SARC_Subcontractor Annual RepsCerts Rev 4.pdf

Form SARC (Rev.4) Previous editions are obsolete Page 1 of 6

FERMI FORWARD DISCOVERY GROUP, LLC

Subcontractor Annual Representations & Certifications (SARC) Offeror Name: Parent Company Name: (If Applicable)

Street: Street:

City: State/Province: City: State/Province:

Zip/Postal: Country: Zip/Postal: Country:

Phone: # of Employees: Phone: # of Employees:

EIN/TIN: Parent Website:

Website: Billing Information: (if different from offeror address):

NAICS U.S. Industry #: Street:

DUNS #: City: State/Province:

Offeror IS NOT Registered in SAM.gov Zip/Postal: Country:

Offeror IS Registered in SAM.gov Entity Registration Expiration Date:

SAM.gov Unique Entity Identifier (UEI):

NOTE TO EXISTING SUBCONTRACTORS THAT HAVE PREVIOUSLY COMPLETED A FERMI FORWARD DISCOVERY GROUP OR FERMI RESEARCH ALLIANCE (FRA) ANNUAL SUBCONTRACTOR CERTIFICATION: ANY COMPANY NAME OR ADDRESS CHANGE NOTIFICATIONS MUST BE PROVIDED ON COMPANY LETTERHEAD. A CURRENT IRS FORM W-8 OR W-9 IS REQUIRED FOR

COMPANY NAME CHANGES.

The procurement of material, supplies, or services (including construction) for a U.S. Government contract requires compliance by Prime Contractors, Subcontractors, and Suppliers with various programs enacted by Statute, Executive Order, or Federal Regulation.

The following certifications are effective for a period of 12 months beginning on the date of signature of this document. If there is any change to the information provided within any section of this document during the period, you are required to promptly inform Fermi Forward Discovery Group, LLC (FermiForward) in writing, no later than 15 days from the change in status.

Please complete all sections.

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A. The Offeror, by checking the applicable box, represents that:

1. Ownership of the Entity is: (Check one box)

U.S. Owned

U.S. Incorporated with Foreign Parent

Foreign Owned, registered for business in (provide country)

2. It operates as: (Check all that apply)

A Corporation incorporated under the laws of: State:_______________________ Country: _____________________________

Privately Held Corporation OR Publicly Traded Corporation

S-Corporation

Limited Liability Company

Partnership

Sole Proprietorship

Joint Venture or Consortium

Educational Institution [Educational institution means a public or nonprofit institution of higher education, such as an accredited college or university, as defined in section 1201(a) of Public Law 89- 329, November 8, 1965, Higher Education Act of 1965 (20 U.S.C. 1142(a))]

Non-Profit, Non-Educational Organization [Non-Profit organization means an organization of the type described in section 501(c)(3) of the Internal Revenue Code of 1954 (26 U.S.C. 501(c)) and exempt from taxation under section 501(a) of the Internal Revenue Code]

Other: _______________________

B. Common Parent

Common parent means that a corporate entity which owns or controls an affiliated group of corporations, that files Federal tax returns on a consolidated basis, one of which the Offeror is a member. (Check one box)

Offeror is neither owned nor controlled by a common parent.

Offeror is owned or controlled by a common parent.

Common parent name:

Affiliated Company(s):

Section I: Business Information

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C. Check all applicable boxes as described under FAR 19.001 Definitions and FAR 19.301-1 Representation by the Offeror:

Large Business Small Business Foreign Business

Small Businesses: If your business is a Small Business and also falls into one of the diversity categories below as defined by the Small Business Administration, please check all additional applicable classifications for the business. (More than one box may apply):

Small Disadvantaged Business Woman-Owned Small Business

Historically Black College/University or Minority Institution

HUB Zone Small Business * *Include copy of certification from the U.S. Small Business Adm.

Veteran-Owned Small Business Service-Disabled Veteran-Owned Small Business

Alaska Native Corporation (ANC) or Indian Tribe ANC, not certified by SBA as Small Disadvantaged Business ANC, not a Small business

Not applicable (no additional sub-categories apply)

D. Executive Compensation FermiForward is required to report information on certain subcontract awards in accordance with FAR 52.204-

10. Based on this requirement, there may be instances when the Offeror is required to register and report the names and the total compensation of each of the five most highly compensated executives for their preceding completed fiscal year within the Federal Funding Accountability and Transparency Act Subaward Reporting System (fsrs.gov).

1. Did your business or organization (represented by a unique entity identifier) during your preceding completed fiscal year 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?

Yes No

2. Did your business or organization (represented by a unique entity identifier) during your preceding completed fiscal year receive $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?

Yes No

3. Does the public have access to information about the compensation of the 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 I-23 Code of 1986? (To determine if the public has access to the compensation information, see the U.S. Security and Exchange Commission total compensation filings at http://www.sec.gov/answers/execomp.htm.)

Yes No

Please list below the name, title, and compensation for the Offeror’s Top Five Executives. This requirement is a time-sensitive requirement. If Offeror answered both 1 & 2 above as “YES” and 3 as “NO”, then the submittal and recording of Executive Compensation by Offeror shall be completed prior to FermiForward Purchase Order or Subcontract award.

