J06 IHS IEE Representation Form Pryor Clinic Constr.pdf
PDF 135 KB Posted
- Attached to
- Pryor Clinic Expansion Construction in Pryor
- Solicitation number
- 75H70126R00024
About this file
This is an Indian Health Service (IHS) Buy Indian Act Indian Economic Enterprise Representation Form template used for federal contract solicitations, sources sought notices, and requests for information.
The form serves as a self-certification document for offerors to declare whether they meet the definition of an "Indian Economic Enterprise" (IEE) with Indian Ownership as defined under 25 U.S.C. 47 and HHSAR 326.601. Offerors must certify their eligibility status at three critical points: when submitting an offer in response to the solicitation, at the time of contract award, and throughout the entire contract performance period. If an offeror's eligibility status changes at any point during these periods, immediate written notification to the Contracting Officer is required. The form requires completion of specific fields including the solicitation/sources sought/RFI number, project title, date, name of the Federally Recognized Tribal Entity, business name, DUNS number, name of the 51% owner of the IEE firm, and certifying signature with printed name. Successful offerors must also maintain registration with the System of Award Management (SAM). The form explicitly warns that submission of false or misleading information constitutes a violation of federal law with penalties enumerable under 18 U.S.C. 1001 for offer submission and 31 U.S.C. 3729-3731 and 18 U.S.C. 287 for false claims during contract performance. Individual Contracting Officers may require supporting documentation of eligibility before awarding set-aside or sole source contracts, and awards are subject to protest if offeror eligibility is questioned.
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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
DUNS Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: 75H70126R00024 |
| PROJECT_TITLE: Pryor Clinic Expansion Construction |
| DoesNot: 0 |
| Does: Off |
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