specialist, Telephone 011-81-176-77-4895, Email shoko.suzuki.jp@us.af.mil.

Alternate POC TSgt Ashley Grant, Contracting Officer, Telephone 011-81-176-77-4895, Email ashley.grant.1@us.af.mil.

CLAUSES INCORPORATED BY REFERENCE

52.203-3 Gratuities APR 1984 52.203-6 Restrictions On Subcontractor Sales To The

Government

SEP 2006

52.203-6 Alt I Restrictions On Subcontractor Sales To The Government (Sep 2006) -- Alternate I

OCT 1995

52.204-10 Reporting Executive Compensation and First-Tier Subcontract Awards

OCT 2016

52.209-6 Protecting the Government's Interest When Subcontracting With Contractors Debarred, Suspended, or Proposed for Debarment

OCT 2015

52.209-10 Prohibition on Contracting With Inverted Domestic Corporations

NOV 2015

52.212-1 Instructions to Offerors--Commercial Items JAN 2017 52.212-4 Contract Terms and Conditions--Commercial Items JAN 2017 252.203-7000 Requirements Relating to Compensation of Former DoD

Officials

SEP 2011

252.204-7008 Compliance With Safeguarding Covered Defense Information Controls

OCT 2016

252.204-7012 Safeguarding Covered Defense Information and Cyber Incident Reporting

OCT 2016

252.204-7015 Notice of Authorized Disclosure of Information for Litigation Support

MAY 2016

252.215-7007 Notice of Intent to Resolicit JUN 2012 252.215-7008 Only One Offer OCT 2013 252.222-7007 Representation Regarding Combating Trafficking in

Persons

JAN 2015

252.225-7050 Disclosure of Ownership or Control by the Government of a Country that is a State Sponsor of Terrorism

OCT 2015

252.232-7003 Electronic Submission of Payment Requests and Receiving Reports

JUN 2012

252.232-7010 Levies on Contract Payments DEC 2006 252.243-7002 Requests for Equitable Adjustment DEC 2012 252.244-7000 Subcontracts for Commercial Items JUN 2013

CLAUSES INCORPORATED BY FULL TEXT

52.212-1 ADDENDUM

ADDENDUM TO 52.212-1 -- Instructions to Offerors -- Commercial Items (Jan 2017) A. To assure timely and equitable evaluation of the quote:

The offeror must follow the instructions contained herein. Offerors are required to meet all solicitation requirements, including terms and conditions, representations and certifications, and technical requirements, in addition to those identified as evaluation factors or subfactors. Failure to meet a requirement may result in an offer being ineligible for award. Offerors must clearly identify any exception to the solicitation terms and conditions and provide complete accompanying rationale.

Complete the necessary fill-ins and certifications in provisions/clauses. The provisions/clauses FAR 52.212-3, 52.223-3 shall be returned along with the quote (see bottom).

The quote shall consist of two (2) separate factors. The Technical Capability will have three (3) subfactors;

FACTOR 1 – TECHNICAL CAPABILITY

SUBFACTOR 1 – Past Experience SUBFACTOR 2 – Education SUBFACTOR 3 – Licensure

FACTOR 2 – PRICE QUOTE

B. The contracting officer has determined:

There is a high probability of adequate price competition in this acquisition. Upon examination of the initial offers, the contracting officer will review this determination and if, in the contracting officer’s opinion, adequate price competition exists, no additional cost information will be required. However, if at any time during this competition the contracting officer determines that adequate price competition no longer exists, offerors may be required to submit uncertified cost or pricing data to support a determination of price reasonableness.

C. Specific Instructions:

FACTOR 1 – TECHNICAL CAPABILITY QUOTE - Limited to no more than 10 pages to include but not limited to attachments, title pages, and table of contents. Submit one (1) original and three (3) copies or original only if submitted electronically. Any attachments provided by the Contracting Office does not count toward the limit

SUBFACTOR 1 - Past Experience:

Contractors must have a minimum of one (1) year of clinical nursing or social work experience.

