Appendix C - Representations and Certifications_Jan 2026.docx

Appendix C –Representations and Certifications Form

Appendix C – Representations and Certifications

RPP Number and Project Name:

Offeror Information:

Name:

Address:

Unique Entity Identifier (UEI) Number:

Point of Contact:

Title/Position:

Offeror Signature: The Offeror must check the below box and type or sign name, which will serve as certification to the Government.

I certify that all the below information and certifications are true and correct. By checking this box and by typing my name below, I authorize my electronic signature to carry the same weight and legal effect as my written signature.

Signature Date

Instructions: The Offeror shall complete the below representations and certifications in accordance with the instructions provided within each section below:

Section A – Appropriate Use of Other Transaction Authority Section B – Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment Section C – Organizational Conflicts of Interest Section D – Hazardous Material Identification and Material Safety Data (optional based on requirement)

A. APPROPRIATE USE OF OTHER TRANSACTION AUTHORITY

1. Prototype projects awarded under the authority of 10 U.S.C. § 4022 must meet one of the conditions at 10 U.S.C. § 4022(d)(1). The conditions are as follows:

(A) There is at least one nontraditional defense contractor* or nonprofit research institution participating to a significant extent** in the prototype project.

(B) All significant participants in the transaction other than the Federal Government are small businesses or nontraditional defense contractors.

(C) At least one third of the total cost of the prototype project is to be paid out of funds provided by sources other than the Federal Government.

*Pursuant to 10 U.S.C. § 3014, a Nontraditional Defense Contractor (NDC) means an entity that is not currently performing and has not performed, for at least the one-year period preceding the solicitation of sources by the Government for the procurement or transaction, any contract or subcontract for the Department of Defense that is subject to full coverage under the cost accounting standards prescribed pursuant to section 1502 of title 41 and the regulations implementing such section (see 10 U.S.C. § 3014). The phrase “the solicitation of sources” refers to the initial agreement solicitation only. A nontraditional defense contractor is considered a nontraditional defense contractor for the duration of the prototype project/agreement’s period of performance, or for any in-scope work modified under the same agreement.

**"Significant Extent" considers, by way of illustration and not limitation, whether the NDC/nonprofit research institution will supply a new key technology, product, or process; supply a novel application or approach to an existing technology, product, or process; provide a material increase in the performance, efficiency, quality, or versatility of a key technology, product, or process; accomplish a significant amount of the prototype project; cause a material reduction in the cost or schedule of the prototype project; or, provide for a material increase in performance of the prototype project.

2. On the following pages, place an X next to the appropriate choice (Condition A, Condition B, or Condition C) and complete the required table. Do not select more than one condition.

Condition (A) ____

Condition (A) will be applicable in the following circumstances:

a. If the Offeror is an NDC or non-profit research institution; or

b. If the Offeror is a Traditional Defense Contractor but will use at least one NDC or nonprofit research institution that will participate to a significant extent as a subcontractor.

If the Offeror is a Traditional Defense Contractor and is NOT an NDC or non-profit research institution and relies on Condition A, the Offeror shall complete the table below for only the NDC(s)/non-profit research institution(s) that is/are providing “participation to a significant extent”. Add rows as necessary. The Offeror should provide sufficient detail and description of the significant participant’s contribution to establish “participation to a significant extent.” Vague descriptions or a lack of detail may create delay and/or impact the Government’s ability to determine statutory compliance. The Government reserves the right to ask for additional information from the Offeror to determine significant participation. If any significant participant listed below is replaced or ceases to be a significant participant on this effort for any reason, the Offeror will provide an updated Representations and Certifications form to the Government documenting how compliance with 10 U.S.C. § 4022(d) will be met.

Instructions: Please provide sufficient detail in this column for the Agreements Officer to make a determination if the participation is significant. Please complete one row for each significant participant. (Delete these instructions if completing this section.)

Condition (B) ____ If the Offeror relies on Condition B, then it shall complete the table below for all significant participants, ALL of which must be NDCs or Small Businesses. The first row in the table must list the Offeror’s information. Add rows as necessary.

