TS-2663-1101135-A21.doc
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- Attached to
- 5X MISSION ASSURANCE SUPPORT SERVICES RECOMPETE Federal contract opportunity
- Solicitation number
- TS-2663-1101135
About this file
This is a Supplier Information Request Form (Form A-21) used by NASA's Jet Propulsion Laboratory (JPL) to collect vendor registration information. The form requires suppliers to provide business identification details including legal name, EIN, CAGE code, NAICS code, and SAM registration status. It collects location and payment addresses, contact information, congressional district, and requires vendors to specify their organization type (e.g., sole proprietor, corporation, LLC) and business classification (large business, small business, various socioeconomic categories).
The form is related to solicitation TS-2663-1101135 for Mission Assurance Support Services, which seeks to award two separate contracts to a single vendor for staff augmentation (Category A) and task-based work (Category Z) supporting JPL's Mission Assurance Division. This is a small business set-aside under NAICS 541715 with a 4-year base period and two 3-year options. The work includes specialized technical engineering services in reliability, environments, electromagnetic compatibility, risk assessment, quality assurance, electronic parts engineering, failure analysis, and structural analysis. The current contract is set to expire this calendar year with a planned phase-in period for the new award.
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Text version
Jet Propulsion Laboratory
California Institute of Technology
Jet Propulsion Laboratory
California Institute of Technology
Supplier Information Request Form (RFP/RFQ/ITB Attachment A-21)
Supplier Identification Information
Legal Business Name (name entered on tax return):
| Business Name / dba (if different from above): |
| Employer Identification Number (EIN): |
| - |
| Social Security Number (if no EIN): |
| - - |
| CAGE Code (Commercial and Government Entity) CAGE Codes are required by the Federal Acquisition Regulations. For more information or to register for a CAGE Code please go to https://cage.dla.mil/Home/UsageAgree |
| NAICS Code (North American Industry Classification System) |
For Primary Business Activity To find your NAICS code by key word please go to https://www.census.gov/eos/www/naics/
SAM Database (System for Award Management)
The System for Award Management is free to use. SAM is a primary source for federal government agencies to find potential vendors. Register at https://www.sam.gov/SAM/.
FORMCHECKBOX
By checking this box the supplier confirms they are registered in the SAM database. (Optional)
| Supplier Location Address |
| Supplier Payment Address ( FORMCHECKBOX |
same as location addr.)
| Street Address: |
| Street Address: |
| City: |
| State: |
| City: |
| State: |
Zip Code (xxxxx-xxxx):
https://www.usps.com
| - |
| Zip Code (xxxxx-xxxx): |
https://www.usps.com
| Country/Province: |
| Country/Province: |
| Contact Name: |
| Contact Name: |
| Contact Email Address |
| Contact Email Address |
Congressional District:
www.house.gov/representatives/find-your-representative
| Congressional District: |
www.house.gov/representatives/find-your-representative
| Phone Number: |
| ( )- - |
| Phone Number: |
| ( )- - |
| Fax Number: |
| ( )- - |
| Fax Number: |
| ( )- - |
Organization Type (please check the appropriate type):
For Information about Organization Type please go to https://www.sba.gov/business-guide/launch-your-business/choose-business-structure
FORMCHECKBOX
Individual/Sole proprietor
FORMCHECKBOX
Non-profit
Tax Exempt payee
Partnership
Government
Corporation; incorporated under the laws of the state of
Limited Liability Company (LLC) --- If “LLC” is checked, you must also select one of the following tax classifications: FORMCHECKBOX D=disregarded FORMCHECKBOX C=corporation FORMCHECKBOX P=partnership
Business Classification (check all appropriate boxes in the left OR right column) For Information about Business Classification please go to https://www.sba.gov/size-standards/
FORMCHECKBOX
Large Business
FORMCHECKBOX
Nonprofit Organization
FORMCHECKBOX
Foreign Business/Institution
FORMCHECKBOX
Government
FORMCHECKBOX
Educational Institution
FORMCHECKBOX
Historically Black Colleges & Universities/ Other Minority Institutions (HBCU/MI)
FORMCHECKBOX
Small Business (SB)
(plus any of the below, if appropriate)
FORMCHECKBOX
Small Disadvantaged Business (SDB)
FORMCHECKBOX
Woman-Owned (WO)
FORMCHECKBOX
HUBZone (HUBZ)
FORMCHECKBOX
Veteran-Owned (VO)
Service-Disabled VO (SDVO)
Notice of Potential Tax Withholding
To comply with CA Revenue and Taxation Code 18662 and CA Franchise Tax Board FTB Publ. 1023, and Internal Revenue Code 1441, JPL must determine if any tax reporting and tax withholding requirements are applicable. See Notice of Potential Tax Withholding (Form 7258) located at: http://www.jpl.nasa.gov/acquisition/terms-conditions/ under the Other Supporting Documents tile for additional information.
Supplier Certification of Information Provided
Subcontractor Name:
Authorized Signature:
Date:
Type/Print Name:
Type/Print Title:
See Page 3 below for Authorization for Electronic Invoice Payments
Authorization for Electronic Invoice Payments
Completion of this form authorizes the Jet Propulsion Laboratory to deposit payments due or that become due into the following bank account.
Name (As shown on the bank account):
Address:
Email Address: (For Remittance Advice)
Name of Financial Institution:
Financial Institution Address:
Account Number:
Bank’s ACH Routing Number:
Additional information necessary for International wire transfers. Wire transfers will be issued in either US dollars or foreign currency per invoice instructions.
Beneficiary BIC or SWIFT Code: __________________________________________________________________ IBAN Number: ___________________________________________________________
Intermediary Bank: (if Required): ___________________________________________________________
Intermediary Bank ABA: ___________________________________________________________ I understand and acknowledge that if the name on the electronic funds transfer (EFT) account is different than as shown on the Caltech-JPL Vendor Master File and as stated above, the financial institution’s procedures may cause a delay in the crediting of said account with my payments, and I hereby expressly relieve Caltech-JPL of any liability I may incur because of a delay caused by the application of a financial institution’s procedures and I agree to hold Caltech-JPL harmless.
I further acknowledge and understand that I must take all steps necessary to change or revoke this EFT authorization in the event I desire to change or revoke this authorization. I understand that any change or revocation must be given to Caltech-JPL at least 30 days prior to the desired effective date of such change or revocation.
I understand and acknowledge that upon the effective date of termination of the JPL contract/purchase order/Agreement, for any reason, from Caltech-JPL this authorization for EFT shall be deemed terminated and that the provisions of the California Code, relating to payment of vendors termination of services, shall apply.
Date Name of Company as it appears on JPL Subcontract or Purchase Order/BPA
Phone Number
Signature of Authorizing Person
JPL 7255-A21, 10/14
JPL 7255-A21, R 7/19 <>
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