Contractors must submit at least twelve (12) months of recent and relevant past experience within the last 36 months. Experience must include all phases of in clinical nursing, social work, care coordination, discharge planning or case management in a medical setting. Recent is defined as experience acquired in the last thirty-six (36) months from the closing date of this solicitation. Not Relevant experience is defined as past/present experience effort that did not involve any of the magnitude of effort and complexities this solicitation required. Relevant is defined as past/present performance efforts involved much of the magnitude of effort and/or complexities this solicitation requires such as; contracts for similar services. Provide documentation of recent and relevant contracts or employment for government agencies and/or commercial customers. This shall include at least two references who can be reached for verification of past experience.

SUBFACTOR 2 – Education:

Prospective contractor must submit a copy of a valid degree showing that they have graduated from a US nationally accredited nursing program recognized by the US Department of Education. The minimum education requirement is an associate degree (ADN) or a Bachelor’s degree in nursing (BSN) accredited by a national nursing accrediting agency recognized by the US Department of Education. Social Worker applicants must at least possess an associate (ASW) or Bachelor’s degree in Social Work (BSW) from a school of social work fully accredited by the US Council on Social Work Education (CSWE)

SUBFACTOR 3 - Licensure:

Submit copy of a vetted license. The Contractor must possess a current, valid and unrestricted license in one of the 50 states and/or the District of Columbia, the Commonwealth of Puerto Rico, or territories of the United States. All licenses must meet all state requirements, be unencumbered and remain in effect during contract employment. The contractor must be in good standing, and under no restrictions, with the state or national licensure board in any state in which a license is held or has been held within the last 10 years.

FACTOR 2 – PRICE - Limited to no more than 2 pages to include attachments. Submit one (1) original and three (3) copies or original only if submitted electronically. Any attachments provided by the Contracting Office does not count toward the limit.

(a) Provide Discount Terms, Offeror Complete Address, Name, Date, CAGE Code, and Signature. In doing so, the offeror accedes to the contract terms and conditions as written in the SOLICITATION, with attachments.

(b) Insert proposed unit and extended prices in the pricing schedule for each contract line item number (CLIN). The extended amount must equal the whole currency unit price multiplied by the number of units. The quote must be submitted for base performance period plus any option years detailed in the solicitation. Provide discount terms when applicable.

(c) Price quote can be submitted in either U.S. Dollars or Japanese Yen. The Government exchange rate that shall be used is ¥112.64 to $1.

D. Documents submitted in response to this RFQ must be fully responsive to and consistent with the following:

(1) Requirements of the RFQ (CLINs, PWS, and attachments) and government standards and regulations pertaining to the PWS.

(2) Evaluation Factors for Award in provision 52.212-2, Evaluation—Commercial Items and its addenda.

(3) Any limitation on the number of quote pages. Pages exceeding the page limitations set forth in this solicitation provision will not be read or evaluated, and will be removed from the quote.

E. Format for quote Factor 1 and 2 shall be as follows:

(1) The quote will be 8 1/2” x 11” paper, except for fold-outs used for charts, tables, or diagrams, which may not exceed 11” x 17”.

(2) A page is defined as one face of a sheet of paper containing information.

(3) Typing shall not be less than 10 pitch.

(4) Elaborate formats, bindings or color presentations are not desired or required.

F. Further changes to the original clause 52.212-1.

(1) Paragraph 52.212-1(c), Period for Acceptance of Offers is tailored as follows: The offeror agrees to hold the prices in its offer firm for 90 calendar days from the date specified for receipt of offers.

(2) Paragraphs 52.212-1(d) and 52.212-1(h) do not apply to this acquisition.

Documents submitted in response to this solicitation must be fully responsive to and consistent with the following:

1. Requirements of the solicitation (Item Numbers) and Performance Work Statement (PWS), and government standards and regulations pertaining to the PWS.

2. Evaluation Factors for Award.

(End of Provision)

Addendum to 52.212-2 EVALUATION--COMMERCIAL ITEMS (OCT 2014)

(a) The Government will award a contract resulting from this solicitation to the responsible offeror whose offer conforming to the solicitation will be most advantageous to the Government, price and other factors considered. The Government will utilize the best value method per FAR 13.106-1.

EVALUATION FACTORS FOR AWARD: Two (2) evaluation factors will be used to evaluate proposals: Technical Capability broken down into three (3) subfactors and determined acceptable or unacceptable as defined in table 1a and Price Proposal.

Table 1a. Technical Acceptable/Unacceptable Rating Method

Adjectival Rating Description Acceptable Proposal meets the requirements of the solicitation.

