Document Sample
RC Powered By Docstoc
					                 REPRESENTATIONS AND CERTIFICATIONS (March 2010)

  NOTICE: Under 15 U.S.C. 645(d), any person who misrepresents a firm’s status as a small, small disadvantaged, or women-owned small business
  concern in order to obtain a contract to be awarded under the preference programs established pursuant to Sections 8(a), 8(d), 9, or 15 of the Small
  Business Act or any other provision of Federal law that specifically references Section 8(d) for a definition of program eligibility, shall (1) be punished by
  imposition of a fine, imprisonment, or both; (2) be subject to administrative remedies including suspension and debarment; and (3) be ineligible for
  participation in programs conducted under the authority of the Act.

  By completing and signing this document the Offeror represents and certifies as part of its offer the following information: (Check or complete all applicable
  boxes or blocks.):

  As used herein, "offer" also means "quotation," "order" also means "subcontract," and "article" also means "clause."

1.     TYPE OF BUSINESS ORGANIZATION The Offeror operates as                          owned small business concern" means a small business concern Not
a ( ) a corporation, incorporated under the laws of the State                         less than 51 percent of which is owned by one or more service-disabled
of _______________ , ( ) an LLC, ( ) an individual, ( ) a partnership,                veterans or, in the case of any publicly owned business, not less than 51
( ) a nonprofit organization, or ( ) a joint venture. Tax Payer                       percent of the stock of which is owned by one or more service-disabled
Identification Number (TIN) ________________________                                  veterans; and (ii)     The management and daily business operations of
                                                                                      which are controlled by one or more service-disabled veterans or, in the
2.     SMALL BUSINESS CONCERN REPRESENTATION The North                                case of a veteran with permanent and severe disability, the spouse or
American Industry Classification (NAICS) code number 561210 and the                   permanent caregiver of such veteran. Service-disabled veteran means a
small business size standard for this procurement is $35.5 million. Based             veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-
on this classification Seller ( ) is, ( ) is not a small business concern.            connected, as defined in 38 U.S.C. 101(16).
Furthermore ( ) all, ( ) not all goods furnished will be manufactured or
produced by a small business concern in the United States, its                        7.      AFFIRMATIVE ACTION COMPLIANCE The Offeror (a) has ( )
possessions, Puerto Rico, or the Trust Territory of the Pacific Islands.              fewer than 50 employees, ( ) 50 or more employees.
As used throughout, "small business concern" means a concern,                         (b) It ( ) has developed and has on file, ( ) has not developed and does
including its affiliates, that is independently owned and operated, not               not have on file at each establishment affirmative action programs
dominant in the field of operation in which it is bidding on Government               required by the rules and regulations of the Secretary of Labor (41 CFR
contracts and subcontracts, and qualified as a small business as defined              60-1 and 60-2) or that (c) It ( ) has ( ) has not previously had contracts
in Section 3 of the Small Business Act (15 U.S.C. 632).                               or subcontracts subject to the requirement of written affirmative action
                                                                                      programs of the rules and regulations of the Secretary of Labor.
REPRESENTATION (a) Representation. The Offeror ( ) is, ( ) is not a                   8.   BUY AMERICAN CERTIFICATE (Must be completed for offers
small disadvantaged business concern. (b) Definitions. "Asian-Indian                  exceeding $2,500). Each end product, except those listed below, is a
American," as used in this provision, means a United States Citizen                   domestic end product (as defined in the Buy American Act), and that
whose origins are in India, Pakistan, or Bangladesh. "Asian-Pacific                   components of unknown origin are considered to have been mined,
American," as used in this provision, means a United States citizen                   produced, or manufactured outside of the United States, ref. FAR 52-
whose origins are in Japan, China, the Philippines, Vietnam, Korea,                   225-1.
