QWEST GOVERNMENT SERVICES, INC.
SUBCONTRACTOR / SUPPLIER
NOTE : Please complete all information as requested herein, or mark N/A (Not Applicable).
Please complete even if you have worked for other QWEST companies.
Please attach a current company prospectus if available
Instructions for Completing the Subcontractor/Supplier
The purpose of this Questionnaire is to determine the business, performance, strategic and contractual
attributes of potential Subcontractors and Suppliers for Qwest Government Services, Incorporated. This is
consistent with our federally audited requirements for assuring responsibility of each subcontractor and
supplier we subcontract with and with QGSI’s Small Business Program and Federal Subcontracting Plans
with each agency.
The following are some points that will expedite processing of your questionnaire:
Complete this questionnaire even though you may have completed questionnaires from other
Qwest Entity Companies. This questionnaire is unique to Qwest Federal Services.
Complete this questionnaire even if you are currently performing under contract to QWEST
Government Services or any other Qwest Entity Companies.
Include copies of your financials for the last two (2) years. Audited reports if available,
accountant reports if audited reports are not available.
Include copies of licenses, certificates of insurance, and training certifications.
On the attached form please designate your type of business under Small Business Category
Definitions as defined on Attachment 1 to this Questionnaire.
Ensure Page 6 is properly signed by an authorized agent of your Company.
Direct any questions while completing your questionnaire to David Hinson at (703) 460-7577
or email: email@example.com.
Please send your completed package with all attachments to:
Manager, Qwest Government Services Procurement
Qwest Small Business Liaison Officer
4250 North Fairfax Drive, 220
Arlington, VA 22203
Voice: (703) 460-7577
Fax: 1-888-523-0016 (Preferred Method of Transmittal)
Information Must Be Printed Or Typed
LEGACOMPANY NAME TELEPHONE NUMBER
STREET ADDRESS CITY
MAILING ADDRESS CITY
INDIVIDUALLY OWNED PARTNERSHIP CORPORATION (list type)
TYPE OF BUSINESS
More than one may apply. Please complete each category that identifies your company.
You must certify these selection in the Representations and Certifications Below
LB SB SDB 8 (a) HUBZone VOB SDVOB Indian
PRINCIPAL OFFICER –
PRINCIPAL CONTACT –
FEDERAL TAX ID SOCIAL DUNS No,
NUMBER SECURITY NO (IF
PROVIDE THE STATES YOU ARE ABLE TO PROVIDE SERVICE(S) AND/OR PRODUCT(S)
____________ _____________ ____________ ____________ ____________
____________ _____________ ____________ ____________ ____________
List other additional
INTERNATIONAL: If yes, provide
Start Date(Month/Year) of
200_ 200_ 199_
Gross Revenues for Each
of the Last 3 Years:
Major Product(s) or
North American Industry
Classification System Code
For these codes see
www/naics.html for the
Federal Experience Has your Company performed work in fulfillment of a federal government contract?
If yes, list contract and if you were prime contractor, subcontractor or a
Has your company worked for Qwest before? Does your company have an agreement with
Yes No Yes No
Please explain: Please provide your contract number and
Does your Company have employees who possess security clearances?
If yes, provide the information below:
Employee Name Type/s of Clearances Status
(C, S, TS, SCI) Active/Inactive)
Does the Company have any business relationships or agreements with any manufacturer?
If yes, please describe below:
Performance History Has the Company, within a three-year period preceding the date of this questionnaire, had one
or more contracts terminated for default by any Federal agency or placed on GSA’s list of
contractor’s ineligible for federal procurement ?
If yes, please describe below:
Foreign Ownership Are any of the Directors, Officers, Partners or Principals of the Company foreign nationals?
If yes, please describe below:
Disclosure of Potential Are any of the Directors, Officers, Partners, Principals, Executives or Employees of the
Conflict of Interest Company employed by or have relatives who are employed by any of the QWEST Companies?
If yes, please describe below, including the name and position of the Qwest employee:
Federal Audit Has your Company had an independent outside audit from the government or others in the
past two (2) years?
If yes, what type of audit and can you provide summary information on the audit outcome if
required by Qwest?