Unacceptable Proposal does not meet the requirements of the solicitation.

FACTOR 1 – TECHNICAL CAPABILITY

SUBFACTOR 1 – Past Experience SUBFACTOR 2 – Education SUBFACTOR 3 – Licensure

SUBFACTOR 1 –Past Experience:

This subfactor is met when the offeror thoroughly, completely, and accurately provides documentation of at least twelve (12) months of recent and relevant past experience within the last thirty six (36) months. This experience shall be in clinical nursing or social work. Contractors must have a minimum of six (6) months of relevant service in special needs care coordination, discharge planning or case management in a medical setting. Contractor must supply resume to include two (2) references for previous positions held. The government will contact submitted names to verify offeror’s past experience.

SUBFACTOR 2 –Education:

This subfactor is met when an offeror thoroughly, completely, and accurately submits and fully addresses all of the following criteria listed in this subfactor. Provide copy of associate degree (ADN) or a Bachelor’s degree in nursing (BSN) accredited by a national nursing accrediting agency recognized by the US Department of Education. Social Worker applicants must at least possess an associate (ASW) or Bachelor’s degree in Social Work (BSW) from a school of social work fully accredited by the US Council on Social Work Education (CSWE)

SUBFACTOR 3 – Licensure:

This subfactor is met when an offeror thoroughly, completely, and accurately submits and fully addresses all of the following criteria listed in this subfactor. Provide proof of valid, unrestricted license to practice as a Registered Nurse (RN) from one of the 50 states, and/or the District of Columbia, the Commonwealth of Puerto Rico, or territories of the United States. All licenses must be unencumbered and remain in effect during contract employment. The contractor must be in good standing, and under no restrictions, with the state in which a license is held or has been held, or the national licensure board, within the last 10 years. Social Worker applicants are not required to possess a license to apply. The 35th Medical Group will verify licenses by the state licensing board website for the state the license was issued from to ensure it is active, current, valid and unrestricted and from a US jurisdiction.

FACTOR 2 – PRICE PROPOSAL

An offeror’s proposed prices will be verified on the Solicitation CLIN Pricing Schedule by multiplying the quantities identified for each item number in the price schedule by the proposed unit price to confirm the extended amount for each price schedule item. The extended price for each line item will then be added together to arrive at a total evaluated price. As this requirement is a “commercial” service that will result in a “firm-fixed-priced” contract, a comparison of offeror’s proposed, competitive prices will satisfy the requirement for price analysis. The price evaluation will be accomplished by conducting price analysis to assess and compare proposed prices and reasonableness of the proposed total evaluated price as defined in FAR 15.404-1 and FAR 15.305.

Firm-fixed-price contract provides for a price that is not subject to any adjustment on the basis of the contractor’s cost experience in performing the contract. (FAR 16.202-1).

B. AWARD DETERMINATION: As a result of the Government‘s aforementioned evaluation, all offerors quotes will be evaluated if they are received by the deadline stated in the solicitation. Of those quotes, an award determination will be made to the offeror whose quote offers the best value to the Government and conforms to the requirements of the solicitation and Performance Work Statement

(PWS).

The Government reserves the right to award a contract for less than the quantity indicated in the solicitation. Contractors should only provide pricing for the amount of time they can actually provide the service. All proposals that receive an acceptable technical rating will then undergo a price comparison based on their monthly rate. A best value determination will be made to determine contract awardee.

(b) Options. The total amount of all options along with a six month extension added to each option year will be used to evaluate the aggregate price; however the total actual value of the contract will not reflect the six month extension as it is dependent on the year it is used and may not be used at all.

Example:

Year Price per

Month Quantity Overall Price Evaluation Six

Month Extension

Total Evaluated Price

Base $12 12 months $144 $72 $216 Option 1 $15 12 months $180 $90 $270

TOTAL EVALUATED PRICE: $486

TOTAL AWARDED CONTRACT AMOUNT: $144 with $180

Unexercised Option

(c) A written notice of award or acceptance of an offer, mailed or otherwise furnished to the successful offeror within the time for acceptance specified in the offer, shall result in a binding contract once the awardee signs or begins work. Before the offer's specified expiration time, the Government may accept an offer (or part of an offer), whether or not there are negotiations after its receipt, unless a written notice of withdrawal is received before award.

