Annual Supplier Certifications | ITC-0109

ITC-0109 2021-05-12.013

Seiler Instrument & Manufacturing Company, Inc. (“SEILER”) is required, as a prime and subcontractor for the United States Government, to certify compliance with the Federal Acquisition Regulations (FARs), Executive Orders, and other laws and regulations. Further, these certification requirements apply to SEILER subcontractors providing materials or services related to a United States Government contract.

Accordingly, we request that you complete and submit the following certifications:

Certification of Business Size and SBA Designation
Equal Employment Opportunity Certificate
Annual Certification regarding Responsibility Matters

These certifications and representations shall be part of all purchase orders placed with your company by SEILER INSTRUMENT COMPANY to the extent required by the applicable FAR, Executive Order, Rule, or Regulation.

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Certification of Business Information, Size, and SBA Designation

Firm/Company Name*

Firm/Company Address*

Street Address City State ZIP Code

Authorized Representative*

First Name Last Name

Title*

Email*

Enter Email Confirm Email

Name of Company President or CEO*

First Name Last Name

DUNS Number

CAGE Code(s)

Predominant North American Industry Classification System (NAICS) Subfactor 3-Digit Code*

Quality Certificates*

(Check all that apply)

ISO 9001:2008 / ISO 9001:2015

AS9100

ISO 13485 Medical

Other

Other Quality Certificates*

Business Indicator*

Indicate your organization’s status as applicable to the Business Type Definitions.

(Check all that apply)

LARGE BUSINESS CONCERN

SMALL BUSINESS CONCERN

HISTORICALLY BLACK COLLEGE OR UNIVERSITY OR MINORITY INSTITUTION

NONPROFIT BUSINESS CONCERN

NATIONAL INDUSTRIES FOR THE BLIND, NATIONAL INDUSTRIES FOR THE SEVERELY HANDICAPPED (NIB/NISH)

FOREIGN-OPERATED BUSINESS CONCERN

WOMAN-OWNED SMALL BUSINESS

VETERAN-OWNED SMALL BUSINESS

MINORITY BUSINESS ENTERPRISE

HANDICAPPED OWNED BUSINESS

SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS (SDVOSB)

ALASKAN NATIVE CORPORATION (ANC) OR INDIAN TRIBE THAT HAS NOT BEEN CERTIFIED BY SBA AS A SMALL DISADVANTAGED BUSINESS

ALASKA NATIVE CORPORATION (ANC) OR INDIAN TRIBE THAT IS NOT A SMALL BUSINESS

CERTIFIED HUB-ZONE SMALL BUSINESS CONCERN

BLACK AMERICAN

HISPANIC AMERICAN

NATIVE AMERICAN

ASIAN-PACIFIC AMERICAN

SUBCONTINENT ASIAN AMERICAN

OTHER MINORITY

SBA Certification*

The "CERTIFIED HUB-ZONE SMALL BUSINESS CONCERN" classification requires certification by the Small Business Administration. Please attach a copy of your SBA Certification. Information on SBA Certifications may be obtained at www.sba.gov.

Accepted file types: pdf, doc, png, Max. file size: 1 MB.

Effective 10-3-2008 the following classifications no longer requires SBA certification by subcontractor or supplier on subcontract procurements. See Federal Register Vol. 73, No. 193 dated 3-Oct-2008 under 13 CFR 124.

SMALL DISADVANTAGED BUSINESS CONCERN
BLACK AMERICAN
HISPANIC AMERICAN
NATIVE AMERICAN
ASIAN-PACIFIC AMERICAN
SUBCONTINENT ASIAN AMERICAN
OTHER MINORITY

MISREPRESENTATION OF STATUS AS A SMALL BUSINESS OR SMALL DISADVANTAGED BUSINESS IN ORDER TO OBTAIN A SUBCONTRACT WILL SUBJECT THE MISREPRESENTER TO THE PENALTIES DEFINED IN 15 USC 645(d) AND FAR 52.219- 1(d)(2).

CERTIFICATION

These certifications and representations shall apply to purchase orders placed by SEILER INSTRUMENT COMPANY one year from the submitted date.