Insurance List the type(s) and amount(s) of insurance coverage held by the Company:
(General Liability, Workman's Compensation , Auto)
Insurance CO./ include phone# Type of Coverage Amount
References Please provide the following financial and major client references
Financial Telephone Account
Financial Institution Contact Name Number Number
Major Clients Client Name Contact Name Telephone Number Years with Client
Awards/Industry Award/Recognition Awarding Month/Year of Description of
Recognition Organization Award Award
Potential Subcontractor/Supplier/Teaming Partner
Representations and Certifications
The potential subcontractor, supplier, offeror, or makes the following Representations and Certifications as
part of his offer. Offeror must check all appropriate boxes, sign and date on last page.
1. SMALL BUSINESS CONCERN REPRESENTATION
The offeror represents and certifies as part of its offer that it [ ] is, [ ] is not a small business concern and that
[ ] all, [ ] not all end items to be furnished will be manufactured or produced by a small business concern in
the United States, its territories or possessions, Puerto Rico, or the Trust territory of the Pacific Islands. "Small
business concern," as used in this provision, means a concern, including its affiliates, that is independently
owned and operated, not dominant in the field of operation in which it is bidding on Government contracts or
subcontracts, and qualified as a small business under the size standards prescribed by the Small Business
Administration (see Code of Federal Regulations (CFR), Title 13, Part 121, as amended, which contains
detailed industry definitions and related procedures).
2. SMALL DISADVANTAGED BUSINESS CONCERN REPRESENTATION
The offeror represents that it [ ] is, [ ] is not a small disadvantaged business (SDB) concern. "Small
disadvantaged business concern," as used in this provision, means a small business concern that (1) is at least
51 percent owned by one or more individuals who are both socially and economically disadvantaged, or a
publicly owned business having at least 51 percent of its stock owned by one or more socially and
economically disadvantaged individuals and (2) has its management and daily business controlled by one or
more such individuals. Qualified groups include Black Americans, Hispanic Americans, Native Americans,
Asian-Pacific Americans, Asian-lndian Americans, and other individuals found to be qualified by the Small
Business Administration under 13 CFR 124.1.
The offeror represents that it [ ] is, [ ] is not qualified under the SBA 8(a) Program. A copy of the SBA
document citing your 8(a) status must be attached hereto.
NOTE: SDB CERTIFICATION [(8a) firms are exempt]
In order to qualify as a SDB, a firm must be certified by the Small Business Administration (SBA) and
registered in the SBA PRO-Net database that certifies they are a SDB. In order to obtain such certification,
a firm must apply to the SBA. The application, available through the SBA, shall include evidence
demonstrating that the firm is owned and controlled by individual(s) claiming disadvantaged status,
together with certifications or narrative referencing the disadvantaged status. A copy of your SDB
certification must accompany the proposal.
3. DISADVANTAGED OWNERSHIP
Complete if the offeror has represented itself as disadvantaged in paragraph 5 of this provision. [The
offeror shall check the category in which its ownership falls]:
____ Black American.
____ Hispanic American.
____ Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians).
____ Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore,
Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust
Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of
Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji,
Tonga, Kiribati, Tuvalu, or Nauru).
____ Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh,
Sri Lanka, Bhutan, the Maldives Islands, or Nepal).
____ Individual/concern, other than one of the proceeding.
4. HUBZONE SMALL BUSINESS
The offeror represents that it [ ] is, [ ] is not a HUBZone small business concern listed, on the date of this
representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small
Business Administration, and no material change in ownership and control, principal place of ownership, or
HUBZone employee percentage has occurred since it was certified by the Small Business Administration in
accordance with 13 CFR part 126.
5. WOMEN-OWNED SMALL BUSINESS REPRESENTATION
The offeror represents that it [ ] is, [ ] is not a women-owned small business concern. "Women-owned small
business concern," as used in this provision, means a small business concern that is at least 51 percent owned
by a woman or women who are U.S. citizens and who also control and operate the business.
