Subcontractor representations and certifications

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Subcontractor Representations and Certifications

All Subcontractors are required to submit annual Representations and Certifications to Charles River Analytics. Subcontractors should fill out each form in this package completely and accurately, and should sign the certifications on pages 13 and 15. Subcontractors should return the completed and signed package to Mark Felix, Director of Contracts, at mfelix@.

The following Federal Acquisition Regulation (FAR) representations and certifications are included, as indicated, and are self-deleting if not applicable:

52.203-2 Certificate of Independent Price Determination

X

52.203-11

Certification and Disclosure Regarding payments to Influence Certain Federal Transactions

X

52.204-3 Taxpayer Identification

X

52.204-5 Women-Owned Business (Other Than Small Business)

X

52.209-2 Prohibition on Contracting with Inverted Domestic Corporations

X

52.209-5 Certification Regarding Responsibility Matters

X

52.215-6 Place of Performance

X

52.219-1 Small Business Program Representations

X

52.222-22 Previous Contracts and Compliance Reports

X

52.222-25 Affirmative Action Compliance

X

52.222-38 Compliance with Veterans' Employment Reporting Requirements

X

52.223-1 Bio-Based product Certification

X

52.223-4 Recovered Material Certification

X

52.225-2 Buy American Certificate

X

52.225-4 Buy American ? Free Trade Agreements ? Israeli Trade Act Certificate

X

52.225-6 Trade Agreements Certificate

X

52.225-20 Prohibition on Conducting Restricted Business Operations in Sudan

X

52.225-25

Prohibition on Contracting with Entities Engaging in Certain Activities or Transactions Relating to Iran

X

52.226-2 Historically Black College or University and Minority Institution Representation

X

52.204-17 Ownership or Control of Offeror

X

52.223-9 Estimate of Percentage of Recovered Material Content for EPA-Designated Products

X

52.227-15 Representation of Limited Rights Data and Restricted Computer Software

X

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Subcontractor Name: Subcontractor Address:

Subcontractor General Information

The Pennsylvania State University 110 Technology Center Building

University Park, PA 16802

Type of Organization: Sole proprietorship Partnership Corporate entity (not tax-exempt) Corporate entity (tax-exempt)

Government entity (Federal, State, or local) Foreign government International organization (per 26 CFR 1.6049-4) Other _S_ta_t_e_R_e_la_t_e_d_I_ns_t_itu_t_io_n_o_f_H_i_g_he_r Education

Taxpayer Identification Number (TIN): Subcontractor will supply TIN TIN: ________2_4_-_60_0_0_3_7_6________ TIN has been applied for (Date Applied: ___________) TIN is not required because: Subcontractor 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 Subcontractor is an agency of instrumentality of a foreign government Subcontractor is an agency of instrumentality of a Federal government

Common Parent (see FAR 52.204-3): Subcontractor is not owned or controlled by a common parent Subcontractor is owned or controlled by a common parent

Name of Common Parent: ________________________________________________ Common Parent TIN: ________________________

Ownership or Control of Subcontractor (see FAR 52.204-11): Does the Subcontractor have an Immediate Owner?

Subcontractor does not have an immediate owner Subcontractor has an immediate owner

o Immediate Owner CAGE Code: ________________________ o Immediate Owner Legal Name: ________________________ (do not use a "doing business as" name) If the Subcontractor has an Immediate Owner, is the Immediate Owner owned or controlled by another entity? Immediate Owner is not owned or controlled by another entity Immediate Owner is owned or controlled by another entity o Highest Level Owner CAGE Code: ________________________ o Highest Level Owner Legal Name: ________________________ (do not use a "doing business as" name)

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Certificate of Independent Price Determination

Pursuant to FAR 52.203-2, the Subcontractor certifies that: 1. The prices referred to in this Contract have been arrived at independently, without, for the purpose of restricting competition, any consultation, communication, or agreement with any other subcontractor or competitor relating to those prices, the intention to submit an offer, or the methods or factors used to calculate the prices offered; 2. The prices referred to in this Contract have not been and will not be knowingly disclosed by the Subcontractor, directly or indirectly, to any other subcontractor or competitor before contract award, unless otherwise required by law; and 3. No attempt has been made or will be made by the Subcontractor to induce any other concern to submit or not to submit an offer for the purpose of restricting competition.

The Subcontractor's signature below certifies that the signatory is the person in the Subcontractor's organization responsible for determining the prices being offered in this proposal, and that the signatory has not participated and will not participate in any action contrary to subparagraphs (1) through (3) above; or that the signatory has been authorized, in writing, to act as agent for the person responsible for such determination and certifies that he/she/they has/have not participated, and will not participate in any action contrary to subparagraphs (1) through (3) above, and certifies that, as an agent, the signatory has not personally participated, and will not participate, in any action contrary to subparagraphs (1) through (3) above.

INTENTIONALLY LEFT BLANK

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Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions

Pursuant to FAR 52.203-11, the Subcontractor hereby certifies to the best of his/her 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 his/her behalf in connection with the awarding of this Contract. If any registrants under the Lobbying Disclosure Act of 1995 have made a lobbying contact on behalf of the Subcontractor with respect to this Contract, the Subcontractor shall submit OMB Standard Form LLL. The Subcontractor need not report regularly employed officers or employees of the Subcontractor to whom payments of reasonable compensation were made. Pursuant to 31 U.S.C. 1352, submission of this Certification and Disclosure is a prerequisite for entering into this Contract. The prohibition and exceptions contained in FAR 52.203-12 (Limitation on Payments to Influence Certain Federal Transactions) are hereby incorporated by reference in this provision. Any person who makes an expenditure prohibited under this provision or who fails to file or amend the required disclosure, shall be subject to a civil penalty of not less than $10,000, for each such failure.

INTENTIONALLY LEFT BLANK

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Women-Owned and Small Business Program Representations

This form should only be filled out if the Subcontractor represents that it is a small business concern, as defined in FAR 52.219-1, or a women-owned business concern, as defined in FAR 52.204-5. The Subcontractor may not represent itself as both a small business concern and a women-owned business concern. If the Subcontractor does not represent itself as either a small business concern or a women-owned business concern, then it should not fill out this form and should proceed to page 7.

The North American Industry Classification System (NAICS) code for this acquisition is 541712

The small business size standard is 500.

Please check the appropriate box (choose only one):

The Subcontractor does not represent itself as a small business concern (please go to page 7). The Subcontractor represents that it is a women-owned business concern (please go to page 7). The Subcontractor represents that it is a small business concern (continue below).

Please check the appropriate box(es), if applicable:

The Subcontractor represents that is a small disadvantaged business concern (please check the category in which your 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, 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 preceding

The Subcontractor represents that it is a women-owned small business concern (WOSB) eligible under the WOSB Program, as defined in FAR 52.219-1(a); 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 that it: Is not a joint venture. Is a joint venture that complies with the requirements of 13 CFR 127 and FAR 52.219-1(c)(4).

Please list the names of the WOSB concern eligible under the WOSB Program and other small businesses that are participating in the joint venture and attach to this form. Each WOSB concern eligible under the WOSB Program participating in the joint venture must submit a separate signed copy of this representation.

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The Subcontractor represents that it is an economically disadvantaged women-owned small business concern (EDWOSB) eligible under the WOSB Program, as defined in FAR 52.219-1(a); 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 that it: Is not a joint venture. Is a joint venture that complies with the requirements of 13 CFR 127 and FAR 52.219-1(c)(4).

Please list the names of the WOSB concern eligible under the WOSB Program and other small businesses that are participating in the joint venture and attach to this form. Each WOSB concern eligible under the WOSB Program participating in the joint venture must submit a separate signed copy of this representation.

The Subcontractor represents that it is a veteran-owned small business concern.

The Subcontractor represents that it is a service-disabled veteran-owned small business concern.

The Subcontractor represents that it is 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 126; and that it: Is not a HUBZone joint venture. Is a HUBZone joint venture that complies with the requirements of 13 CFR 126 and FAR 52.219-1(c)(8).

Please list the names of the HUBZone small business concerns that are participating in the joint venture and attach to this form. Each HUBZone small business concern eligible under the HUBZone Program participating in the joint venture must submit a separate signed copy of this representation.

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 womenowned 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 (1) be punished by imposition of fine, imprisonment, or both; (2) be subject to administrative remedies, including suspension and debarment; and/or (3) be ineligible for participation in programs conducted under the authority of the Act.

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