Samoa, Guam, the U.S. Trust Territory of the Pacific Islands, the
Northern Mariana Islands, Laos, Cambodia, or Taiwan. "Native                                         Excluded End Products            Country of Origin
Americans, " as used in this provision, means American Indians,
Eskimos, Aleuts, and Native Hawaiians. "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 persons who are both
socially and economically disadvantaged, or a publicly owned business
having at least 51 percent of it s stock owned by one or more socially                (See FAR 25.108(d) for goods excepted from the Buy American Act)
and economically disadvantaged persons and (2) has its management
and daily business controlled by one or more such persons. Qualified
groups. The Offeror shall presume that socially and economically                      9.      ANTI-KICKBACK By submission of this offer, the Offeror certifies
disadvantaged persons include Black Americans, Hispanic Americans,                    that it has not provided, attempted to provide, offered to provide,
Native Americans, Asian-Pacific Americans, Asian-Indian Americans,                    solicited, accepted, or attempted to accept any kick-back; and has not
and other persons found to be qualified by the SBA under 13 CFR 124.1.                included, directly or indirectly, the amount of any kick-back in the offer.
                                                                                      “Kick-back” means any money, fee, commission, credit, gift, gratuity,
4.    WOMEN-OWNED SMALL BUSINESS REPRESENTATION (a)                                   thing of value, or compensation of any kind that is provided, directly or
Representation. The Offeror ( ) is, ( ) is not a women-owned small                    indirectly, to any Government prime contractor (e.g., the Company),
business concern. (b) Definition. "Women-owned," as used in this                      prime contractor employee, subcontractor at any tier, or employee of a
provision, means a small business that is at least 51 percent owned by a              subcontractor at any tier, for the purpose of improperly obtaining or
woman or women who are U.S. citizens and who also control and                         rewarding favorable treatment in connection with a Government prime
operate the business.                                                                 contract or in connection with a subcontract at any tier relating to a
                                                                                      Government prime contract.
The Offeror ( ) is, ( ) is not, a veteran-owned small business concern.               10. PREFERENCE FOR LABOR SURPLUS AREA CONCERNS (a)
"Veteran-owned small business concern" means a small business                         This acquisition is not a set-aside for labor surplus area (LSA) concerns,
concern (i)   Not less than 51 percent of which is owned by one or                    unless otherwise stated in the solicitation documents. However, the
more veterans (as defined in 38 U.S.C. 101(2)) or, in the case of any                 Offerors status as such a concern may affect (1) entitlement to award in
publicly owned business, not less than 51 percent of the stock of which is            case of tie offers or (2) offer evaluation in accordance with the Buy
owned by one or more veterans; and (ii)       The management and daily                American Act article of the order. To determine whether the Offeror is
business operations of which are controlled by one or more veterans.                  entitled to a preference under (1) or (2) above, the Offeror must identify
                                                                                      below the LSA in which the costs to be incurred on account of
6.    SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS                                   manufacturing or production (by the Offeror or the first-tier
REPRESENTATION The Offeror ( ) is, ( ) is not, a service-disabled                     subcontractors) amount to more than 50 percent of the order price. (b)
veteran-owned small business concern. "Service-disabled veteran-                      Failure to identify the locations as specified above will preclude
consideration of the Offeror as an LSA concern. If the Offeror is                 authorized agent, does certify that the principals named in subparagraph
awarded an order as an LSA concern and would not have otherwise                   (b)(2)(I) above have not participated and will not participate in any action
qualified for award, the Offeror shall perform the order or cause the order       contrary to subparagraphs (a)(1) through (a)(3) above; and (2) (iii) As an
to be performed in accordance with the obligations of the LSA concern.            agent, has not personally participated and will not participate in any
                                                                                  action contrary to subparagraphs (a)(1) through (a)(3) above. (c) If the
11. CERTIFICATION OF NONSEGREGATED FACILITIES                                     Offeror deletes or modifies subparagraph (a)(2) above, the Offeror must
(a) "Segregated facilities," as used in this provision, means any waiting         furnish with its offer a signed statement setting forth in detail the
rooms, work areas, restrooms and washrooms, restaurants and other                 circumstances of the disclosure.
