Indian Firm Representation Form.pdf
PDF 46 KB Posted
- Attached to
- BASELINE MONOFILAMENT ADA/LEAP/LOPS, 5. 07/10
- Solicitation number
- 75H70425Q00031
About this file
The document is an Indian Firm Representation Form from the Department of Health & Human Services Indian Health Service, used to self-certify an offeror's status as an "Indian Firm" under the Buy Indian Act. The form requires businesses to represent whether they meet the definition of an Indian Firm with Indian Ownership at three key points: when making an offer, at contract award, and throughout the contract performance period.
The form outlines specific requirements for Indian Economic Enterprises (IEEs), including that the combined Indian ownership must constitute at least 51%, the enterprise must receive at least 51% of contract earnings, and daily business operations must be controlled by one or more individuals who are Indians. Businesses must also be registered with Dun & Bradstreet (D&B) and the System of Award Management (SAM). False or misleading information can result in legal penalties under 18 U.S.C. 1001 and other statutes. The form provides spaces for business name, DUNS number, signature, and printed name to complete the self-certification process.
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
Indian Health Service
Division of Acquisition Policy (DAP) 5600 Fishers Lane
Rockville, MD 20857
INDIAN HEALTH SERVICE
BUY INDIAN ACT
INDIAN FIRM REPRESENTATION FORM
SOLICIATION NUMBER: _________________________________________________
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 Firm” (HHSAR 326.602) with “Indian Ownership” (HHSAR 326.603), in response to this solicitation and resultant contract.
The enterprise must meet the definition of “Indian Firm” 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 DUN and Bradstreet (D&B) and 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 Firm” with “Indian Ownership” under the authority of the Buy Indian Act.
Business Name Certifying Signature
DUNS Number Print Name
| SOLICITATION NUMBER: |
| PROJECT TITLE: |
| DATE: |
| Business Name: |
| DUNS Number: |
| Print Name: |
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