IHS IEE Representation Form_Jan 2022_508 Compliant.pdf
PDF 2 MB Posted
- Solicitation number
- SS-GSU-24-0020
About this file
This document is an Indian Economic Enterprise (IEE) Representation Form for a federal contract opportunity related to the Kayenta Health Center. The form allows an offeror to self-certify that it meets the definition of an "Indian Economic Enterprise" under the Buy Indian Act in response to a sources sought notice, request for information, or solicitation. The contract opportunity is for non-personal healthcare services, specifically emergency physician services, at the Kayenta Health Center in Arizona. The anticipated period of performance is from July 1, 2024 to June 30, 2025 with four option periods. The applicable NAICS code is 621111 with a $16 million small business size standard. The contracting agency is the Indian Health Service, and the responses to the sources sought notice will be used to determine the acquisition strategy, which may include an Indian-owned enterprise set-aside. Interested parties must submit a capabilities package by April 26, 2024 that includes information about their Buy Indian Act or other socioeconomic status, recent relevant experience, and a statement of intent to submit a quote.
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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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