PR-FRM-12 Rev 07a Reps and Certs.doc

ASRC Federal Legal Entity Below:

Annual Commercial Item Acquisition REPRESENTATIONS AND CERTIFICATIONS Offeror will complete all of this Representations and Certifications form. Failure to furnish the following representations and certification may be cause of the rejection of Offeror’s bid(s) or proposal(s) as non-responsive, resulting in no contract award. U.S. government regulations prohibit ASRC Federal and its Subsidiaries (ASRC) from awarding a seller a procurement funded under a U.S. Government contract unless the seller certifies that it complies with certain U.S. policies. Your company is a potential supplier of goods and services to ASRC whose purchase by ASRC may be funded under a U.S. Government contract. Accordingly, to be eligible for award you are required to complete the Representations and certification according to the following table:

Upon completion, please have the Representations and Certifications signed by an authorized representative of your company, date them and return them to ASRC as instructed.

ACKNOWLEDGED:

a. By signing below, the Offeror/Seller agrees to the foregoing and attests that the Representations and Certifications set forth in Parts A, B and C, herein are current, accurate, and complete. Further, if Offeror’s/Seller’s status certified herein should change prior to any award based on this certification, the Offeror/Seller shall immediately notify, in writing, the person/office to whom this original certification was sent and submit an amended certification with any related data that may be required as a result of the change.

b. I hereby acknowledge an understanding of the U.S. Government contracting and subcontracting programs and confirm the accuracy of the statements made in this document.

c.

The Offeror/Seller’s business organization FORMCHECKBOX

PERMITS FORMCHECKBOX

DOES NOT PERMIT authorized Offeror/Seller representatives to use electronic signatures as legally binding.

d.

The Offeror/Seller FORMCHECKBOX

RESIDES FORMCHECKBOX

DOES NOT RESIDE in a legal jurisdiction that accepts electronic signatures as legally binding.

Firm Name:

Email:

Phone:

Fax:

Signature:

Date:

Typed Name:

Title

SUPPLIER INFORMATION AND BUSINESS DECLARATION FORM

SUPPLIER INFORMATION AND BUSINESS DECLARATION FORM

It is the policy of ASRC Federal and its Subsidiaries that small businesses, small disadvantaged business concerns, woman-owned small businesses and HUBZone, veteran and service disabled veterans small businesses concerns, have the maximum practicable opportunity to participate in the performance of contracts awarded by ASRC. In order to comply with this policy, please provide the following information and a copy of your W-9.

(All information on this form is required)

*Supplier's Name

No. of Employees

*Street Address *Phone Number

Fax Number

*City *State *Zip

*Email Address

Remittance Street Address (* if different from Above)

City State Zip

*DUNS # *Federal Tax ID No. (EID) *Cage Code *Common parent.

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* Supplier is not owned or controlled by a common parent as defined in paragraph (a) of this provision.

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*Name and TIN of common parent:

*Name

*TIN

*This company is (check the ones that apply):

A Division of:

A Subsidiary of:

An Affiliate of:

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Individual

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Partnership

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Independently Owned and Operated

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Consultant

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Distributor

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Retailer

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Manufacturer

Corporation, incorporated under the laws of the state:

Foreign Owned (non USA)

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Non-Profit

1099 Required:

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Yes

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No

Other

*Identify Major Supplies/Services Primary North American Industry Classification System (NAICS) Codes NAICS:

*Business Size/Type (select one only):

Small Business

Large Business

*(Block 1) Business Ownership (select the ones that apply):

Minority

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SBA Certified Disadvantaged

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Women-Owned Business

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Historically Black College/Minority Institute

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Service Disabled Veteran owned

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HUB Zone (Certified by SBA)

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Veteran Owned

(Block 2) If Minority/Disadvantaged is selected above, please check the appropriate category in which business ownership falls:

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African American

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Asian Pacific American

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Hispanic American FORMCHECKBOX Native American

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Subcontinent Asian American

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Alaska Native Corp (ANC) FORMCHECKBOX Other than those listed

Authorized Signature

Title

Printed Name

Date

ASRC Federal and its Subsidiaries (ASRC) may award procurement to the seller where the costs will be charged to a U.S. government prime or subcontract. If so, the seller is advised that the U.S. government may impose a penalty against a firm misrepresenting its business size and/or disadvantaged status for the purposes of obtaining procurement that is to be included as part, or all of a goal contained in ASRC’s Subcontracting plan. Eligibility as a small business is based on the regulations issued by the Small Business Administration in CFR 13, Part 121 of the SBA Rules and Regulations and FAR 52.219-1.