EXECUTIVE NAME EXECUTIVE TITLE EXECUTIVE COMPENSATION

http://www.sec.gov/answers/execomp.htm

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A. Accounting System (Check one box)

Offeror’s Accounting System has been reviewed via the Single Audit (formerly OMB Circular A-133) or by DCAA/DCMA and is approved/deemed adequate. (Attach Offeror’s Accounting System Approval letter issued by DCAA/DCMA or a copy of the Annual Single Audit Report.)

Offeror’s Accounting System has been reviewed via the Single Audit (formerly OMB Circular A-133) or by DCAA/DCMA and deemed non-compliant or disapproved. (Comment on any non-compliance):

Offeror’s Accounting System has not been reviewed via the Single Audit (formerly OMB Circular A-133) or by DCAA/DCMA. (FermiForward may initiate a request for an accounting system review if a subcontract/purchase order with any interim billing provisions or non-FFP line items is being contemplated.)

B. Responsible Offeror

Offeror deems itself responsible in accordance with FAR 9.104 which includes having adequate financial resources to perform the contract, or the ability to obtain them; being able to comply with the delivery or performance schedule; having a satisfactory performance record; having a satisfactory record of integrity and business ethics; having the necessary organization, experience, accounting and operational controls, and technical skills, or the ability to obtain them; having the necessary production, construction, and technical equipment and facilities or the ability to obtain them; and, be otherwise qualified and eligible to receive an award under applicable laws and regulations.

Offeror’s policy or practices prohibits engaging in the trafficking of persons, the use of forced labor, or the procuring of commercial sex acts in the country or countries in which it conducts business and is in compliance with 22 U.S.C 7104, FAR 52.222-50, Combating Trafficking in Persons, and Executive Order 13627.

C. FAR 52.222-54 Employment Eligibility Verification

E-Verify is not required as the components of paragraph (e) of FAR 52.222-54 Employment Eligibility Verification do not apply.

Offeror is currently enrolled in E-Verify and will include FAR 52.222-54 in applicable lower-tier subcontracts.

Offeror will enroll in E-Verify within 30 calendar days of subcontract award and will include FAR 52.222-54 in applicable lower-tier subcontracts.

Section II: Offeror Responsibility

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Section IV: Federal Acquisition Regulation (FAR) Certifications

Compliance with U.S. Export/Import Control Laws and Regulations:

Offeror agrees to comply with all applicable U.S. export control laws and regulations, specifically including, but not limited to, the requirements of the Export Administration Act, 50 U.S.C. app. 2401-2420, including the Export Administration Regulations, 15 C.F.R. 730-774. This includes agreeing to not provide export-controlled items via any method, without the authority of an export license, exception, or other applicable authorization from the U.S. Government.

Offeror agrees that it shall immediately notify FermiForward if Offeror is, or becomes, listed in any Denied Parties List or if Offeror’s export privileges are otherwise denied, suspended, or revoked in whole or in part by any U.S. Government agency.

A. Compliance with FAR 52.222-26 or 52.222-27, Equal Opportunity (Check as applicable) Offeror Has , Has Not been required to submit Standard Form 100 (EEO-1).

AND

Offeror represents that it Has , Has Not filed Standard Form 100 (EEO-1).

OR

Offeror certifies that it is exempt per FAR 22.807, Equal Employment Opportunity, Exemptions Cite specific exemption:

B. Certification of Affirmative Action as described under FAR 52.222-25 (Respond to only one statement) Offeror represents that at each establishment, affirmative action programs required by the rules and regulations of the Secretary of Labor (41CFR 60-1 and 60-2):

ARE developed and ARE on file ARE not developed and ARE not on file

OR

Offeror has not previously had contracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor.

OR

Offeror certifies that it is exempt per FAR 22.807, Equal Employment Opportunity Exemptions Cite specific exemption:

C. Limitations on Pass-Through Charges:

AND

Offeror represents that it will not subcontract more than 70 percent of the total cost of the work to be performed under any cost reimbursement subcontract greater than the Simplified Acquisition Threshold issued by FermiForward;

Offeror acknowledges that cost reimbursement subcontracts greater than the Simplified

Acquisition Threshold issued by FermiForward shall be subject to FAR 52.215-23, Limitations on Pass- Through Charges.

Section III: Export / Import Control Certifications

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As a duly authorized representative of the company denoted below, I certify the accuracy of all statements herein, acknowledge an awareness of the U.S. Government’s contracting and subcontracting programs, and confirm that our company will comply with all statements herein.

I understand that this certification shall apply to all requests for quotations, requests for proposals, purchase orders, or subcontracts received from FermiForward and understand that I am responsible for notifying FermiForward of any changes in status affecting this certification.

I further acknowledge that where information must be exchanged between our company and FermiForward, regardless of the media or method used to exchange information, we shall preserve in confidence FermiForward’s information and shall, unless otherwise authorized in writing by an authorized agent of FermiForward, prevent disclosure to third parties. We shall further restrict disclosure of FermiForward’s information to our employees on a need-to-know basis and will advise the restrictions of disclosure and use. If we determine an unauthorized use or disclosure of FermiForward’s information, we shall promptly notify FermiForward of the disclosure and shall endeavor to prevent further unauthorized use or disclosure.

Printed Name Title

Email Address Phone Number

Signature Date

Section V: Certification