eating areas, time clocks, locker rooms and other storage or dressing
areas, parking lots, drinking fountains, recreation or entertainment areas,       14. CLEAN AIR AND WATER CERTIFICATION (Must be completed
transportation and housing facilities provided for employees that are             for offers exceeding $100,000). The Offeror certifies that (a) Any facility
segregated by explicit directive or are in fact segregated on the basis of        to be used in the performance of this proposed order ( ) is, ( ) is not
race, color, religion, or national origin because of habit, local custom, or      listed on the Environmental Protection Agency (EPA) List of Violating
otherwise.                                                                        Facilities; (b) Before award, the Offeror will immediately notify the
                                                                                  Contractor of the receipt of any communication from the Administrator, or
(b) By the submission of this offer, the Offeror certifies that it does not       a designee, of the EPA, indicating that any facility that the Offeror
and will not maintain or provide for its employees any segregated                 proposes to use for the performance of the order is under consideration
facilities at any of it establishments, and that it does not and will not         to be listed on the EPA List of Violating Facilities; and (c) The Offeror will
permit its employees to perform their services at any location under its          include a certification substantially the same as this certification,
control where segregated facilities are maintained. The Offeror agree             including this paragraph (c), in every nonexempt lower-tier subcontract.
that a breach of this certification is a violation of the Equal Opportunity
article in the order.                                                             15.      CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
                                                                                  PROPOSED DEBARMENT,                   AND OTHER RESPONSIBILITY
(c) The Offeror further agrees that (except where it has obtained identical       MATTERS (a) To the best of its knowledge and belief, (1) The Offeror
certifications from proposed lower-tier subcontractors for specific time          and/or any of its principals - ( ) are ( ) are not presently debarred,
periods) it will (1) Obtain identical certifications from proposed                suspended, proposed for debarment, or declared ineligible for the award
lower-tier subcontractors before the award of lower-tier subcontracts             of contracts by any Federal agency; (ii) Have ( ) have not ( ), within a
under which the lower-tier subcontractor will be subject to the Equal             3-year period preceding this offer, been convicted of or had a civil
Opportunity article; (2) Retain the certifications in the files; and              judgment rendered against them for: commission of fraud or a criminal
(3) Forward the following notice to the proposed lower-tier                       offense in connection with obtaining, attempting to obtain, or performing
subcontractors (except if the proposed subcontractors have submitted              a public (Federal, state, or local) contract or subcontract; violation of
identical certifications for specific time periods):                              Federal or state antitrust statutes relating to the submission of offers; or
                                                                                  commission of embezzlement, theft, forgery, bribery, falsification or
12.      CONTINGENT FEE REPRESENTATION AND AGREEMENT                              destruction of records, making false statements, or receiving stolen
(Must be completed for offers exceeding $25,000). (a) Representation.             property; and (iii) are ( ) are not presently indicted for, or otherwise
The Offeror represents that, except for full-time bona fide employees             criminally or civilly charged by a governmental entity with, commission of
working solely for the Offeror, the Offeror (1) ( ) Has, ( ) has not              any of the offenses enumerated in Subdivision a.1.ii. above. (2) The
employed or retained any person or company to solicit or obtain this              Offeror ( ) has ( ) has not, within a 3-year period preceding this offer,
order; and (2) ( ) Has, ( ) has not paid or agreed to pay to any person           had one of more contracts terminated for default by any Federal agency.
or company employed or retained to solicit or obtain this order any               (3) “Principals,” for the purpose of this certification, means officers;
commission, percentage fee, brokerage fee, or other fee contingent upon           directors; owners; partners; and persons having primary management or
or resulting from the award of this order. (b) Agreement. The Offeror             supervisory responsibilities within a business entity (e.g., general
agrees to provide information relating to the above representation as             manager; plant manager; head of a subsidiary, division or business
requested by the Contractor and, when subparagraph (a)(1) or (a)(2) is            segment; and similar positions). This certification concerns a matter
answered affirmatively, to promptly submit to the Contractor (1) A                within the jurisdiction of an agency of the United States and the making
completed Standard Form 119, Statement of Contingent or Other Fees.               of a false, fictitious, or fraudulent certification may render the maker
(SF 119); or (2) A signed statement indicating that the SF 119 was                subject to prosecution under Section 1001, Title 18, United States Code.