If the offeror is currently registered in the System for Award Management (SAM), and has completed the Representations and Certifications section of SAM electronically, the offeror may choose to use paragraph (a) of this provision instead of completing the corresponding individual representations and certifications herein. The offeror shall indicate which option applies by checking one of the following boxes:

(i) Paragraph (a) applies, If checked, Offeror must complete Part B and Part C below.

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(ii) Paragraph (a) does not apply and the offeror must completed Part A, B and C below

(a) The offeror has completed the annual representations and certifications electronically via the SAM website. After reviewing the SAM database information, the offeror verifies by submission of the offer that the representations and certifications currently posted electronically, have been entered or updated within the last 12 months, are current, accurate, complete, and applicable (including the business size standard applicable to the NAICS code), as of the date of this offer and are incorporated in this offer by reference (see FAR 4.1201) Further, the offeror certifies the representations and certifications posted in the SAM database are equally made to ASRC Federal, including all entities;;

PART “A”

THIS PART APPLIES IF OFFEROR IS NOT REGISTERED IN THE SYSTEMS FOR AWARDS MANAGEMENT

52.203-11 CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS a.

The definitions and prohibitions contained in the clause, at FAR 52.203-12, Limitation on Payments to Influence Certain Federal Transactions, included in this solicitation, are hereby incorporated by reference in paragraph (b) of this certification.

b.

The Offeror/Seller hereby certifies to the best of his or her knowledge and belief that, as of the date of execution of this certification –

1) No Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on his or her behalf in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement;

2) If any funds other than Federal appropriated funds (including profit or fee received under a covered Federal transaction) have been paid, or will be paid, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on his or her behalf in connection with this solicitation, the Offeror/Seller shall complete and submit, with its offer, OMB standard form LLL, Disclosure of Lobbying Activities, to the Contracting Officer, and

3) He or she will include the language of this certification in all subcontract awards at any tier and require that all recipients of subcontract awards in excess of $100,000 shall certify and disclose accordingly.

c.

Submission of this certification and disclosure is a prerequisite for making or entering into this contract imposed by section 1352, title 31, United States Code. Any person who makes an expenditure prohibited under this provision or who fails to file or amend the disclosure form to be filed or amended by this provision, shall be subject to a civil penalty of not less than $10,000, and not more than $100,000, for each such failure.

52.203-18 PROHIBITION ON CONTRACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL CONFIDENTIALITY AGREEMENTS OR STATEMENTS-REPRESENTATION (JAN 2017) In accordance with section 743 of Division E, Title VII, of the Consolidated and Further Continuing Appropriations Act, 2015 (Pub. L. 113-235) and its successor provisions in subsequent appropriations acts (and as extended in continuing resolutions), Government agencies are not permitted to use funds appropriated (or otherwise made available) for contracts with an entity that requires employees or subcontractors of such entity seeking to report waste, fraud, or abuse to sign internal confidentiality agreements or statements prohibiting or otherwise restricting such employees or subcontractors from lawfully reporting such waste, fraud, or abuse to a designated investigative or law enforcement representative of a Federal department or agency authorized to receive such information.

The prohibition in the paragraph above of this provision does not contravene requirements applicable to Standard Form 312, (Classified Information Nondisclosure Agreement), Form 4414 (Sensitive Compartmented Information Nondisclosure Agreement), or any other form issued by a Federal department or agency governing the nondisclosure of classified information.

