Rep Cert

The following Representation & Certification provisions must be completed and this form must be signed and returned as part of the Offeror’s proposal. As used herein, the term “contract” shall mean the UC/LBNL award resulting from the Offeror’s proposal; “offer” includes “bid,” “proposal,” and “quotation;” and “Offeror” includes “bidder,” “proposer,” and “quoter”, as may be applicable.

1. OFFEROR INFORMATION

(Complete and check all that applies.)
Legal Name of Business Entity:

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SAM Unique Entity Identifier Number (UEI):

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Legal Name of Parent Company (if applicable)

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List Legal Name of All Direct, Indirect, Aggregate Owned Affiliates (attach an additional sheet if needed)

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Place of Performance (principal plant or place of business where the items will be produced, supplied from stock, or where the service will be performed): Zip+4 FORMTEXT Country FORMTEXT # of employees (If known and not a government entity):

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Type of Domestic Organization
FORMCHECKBOX For-Profit FORMCHECKBOX Other Non-Profit
FORMCHECKBOX Sole Proprietorship FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX Limited Liability Co. (LLC) incorporated or organized in the State of:

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FORMCHECKBOX Government entity (Federal, state, or local) FORMCHECKBOX Joint Venture, with:

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FORMCHECKBOX Indian Organization (see FAR 52.226-1 for definition) FORMCHECKBOX Indian owned Economic Enterprise (see FAR 52.226-1 for definition) Eligibility Designations for Higher Education Programs as defined by the U.S. Department of Education https://www.ed.gov/grants-and-programs/grants-higher-education/eligibility-designations-higher-education-programs FORMCHECKBOX Minority Serving Institution
FORMCHECKBOX Historically Black College/University
FORMCHECKBOX Hispanic Serving Institution
FORMCHECKBOX Emerging Research Institution
FORMCHECKBOX Other (describe):

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Type of Foreign Organization
FORMCHECKBOX Foreign Government entity (describe below) FORMCHECKBOX Non-U.S. company, institution, or organization (describe below) FORMCHECKBOX Nonresident alien or foreign corporation or partnership that does not have an office or a place of business in the U.S or personnel located in the U.S in furtherance of its trade or business. FORMCHECKBOX Other (describe):

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2. CERTIFICATION AND DISCLOSURE ON PAYMENTS TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS (Per FAR 52.203-11)
(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).