IHS IEE Representation Form.pdf
PDF 813 KB Posted
- Attached to
- Pryor Clinic Expansion Construction in Pryor
- Solicitation number
- SS75H70126R00024
About this file
This is an Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form used by the Department of Health & Human Services to certify offeror eligibility for set-aside or sole source contracts under the Buy Indian Act authority.
The form requires offerors to self-certify that they meet the definition of an "Indian Economic Enterprise" with Indian ownership as defined in HHSAR 326.601. Certification must be valid at three critical points: when the offer is submitted, at the time of contract award, and throughout the full contract performance period. Any changes in eligibility status during these periods require immediate written notification to the Contracting Officer. The form specifies that successful offerors must also be registered with the System of Award Management (SAM). Individual Contracting Officers may request documentation of eligibility before awarding contracts, and awards are subject to protest if the successful offeror's eligibility is questioned. The form includes penalties for false or misleading information, including violations under 18 U.S.C. 1001 for false statements in offers and 31 U.S.C. 3729-3731 and 18 U.S.C. 287 for false claims during contract performance. Required fields include the Solicitation/Sources Sought/RFI number, project title, date, name of the 51% owner, name of the federally recognized tribal entity, business name, DUNS number, certifying signature, and printed name of the signatory.
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Other files
| File | Type | Posted |
|---|---|---|
| Drawings Pryor Clinic Constr.pdf | ||
| SOW Pryor Clinic Constr.pdf | ||
| Sources Sought Pryor Clinic Const.pdf | ||
| Specs Pryor Clinic Constr.pdf |
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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: SS75H70126R00024 |
| PROJECT_TITLE: Pryor Clinic Expansion Construction, BI21CR202C6 |
| DoesNot: 0 |
| Does: Off |
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