By submission of its offer, the Offeror represents that it will not require its employees or subcontractors to sign or comply with internal confidentiality agreements or statements prohibiting or otherwise restricting such employees or subcontractors from lawfully reporting waste, fraud, or abuse related to the performance of a Government contract to a designated investigative or law enforcement representative of a Federal department or agency authorized to receive such information (e.g., agency Office of the Inspector General).

52.209-2 Prohibition on Contracting with Inverted Domestic Corporations—Representation

(a) Definitions. “Inverted domestic corporation” and “subsidiary” have the meaning given in the clause of this contract entitled Prohibition on Contracting with Inverted Domestic Corporations (52.209-10).

(b) Government agencies are not permitted to use appropriated (or otherwise made available) funds for contracts with either an inverted domestic corporation, or a subsidiary of an inverted domestic corporation, unless the exception at 9.108-2(b) applies or the requirement is waived in accordance with the procedures at 9.108-4.

(c) Representation. The Offeror represents that—

(1) It FORMCHECKBOX

IS, FORMCHECKBOX

IS NOT an inverted domestic corporation; and

(2) It FORMCHECKBOX

IS, FORMCHECKBOX

IS NOT a subsidiary of an inverted domestic corporation

52.209-5 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS a.

The Offeror/Seller certifies, to the best of its knowledge and belief, that–

1) The Offeror/Seller and/or any of its Principals –

A)

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ARE FORMCHECKBOX

ARE NOT presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

B)

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HAVE FORMCHECKBOX

HAVE NOT, within the three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property;

C)

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ARE FORMCHECKBOX

ARE NOT presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subdivision (a)(1)(i)(B) of this provision; and

2) The Offeror/Seller, aside from the offenses enumerated in paragraphs (a)(1)(i)(A), (B) and (C) of this provision, A)

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HAS FORMCHECKBOX

HAS NOT, within the past three years, relative to tax, labor and employment, environmental, antitrust, or consumer protection laws –

(i) Been convicted of a Federal or state felony (or has any Federal or state felony indictments currently pending against them); or

(ii) Had a Federal court judgment in a civil case brought by the United States rendered against them; or

(iii) Had an adverse decision by a Federal administrative law judge, board, or commission indicating a willful violation of law.

B) If the Offeror/Seller has responded affirmatively, the Offeror/Seller shall provide additional information if requested by BUYER and

C) The Offeror/Seller FORMCHECKBOX

HAS FORMCHECKBOX

HAS NOT within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal agency.

b.

“Principals,” for the purposes of this certification, means officers, directors, owners, partners, and persons having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a subsidiary, division, or business segment; and similar positions).

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURSIDICTION OF AN AGENCY OF THE UNITED STATES AND THE MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER SECTION 1001, TITLE 18, UNITED STATES CODE.

1) The Offeror/Seller shall provide immediate written notice to BUYER if, at any time prior to contract award, the Offeror/Seller learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

2) A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Offeror/Seller’s responsibility. Failure of the Offeror/Seller to furnish a certification or provide such additional information as requested by BUYER may render the Offeror/Seller nonresponsible.

3) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Offeror/Seller is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

4) The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Offeror/Seller knowingly rendered an erroneous certification, in addition to the other remedies available, BUYER may terminate the contract resulting from this solicitation for default.

52.209-11 Representation by Corporations Regarding Delinquent Tax Liability or a Felony Conviction under any Federal Law

(a) As required by sections 744 and 745 of Division E of the Consolidated and Further Continuing Appropriations Act, 2015 (Pub. L. 113-235), and similar provisions, if contained in subsequent appropriations acts, the Government will not enter into a contract with any corporation that—

(1) Has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability, where the awarding agency is aware of the unpaid tax liability, unless an agency has considered suspension or debarment of the corporation and made a determination that suspension or debarment is not necessary to protect the interests of the Government; or

(2) Was convicted of a felony criminal violation under any Federal law within the preceding 24 months, where the awarding agency is aware of the conviction, unless an agency has considered suspension or debarment of the corporation and made a determination that this action is not necessary to protect the interests of the Government.

