IHS IEE Representation Form.pdf
PDF 130 KB Posted
- Attached to
- BPA for Miscellaneous Electrophysiological Medical Supplies for Northern Navajo Medical Center
- Solicitation number
- IHS1487371
About this file
This document includes an Indian Health Service Indian Economic Enterprise Representation Form and details of a related federal contract opportunity.
The representation form is to be completed by offerors in response to sources sought notices, requests for information, or solicitations from the Indian Health Service to self-certify as an "Indian Economic Enterprise" as defined by the Buy Indian Act. It requires the offeror to represent whether it does or does not meet the definition and provide identifying information including the name of the 51% tribal owner, certifying signature, business name, Unique Entity Identifier, and DUNS number.
The federal contract opportunity is a sources sought notice for a blanket purchase agreement for miscellaneous electrophysiological medical supplies for the Rehabilitation Department at the Northern Navajo Medical Center in Shiprock, New Mexico. The period of performance is 12 months from date of award. Responses are requested by February 14, 2024 to determine the acquisition strategy such as an Indian-owned enterprise set-aside, total small business set-aside, or other socio-economic set-aside. Required response information includes confirmation of Buy Indian set-aside eligibility, a completed representation form, and business size. The applicable NAICS code is 334510.
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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
UEI Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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