6. VETERAN-OWNED SMALL BUSINESS REPRESENTATION
The offeror represents that it [ ] is, [ ] is not a veteran-owned small business concern. "Veteran-owned small
business concern" as used in this provision means a small business concern that is at least 51 percent owned
by one or more veterans (as defined at 38 U.S.C 101(2)) or, in the case of a NY publicly owned business, at
least 51 percent of the stock of which is owned by one or more veterans; and the management and daily
operations of which are controlled by one or more veterans.
7. SERVICE-DISABLED VETERAN- OWNED SMALL BUSINESS REPRESENTATION
The offeror represents that it [ ] is [ ] is not a service-disabled veteran-owned small business concern.
"Service-disabled veteran-owned small business concern" as used in this provision means a small business
concern that is at least 51% owned by one or more service-disabled veterans or, in the case of a publicly
owned business, at least 51 percent of the stock of which is owned by one or more service-disabled veterans,
and the management and daily operations of which are controlled by one or more service-disabled veterans, or
in the case of a veteran with permanent and severe disability, the spouse or permanent caregiver of such
NOTE: Under 15 U.S.C. 645(d), any person who misrepresents its size status shall (1) be punished by a fine,
imprisonment, or both; (2) be subject to administrative remedies; and (3) be ineligible for participation in
programs conducted under the authority of the Small Business Act.
8. CERTIFICATION OF NONSEGREGATED FACILITIES
"Segregated facilities," as used in this provision, means any waiting rooms, work areas, rest
rooms and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other
storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas,
transportation, and housing facilities provided for employees, that are segregated by explicit
directive or are in fact segregated on the basis of race, color, religion, or national origin because
of habit, local custom, or otherwise.
By the submission of this offer, the offeror certifies that it does not and will not maintain or provide for its
employees any segregated facilities at any of its establishments, and that it does not and will not permit its
employees to perform their services at any location under its control where segregated facilities are
maintained. The offeror agrees that a breach of this certification is a violation of the Equal Opportunity clause
in any subcontract or purchase order resulting from this solicitation.
The offeror further agrees that (except where it is obtained identical certifications from proposed
subcontractors for Specific time Periods) it will:
(1) Obtain identical certifications from proposed subcontractors before the award of
subcontracts under which the subcontractor will be subject to the Equal Opportunity clause;
(2) Retain the certifications in the files; and
(3) Forward the following notice to the proposed subcontractors (except if the proposed subcontractors have
submitted identical certifications for specific time periods):
NOTICE TO PROSPECTIVE SUBCONTRACTORS OR REQUIREMENT FOR
CERTIFICATIONS OF NONSEGREGATED FACILITIES
A certification of Nonsegregated Facilities must be submitted before the award of a subcontract under which
the subcontractor will be subject to the Equal Opportunity clause. The certifications may be submitted either
for each subcontract or for all subcontracts during a period (i.e., quarterly, semiannually, or annually).
9. PREVIOUS CONTRACTS AND COMPLIANCE REPORTS
The offeror represents that it (a) [ ] has, [ ] has not participated in a previous contract or subcontract subject to
the Equal Opportunity clause of this solicitation, (b) [ ] has, [ ] has not, filed all required compliance reports;
and (c) representations indicating submission of required compliance reports, signed by proposed
subcontractors, will be obtained before subcontract awards.
10. AFFIRMATIVE ACTION COMPLIANCE
The offeror represents that (a) it [ ] has developed and has on file, [ ] has not developed and does not have on
file, at each establishment, affirmative action programs required by the rules and regulations of the Secretary
of Labor (41 CFR 60-1 and 60-2), or (b) it [ ] has not previously had contracts subject to the written
affirmative action programs requirement of the rules and regulations of the Secretary of Labor.
11. DAVIS-BACON ACT CERTIFICATION
(Applicable to construction, alteration and repair of public buildings)
The offeror hereby certifies that it is familiar with, and, if applicable, will comply with, the Davis-Bacon Act
(40 U.S.C. Section 276a). The offeror further agrees to indemnify and hold harmless Qwest Government
Services Inc. from and against all claims, losses, demands, liabilities, obligations, costs and expenses
(including reasonable attorney's fees), or rights of actions which arise out of, result from, or are caused by
offer's noncompliance with the Davis-Bacon Act.
