RFQ Solicitation No.480664 - Enclosure B - Annual Reps & Certs (AMS-Form-050).pdf

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Custom Fabricated Stainless Steel End Tubes & Housing Body
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480664
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This is an Annual Representations & Certifications form (AMS-Form-050) used by Brookhaven National Laboratory to collect and maintain required registration data from offerors seeking to provide goods or services in support of U.S. Government contracts. The form is designed to efficiently gather both required registration information and applicable additional representations and certifications.

The form comprises three primary sections. Section A.1 requires all offerors to provide business information including company name, address, contact details, Unique Entity Identifier, NAICS code, physical business location, and primary performance location. Section A.2 applies exclusively to Small Business Offerors and requires certification of business size status, small business subcategory designations (such as woman-owned, veteran-owned, service-disabled veteran-owned, HUBZone, or economically disadvantaged women-owned), and NAICS code representations with authorized signatures. Section B contains additional representations and certifications required for work under U.S. Government prime contracts, including certifications regarding payments to influence federal transactions (FAR 52.203-11), reporting of executive compensation and first-tier subcontract awards (FAR 52.204-10), responsibility matters including debarment status and tax delinquency (FAR 52.209-5), information regarding federal contracts and administrative proceedings (FAR 52.209-7), previous contracts compliance (FAR 52.222-22), affirmative action programs (FAR 52.222-25), government property acknowledgment, and Buy American Supplies certifications (FAR 52.225-1 and 52.225-9). Section C requires authorization and signature by an offeror's authorized representative, with attestation to the accuracy of submitted information and acknowledgment of potential penalties for misrepresentation.

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ANNUAL REPRESENTATIONS ERTIFICATIONS

Offeror: Offerors Offeror

All Offerors Section A.1. Section C all Small Business Offerors Section A.

Section A.1.:

A.1. Part I:

A.1. Part II:

Offeror

Offeror’s

AMS-Form-050 Rev. 1.0 - 09/2023

Offeror Yes No

Yes Offeror Offeror’s

Offeror

Section A. .: Applicable Only to Small Business Offerors

Offeror Offeror

Offeror

Offeror Offeror’s Section C, “Authorized Signature of Offeror ” Offeror Offeror Offeror

A. .1. Reference:

Offeror Offeror Offeror

Offeror

AND

Offeror Offeror

Offeror

Representations

NAICS Code : Small Business Concern ( Yes):

Offeror

Offeror

Offeror

Offeror

Offeror

Offeror

Offeror

Offeror

Offeror

Offeror and

Offeror

Offeror

Definitions and and and

Notice and

A. .2. Reference:

Offeror Offeror’s

Section B: Additional Representations and Certifications Required for Work Under U.S. Government Prime Contracts

B.1. FAR 52.203-11 (SEP 2007)

Offeror’s designated representative hereby certifies that he or she has read and understands (a) – (e), below.

Offeror

Offeror Offeror

Offeror Offeror

B.2 FAR 52.204-10 ( )

B. Offeror’s

Offeror Offeror

Offeror’s

Offeror’s Offeror

Yes No Yes

Offeror Offeror

Offeror

Yes No

Offeror’s Offeror

Yes No

Yes

No Offeror

Yes No

Yes Offeror

No

Offeror Offeror’s Offeror’s Offeror

Offeror Offeror’s

Executive Name: Executive Total Compensation:

Offeror Offeror

B. . FAR 52.209-5 ( )

Offeror:

Offeror

Offeror

This Certification Concerns a Matter Within the Jurisdiction of an Agency of the United States and the Making of a False, Fictitious, or Fraudulent Certification May Render the Maker Subject to Prosecution Pursuant to 18 U.S.C. 1001.

Offeror Offeror

Offeror’s Offeror Offeror

Offeror

Offeror

B. . FAR 52.209-7 ( ) —

Offeror

Definitions

Offeror Offeror

Offeror Offeror

Offeror Offeror

Offeror

B. . FAR 52.222-22 (FEB 1999)

Offeror

B. . FAR 52.222-25 (APR 1984)

Offeror

OR

B. . Government Property Certification

Offeror

Section C: Authorized Signature of Offeror

Certification of Offeror or Offeror’s Authorized Representative:

Offeror Offeror Offeror’s

Offeror

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