Representation Form.pdf
PDF 2 MB Posted
- Solicitation number
- IHS_SS_26_0804
About this file
This is an Indian Economic Enterprise (IEE) Representation Form used by the Indian Health Service (IHS) for the Buy Indian Act set-aside program. The form applies to Solicitation/Sources Sought/RFI #IHS_SS_26_0804 for the Community Health Workers/Representatives (CHW/CHR) Training project.
The form constitutes a self-certification that an enterprise meets the definition of an "Indian Economic Enterprise" as defined in HHSAR 326.601 under the authority of 25 U.S.C. 47. Offerors must meet the eligibility requirements at three critical points: when submitting an offer, at the time of contract award, and throughout the full contract performance period. Any changes in eligibility status during these periods require immediate written notification to the Contracting Officer. Successful offerors must be registered with the System of Award Management (SAM). The form requires the offeror to indicate whether or not it meets the IEE definition with Indian Ownership, and must include the name of the federally recognized tribal entity, the 51% owner of the IEE firm, the business name, unique entity identifier (UEI) number, certifying signature, and printed name. False or misleading information submitted in connection with this certification violates 18 U.S.C. 1001 and is subject to criminal penalties, while false claims during contract performance are subject to civil penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287.
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| File | Type | Posted |
|---|---|---|
| Sources Sought_CHW CHR.pdf |
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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 enterprise 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 a 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 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
Unique Entity Identifier (UEI) Number
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: IHS_SS_26_0804 |
| PROJECT_TITLE: Community Health Workers/Representatives (CHW/CHR) Training |
| DoesNot: 0 |
| Does: Off |
| Date1_af_date: |
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