12. BUY AMERICAN ACT - SUPPLIES
(a) The Buy American Act (41 U.S.C. 10) provides that the Government gives preference to domestic end
"Components," as used in this clause, means those articles, materials, and supplies incorporated directly
into the end products.
"Domestic end product," as used in this clause, means (1) an unmanufactured end product mined or
produced in the United States, or (2) an end product manufactured in the United States, if the cost of its
components mined, produced, or manufactured in the United States exceeds 50 percent of the cost of all its
components. Components of foreign origin of the same class or kind as the products referred to in
subparagraphs (b)(2) or (3) of this clause shall be treated as domestic. Scrap generated, collected, and
prepared for processing in the United States is considered domestic.
"End products," as used in this clause, means those articles, materials, and supplies to be acquired for
public use under this contract.
(b) The Contractor shall deliver only domestic end products, except those--
(1) For use outside the United States;
(2) That the Government determines are not mined, produced, or manufactured in the United States in
sufficient and reasonably available commercial quantities of a satisfactory quality;
(3) For which the agency determines that domestic preference would be inconsistent with the public
(4) For which the agency determines the cost to be unreasonable (see FAR 25.105).
13. BUY AMERICAN CERTIFICATE
The offeror certifies that each end product, except those listed below, is a domestic end product (as defined
in the clause entitled "Buy American Act--Supplies"), and that components of unknown origin are
considered to have been mined, produced, or manufactured outside the United States.
Excluded End Products Country of Origin
14. CONTINGENT FEE
Except for full-time bona fide employees working solely for Seller, Seller warrants that he has not
employed or retained and shall not employ or retain any person or company to solicit or obtain contracts or
subcontracts from Qwest and has not agreed and shall not agree to pay any such person or company any
commission, percentage, brokerage or other fee contingent upon or resulting from the award of such
contract or subcontract.
15. SERVICE CONTRACT ACT CERTIFICATION
If FAR Clause 52.222-41, "Service Contract Act of 1965" is applicable to this procurement, the offeror
certifies that it is familiar with and will comply with the requirements of the clause.
The offerer further agrees to indemnify and hold Qwest Government Services Inc. harmless from and against
all claims, losses, demands, liabilities, obligations, costs, expenses (including reasonable attorney's fees), or
rights of action which arise out of, results from, or are caused by offerer's noncompliance with the Service
Contract Act of 1965.
16. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT
AND OTHER RESPONSIBILITY MATTERS
(a) (1) The Offeror certifies, to the best of its knowledge and belief, that
(i) The Offeror and/or any of its Principals
(A) Are [ ] are not [ ] presently debarred, suspended, proposed for debarment, or declared
ineligible for the award of contracts by a Federal Agency;
(B) Have [ ] or have not [ ], within the three year period preceding this offer, been convicted
of or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public Federal,
state, or local contract or subcontract; violation of Federal or state antitrust statutes relating to
the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification
or destruction of records, making false statement, or receiving stolen property,
(C) Are [ ] are not [ ] presently indicted for, or otherwise criminally or civilly charged by a
governmental entity with, commission of any of the offenses enumerated in subdivision (a) (1)
(i) (B) of this provision;
(ii) (A) The offeror, aside from the offenses enumerated in paragraphs (a)(1)(I)(A), (B), and (C) of this
provision, has [ ] has not [ ] within the past three years, relative to tax, labor and employment,
environmental, antitrust, or consumer protection laws--
(1) Been convicted of a Federal or state felony (or has any Federal or state felony indictments
currently pending against them), or
(2) Had a Federal court judgment in a civil case brought by the United States rendered against
(3) Had an adverse decision by a Federal administrative law judge, board, or commission
indicating a willful violation of law.
(B) If the offeror has responded affirmatively, the offeror shall provide additional information if
requested by the Contracting Officer, and
(iii) The Offeror has [ ] has not [ ], within a 3-year period preceding this offer, had one or more
contracts/subcontracts terminated for default by any Federal agency.