Note: Since ALL significant participants must be NDCs or Small Businesses, and since the Offeror will be a significant participant in every project, the Offeror must be an NDC and cannot be a Traditional Defense Contractor to meet this Condition B. In practice, Condition B is rarely relied on because 1) a Traditional Defense Contractor cannot rely on Condition B, and 2) an NDC can more easily rely on Condition A based on its own significant participation rather than having to provide information about all significant participants as required by Condition B. If any significant participant listed below is replaced or ceases to be a significant participant on this effort for any reason, I will provide an updated Representations and Certifications form to the Government documenting how compliance with 10 U.S.C. § 4022(d) will be met.

Instructions: Please provide sufficient detail in this column for the Agreements Officer to make a determination if the participation is significant. Please complete one row for each significant participant. (Delete these instructions if completing this section.)

Condition (C)____ If the Offeror relies on Condition C, it shall complete the table below. Resource-share in a transaction occurs when a portion of the total cost of the project is to be paid out of funds provided by sources other than the Federal Government. During performance of the PPA, the contractor will be required to provide financial reporting with appropriate visibility into expenditures of Government funds vs. private funds via Resource Share Report.

B.

B. REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND VIDEO SURVEILLANCE SERVICES OR EQUIPMENT

(For applicability during PPA period of performance, see Appendix B – Project Other Terms and Conditions, A-1000.)

The Government requires that the Offeror reviews the following provisions, complete the representation at the end of this document, and return any additional disclosures required by paragraph (e) below.

(a) Definitions. As used in this provision -

Backhaul, covered telecommunications equipment or services, critical technology, interconnection arrangements, reasonable inquiry, roaming, and substantial or essential component have the meanings provided in Appendix B – Project Other Terms and Conditions, clause A-1000, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services Equipment.

(b) Prohibition.

(1) Section 889(a)(1)(A) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L. 115-232) prohibits the head of an executive agency on or after August 13, 2019, from procuring or obtaining, or extending or renewing a contract/agreement to procure or obtain, any equipment, system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. Nothing in the prohibition shall be construed to—

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(2) Section 889(a)(1)(B) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L. 115-232) prohibits the head of an executive agency on or after August 13, 2020, from entering into a contract/agreement or extending or renewing a contract/agreement with an entity that uses any equipment, system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. This prohibition applies to the use of covered telecommunications equipment or services, regardless of whether that use is in performance of work under a Federal contract/agreement. Nothing in the prohibition shall be construed to—

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(c) 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.”

(d) Representation. The Offeror represents that -

1. It will □ will not□ provide covered telecommunications equipment or services to the Government in the performance of any agreement resulting from this RPP. The Offeror shall provide the additional disclosure information required at paragraph (e)(1) of this section if the Offeror responds "will" in paragraph (d)(1) of this section; and

2. After conducting a reasonable inquiry, for purposes of this representation, the Offeror represents that—

It does □ does not □ use covered telecommunications equipment or services, or use any equipment, system, or service that uses covered telecommunications equipment or services. The Offeror shall provide the additional disclosure information required at paragraph (e)(2) of this section if the Offeror responds "does" in paragraph (d)(2) of this section.

(e) Disclosures.

(1) Disclosure for the representation in paragraph (d)(1) of this provision. If the Offeror has responded "will" in the representation in paragraph (d)(1) of this provision, the Offeror shall provide the following information as part of the offer:

(i) For covered equipment—

A. The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier, CAGE code, and whether the entity was the original equipment manufacturer (OEM) or a distributor, if known);

B. A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

C. Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(ii) For covered services—

A. If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

B. If not associated with maintenance, the Product Service Code (PSC) of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(2) Disclosure for the representation in paragraph (d)(2) of this provision. If the Offeror has responded "does" in the representation in paragraph (d)(2) of this provision, the Offeror shall provide the following information as part of the offer:

(i) For covered equipment—

A. The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier, CAGE code, and whether the entity was the OEM or a distributor, if known);

B. A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

C. Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

(ii) For covered services—

A. If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

B. If not associated with maintenance, the PSC of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

C.

C. ORGANIZATIONAL CONFLICTS OF INTEREST

If the Offeror believes that a potential or actual OCI exists for this proposed prototype project, the Offeror shall provide a written notification to the Agreements Officer, which indicates that there is a potential or actual OCI and submit an OCI Mitigation Plan, for review and approval. The OCI Mitigation Plan shall describe, in detail, the circumstance(s) that create(d) the potential or actual OCI; and outline, in detail, the actions to be taken in the performance of the project (as applicable) to mitigate the OCI.

