Fillable Printable Representations And Certifications

Representations And Certifications

INITIALS: &

LESSOR GOVERNMENT

REPRESENTATIONS AND CERTIFICATIONS

(Acquisition of Leasehold Interests in Real Property)

Solicitation Number Dated

Complete appropriate boxes, sign the form, and attach to offer.

The Offeror makes the following Representations and Certifications. NOTE: The "Offeror," as used on

this form, is the owner of the property offered, not an individual or agent representing the owner.

1. 52.219-1 - SMALL BUSINESS PROGRAM REPRESENTATIONS (APR 2011)

(a) (1) The North American Industry Classification System (NAICS) code for this acquisition

is 531190.

(2) The small business size standard is $20.5 Million in annual average gross revenue of

the concern for the last 3 fiscal years.

(3) The small business size standard for a concern which submits an offer in its own

name, other than on a construction or service contract, but which proposes to furnish

a product which it did not itself manufacture, is 500 employees.

(b) Representations.

(1) The offeror represents as part of its offer that it

[ ]

is,

[ ]

is not a small business

concern.

(2) [

Complete only if the offeror represented itself as a small business concern in

paragraph (b)(1) of this provision

.] The offeror represents, for general statistical

purposes, that it

[ ]

is,

[ ]

is not, a small disadvantaged business concern as defined

in 13 CFR 124.1002.

(3) [

Complete only if the offeror represented itself as a small business concern in

paragraph (b)(1) of this provision

.] The offeror represents as part of its offer that it

[ ]

is,

[ ]

is not a women-owned small business concern.

(4) Women-owned small business (WOSB) concern eligible under the WOSB Program.

[

Complete only if the offeror represented itself as a women-owned small business

concern in paragraph (b)(3) of this provision.

] The offeror represents as part of its offer

that—

(i) It

[ ]

is,

[ ]

is not a WOSB concern eligible under the WOSB Program, has

provided all the required documents to the WOSB Repository, and no change

in circumstances or adverse decisions have been issued that affects its

eligibility; and

(ii) It

[ ]

is,

[ ]

is not a joint venture that complies with the requirements of 13 CFR

part 127, and the representation in paragraph (b)(4)(i) of this provision is

accurate in reference to the WOSB concern or concerns that are participating

in the joint venture. [

The offeror shall enter the name or names of the WOSB

concern or concerns that are participating in the joint venture:

]

Each WOSB concern participating in the joint venture shall submit a separate

signed copy of the WOSB representation.

(5) Economically disadvantaged women-owned small business (EDWOSB) concern.

[

Complete only if the offeror represented itself as a women-owned small business

concern eligible under the WOSB Program in (b)(4) of this provision.

] The offeror

represents as part of its offer that—

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(i) It

[ ]

is,

[ ]

is not an EDWOSB concern eligible under the WOSB Program, has

provided all the required documents to the WOSB Repository, and no change

in circumstances or adverse decisions have been issued that affects its

eligibility; and

(ii) It

[ ]

is,

[ ]

is not a joint venture that complies with the requirements of 13 CFR

part 127, and the representation in paragraph (b)(5)(i) of this provision is

accurate in reference to the EDWOSB concern or concerns that are

participating in the joint venture. [

The offeror shall enter the name or names of

the EDWOSB concern or concerns that are participating in the joint venture:

]

Each EDWOSB concern participating in the joint venture shall submit a

separate signed copy of the EDWOSB representation.

(6) [

Complete only if the offeror represented itself as a small business concern in

paragraph (b)(1) of this provision

.] The offeror represents as part of its offer that it

[ ]

is,

[ ]

is not a veteran-owned small business concern.

(7) [

Complete only if the offeror represented itself as a veteran-owned small business

concern in paragraph (b)(6) of this provision

.] The offeror represents as part of its offer

that it

[ ]

is,

[ ]

is not a service-disabled veteran-owned small business concern.