(2) “Principals," for the purposes of this certification, means officers; directors; owners; partners; and, persons
having primary management or supervisory responsibilities within a business entity (e.g., general
manager; plant manager; head of a subsidiary, division, or business segment, and similar positions).
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 UNDER SECTION
1001, TITLE 18, UNITED STATES CODE.
(b) The Offeror shall provide immediate written notice to the Contractor if, at any time prior to subcontract
award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
(c) A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in
withholding of an award under this solicitation. However, the certification will be considered in connection
with a determination of the Offeror's responsibility. Failure of the Offeror to furnish a certification or provide
such additional information as requested by the Contractor may render the Offeror non-responsible.
(d) Nothing contained in the foregoing shall be construed to require establishment of a system of records in
order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and
information of an Offeror is not required to exceed that which is normally possessed by a prudent person in
the ordinary course of business dealings.
(e) The certification in paragraph (a) of this provision is a material representation of fact upon which reliance
was placed when making award. If it is later determined that the Offeror knowingly rendered an erroneous
certification, in addition to other remedies available to the Government, the Contractor may terminate the
contract resulting from this solicitation for default.
17. CLEAN AIR AND WATER CERTIFICATION
The offeror certifies that:
(a) Any facility to be used in the performance of this proposed subcontract [ ] is, [ ] is not listed on the
Environmental Protection Agency List of Violating Facilities;
(b) The offeror will immediately notify the Contracting Agent before award, of the receipt of any
communication from the Administrator, or a designee, of the Environmental Protection Agency, indicating
that any facility that the offeror proposes to use for the performance of the subcontract is under consideration
to be listed on the EPA List of violating Facilities; and
(c) The offeror will include a certification substantially the same as this certification, including this paragraph
(c) in every nonexempt subcontract.
18. CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE
CERTAIN FEDERAL TRANSACTIONS
(a) The definitions and prohibitions contained in the clause, at FAR 52.203-12, Limitation on Payments to
Influence Certain Federal Transactions, included in this solicitation, are hereby incorporated by reference in
paragraph (b) of this certification.
(b) The offeror, by signing its offer, hereby certifies to the best of his or her knowledge and belief that
(1) No Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, or a employee
of a Member of Congress on his or her behalf in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment or modification of any
Federal contract, grant, loan, or cooperative agreement:
(2) If any funds other than Federal appropriated funds (including profit or fee received under a
covered Federal transaction) have been paid, or will be paid, to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress on his or her behalf in connection
with this solicitation, the offeror shall complete and submit, with its offer OMB standard form L.L.L
Disclosure of Lobbying Activities, to the Contracting Officer, and
(3) He or she will include the language of this certification in all subcontract awards at any tier and
require that all recipients of subcontract awards in excess of $100,000 shall certify and disclose
(c) Submission of this certification and disclosure is a prerequisite for making or entering into this contract
imposed by section 1352, title 31, United States Code. Any person who makes an expenditure prohibited
under this provision of who fails to file or amend the disclosure form to be filed or amended by this provision,
shall be subject to a civil penalty of not less than $10,000, and not more than $100,000, for each such failure.
19. CERTIFICATE OF INDEPENDENT PRICE DETERMINATION
(a) The Offeror certifies that -
(1) The prices in this offer have been arrived at independently, without, for the purpose of restricting
competition, any consultation, communication, or agreement with any other offeror or competitor relating to -
(i) Those prices:
(ii) The intention to submit an offer; or
(iii) The methods or factors used to calculate the price offered:
(2) The prices in this offer have not been and will not be knowingly disclosed by the offeror, directly or
indirectly, to any other offeror or competition before bid opening (in the case of a sealed bid solicitation) or
contract award (in the case of a negotiated solicitation) unless otherwise required by law; and
(3) No attempt has been made or will be made by the offeror to induce any other concern to submit or not to
submit an offer for the purpose of restricting competition.