(End of provision)

52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS--COMMERCIAL ITEMS

(NOV 2017) ALTERNATE I (OCT 2014)

The offeror shall complete only paragraphs (b) of this provision if the Offeror has completed the annual representations and certification electronically via the System for Award Management (SAM) Web site located at https://www.sam.gov/portal . If the Offeror has not completed the annual representations and certifications electronically, the Offeror shall complete only paragraphs (c) through (u) of this provision.

(a) Definitions. As used in this provision--

“Economically disadvantaged women-owned small business (EDWOSB) concern” means a small business concern that is at least 51 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 13 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—

(1) Exacted from any person under the age of 18 under the menace of any penalty for its nonperformance and for which the worker does not offer himself voluntarily; or

(2) Performed by any person under the age of 18 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 of the 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 of the 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 of an 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—

(1) PSC 5510, 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 9410, Crude Grades of Plant Materials;

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

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

(8) PSC 9610, Ores;

(9) PSC 9620, Minerals, Natural and Synthetic; and

(10) 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.

“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 Act of 2007 (Pub. L. 110-174).

Restricted business operations do not include business operations that the person (as that term is defined in Section 2 of the Sudan Accountability and Divestment Act of 2007) conducting the business can demonstrate—

(1) 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 Department of the 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 of providing goods or services to an internationally recognized peacekeeping force or humanitarian organization;

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

(6) Have been voluntarily suspended.

“Sensitive technology”—

(1) Means hardware, software, telecommunications equipment, or any other technology that is to be used specifically—

(i) To restrict the free flow of unbiased information 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 International Emergency Economic Powers Act (50 U.S.C. 1702(b)(3)).

“Service-disabled veteran-owned small business concern”—

(1) Means a small business concern—

(i) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and

(ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran.

(2) Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16).

“Small business concern” means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a small business under the criteria in 13 CFR Part 121 and size standards in this solicitation.

“Small disadvantaged business concern, consistent with 13 CFR 124.1002,” means a small business concern under the size standard applicable to the acquisition, that--

(1) Is at least 51 percent unconditionally and directly owned (as defined at 13 CFR 124.105) by--

(i) One or more socially disadvantaged (as defined at 13 CFR 124.103) and economically disadvantaged (as defined at 13 CFR 124.104) individuals who are citizens of the 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 13 CFR 124.104(c)(2); and

(2) The management and daily business operations of which are controlled (as defined at 13.CFR 124.106) by individuals, who meet the criteria in paragraphs (1)(i) and (ii) of this definition.

“Subsidiary” means an entity in which more than 50 percent of the entity is owned—

(1) Directly by a parent corporation; or

(2) Through another subsidiary of a parent corporation.

“Veteran-owned small business concern” means a small business concern—

(1) Not less than 51 percent of which is owned by one or more veterans(as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the 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 business concern” means a concern which is at least 51 percent owned by one or more women; or in the case of any publicly owned business, at least 51 percent of the its stock is owned by one or more women; and whose management and daily business operations are controlled by one or more women.

“Women-owned small business concern” means a small business concern --

(1) That is at least 51 percent owned by one or more women or, in the case of any publicly owned business, at least 51 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.

“Women-owned small business (WOSB) concern eligible under the WOSB Program (in accordance with 13 CFR part 127),” means a small business concern that is at least 51 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.

(b)

(1) 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 posted on the SAMwebsite.

(2) The offeror has completed the annual representations and certifications electronically via the SAM website accessed through https://www.acquisition.gov. After reviewing the SAM database information, the offeror verifies by submission of this offer that the representation and certifications currently posted electronically at FAR 52.212-3, Offeror Representations and Certifications—Commercial Items, have been entered or updated in the last 12 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard applicable to the NAICS code referenced for this solicitation), as of the date of this offer and are incorporated in this offer by reference (see FAR 4.1201), except for paragraphs ___ . [Offeror to identify the applicable paragraphs at (c) through (u) of this provision that the offeror has completed for the purposes of this 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 of the 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 certifications posted electronically on SAM.]

(c) Offerors must complete the following representations when the resulting contract is to be performed in the United States or its outlying areas. Check all that apply.