(8) [

Complete only if the offeror represented itself as a small business concern in

paragraph (b)(1) of this provision

.] The offeror represents, as part of its offer, that—

(i) 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 changes in

ownership and control, principal office, or HUBZone employee percentage

have occurred since it was certified in accordance with 13 CFR Part 126; and

(ii) It

[ ]

is,

[ ]

is not a HUBZone joint venture that complies with the requirements

of 13 CFR Part 126, and the representation in paragraph (b)(8)(i) of this

provision is accurate for each HUBZone small business concern participating in

the HUBZone joint venture. [

The offeror shall enter the names of each of the

HUBZone small business concerns participating in the HUBZone joint venture:

Each HUBZone small business concern participating in the HUBZone joint

venture shall submit a separate signed copy of the HUBZone representation.

(c)

Definitions

. As used in this provision—

“Economically disadvantaged women-owned small business (EDWOSB) concern” means a

small business concern that is at least 51 percent directly and unconditionally owned by, and

the management and daily business operations of which are controlled by, one or more

women who are citizens of the United States and who are economically disadvantaged in

accordance with 13 CFR part 127. It automatically qualifies as a women-owned small

business concern eligible under the WOSB Program.

“Service-disabled veteran-owned small business concern”—

(1) Means a small business concern—

(i) Not less than 51 percent of which is owned by one or more service-disabled

veterans or, in the case of any publicly owned business, not less than 51

percent of the stock of which is owned by one or more service-disabled

veterans; and

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(ii) The management and daily business operations of which are controlled by one

or more service-disabled veterans or, in the case of a service-disabled veteran

with permanent and severe disability, the spouse or permanent caregiver of

such veteran.

(2) “Service-disabled veteran” means a veteran, as defined in 38 U.S.C.101(2)

, with a

disability that is service-connected, as defined in 38 U.S.C. 101(16).

“Small business concern” 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, and qualified as a small business under the criteria in 13 CFR

Part 121 and the size standard in paragraph (a) of this provision.

“Veteran-owned small business concern” means a small business concern—

(1) Not less than 51 percent of which is owned by one or more veterans (as defined at 38

U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51

percent of the stock of which is owned by one or more veterans; and

(2) The management and daily business operations of which are controlled by one or

more veterans.

“Women-owned small business concern” means a small business concern—

(1) That is at least 51 percent owned by one or more women; or, in the case of any

publicly owned business, at least 51 percent of the stock of which is owned by one or

more women; and

(2) Whose management and daily business operations are controlled by one or more

women.

“Women-owned small business (WOSB) concern eligible under the WOSB Program” (in

accordance with 13 CFR part 127), means a small business concern that is at least 51

percent directly and unconditionally owned by, and the management and daily business

operations of which are controlled by, one or more women who are citizens of the United

States.

(d) Notice.

(1) If this solicitation is for supplies and has been set aside, in whole or in part, for small

business concerns, then the clause in this solicitation providing notice of the set-aside

contains restrictions on the source of the end items to be furnished.

(2) Under 15 U.S.C. 645(d)

, any person who misrepresents a firm’s status as a business

concern that is small, HUBZone small, small disadvantaged, service-disabled veteran-

owned small, economically disadvantaged women-owned small, or women-owned

small eligible under the WOSB Program in order to obtain a contract to be awarded

under the preference programs established pursuant to section 8, 9, 15, 31, and 36 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—

(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.

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2. 52.204-5 - WOMEN-OWNED BUSINESS (OTHER THAN SMALL BUSINESS) (MAY 1999)

(a)

Definition

. "Women-owned business concern," as used in this provision, means a concern

which is at least 51 percent owned by one or more women; or in the case of any publicly

owned business, at least 51 percent of its stock is owned by one or more women; and

whose management and daily business operations are controlled by one or more women.

(b)

Representation

. [Complete only if the Offeror is a women-owned business concern and has

not represented itself as a small business concern in paragraph (b)(1) of FAR 52.219-1,

Small Business Program Representations, of this solicitation. ] The Offeror represents that it

[ ]

is a women-owned business concern.

3. 52.222-22 - PREVIOUS CONTRACTS AND COMPLIANCE REPORTS (FEB 1999)

(Applicable when the estimated value of the acquisition exceeds $10,000)

The Offeror represents that—

(a) It

[ ]

has,

[ ]

has not participated in a previous contract or subcontract subject to the Equal

Opportunity clause of this solicitation;

(b) It

[ ]

has,

[ ]

has not filed all required compliance reports; and

subcontractors, will be obtained before subcontract awards. (Approved by OMB under

Control Number 1215-0072.)