(b) Each signature on the offer is considered to be a certification by the signatory that the signatory -
(1) Is the person tin the offeror's organization responsible for determining the prices being offered in this bid
or proposal, and that the signatory has not participated and will not participate in any action contrary to
subparagraphs (a)(1) through (a)(3) of this provision, or
(2)(I) Has been authorized, in writing, to act as agent for the following principals in certifying that those
principals have not participated and will not participate in any action contrary to subparagraphs (a)(1) through
(a)(3) of this provision ____________________________________________________________[insert full
name of person(s) in the offeror's organization responsible for determining the prices offered in this bid or
proposal, and the title of his or her position in the offeror's organization];
(ii) As an authorized agent, does certify that the principals named in subdivision (b)(2)(I) of this
provision have not participated and will not participate in any action contrary to subparagraphs (a)(1) through
(a)(3) of this provision; and
(iii) As an agent, has not personally participated, and will not participate, in any action contrary to
subparagraphs (a)(1) through d(a)(3) of this provision.
(c) If the offeror deletes or modifies subparagraph (a)(2) of this provision, the offeror must furnish with its
offer a signed statement setting forth in detail the circumstances of the disclosure.
20. COST ACCOUNTING STANDARDS NOTICES AND CERTIFICATION (FAR 52.230-1)
NOTE: This notice does not apply to small businesses, commercial subcontracts, foreign
governments or Firm Fixed Price Subcontracts where cost or pricing data is not required.
The offeror claims an exemption by virtue of its status as a [ ] small business, [ ] foreign
government, [ ] commercial subcontract .[ ] FFP subcontract.
This notice is in three parts, identified by Roman numerals I through III.
I. DISCLOSURE STATEMENT--COST ACCOUNTING PRACTICES AND CERTIFICATION
(a) Any subcontract in excess of $500,000, not exempted above, will be subject to the requirements of the
Cost Accounting Standards Board (CASB) (48 CFR Chapter 99) except for those subcontracts exempt as
specified in 48 CFR 9903.201-1.
(b) Any offeror submitting a proposal which, if accepted, will result in a subcontract subject to the
requirements of the CASB must, as a condition of subcontracting, submit a Disclosure Statement as required
by regulations of the Board. When required the Disclosure Statement must be submitted as a part of the
offeror's proposal under the solicitation unless the offeror has already submitted a Disclosure Statement
disclosing the practices used in connection with the pricing of its proposals. If an applicable Disclosure
Statement has already been submitted, the offeror may satisfy the requirement for submission by providing
the information requested in paragraph (c) below.
CAUTION: A practice disclosed in a Disclosure Statement shall not, by virtue of such disclosure, be deemed
to be a proper, approved, or agreed to practice for pricing proposals or accumulating and reporting
subcontract performance cost data.
(c) Offeror shall check the appropriate box (1)), (2), (3), or (4) below:
[ ] (1) Certificate of Concurrent Submission of Disclosure Statement
The offeror hereby certifies that, as a part of its bid, copies of its Disclosure Statement have been concurrently
submitted as follows:
(i) original and one copy to the offeror's cognizant Administrative Contracting Officer (ACO), and
(ii) one copy to the offeror's cognizant contract/subcontract auditor.
(Disclosure must be on Form Number CASB-DS-1Or CASB-DS-22. Forms may be obtained from the
offeror's cognizant ACO.)
Date of Disclosure Statement:__________________
Name and Address of ACO where filed:
(City) (State) (Zip Code)
The offeror further certifies that practices used in estimating costs in pricing its proposals are consistent with
the cost accounting practices disclosed in the concurrently submitted Disclosure Statement.
[ ] (2) Certificate of Previously Submitted Disclosure Statement
The offeror hereby certifies that its Disclosure Statement was previously filed as follows:
Date of Disclosure Statement:__________________
Name and Address of ACO where filed:
(City) (State) (Zip Code)
The offeror further certifies that practices used in estimating costs in pricing its proposals are consistent with
the cost accounting practices disclosed in the previously submitted Disclosure Statement.
[ ] (3) Certificate of Monetary Exemption
The offeror hereby certifies that, together with all divisions, subsidiaries, and affiliates under offeror's
common control, it did not receive net awards of negotiated/competitive prime contracts and subcontracts
subject to CAS totaling more than $50 Million (of which at least one award exceeded $1 million) in the cost
accounting period immediately preceding the period in which its proposal was submitted. The offeror further
certifies- that if such status changes before an award is made to it resulting from its proposal, the offeror will
advise the Contractor immediately.