previously submitted to the Contractor, including the date and applicable         c. The Offeror shall provide immediate written notice to the Contractor if
solicitation or order number, and representing that the prior SF 119              at any time prior to contract award, the Offeror learns that its certification
applies to this offer. For interpretation of the representation, including the    was erroneous when submitted or has become erroneous by reason of
term "bona fide employee," see Subpart 3.4 of the Federal Acquisition             changed circumstances. d. A certification that any of the circumstances
Regulations.                                                                      in Paragraph a above exists will not necessarily result in withholding of
                                                                                  an award under this solicitation. However, the certification will be
13. CERTIFICATE OF INDEPENDENT PRICE DETERMINATION                                considered in connection with a determination of the Offerors
(a) The Offeror certifies that (1) The prices in this offer have been arrived     responsibility. Failure of the Offeror to furnish a certification to the
at independently, without, for the purpose of restricting competition, any        Contractor or provide such additional information as requested may
consultation, communication, or agreement with any other Offeror or               render the Offeror non-responsible. e. Nothing contained in the foregoing
competitor relating to (I) those prices, (ii) the intention to submit an offer,   shall be construed to require establishment of a system of records in
or (iii) the methods or factors used to calculate the prices offered; (2) The     order to allow the Offeror to provide, in good faith, the certification
Offeror has not disclosed and will not knowingly disclose directly or             required by Paragraph a above. The knowledge and information of an
indirectly the prices in this offer to any other Offeror or competitor before     Offeror is not required to exceed that which is normally possessed by a
subcontract award unless otherwise required by law; and (3) The Offeror           prudent person in the ordinary course of business dealings. The
has not attempted and will not attempt to induce any other concern to             certification in Paragraph a above is a material representation of fact
submit or not to submit an offer for the purpose of restricting competition.      upon which reliance will be placed when making an award. If it is later
(b) Each signature on the offer is considered to be a certification by the        determined that the Offeror knowingly rendered an erroneous
signatory that the signatory (1) Is the person in the Offerors organization       certification, the Contractor may, in addition to other remedies available
responsible for determining the prices being offered in this proposal and         to it, terminate any contract resulting from this solicitation for default.
that the signatory has not participated and will not participate in any
action contrary to subparagraph (a)(1) through (a)(3) above; or (2)               16. CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS
(i) Has been authorized in writing to act as agent for the following              TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS                          (a) The
principals in certifying that those principals have not participated and will     definitions and prohibitions contained in the clause, at FAR 52.203-12,
not participate in any action contrary to subparagraphs (a)(1) through            Limitation on Payments to Influence Certain Federal Transactions,
(a)(3) above [insert full name of person(s) in the Offerors organization          included in this solicitation, are hereby incorporated by referenced in
responsible for determining the prices offered in this proposal and the           paragraph (b) of this certification. (b) The offeror, by signing its offer,
title of his or her position in the Offerors organization]; (2) (ii) As an        hereby certifies to the best of his or her knowledge and belief that on or
after December 23, 1989, - (1) No Federal appropriated funds have                             facilities primarily engaged in solvent recovery services
been paid or will be paid to any person for influencing or attempting to                      on a contract or fee basis); or
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
                                                                                        The facility is not located in the United States or its outlying
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                If certifying to one of the above exemptions, and after award of the
Federal loan, the entering into of any cooperative agreement, and the               contract circumstances change so that its owned or operated
extension, continuation, or renewal, amendment or modification of any               facilities used in the performance of this contract is no longer
Federal contract, grant, loan, or cooperative agreement; (2) If any funds           exempt, you are to notify the Contractor.
other than Federal appropriated funds (including profit or fee received
under a covered Federal transaction) have been paid, or will be paid, to       19. ORGANIZATIONAL CONFLICTS OF INTEREST ( ) To the best of
any person for influencing or attempting to influence an officer or            my knowledge and belief, no facts exist relevant to any past, present, or
employee of any agency, a Member of Congress, an officer or employee           currently planned interest or activity (financial, contractual, personal,
of Congress, or an employee of a Member of Congress on his or her              organizational, or otherwise) which relate to the proposed work; and bear
behalf in connection with this solicitation, the offeror shall complete and    on whether I have (or the organization has) a possible conflict of interest
submit, with its offer, OMB standard form LLL, Disclosure of Lobbying          with respect to (1) being able to render impartial, technically sound, and
Activities, to the Contracting Officer, and (3) He or she will include the     objective assistance or advise, or (2) being given an unfair (*)
language of this certification in all subcontract awards at any tier and       competitive          advantage           on          Proposal/Subcontract
require that all recipients of subcontract awards in excess of $100,00         #________________________.
