MEMO TO SHARON LEVY FROM DELETED RE REPRESENTATION AND CERTIFICATIONS; EFT FORM

• Document Type: FOIA
• Keywords: CONTRACTS
• Keywords: GOOGLE INC
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001487891
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 15
• Document Creation Date: June 22, 2015
• Document Release Date: September 29, 2008
• Case Number: F-2007-00886
• Publication Date: August 30, 2004

(b) (3)
(b) (6)
PCWare
Date: 8/30/04 Pages: 15 (including cover)
To: Sharon Levy Fax:
From: Fax: [phone]
Re: Representations and Certifications; EFT Form
Sharon,
Please find the following attachments enclosed:
(1) Representations and Certifications
(2) Electronic Funds Transfer Form
asked me to forward these documents to you regarding our upcoming Google
purchase. The Representations and Certifications form requires that you provide certain
information regarding Google's business size and status. The EFT form just provides
payment information so that we can wire transfer funds to your company.
Please have Your legal office completed these forms and return them to
Please call) one it you have any questions
regarding these forms.
today on
Regards,
 ELECTRONIC FUNDS TRANSFER (EFT)
INFORMATION
NOTE: ALL PAYMENTS ARE MADE VIA ELECTRONIC FUNDS TRANSFER (EFT) -
FAILURE TO PROVIDE EFT INFORMATION MAY RESULT IN SEVERE DELAYS IN
INVOICE PAYMENT.
NAME OF THE FINANCIAL INSTITUTION TO RECEIVE PAYMENT FOR YOUR
COMPANY:
COMPLETE ADDRESS.OF THE FINANCIAL INSTITUTION:
FINANCIAL INSTITUTIONS NINE-DIGIT ABA ROUTING NUMBER:
CONTRACTORS: ACCOUNT NUMBER TO BE CREDITED WITH FUNDS:.
TYPE OF ACCOUNT AT THE FINANCIAL INSTITUTION:
CHECKING SAVINGS
NAME, TITLE AND TELEPHONE NUMBER OF COMPANY CONTRACT PERSON:
 Google
Section K - Reps & Certs.
Page, 1 of 13
SECTION K - REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS OF OFFERORS
OR QUOTERS
K-1.52.252-1 Solicitation Provisions Incorporated by Reference. (FEB 1998)
This solicitation incorporates one or more solicitation provisions by reference, with the same force and effect as if
they were given in full text. Upon request, the Contracting Officer will make their full text available. The offeror is
cautioned that the listed provisions may include blocks that must be completed by the offeror and submitted with its
quotation or offer. In lieu of submitting the full text of those provisions, the offeror may identify the provision by
paragraph identifier and provide the appropriate information with its quotation or offer. Also, the full text of a
solicitation provision may be accessed electronically at this/these address(es):
http://www.arnet.gov/far/
http://www-far.npr.gov/References/References.html
K-2.52.203-11
Certification and Disclosure Regarding Payments
To Influence Certain Federal Transactions.
APR 1991
K-3. 52.222-21
Prohibition of segregated facilities.
FEB 1999
K-4. 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, 604 IA, 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.
(c) The TIN may be used by the Government to collect and report on any delinquent amounts 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.
 Google
Section K - Reps & Certs.
Page 2 of 13
(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;
[ ] Offeror is an agency or instrumentality of the Federal Government.
(e) 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
(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
K-5. 52.209-5 Certification Regarding Debarment, Suspension,
Proposed Debarment, and Other Responsibility Matters MAR 1996
(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,
 Google
Section K - Reps & Certs.
Page 3 of 13
forgery, bribery, falsification or destruction of records, making false statements, tax
evasion, or receiving stolen property; and
 Google
Section K - Reps & Certs.
Page 4 of 13
(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.
(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) "Principals," for the purposes of this certification, means officers; directors; owners; partners;
and, persons having primary management or supervisory responsibilities within a business entity
(e.g., general manager; plant manager; head of a subsidiary, 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.
(c) 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 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.
K-6 52.215-6 Place of Performance (OCT 87)
(a) The Offeror or respondent, in the performance of any contract resulting from this solicitation,
intends does not intend to use one or more plants or facilities located at a different address
from the address of the offeror or respondent as indicated in this proposal or response to request for
information.
(b) If the Offeror or respondent checks "intends in paragraph (a) of this provision, it shall insert in the
following spaces the required information:
PLACE OF PERFORMANCE NAME AND ADDRESS OF OWNER
(STREET ADDRESS CITY AND OPERATOR OF THE PLANT
STATE, COUNTY,ZIP CODE) OR FACILITY IF OTHER THAN
OFFEROR OR RESPONDENT
 Google
Section K - Reps & Certs.
Page 5 of 13
K-7 52.215-11 Price Reduction for Defective Cost
or Pricing Data-Modifications OCT 1997
(a) This clause shall become operative only for any modification to this contract involving a pricing
adjustment expected to exceed the threshold for submission of cost or pricing data at FAR 15.403-4,
except that this clause does not apply to any modification if an exception under FAR 15.403-1 applies.