4. 52.222-25 - AFFIRMATIVE ACTION COMPLIANCE (APR 1984)

(Applicable when the estimated value of the acquisition exceeds $10,000)

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. (Approved by OMB

under Control Number 1215-0072.)

5. 552.203-72 REPRESENTATION BY CORPORATIONS REGARDING AN UNPAID

DELINQUENT FEDERAL TAX LIABILITY OR A FELONY CONVICTION UNDER

ANY FEDERAL LAW (DEVIATION) (APR 2012)

(a) In accordance with Sections 630 and 631 of Division of the Consolidated Appropriations Act,

2012 (Pub. L. 112-74), none of the funds made available by that Act may be used to enter

into a contract action with any corporation that---

(1) Has any unpaid Federal tax liability that has been assessed, for which all judicial and

administrative remedies have been exhausted or have lapsed, and that is not being

paid in a timely manner pursuant to an agreement with the authority responsible for

collecting the tax liability, where the awarding agency is aware of the unpaid tax

liability, unless the agency has considered suspension or debarment of the

corporation and made a determination that this further action is not necessary to

protect the interests of the Government, or

(2) Was convicted, or had an officer or agent of such corporation acting on behalf of the

corporation convicted of a felony criminal violation under any Federal law within the

preceding 24 months, where the awarding agency is aware of the conviction, unless

the agency has considered suspension or debarment of the corporation or such officer

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or agent and made a determination that this action is not necessary to protect the

interests of the Government.

(b) The Contractor represents that—

(1) It is [ ] is not [ ] a corporation that has any unpaid Federal tax liability that has been

assessed, for which all judicial and administrative remedies have been exhausted or

have lapsed, and that is not being paid in a timely manner pursuant to an agreement

with the authority responsible for collecting the tax liability.

(2) It is [ ] is not [ ] a corporation that was convicted, or had an officer or agent of the

corporation acting on behalf of the corporation, convicted of a felony criminal violation

under any Federal law within the preceding 24 months.

6. 52.203-02 - CERTIFICATE OF INDEPENDENT PRICE DETERMINATION (APR 1985)

(Applicable when the estimated value of the acquisition exceeds the simplified lease acquisition

threshold)

(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 prices 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 competitor 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 in 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) above; 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) above

[ 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) above have not participated, and will not participate, in any action

contrary to subparagraphs (a)(1) through (a)(3) above; and

(iii) As an agent, has not personally participated, and will not participate, in action

contrary to subparagraphs (a)(1) through (a)(3) above.

offer a signed statement setting forth in detail the circumstances of the disclosure.

7. 52.203-11 - CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE

CERTAIN FEDERAL TRANSACTIONS (SEP 2007)

(Applicable when the estimated value of the acquisition exceeds $100,000)

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(a)

Definitions.

As used in this provision—“Lobbying contact” has the meaning provided at

2 U.S.C. 1602(8)

. The terms “agency,” “influencing or attempting to influence,” “officer or

employee of an agency,” “person,” “reasonable compensation,” and “regularly employed” are

defined in the FAR clause of this solicitation entitled “Limitation on Payments to Influence

Certain Federal Transactions” (52.203-12

(b)

Prohibition

. The prohibition and exceptions contained in the FAR clause of this solicitation

entitled “Limitation on Payments to Influence Certain Federal Transactions” ( 52.203-12

) are

hereby incorporated by reference in this provision.

(c)

Certification

. The offeror, by signing its offer, hereby certifies to the best of its knowledge and

belief that 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, an officer or employee of Congress, or an employee of a Member of Congress on

its behalf in connection with the awarding of this contract.

(d)

Disclosure

. If any registrants under the Lobbying Disclosure Act of 1995 have made a

lobbying contact on behalf of the offeror with respect to this contract, the offeror shall

complete and submit, with its offer, OMB Standard Form LLL, Disclosure of Lobbying

Activities, to provide the name of the registrants. The offeror need not report regularly

employed officers or employees of the offeror to whom payments of reasonable

compensation were made.

(e)

Penalty

. Submission of this certification and disclosure is a prerequisite for making or

entering into this contract imposed by 31 U.S.C. 1352

.Any person who makes an

expenditure prohibited under this provision or who fails to file or amend the disclosure

required 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.

