IHS IEE Representation Form.pdf
PDF 129 KB Posted
- Solicitation number
- IHS1504291
About this file
The document is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise (IEE) Representation Form, which is a self-certification form for tribal-owned businesses seeking to participate in a federal contract opportunity. The form requires offerors to certify that they meet the definition of an "Indian Economic Enterprise" with at least 51% Indian ownership, and must maintain this status throughout the solicitation, contract award, and performance periods.
This specific form is associated with Solicitation Number IHS1504291 for Mobile CT Scanner Services across multiple Great Plains Area IHS facilities, including Pine Ridge, Rosebud, and Cheyenne River Health Center. The contract is a Buy Indian Act set-aside, meaning only Indian-owned small businesses can submit offers. The performance period is from 06/01/2025 to 11/30/2025 (6 months), with evaluation criteria prioritizing past performance, experience, qualifications, and logistics over price. Offers must be submitted via email to the Contracting Officer, Ashleigh Yazzie, and include specific documentation such as pricing schedules, project references, logistics plans, and this IEE Representation Form.
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Other files
| File | Type | Posted |
|---|---|---|
| Wage Determination_Service Contract Act WD 2015-5377_Date_05_12_2025.txt | TXT text file | |
| Statement of Work.docx | DOCX document |
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
Indian Health Service
Office of Management Services Division of Acquisition Policy (DAP)
5600 Fishers Lane Rockville, MD 20857
INDIAN HEALTH SERVICE
BUY INDIAN ACT
INDIAN ECONOMIC ENTERPRISE
REPRESENTATION FORM
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 the 51% owner of IEE Firm
Certifying Signature
Print Name
Name of Federally Recognized Tribal Entity
Business Name
DUNS Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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