(b) If any price, including profit or fee, negotiated in connection with any modification under this clause,
or any cost reimbursable under this contract, was increased by any significant amount because (1) the
Contractor or a subcontractor furnished cost or pricing data that were not complete, accurate, and current
as certified in its Certificate of Current Cost or Pricing Data, (2) a subcontractor or prospective
subcontractor furnished the Contractor cost or pricing data that were not complete, accurate, and current as
certified in the Contractor's Certificate of Current Cost or Pricing Data, or (3) any of these parties
furnished data of any description that were not accurate, the price or cost shall be reduced accordingly and
the contract shall be modified to reflect the reduction. This right to a price reduction is limited to that
resulting from defects in data relating to modifications for which this clause becomes operative under
paragraph (a) of this clause.(c) Any reduction in the contract price under paragraph (b) of this clause due to
defective data from a prospective subcontractor that was not subsequently awarded the subcontract shall be
limited to the amount, plus applicable overhead and profit markup, by which--
(1) The actual subcontract; or
(2) The actual cost to the Contractor, if there was no subcontract, was less than the prospective
subcontract cost estimate submitted by the Contractor; provided, that the actual subcontract price
was not itself affected by defective cost or pricing data.
(d)(1) If the Contracting Officer determines under paragraph (b) of this clause that a price or cost reduction
should be made, the Contractor agrees not to raise the following matters as a defense:
(i) The Contractor or subcontractor was a sole source supplier or otherwise was in a
superior bargaining position and thus the price of the contract would not have been
modified even if accurate, complete, and current cost or pricing data had been submitted.
(ii) The Contracting Officer should have known that the cost or pricing data in issue
were defective even though the Contractor or subcontractor took no affirmative action to
bring the character of the data to the attention of the Contracting Officer.
(iii) The contract was based on an agreement about the total cost of the contract and there
was no agreement about the cost of each item procured under the contract.
(iv) The Contractor or subcontractor did not submit a Certificate of Current Cost or
Pricing Data.
(2)(i) Except as prohibited by subdivision (d)(2)(ii) of this clause, an offset in an amount
determined appropriate by the Contracting Officer based upon the facts shall be allowed against
the amount of a contract price reduction if--
(A) The Contractor certifies to the Contracting Officer that, to the best of the
Contractor's knowledge and belief, the Contractor is entitled to the offset in the
amount requested; and
 Google
Section K - Reps & Certs
Page 6 of 13
(B) The Contractor proves that the cost or pricing data were available before the
"as of' date specified on its Certificate of Current Cost or Pricing Data, and that
the data were not submitted before such date.
ii) An offset shall not be allowed if--
(A) The understated data were known by the Contractor to be understated
before the "as of' date specified on its Certificate of Current Cost or Pricing
Data; or
(B) The Government proves that the facts demonstrate that the contract price
would not have increased in the amount to be offset even if the available data
had been submitted before the "as of' date specified on its Certificate of Current
Cost or Pricing Data.
(e) If any reduction in the ontract price under this clause reduces the price of items for which payment was made
prior to the date of the mo ification reflecting the price reduction, the Contractor shall be liable to and shall pay the
United States at the time s ch overpayment is repaid--
(1) Siml e interest on the amount of such overpayment to be computed from the date(s) of
overpay tent to the Contractor to the date the Government is repaid by the Contractor at the
applicati - underpayment rate effective for each quarter prescribed by the Secretary of the
Treasur; under 26 U.S.C. 6621(a)(2); and
(2) A pe. alty equal to the amount of the overpayment, if the Contractor or subcontractor
knowin? y submitted cost or pricing data that were incomplete, inaccurate, or noncurrent.
K-8. 52.215-19 notification of Ownership Changes OCT 1997
(a) The Contracts shall make the following notifications in writing:
(1) Whe the Contractor becomes aware that a change in its ownership has occurred, or is certain
to occur that could result in changes in the valuation of its capitalized assets in the accounting
records, ae Contractor shall notify the Administrative Contracting Officer (ACO) within 30 days.
(2) The i ontractor shall also notify the ACO within 30 days whenever changes to asset valuations
or any o ter cost changes have occurred or are certain to occur as a result of a change in
ownersh i.
(b) The Contract( shall--
(1) Mau ain current, accurate, and complete inventory records of assets and their costs;
(2) Prov '? le the ACO or designated representative ready access to the records upon request;
(3) Ensu e that all individual and grouped assets, their capitalized values, accumulated
deprecia'.on or amortization, and remaining useful lives are identified accurately before and after
each of f Le Contractor's ownership changes; and
(4) Reta t and continue to maintain depreciation and amortization schedules based on the asset
records i i taintained before each Contractor ownership change.
(c) The Contracto shall include the substance of this clause in all subcontracts under this contract that
meet the applicat lity requirement of FAR 15.408(k).