(b) The Offeror represents that—

(1) It IS FORMCHECKBOX

IS NOT FORMCHECKBOX

a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability; and

(2) It IS FORMCHECKBOX

IS NOT FORMCHECKBOX

a corporation that was convicted of a felony criminal violation under a Federal law within the preceding 24 months.

52.222-22 PREVIOUS CONTRACTS AND COMPLIANCE REPORTS

The Offeror/Seller represents that:

a.

It FORMCHECKBOX

HAS FORMCHECKBOX

HAS NOT participated in a previous contract or subcontract subject to the Equal Employment Opportunity clause of any solicitation/procurement (FAR 52.222-26).

b.

It FORMCHECKBOX

HAS FORMCHECKBOX

HAS NOT filed all required compliance reports.

c.

Types of Equal Opportunity Certifications:

52.222-25 AFFIRMATIVE ACTION COMPLIANCE

The Offeror/Seller represents that:

a.

It FORMCHECKBOX

HAS FORMCHECKBOX

HAS NOT developed an affirmative action program as required by the rules and regulations of the Secretary of Labor (41 CFR 60-1 and 60-2).

b.

It FORMCHECKBOX

HAS FORMCHECKBOX

HAS NOT previously had contracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor.

c.

It FORMCHECKBOX

HAS FORMCHECKBOX

HAS NOT fewer than fifty (50) employees.

This contractor and subcontractor shall abide by the requirements of 41 CFR §§ 60-1.4(a), 60-300.5(a) and 60 741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, protected veteran status or disability.

52.225-2 BUY AMERICAN ACT CERTIFICATE

(a) The offeror certifies that each end product, except those listed in paragraph (b) of this provision, is a domestic end product and that for other than COTS items, the offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The offeror shall list as foreign end products those end products manufactured in the United States that do not qualify as domestic end products, i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) of the definition of “domestic end product.” The terms “commercially available off-the-shelf (COTS) item,” “component,” “domestic end product,” “end product,” “foreign end product,” and “United States” are defined in the clause of this solicitation entitled “Buy American Act—Supplies.”

(b) Foreign End Products:

(c) The Prime Contractor will evaluate offers in accordance with the policies and procedures of Part 25 of the Federal Acquisition Regulation.

252.209-7001 DISCLOSURE OF OWNERSHIP OR CONTROL BY THE GOVERNMENT OF A TERRORIST COUNTRY a.

Prohibition on award. In accordance with 10 U.S.C. 2327, no contract may be awarded to a firm or a subsidiary of a firm if the government of a terrorist country has a significant interest in the firm or subsidiary or, in the case of a subsidiary, the firm that owns the subsidiary, unless a waiver is granted by the Secretary of Defense.

b.

Disclosure. If the government of a terrorist country has a significant interest in the Offeror/Seller or a subsidiary of the Offeror/Seller, the Offeror/Seller shall disclose such interest in an attachment to its offer. If the Offeror/Seller is a subsidiary, it shall also disclose any significant interest the government of a terrorist country has in any firm that owns or controls the subsidiary. The disclosure shall include-

1) Identification of each government holding a significant interest; and

2) A description of the significant interest held by each government.

252.209-7002 DISCLOSURE OF OWNERSHIP OR CONTROL BY A FOREIGN GOVERNMENT

(a) Prohibition on award. No contract under a national security program may be awarded to an entity controlled by a foreign government if that entity requires access to proscribed information to perform the contract, unless the Secretary of Defense or a designee has waived application of 10 U.S.C. 2536(a).

(b) Disclosure. The Offeror/Seller shall disclose any interest a foreign government has in the Offeror/Seller when that interest constitutes control by a foreign government as defined in this provision. If the Offeror/Seller is a subsidiary, it shall also disclose any reportable interest a foreign government has in any entity that owns or controls the subsidiary, including reportable interest concerning the Offeror/Seller's immediate parent, intermediate parents, and the ultimate parent. EQUAL OPPORTUNITY (FAR 52.222-26) The Offeror/Seller represents that it is in agreement with the subject clause and the Executive Order 11246, as amended, and the rules, regulations, and Orders of the Secretary of Labor pertaining to Equal Opportunity.