(1) Small business concern. The offeror represents as part of its offer that it [ ___ ] is, [ ___ ] is not a small business concern.

(2) Veteran-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this 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 itself as 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 service-disabled veteran-owned small business concern.

(4) Small disadvantaged business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.]The offeror represents that it [ ___ ] is, [ ___ ] is not, a small disadvantaged business concern as defined in 13 CFR 124.1002.

(5) Women-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.]The offeror represents that it [ ___ ] is, [ ___ ] is not a women-owned small business concern.

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

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

(i) It [ ___ ] 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 [ ___ ] is, [ ___ ] is not a joint venture that complies with the requirements of 13 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 name or names of the WOSB concern eligible under the WOSB Program and other small businesses that are participating in the joint venture: ___ .] Each WOSB concern eligible under the WOSB Program participating in the joint venture shall submit a separate signed copy of the WOSB representation.

(7) Economically disadvantaged women-owned small business (EDWOSB) concern. [Complete only if the offeror represented itself as a WOSB concern eligible under the WOSB Program in (c)(6) of this provision.] The offeror represents that—

(i) It [ ___ ] is, [ ___ ] is not an EDWOSB concern, 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 [ ___ ] is, [ ___ ] is not a joint venture that complies with the requirements of 13 CFR part 127, and the representation in paragraph (c)(7)(i) of this provision is accurate for each EDWOSB concern participating in the joint venture. [The offeror shall enter the name or names of the EDWOSB concern and other small businesses that are participating in the joint venture: ___ .] Each EDWOSB concern participating in the joint venture shall submit a separate signed copy of the EDWOSB representation.

(8) Women-owned business concern (other than small business concern). [Complete only if the offeror is a women-owned business concern and did not represent itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it [ ___ ] is, a women-owned business concern.

(9) Tie bid priority for labor surplus area concerns. If this is an invitation for bid, small business offerors may identify 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 price:

13 FORMTEXT ___

(10) HUBZone small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents, as part of its offer, that--

(i) It [ ___ ] is, [ ___ ] is not a HUBZone small business concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration, and no material changes in ownership and control, principal office, or HUBZone employee percentage have occurred since it was certified in accordance with 13 CFR part 126;

and

(ii) It [ ___ ] is, [ ___ ] is not a HUBZone joint venture that complies with the requirements of 13 CFR part 126, and the representation in paragraph (c)(10)(i) of this provision is accurate for each HUBZone small business concern participating in the HUBZone joint venture. [The offeror shall enter the names of each of the HUBZone small business concerns participating in the HUBZone joint venture: ___ .] Each

HUBZone small business concern participating in the HUBZone joint venture shall submit a separate signed copy of the HUBZone representation.

(11) (Complete if the offeror has represented itself as disadvantaged in paragraph (c)(4) of this provision.)

[The offeror shall check the category in which its ownership falls]:

___ Black American.

___ Hispanic American.

___ Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians).

___ Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, Republic of Palau, Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru).

___ Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal).

___ Individual/concern, other than one of the preceding.

(d) Representations required to implement provisions of Executive Order 11246 --

(1) Previous contracts and compliance. The offeror represents that --

(i) It [ ___ ] has, [ ___ ] has not, participated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation; and

(ii) It [ ___ ] has, [ ___ ] has not, filed all required compliance reports.

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

(i) It [ ___ ] has developed and has on file, [ ___ ] 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 60-1 and 60-2), or

(ii) It [ ___ ] has not previously had contracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor.

(e) Certification Regarding Payments to Influence Federal Transactions (31 U.S.C. 1352). (Applies only if the contract is expected to exceed $150,000.) By submission 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 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 with the award of any resultant contract. If any registrants under the Lobbying

Disclosure Act of 1995 have made a lobbying contact on behalf of the offeror with respect to this contract, the offeror shall complete and submit, with its offer, OMB Standard Form LLL, Disclosure of Lobbying Activities, to provide the name of the registrants. The offeror need not report regularly employed officers or employees of the offeror to whom payments of reasonable compensation were made.

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

(1) The offeror certifies that each end product, except those listed in paragraph (f)(2) 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 offeror shall list as foreign 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) of the 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

[List as necessary]

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

(g)

(1) Buy American -- Free Trade Agreements -- Israeli Trade Act Certificate. (Applies only if the clause at FAR 52.225-3, Buy American -- Free Trade Agreements -- Israeli Trade Act, is included in this solicitation.)

(i) The offeror certifies that each end product, except those listed in paragraph (g)(1)(ii) or (g)(1)(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,” “Israeli end product,” and “United States” are defined in the clause of this solicitation entitled “Buy American--Free Trade Agreements--Israeli 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 “Buy American—Free Trade Agreements—Israeli Trade Act”:

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 (g)(1)(ii) or this provision) as defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act.” The offeror shall list as other foreign 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) of the definition of “domestic end product.”

Other Foreign End Products:

LINE ITEM NO. COUNTRY OF ORIGIN

[List as necessary]

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

(2) Buy American—Free Trade Agreements—Israeli Trade Act Certificate, Alternate I. If Alternate I to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (g)(1)(ii) for paragraph (g)(1)(ii) of the basic provision:

(g)(1)(ii) The offeror certifies that the following supplies are Canadian end products as defined in the clause of this solicitation entitled “Buy American—Free Trade Agreements—Israeli Trade Act”:

Canadian End Products:

Line Item No.:

[List as necessary]

(3) Buy American—Free Trade Agreements—Israeli Trade Act Certificate, Alternate II. If Alternate II to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (g)(1)(ii) for paragraph (g)(1)(ii) of the basic provision:

(g)(1)(ii) 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-- Israeli Trade Act'':

Canadian or Israeli End Products:

Line Item No.: Country of Origin:

[List as necessary]

(4) Buy American—Free Trade Agreements—Israeli Trade Act Certificate, Alternate III. If Alternate III to the clause at 52.225-3 is included in this solicitation, substitute the following paragraph (g)(1)(ii) for paragraph (g)(1)(ii) of the basic provision:

(g)(1)(ii) 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 of this solicitation entitled “Buy American—Free Trade Agreements— Israeli 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.: Country of Origin:

[List as necessary]

(5) Trade Agreements Certificate. (Applies only if the clause at FAR 52.225-5, Trade Agreements, is included in this solicitation.)

(i) The offeror certifies that each end product, except those listed in paragraph (g)(5)(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.: Country of Origin:

[List as necessary]

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

For line items covered by the WTO GPA, the Government will evaluate offers of U.S.-made or designated country end products without regard to the restrictions of the Buy American statute. The Government 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 of the solicitation.

(h) Certification Regarding Responsibility Matters (Executive Order 12689). (Applies only if the 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/or any of its principals--

(1) [ ___ ] Are, [ ___ ] are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

(2) [ ___ ] Have, [ ___ ] have not, within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense 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 receiving stolen property; and

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

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

(i) Taxes are considered delinquent if both of the 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 if there is a pending administrative or judicial challenge. In the case of a judicial challenge to the liability, the liability is not finally determined until all judicial appeal rights have been exhausted.

(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 of deficiency, 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 Court review, this will not be a final tax liability until the taxpayer has exercised all judicial appear 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 of Appeals Contesting the lien filing, and to further appeal to the Tax Court if the IRS determines to sustain the lien filing. In the course of the 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 all judicial 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 taxpayer 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 11 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)(1) 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 22.1503(b).]

(1) Listed End Product

Listed End Product: Listed Countries of Origin:

(2) Certification. [If the Contracting Officer has identified end products and countries of origin in paragraph (i)(1) of this provision, then the offeror must certify to either (i)(2)(i) or (i)(2)(ii) by checking the appropriate block.]

[ ___ ] (i) The offeror will not supply any end product listed in paragraph (i)(1) of this provision 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 (i)(1) of this provision that was mined, produced, or manufactured in the corresponding country as listed for that product. The offeror certifies that is has made a good faith effort to determine 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 efforts, the offeror certifies that it is not aware of any such use of child labor.

(j) Place of manufacture. (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) [ ___ ] 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) [ ___ ] 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 (k)(1) or (k)(2) applies.]

(1) [ ___ ] Maintenance, calibration, or repair of certain equipment as described in FAR 22.1003-4(c)(1).

The offeror [ ___ ] does [ ___ ] does not certify that—

(i) The items of equipment to be serviced under this contract are used regularly for other than Governmental purposes 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;

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