8. 52.209-5 - CERTIFICATION REGARDING RESPONSIBILITY MATTERS (APR 2010)

(Applicable when the estimated value of the acquisition exceeds the simplified lease acquisition

threshold)

(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 any

Federal agency;

(B) Have

[ ]

have not

[ ]

, within a 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

statements, tax evasion, violating Federal criminal tax laws, or receiving

stolen property (if offeror checks “have”, the offeror shall also see

52.209-7

, if included in this solicitation);

[ ]

are not

[ ]

presently indicted for, or otherwise criminally or civilly

charged by a governmental entity with, commission of any of the

offenses enumerated in paragraph (a)(1)(i)(B) of this provision;

(D) Have

[ ]

, have not

[ ]

, within a three-year period preceding this offer,

been notified of any delinquent Federal taxes in an amount that exceeds

$3,000 for which the liability remains unsatisfied.

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(1) Federal taxes are considered delinquent if both of the following

criteria apply:

(i)

The tax liability is finally determined

. The liability is finally

determined if it has been assessed. A liability is not

finally determined if there is a pending administrative or

judicial challenge. In the case of a judicial challenge to

the liability, the liability is not finally determined until all

judicial appeal rights have been exhausted.

(ii)

The taxpayer is delinquent in making payment

. A

taxpayer is delinquent if the taxpayer has failed to pay

the tax liability when full payment was due and required.

A taxpayer is not delinquent in cases where enforced

collection action is precluded.

(2)

Examples

(i) The taxpayer has received a statutory notice of

deficiency, under I.R.C. § 6212, which entitles the

taxpayer to seek Tax Court review of a proposed tax

deficiency. This is not a delinquent tax because it is not

a final tax liability. Should the taxpayer seek Tax Court

review, this will not be a final tax liability until the

taxpayer has exercised all judicial appeal rights.

(ii) The IRS has filed a notice of Federal tax lien with

respect to an assessed tax liability, and the taxpayer has

been issued a notice under I.R.C. § 6320 entitling the

taxpayer to request a hearing with the IRS Office of

Appeals contesting the lien filing, and to further appeal to

the Tax Court if the IRS determines to sustain the lien

filing. In the course of the hearing, the taxpayer is

entitled to contest the underlying tax liability because the

taxpayer has had no prior opportunity to contest the

liability. This is not a delinquent tax because it is not a

final tax liability. Should the taxpayer seek tax court

review, this will not be a final tax liability until the

taxpayer has exercised all judicial appeal rights.

(iii) The taxpayer has entered into an installment agreement

pursuant to I.R.C. § 6159. The taxpayer is making timely

payments and is in full compliance with the agreement

terms. The taxpayer is not delinquent because the

taxpayer is not currently required to make full payment.

(iv) The taxpayer has filed for bankruptcy protection. The

taxpayer is not delinquent because enforced collection

action is stayed under 11 U.S.C. 362 (the Bankruptcy

Code).

(ii) The Offeror has

[ ]

has not

[ ]

, within a three-year period preceding this offer,

had one or more contracts terminated for default by any Federal agency.

(2) “Principal,” for the purposes of this certification, means an officer, director, owner,

partner, or a person having primary management or supervisory responsibilities within a

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business entity (

e.g.

, general manager; plant manager; head of a 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 Contracting Officer if, at any time

prior to contract award, the Offeror learns that its certification was erroneous when submitted

or has become erroneous by reason of changed circumstances.

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 Contracting Officer may render the Offeror nonresponsible.

(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 Contracting Officer may terminate the contract resulting from this

solicitation for default.

9. 52.204-3 - TAXPAYER IDENTIFICATION (OCT 1998)

(a)

Definitions

“Common parent,” as used in this provision, means that corporate entity that owns or

controls an affiliated group of corporations that files its Federal income tax returns on a

consolidated basis, and of which the Offeror is a member.

“Taxpayer Identification Number (TIN),” as used in this provision, means the number

required by the Internal Revenue Service (IRS) to be used by the Offeror in reporting income

tax and other returns. The TIN may be either a Social Security Number or an Employer

Identification Number.