shall certify and disclose accordingly. Submission of this certification and
disclosure is a prerequisite for making or entering into this contract         (*) An unfair competitive advantage does not include the normal flow of
imposed by section 1352, title 31, United Sates Code. Any person who           benefits from the performance of the subcontract.
makes an expenditure prohibited under this provision or who fails to file
or amend the disclosure form to be filed or amended by this provision,                                             (or)
shall be subjected to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.                                      ( ) A possible conflict of interest exists and are fully disclosed on the
                                                                               attached ( ) pages as follows:
17. EQUAL OPPORTUNITY (a) Offeror (                 ) has, (   ) has not,
participated in a previous contract or subcontract subject to the Equal                 The company, agency, organization in which you (or the
Opprtunity clause of this solicitation, or the clause contained in section               organization) have a past, present, or currently planned
201 of Executive Order No. 11114; (b) Offeror ( ) has, ( ) has not, filed                interest or activities (financial, contractual, organizational, or
all required compliance reports; and (c) Representations indicating                      otherwise);
submission of required compliance reports, signed by proposed                           A brief description of the relationship;
subcontractors, will be obtained before subcontract award.                              The period of the relationship;
                                                                                        The extent of the relationship (eg. value of financial interest of
18. TOXIC CHEMICAL RELEASE REPORTING Submission of this                                  work; percentage of total holdings).
certification is a prerequisite for making or entering into this subcontract
imposed by Executive Order 12969, August 8, 1995.                              If a possible conflict of interest exists a questionnaire may be required in
(a) By signing this offer, the Offeror certifies that—(1) As the owner or      order to obtain additional information.
operator of facilities that will be used in the performance of this
subcontract that are subject to the filing and reporting requirements          20. AFFIRMATIVE PROCUREMENT (a) In the performance of this
described in section 313 (a) and (g) of the Emergency Planning and             contract, if available, the offeror agrees to provide or make maximum use
Community Right-To-Know Act of 1986 (EPCRA) (42 U.S.C. 11023 (a)
                                                                               of recovered/energy efficient materials as required by the Resource
and (g)), and section 6607 of the Pollution Prevention Act of 1990 (PPA)
(42 U.S.C. 13106). The Offeror shall file, for each facility subject to the    Conservation and Recovery Act of 1976; and biobased products that are
Form R filing and reporting requirements, the annual Form R throughout         United States Department of Agriculture (USDA)-designated items
the life of the contract. (2) None of its owned or operated facilities to be   unless—
used in performance of this subcontract is subject to the Form R filing        (1) The product cannot be acquired—
and reporting requirements because each such facility is exempt for at         (i) Competitively within a time frame providing for compliance with the
least one of the following reasons: [Check each block that is appicable.]      contract performance schedule;
                                                                               (ii) Meeting contract performance requirements; or
                                                                               (iii) At a reasonable price.
          The facility does not manufacturer, process, or otherwise use       (2) The product is to be used in an application covered by a USDA
           any toxic chemicals listed in 40CFR 372.65;                         categorical exemption (see 7 CFR 2902.10 et seq.).
          The facility does not have 10 or more full time employees as
           specified in section 313(b)(1)(a) of EPCRA, 42U.S.C.
          The facility does not meet the reporting thresholds of toxic
           chemicals established under section 313(f) of EPCRA, 42
           U.S.C. 11023(f) (including the alternate thresholds at 40 CFR
           372.27, provided an appropriate certification form has been
                                                                               Offeror's Name
           filed with EPA);
          The facility does not fall within the following Standard            _____________________________________________
           Industrial Classification (SIC) codes or their corresponding        Name and Title of Individual
           North American Industry Classification system sectors:              Authorized to Sign/Certify for Offeror
           Major group code 10 (except 1011, 1081, and 1094).
           Major group code 12 (except 1241).
           Major group codes 20 through 39.                                   _____________________________________________
           Industry code 4911, 4931, or 4939 (limited to facilities that      Signature
               combust coal and/or oil for the purpose of generating
               power for distribution in commerce).                            _____________________________________________
           Industry code 4953 (limited to facilities regulated under          Date
               the Resource Conservation and Recovery Act, Subtitle C
               (42 U.S.C. 6921, et seq.)), 5169, 5171, or 7389 (limited to

Shared By: