IHS IEE Representation Form__508 Compliant_ BLANK.docx
DOCX document 45 KB Posted
- Solicitation number
- 75H71126Q00005
About this file
This is a blank Indian Economic Enterprise (IEE) Representation Form issued by the Indian Health Service (IHS), Office of Management Services, Division of Acquisition Policy. The form serves as a self-certification document for offerors responding to IHS solicitations, sources sought notices, or requests for information under the Buy Indian Act authority (25 U.S.C. 47). Offerors must certify whether they meet the definition of an "Indian Economic Enterprise" as defined in HHSAR 326.601, with the enterprise required to maintain eligibility at three critical points: at the time of offer submission, at contract award, and throughout the full contract performance period. The form requires the offeror to provide the name of the federally recognized tribal entity, the name of the 51% owner of the IEE firm, the business name, DUNS number, and a certifying signature with printed name.
The form emphasizes that offerors must register with the System of Award Management (SAM) and warns that submission of false or misleading information constitutes a violation of 18 U.S.C. 1001, with penalties including contract protests and potential debarment. Any contractor whose eligibility status changes during the contract term must immediately notify the Contracting Officer in writing. This is a template document with blank fields for completion by individual offerors and is not specific to any single solicitation or contract opportunity.
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
INDIAN HEALTH SERVICE BUY INDIAN ACT
INDIAN ECONOMIC ENTERPRISE
REPRESENTATION FORM
Indian Health Service Office of Management Services Division of Acquisition Policy (DAP) 5600 Fishers Lane Rockville, MD 20857
SOLICITATION/SOURCES SOUGHT/RFI #:
PROJECT TITLE:
DATE:
In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.
The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:
(1) At the time an offer is made in response to this solicitation;
(2) At the time of contract award; and
(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.
Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).
Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.
False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.
REPRESENTATION
The Offeror represents as part of its offer that it does _, does not _ _ meet the definition of an “Indian__
Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.
Name of Federally Recognized Tribal Entity Name of the 51% owner of IEE Firm
Business Name Certifying Signature
DUNS Number Print Name image1.png image2.png image3.png image4.png
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