(b) All Offerors must submit the information required in paragraphs (d) through (f) of this

provision to comply with debt collection requirements of 31 U.S.C. 7701(c) and 3325(d),

reporting requirements of 26 U.S.C. 6041, 6041A, and 6050M, and implementing regulations

issued by the IRS. If the resulting contract is subject to the payment reporting requirements

described in Federal Acquisition Regulation (FAR) 4.904, the failure or refusal by the Offeror

to furnish the information may result in a 31 percent reduction of payments otherwise due

under the contract.

arising out of the Offeror’s relationship with the Government (31 U.S.C. 7701(c)(3)). If the

resulting contract is subject to the payment reporting requirements described in FAR 4.904,

the TIN provided hereunder may be matched with IRS records to verify the accuracy of the

Offeror’s TIN.

(d)

Taxpayer Identification Number (TIN)

[ ]

TIN:

[ ]

TIN has been applied for.

[ ]

TIN is not required because:

[ ]

Offeror is a nonresident alien, foreign corporation, or foreign partnership that does not

have income effectively connected with the conduct of a trade or business in the

United States and does not have an office or place of business or a fiscal paying

agent in the United States;

[ ]

Offeror is an agency or instrumentality of a foreign government;

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[ ]

Offeror is an agency or instrumentality of the Federal government;

(e)

Type of organization

[ ]

Sole proprietorship;

[ ]

Government entity (Federal, State, or local);

[ ]

Partnership;

[ ]

Foreign government;

[ ]

Corporate entity (not tax-exempt);

[ ]

International organization per 26 CFR 1.6049-4;

[ ]

Corporate entity (tax-exempt);

[ ]

Other

(f)

Common Parent

[ ]

Offeror is not owned or controlled by a common parent as defined in paragraph (a) of

this provision.

[ ]

Name and TIN of common parent:

Name

TIN

10. 52.204-6 – DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER (APR 2008)

(a) The offeror shall enter, in the block with its name and address on the cover page of its offer,

the annotation “DUNS” or “DUNS+4” followed by the DUNS number or “DUNS+4” that

identifies the offeror’s name and address exactly as stated in the offer. The DUNS number is

a nine-digit number assigned by Dun and Bradstreet, Inc. The DUNS+4 is the DUNS number

plus a 4-character suffix that may be assigned at the discretion of the offeror to establish

additional CCR records for identifying alternative Electronic Funds Transfer (EFT) accounts

(see Subpart 32.11

) for the same concern.

(b) If the offeror does not have a DUNS number, it should contact Dun and Bradstreet directly to

obtain one.

(1) An offeror may obtain a DUNS number—

(i) Via the Internet at http://fedgov.dnb.com/webform

or if the offeror does not

have internet access, it may call Dun and Bradstreet at 1-866-705-5711 if

located within the United States; or

(ii) If located outside the United States, by contacting the local Dun and Bradstreet

office. The offeror should indicate that it is an offeror for a U.S. Government

contract when contacting the local Dun and Bradstreet office.

(2) The offeror should be prepared to provide the following information:

(i) Company legal business name.

(ii) Tradestyle, doing business, or other name by which your entity is commonly

recognized.

(iii) Company physical street address, city, state and ZIP Code.

(iv) Company mailing address, city, state and ZIP Code (if separate from physical).

(v) Company telephone number.

(vi) Date the company was started.

(vii) Number of employees at your location.

(viii) Chief executive officer/key manager.

(ix) Line of business (industry).

(x) Company Headquarters name and address (reporting relationship within your

entity).

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11. DUNS NUMBER (JUN 2004)

Notwithstanding the above instructions, in addition to inserting the DUNS Number on the offer

cover page, the Offeror shall also provide its DUNS Number as part of this submission:

DUNS Number

12. CENTRAL CONTRACTOR REGISTRATION (MAY 2012)

The Central Contractor Registration (CCR) System is a centrally located, searchable database

which assists in the development, maintenance, and provision of sources for future procurements.

The Offeror must be registered in the CCR prior to lease award. The Offeror shall register via the

Internet at https://www.acquisition.gov

. To remain active, the Offeror/Lessor is required to update

or renew its registration annually.

[ ]

Registration Active and Copy Attached

[ ]

Will Activate Registration and Submit Copy to the Government Prior to Award

OFFEROR OR

AUTHORIZED

REPRESENTATIVE

NAME, ADDRESS (INCLUDING ZIP CODE)

NAME

STREET

CITY, STATE, ZIP

Signature

TELEPHONE NUMBER

Date

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