[ ] (4) Certificate of Interim Exemption
The offeror hereby certifies that:
(i) It first exceeded the monetary exemption for disclosure, as defined in (3) above, in the cost accounting
period immediately preceding the period in which its offer was submitted; and,
(ii) In accordance with 48 CFR 9903.202-1, the offeror is not yet required to submit a Disclosure Statement.
The offeror further certifies that if an award resulting from its proposal has not been made within 90 days after
the end of that period, the offeror will immediately submit a revised certificate to its Contracting Officer in the
form specified under (1) or (2) above, as appropriate, to verify submission of a completed Disclosure
CAUTION: Offerors currently required to disclose, because they were awarded a CAS-covered national
defense prime contract or subcontract of $50 million or more in the current cost accounting period,
may not claim this exemption (4). Further, the exemption applies only in connection with proposals
submitted before expiration of the 90-day period following the cost accounting period in which the
monetary exemption was exceeded.
II. COST ACCOUNTING STANDARD--ELIGIBILITY FOR MODIFIED CONTRACT
If the offeror is eligible to use the modified provisions of 48 CFR 9903.201-2(b) and elects to do so, the
offeror shall so indicate by checking the box below. Checking the box below shall mean that the resultant
subcontract is subject to the Disclosure and Consistency of Cost Accounting Practices clause in lieu of the
Cost Accounting Standards clause.
[ ] The offeror hereby claims an exemption from the Cost Accounting Standards clause under the provisions
of 48 CFR 3303.201 (b) and certifies that the offeror is eligible for use of the Disclosure and Consistency of
Cost Accounting Practices clause because:
during the cost accounting period immediately preceding the period in which its proposal was
submitted, the offeror received less than $50 million in awards of CAS-covered prime contracts
and subcontracts, or the offeror did not receive a single CAS covered award exceeding $1
million. The offeror further certifies that if such status changes before an award resulting from its
proposal, the offeror will advise the Contractor immediately.
CAUTION: An offeror may not claim the above eligibility for modified subcontract coverage if its proposal
is expected to result in the award of a subcontract of $50 million or more or if, during its current cost
accounting period, the offeror has been awarded a single CAS-covered prime contract or subcontract
of $25 million or more.
III. ADDITIONAL COST ACCOUNTING STANDARDS APPLICABLE TO EXISTING
The offeror shall indicate below whether award of the contemplated subcontract would, in
accordance with paragraph (a) (3) of the Cost Accounting Standards clause, require a change in
offeror's established cost accounting practices affecting existing contracts and subcontracts.
[ ] YES [ ] NO
NOTE: If the offeror checked "yes" above and is awarded the contemplated subcontract, the offeror will be
required to comply with the requirements of paragraphs (a)(i), (b), and (c) of the Administration of Cost
Accounting Standards clause.
Matters set forth in the foregoing are true and correct to the best of my knowledge. Permission is hereby granted to
QWEST Government Services, Inc., its employees and agents to make inquiries regarding the foregoing matters and all
matters relevant thereto. Failure to complete any questions pertinent to your firm may result in disqualification
The undersigned, on behalf of the Seller, certifies the information contained in this form to be true and correct to the best
of Seller's knowledge. I recognize that the Corporation may forward these certifications to the U.S. Government and that
if any of the above statements are intentionally false, I may be subject to the penalties prescribed in 18 U.S.C. 1001.
Legal Name of Company
SEAL (if a corporation):
Corporate Secretary Date
IMPORTANT: Under 15 U.S.C. 645(d), any person who misrepresents a firm's status as a small, small
disadvantaged, small women-owned, or HUBZone small business in order to obtain a contract to be
awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small
Business Act or any other provision of the Federal law that specifically references section 8(d) for a
definition of program eligibility, shall (i) be punished by imposition of fine, imprisonment, or both; (ii) be
subject to administrative remedies, including suspension and debarment; and (iii) be ineligible for
participation in programs conducted under the authority of the Act.