PART “B”

THIS PART APPLIES TO ALL OFFEROR

52.204-10 Reporting Executive Compensation and First-Tier Subcontract Awards, is part of this subcontract.

FAR clause 52.204-10 requires the prime contractor to provide information on its first-tier subcontractors and to disclose to the Subcontractor that the information will be made available to the public as required by FAR 52.204-10. Based on this requirement, the Subcontractor certifies that:

a.

The Subcontractor FORMCHECKBOX

IS FORMCHECKBOX

IS NOT an individual. (If ‘is’ is marked, Complete Part C, then sign and date it below and return to ASRC.)

b.

The Subcontractor FORMCHECKBOX

DID FORMCHECKBOX

DID NOT have a gross income less than $300,000 in the previous tax year. (If ‘did’ is marked, complete Part C,then sign and date it below and return it to ASRC. If “did not” is marked, complete the remainder of the certification, then sign and date it below and return to ASRC.)

1) The Subcontractor’s DUNS Number is:

2) The Subcontractor’s physical address is:

Street Address:

City, State, nine-digit zip code, Country:

Congressional District:

3) The subcontractor’s primary performance location, if different from above address is:

Street Address:

City, State, nine-digit zip code, Country:

Congressional District:

4) The applicable North American Industry Classification System Code (NAICS) is:

5) The Subcontractor represents that, in its preceding fiscal year, the Subcontractor:

i)

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DID FORMCHECKBOX

DID NOT receive 80 percent or more of its annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants), cooperative agreements, and other forms of Federal financial assistance; and $25,000,000 or more in annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants), cooperative agreements, and other forms of Federal financial assistance; and ( If ‘did not’ is marked, complete Part C, then sign and date it below and return it to ASRC.)

ii)

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DOES FORMCHECKBOX

DOES NOT provide public access to information about the compensation of the senior executives through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986. If ‘does not’ is marked, the Subcontractor shall provide the names and total compensation (as defined in FAR 52.204-10) of each of the Subcontractor’s five most highly compensated executives, for the completed fiscal year preceding the year the subcontract is awarded. (If “does” is marked, complete Part C, then sign and date it below and return to ASRC. Otherwise, complete the required information below for your preceding completed tax year, complete Part C then sign, date, and return this certification to ASRC.)

Subcontractor Representative typed/printed name:

Subcontractor Representative typed/printed title:

Subcontractor Representative Signature:

Date:

Please indicate, by checking the appropriate box(es), the states or districts which your company is authorized to collect sales tax:

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All

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Alabama

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Alaska

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Arizona

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Arkansas

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California

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Colorado

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Connecticut

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Delaware

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District of Columbia

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Florida

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Georgia

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Hawaii

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Idaho

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Illinois

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Indiana

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Iowa

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Kansas

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Kentucky

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Louisiana

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Maine

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Maryland

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Massachusetts

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Michigan

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Minnesota

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Mississippi

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Missouri

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Montana

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None

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Nebraska

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Nevada

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New Hampshire

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New Jersey

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New Mexico

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New York

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North Carolina

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North Dakota

Ohio

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Oklahoma

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Oregon

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Pennsylvania

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Rhode Island

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South Carolina

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South Dakota

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Tennessee

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Texas

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Utah

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Vermont

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Virginia

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Washington

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West Virginia

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Wisconsin

Wyoming

PART “C”

THIS PART APPLIES TO ALL OFFEROR

FAR 52.204-26 Covered Telecommunications Equipment or Services - Representation (Dec 2019)

(a) Definitions. As used in this provision, Covered telecommunications equipment or services has the meaning provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

(b) Procedures. The Offeror shall review the list of excluded parties in the System for Award Management (SAM) (https://www.sam.gov) for entities excluded from receiving federal awards for "covered telecommunications equipment or services."

(c) Representation. The Offeror represents that it [ ] does [ ] does not provide covered telecommunications equipment or services as a part of its offered products or services to the Government in the performance of any contract, subcontract, or other contractual instrument Form ASRCFH_PUR007 Rev. 02/12 PR-FRM-12 Rev 07a 9/1/20