Indian Firm Representation Form.pdf
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- Attached to
- Sources Sought: Exercise Equipment for the Great Plains Area IHS Youth Regional Treatment Center
- Solicitation number
- IHS-SS-26-1528124
About this file
This is a self-certification form for the Indian Health Service (IHS) Buy Indian Act program administered by the Department of Health and Human Services, Division of Acquisition Policy.
The form requires offerors responding to IHS solicitations to certify whether they meet the definition of an "Indian Firm" with "Indian Ownership" under 25 U.S.C. 47 and HHSAR regulations 326.602 and 326.603. Offerors must maintain eligibility status at three critical points: when submitting an offer, at the time of contract award, and throughout the entire contract performance period. Any loss of eligibility during these periods requires immediate written notification to the Contracting Officer. The form is a template that captures the solicitation number, project title, and date, and requires the certifying official to complete fields for business name, DUNS number, certifying signature, and printed name. Successful offerors must also be registered with Dun and Bradstreet (D&B) and the System of Award Management (SAM). The form includes warnings that false or misleading information constitutes a violation under 18 U.S.C. 1001, and false claims during contract performance are subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287. Contracting Officers may require documentation of eligibility before award, and awards are subject to protest if the successful offeror's eligibility is questioned.
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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: |
| Check Box1: Off |
| Check Box2: Off |
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