Name*

First Last

Title*

Certification of Business Size and SBA Acknowledgement*

I hereby acknowledge and confirm the accuracy of the statements made above.*

Business Type Definitions

Large Business - A concern that exceeds the small business size standards.
Small Business - One which (including its affiliates) is independently owned and operated; is not dominant in its field of operation; and can qualify under the size standard criteria as defined by the Small Business Administration. The Code of Federal Regulation, Title 13 Part 121 contains detail industry definitions regarding size standards. See also 15 U.S.C. w 632.
Socially and Economically Disadvantaged Small Business (Minority) - As used in this contract the term “small business concern” shall mean a small business as defined pursuant to Section 3 of the Small Business Act and relevant regulations promulgating pursuant thereto. The term “small business concern owned and controlled by socially and economically disadvantaged individuals” shall mean a small business concern consistent with the 13 CFR 124, subpart B; and (A) No material change in disadvantaged ownership and control: and (B) Where the concern is owned by one or more disadvantaged individuals, the net worth of each individual does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2).
Woman-Owned Business - A small business concern that is at least 51 percent owned by a woman or women who also control and operate it. “Control” in this context means exercising the power to make policy decisions. “Operate” means being actively involved in the day-to-day management.
Historically Black Colleges and Universities (HBCU) and Minority Institutions (MI) - The term “Historically Black Colleges and Universities” means institutions that were established before 1964 and have a principal mission that was, and is, the education of Black Americans and that meet the requirements set forth by the Department of Education, Title 34, of the Code of Federal Regulations (CFR) Part 608.2. The term “minority institutions” means institutions that substantially increase the higher education opportunities for minority and/or low income who are educationally disadvantaged or underrepresented in post-secondary education and meet the requirements set forth by the Department of Education, Title 34 of the Code of Federal Regulations (CFR) Part 607.2.
Non-profit Business - Any organization not conducted or maintained for the purpose of making profit. Included in this category are sheltered workshops, universities, colleges and local, state and federal governments.
Foreign Business - Any business concern that has its principal place of business outside the United States, its territories and possessions and is not incorporated within the United States.
Handicapped Business - A public or private organization which agrees that at least 75 percent of the Direct Labor required by contract will be performed by handicapped individuals, which means employment of persons who have physical, mental, or emotional impairments, defect ailment, disease or disability of a permanent nature which in any way limits the selection of the employment type for which the individual would otherwise be qualified or qualifiable to perform.
HUBZone Small Business - A qualifying Small Business Concern located in a historically underutilized business zone whose principal office is located in the HUBZone tract and whose workforce consists of at least 35% of its employees residing within a HUBZone.
U.S. Veteran-owned Small Business - A small business concern, not less than 51 percent of which is owned by one or more 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 veterans; and the management and daily business operations of which are controlled by one or more veterans.
U.S. Service-disabled Veteran-owned Small Business - A small business concern 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 the management and daily business 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 a veteran.
Alaska Native Corporations (ANC's) - A business concern: (i) that is an Alaska Native Corporation owned and controlled by Natives (as determined pursuant to section 1626(e)(1) of title 43); or (ii) that is a direct or indirect subsidiary corporation, joint venture, or partnership of an Alaska Native Corporation qualifying pursuant to section 1626(e)(1) of title 43, if that subsidiary, joint venture, or partnership is owned and controlled by Natives (as determined pursuant to section 1626(e)(2) of title 43).
Indian Tribes - A business concern: (i) that is wholly owned by one or more Indian tribal governments, or by a corporation that is wholly owned by one or more Indian tribal governments; or (ii) that is owned in part by one or more Indian tribal governments, or by a corporation that is wholly owned by one or more Indian tribal governments, if all other owners are either United States citizens or small business concerns. (See FAR 26.101 for further definition).

Equal Employment Opportunity Certificate

SEILER INSTRUMENT COMPANY IS AN EQUAL OPPORTUNITY EMPLOYER AND IS COMMITTED TO FULFILLING ITS OBLIGATIONS UNDER EXECUTIVE ORDER 11246 AND RELATED UNITED STATES GOVERNMENT CONTRACTUAL AND REGULATORY REQUIREMENTS. ACCORDINGLY, WE REQUEST THIS CERTIFICATION FROM ALL VENDORS RECEIVING UNITED STATES GOVERNMENT SUBCONTRACTS. PLEASE REVIEW, EXECUTE AND RETURN THIS CERTIFICATE TO US WITHIN 30 DAYS.

These Certifications and Agreements are required on an annual basis and will continue in effect as long as required by any applicable Law, Executive Order, or the Federal Acquisition Regulation (FAR).

52.222-22 - CERTIFICATION OF PREVIOUS CONTRACTS AND COMPLIANCE REPORTS (FEB 1999)

1. Supplier represents that it —*

has

has not

participated in a previous contract or subcontract subject to the Equal Opportunity clause at FAR 52.222-26.

2. Certification of Compliance Report*

Supplier certifies that it has filed Standard Form 100 "Equal Opportunity Employer Information Report EEO-1” within 12 months of the current date.

Supplier certifies that it has 50 or more employees. If awarded a contract of $50,000 or more or individual contracts that aggregately exceed $50,000, supplier will complete and file Standard Form 100.

Supplier certifies that it has less than 50 employees and is, therefore exempt.

3. The Supplier represents that it —*

does

does not

obtain representations indicating submission of required compliance reports from each of its proposed subcontractors before awarding a subcontract.

4. 52.222-25 (APR 1984) - Affirmative Action Compliance*

Supplier certifies that it has 50 or more employees, holds a contract of $50,000 or more as a prime or subcontractor and maintains an affirmative action program pursuant to the regulations of the Secretary of Labor in 41 CFR 60-1 and 60-2.

Supplier certifies that it has less than 50 employees and is, therefore exempt.

5. Certification of Affirmation Action for Disabled Veterans and Veterans of the Vietnam Era Compliance*

Supplier certifies that it has at least one contract of $100,000 or more and that it complies with the requirements of FAR 52.222-35 “EQUAL OPPORTUNITY FOR VETERANS (SEPT 2010)” and FAR 52.222-37 “EMPLOYMENT REPORTS ON VETERANS (SEPT 2010).”

Supplier certifies that, if awarded a contract of $100,000 or more, or individual contracts that in the aggregate meet or exceed $100,000, it will comply with the requirements of FAR 52.222-35 “EQUAL OPPORTUNITY FOR VETERANS (SEPT 2010)” and FAR 52.222-37 “EMPLOYMENT REPORTS ON VETERANS (SEPT 2010).”

6. Certification of Workers with Disabilities*

Supplier certifies that it has at least one contract of $15,000 or more and that it complies with the requirements of FAR 52.222-36 “AFFIRMATIVE ACTION FOR WORKERS WITH DISABILITIES (OCT 2010).”

Supplier certifies that if awarded a contract of $15,000 or more it will comply with the requirements of FAR 52.222-36 “AFFIRMATIVE ACTION FOR WORKERS WITH DISABILITIES (OCT 2010).”

7. Flowdown Clauses

In addition to the certification above, the Supplier hereby represents that it has read, understands, and fully complies with each of the following clauses. These clauses are located in the Federal Acquisition Regulation at the citations indicated below. They can also be found in Title 48 of the Code of Federal Regulations. The full text of these clauses are provided on the internet at www.acquisition.gov. However SEILER INSTRUMENT COMPANY does not take responsibility for the content of this website and reliance on the content of the website is solely at seller’s risk.

52.219-8 - UTILIZATION OF SMALL BUSINESS CONCERNS (MAY 2004)
52.222-21 - PROHIBITION OF SEGREGATED FACILITIES (FEB 1999)
52.222-26 - EQUAL OPPORTUNITY (MAR 2007)
52.222-35 - EQUAL OPPORTUNITY FOR VETERANS (SEP 2010)
52.222-36 - AFFIRMATIVE ACTION FOR WORKERS WITH DISABILITIES (OCT 2010)
52.222-37 - EMPLOYMENT REPORTS ON VETERANS (SEP 2010)

CERTIFICATION

These certifications and representations shall apply to purchase orders placed by SEILER INSTRUMENT COMPANY one year from the submitted date.

Name*

First Last

Title*

EEO Acknowledgement*

I hereby acknowledge and confirm the accuracy of the statements made above.*

Annual Certification Regarding Responsibility Matters

FAR 52.209-5 (OCT 2015)

The Supplier certifies, to the best of its knowledge and belief, that —
1. The Supplier 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 supplier checks “have”, the supplier shall also see 52.209-7, if included in this solicitation); and

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; and

D.*

Have

Have not

within a three-year period preceding this offer, been notified of any delinquent Federal taxes in an amount that exceeds $3,500 for which the liability remains unsatisfied.

1. 1. 1. Federal taxes are considered delinquent if both of the following criteria apply:
      1. 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.
      2. 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.
      1. The taxpayer has received a statutory notice of deficiency, under I.R.C. Sec. 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.
      2. 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. Sec. 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.
      3. The taxpayer has entered into an installment agreement pursuant to I.R.C. Sec. 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.
      4. 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 Supplier —*

has

has not

within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal agency.

"Principal,"" for the purposes of this certification, means an officer, director, owner, partner, or a person having primary management or supervisory responsibilities within a 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.
The Supplier shall provide immediate written notice to the SEILER INSTRUMENT COMPANY- Buyer of Record if, at any time prior to contract award, the Supplier learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
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 Supplier's responsibility. Failure of the Supplier to furnish a certification or provide such additional information as requested by the Buyer may render the Supplier nonresponsible.
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 a Supplier is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making an award. If it is later determined that the Supplier knowingly rendered an erroneous certification, in addition to other remedies available to the Government, the SEILER INSTRUMENT COMPANY may terminate the contract resulting from this solicitation for default.

Name*

First Last

Title*

SBA Acknowledgement*

I hereby acknowledge and confirm the accuracy of the statements made above.*

Name

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