If the Offeror does not believe that a potential or actual OCI exist(s) for this proposed prototype project, the Offeror shall check the boxes below. For any box that is not checked, the Offeror shall provide the written notification noted above to the Agreements Officer prior to award along with an OCI Mitigation Plan.

☐ a. The Offeror has not identified an actual or potential OCI, under which as part of its performance of another Government procurement, the Offeror has access to nonpublic information that may provide it with a competitive advantage in competition for the acquisition identified above or a future agreement.

☐ b. The Offeror has not identified an actual or potential OCI, under which as part of its performance of another Government procurement, the Offeror has access to a competitor’s, or potential competitor’s, business or proprietary information.

☐ c. The Offeror has not identified an actual or potential OCI, under which as part of its performance of another Government procurement, the Offeror has drafted the Statement of Work, Specifications, Purchase Description or other Requirements for this proposed agreement.

☐ d. The Offeror has not identified an actual or potential OCI, under which as part of its performance of another Government procurement, the Offeror would evaluate itself or a related entity for this proposed agreement, either through an assessment of its performance or through an evaluation of proposals.

☐ e. The Offeror reviewed the nature of the work to be performed on this proposed procurement, and the offeror determined that the nature of work to be performed does not create an actual or potential conflict of interest, for the Offeror, on a previously awarded, current or future acquisition.

D. HAZARDOUS MATERIAL IDENTIFICATION AND MATERIAL SAFETY DATA (For applicability during PPA period of performance, see Appendix B – Project Other Terms and Conditions, E-5000.)

(a) “Hazardous material,” as used in this clause, includes any material defined as hazardous under the latest version of Federal Standard No.313 (including revisions adopted during the term of the PPA).

(b) The Offeror must list any hazardous material, as defined in paragraph (a) of this clause, to be delivered under this PPA. The hazardous material shall be properly identified and include any applicable identification number, such as National Stock Number or Special Item Number. This information shall also be included on the Material Safety Data Sheet submitted under this PPA.

Material (If none, insert “None”) Identification No.

(c) This list must be updated during performance of the PPA whenever the contractor determines that any other material to be delivered under this PPA is hazardous.

(d) The apparently successful Offeror agrees to submit, for each item as required prior to award, a Material Safety Data Sheet, meeting the requirements of 29 CFR1910.1200(g) and the latest version of Federal Standard No.313, for all hazardous material identified in paragraph (b) of this clause. Data shall be submitted in accordance with Federal Standard No.313, whether or not the apparently successful Offeror is the actual manufacturer of these items. Failure to submit the Material Safety Data Sheet prior to award may result in the apparently successful Offeror being considered nonresponsible and ineligible for award.

(e) If, after PPA award, there is a change in the composition of the item(s) or a revision to Federal Standard No.313, which renders incomplete or inaccurate the data submitted under paragraph (d) of this clause, the contractor shall promptly notify the Agreements Officer and resubmit the data.

(f) Neither the requirements of this clause nor any act or failure to act by the Government shall relieve the contractor of any responsibility or liability for the safety of Government, contractor, or subcontractor personnel or property.

(g) Nothing contained in this clause shall relieve the contractor from complying with applicable Federal, State, and local laws, codes, ordinances, and regulations (including the obtaining of licenses and permits) in connection with hazardous material.

(h) The Government’s rights in data furnished under the resulting PPA with respect to hazardous material are as follows:

(1) To use, duplicate and disclose any data to which this clause is applicable. The purposes of this right are to-

(i) Apprise personnel of the hazards to which they may be exposed in using, handling, packaging, transporting, or disposing of hazardous materials;

(ii) Obtain medical treatment for those affected by the material; and

(iii) Have others use, duplicate, and disclose the data for the Government for these purposes.

(2) To use, duplicate, and disclose data furnished under this clause, in accordance with paragraph (h)(1) of this clause, in precedence over any other clause of this PPA providing for rights in data.

(3) The Government is not precluded from using similar or identical data acquired from other sources.

DISTRIBUTION STATEMENT A. Approved for public release: distribution unlimited.

DISTRIBUTION STATEMENT A. Approved for public release: distribution unlimited.