Atch F - IEE Representation Form REV.pdf
PDF 201 KB Posted
- Attached to
- BIA Set-Aside: Radiology Technologist
- Solicitation number
- RFP-24-PHX-023
About this file
This document is an Indian Economic Enterprise (IEE) Representation Form related to a federal contract opportunity. The form requires the offeror to self-certify that they meet the definition of an "Indian Economic Enterprise" in accordance with the Buy Indian Act, throughout the solicitation, award, and performance periods. Successful offerors must also be registered in SAM. Any false or misleading information submitted is punishable under federal law.
The related federal contract opportunity is for the Department of Health and Human Services Indian Health Service to acquire non-personal professional Diagnostic Radiologic Technologist-CT services for the Supai Health Clinic in Arizona. The contract will have a 12-month base period with four 12-month option periods. The intent is to establish a method to minimize disruptions in clinical service due to staff changes and shortages at this remote location. Respondents must submit all requested documents to the Contracting Officer.
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Other files
| File | Type | Posted |
|---|---|---|
| U00001_QA Response 1.pdf | ||
| U00001_QA Response 2.pdf | ||
| Atch A - Rate Schedule RFP-24-PHX-23.xlsx | XLSX spreadsheet | |
| Atch H -Provisions Clauses Terms and Instructions.pdf | ||
| Atch E - Timesheet for Contract Service.xlsx | XLSX spreadsheet | |
| Atch C - 2024 Tax Exemption.pdf | ||
| Combined Synopsis Solicitation.pdf | ||
| Atch B - Business Associate Agreement.pdf | ||
| Atch G - Wage Determination Supai.pdf | ||
| Atch D - Supai Radiologist SOW.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 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
Unique Entity Identifier (UEI) Number
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
| Date1_af_date: |
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