IHS IEE Representation Form__508 Compliant_ BLANK.docx
DOCX document 45 KB Posted
- Solicitation number
- 75H71126Q00011
About this file
This is an Indian Economic Enterprise (IEE) Representation Form required by the Indian Health Service (IHS) for the Buy Indian Act set-aside solicitation 75H71126Q00011. The form is a self-certification template used to verify that an offeror meets the definition of an "Indian Economic Enterprise" with Indian ownership as defined under 25 U.S.C. 47 and HHSAR 326.601. Offerors must certify their eligibility status by checking the appropriate box indicating whether they do or do not meet the IEE definition, and provide supporting information including the name of the federally recognized tribal entity, the name and ownership percentage of the IEE firm owner, the business name, DUNS number, and a certifying signature with printed name.
The certification must be valid at three critical points: at the time of offer submission, at the time of contract award, and throughout the entire contract performance period. Contractors are required to notify the Contracting Officer immediately if they cease to meet eligibility requirements at any point. The form emphasizes that false or misleading information constitutes a violation of federal law subject to penalties under 18 U.S.C. 1001 for false statements and 31 U.S.C. 3729-3731 for false claims. Additionally, all successful offerors must be registered in the System of Award Management (SAM), and the Contracting Officer may require documentation of eligibility before awarding the contract.
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| SOW Lift Station and SSL - EsignAFB.pdf | ||
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| WD.pdf | ||
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| 75H71126Q00011 6.10.2026.pdf | ||
| 75H71126Q00011 Amendment 0001.pdf | ||
| 75H71126Q00011.pdf |
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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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