IHS IEE Representation Form_Jan 2022_508 Compliant.pdf
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- Solicitation number
- NAO24-001
About this file
This document is the Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise Representation Form. It is a self-certification form for offerors to represent that they meet the definition of an "Indian Economic Enterprise" under the Buy Indian Act in response to a sources sought notice, RFI, or solicitation. The form outlines the requirements for meeting the definition of an Indian Economic Enterprise throughout the offer, award, and contract performance periods. Successful offerors must also be registered in the System for Award Management. The form requires the offeror to provide information such as the name of the 51% owner, the name of the Federally Recognized Tribal Entity, the business name, and the DUNS number. This representation is necessary for offerors seeking set-aside contracts under the Buy Indian Act authority.
The related federal contract opportunity is for the replacement of an existing Uninterruptible Power Supply (UPS) system at the Navajo Area Office of the Indian Health Service. This is a sources sought notice only, not a solicitation. IHS is seeking capable sources, including Indian Economic Enterprises, to provide the UPS system, setup, installation, warranty, and maintenance services. The applicable NAICS code is 335999 - All Other Miscellaneous Electrical Equipment and Component Manufacturing. Interested sources must submit a capabilities package with specific information by July 3, 2024 to be considered for this potential set-aside opportunity.
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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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