 Google
Section K - Reps & Certs.
Page 7 of 13
K-9.52.222-1 NOTICE TO THE GOVERNMENT OF LABOR DISPUTES (FEB 1997)
If the Contractor has knowledge that any actual or potential labor dispute is delaying or threatens
to delay the timely performance of this contract, the Contractor shall immediately give notice,
including all relevant information, to the Contracting Officer.
K-10. 52.222-25 Affirmative Action Compliance
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.
K-il. 52.222-22 PREVIOUS CONTRACTS AND COMPLINANCE REPORTS (FEB 1999)
The Offeror represents that-
(a) It _ has, (J has not participated in a pervious contract or subcontract subject to
the equal opportunity clause of this solicitation;
(b) It _ has, (J has not filed all required compliance reports; and
(c) Representations indicating submissions of required compliance reports, signed by proposed by
subcontractors, will be obtained before subcontract awards.
K-12. 52.223-13 Certification of Toxic Chemical Release Reporting OCT 1996
(a) Submission of this certification is a prerequisite for making or entering into this contract imposed by
Executive Order 12969, August 8, 1995.
(b) By signing this offer, the offeror certifies that -
(1) As the owner or operator of facilities that will be used in the performance of this contract that
are subject to the filing and reporting requirements described in section 313 of the Emergency
Planning and Community Right-to-Know Act of 1986 (EPCRA) (42 U.S.C. 11023) and section
6607 of the Pollution Prevention Act of 1990 (PPA) (42 U.S.C. 13106), the offeror will file and
 Google
Section K -Reps & Certs.
Page 8 of 13
continue to file for such facilities for the life of the contract the Toxic Chemical Release Inventory
Form (Form R) as described in sections 313(a) and (g) of EPCRA and section 6607 of PPA; or
(2) None of its owned or operated facilities to be used in the performance of this contract is
subject to the Form R filing and reporting requirements because each such facility is exempt for at
least one of the following reasons: (Check each block that is applicable.)
(i) The facility does not manufacture, process, or otherwise use any toxic chemicals
listed under section 313(c) of EPCRA, 42 U.S.C. 11023(c);
(ii) The facility does not have 10 or more full-time employees as specified in section
313(b)(1)(A) of EPCRA, 42 U.S.C. 11023(b)(1)(A);
_(iii) 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 filed
with EPA);
(iv) The facility does not fall within Standard Industrial Classification Code (SIC)
designations 20 through 39 as set forth in section 19.102 of the Federal Acquisition
Regulation; or
_ (v) The facility is not located within any State of the United States, the District of
Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the United
States Virgin Islands, the Northern Mariana Islands, or any other territory or possession
over which the United States has jurisdiction.
K-13. 52.225-1 Buy American Act - Supplies. (JUN 2003)
(1) For components purchased by the Contractor, the acquisition cost, including transportation
costs to the place of incorporation into the end product (whether or not such costs are paid to a
domestic firm), and any applicable duty (whether or not a duty-free entry certificate is issued); or
(2) For components manufactured by the Contractor, all costs associated with the manufacture of
the component, including transportation costs as described in paragraph (1) of this definition, plus
allocable overhead costs, but excluding profit. Cost of components does not include any costs
associated with the manufacture of the end product.
"Domestic end product" means -
(1) An unmanufactured end product mined or produced in the United States; or
(2) An end product manufactured in the United States, if the cost of its components mined,
produced, or manufactured in the United States exceeds 50 percent of the cost of all its
components. Components of foreign origin of the same class or kind as those that the agency
determines are not mined, produced, or manufactured in sufficient and reasonably available
commercial quantities of a satisfactory quality are treated as domestic. Scrap generated, collected,
and prepared for processing in the United States is considered domestic.
"End product" means those articles, materials, and supplies to be acquired under the contract for public use.
"Foreign end product" means an end product other than a domestic end product.
 Google
Section K - Reps & Certs.
Page 9 of 13
"United States" means the 50 States, the District of Columbia, and outlying areas.
(b) The Buy American Act (41 U.S.C. 10a-IOd) provides a preference for domestic end products for
supplies acquired for use in the United States.
(c) Offerors may obtain from the Contracting Officer a list of foreign articles that the Contracting Officer
will treat as domestic for this contract.
(d) The Contractor shall deliver only domestic end products except to the extent that it specified delivery
of foreign end products in the provision of the solicitation entitled "Buy American Act - Certificate."
K-14. 52.227-6 Royalty Information APR 1984
(a) Cost or charges for royalties. When the response to this solicitation contains costs or charges for
royalties totaling more than $250, the following information shall be included in the response relating to
each separate item of royalty or license fee:
(1) Name and address of licensor.
(2) Date of license agreement.
(3) Patent numbers, patent application serial numbers, or other basis on which the royalty is
payable.
(4) Brief description, including any part or model numbers of each contract item or component on
which the royalty is payable.
(5) Percentage or dollar rate of royalty per unit.
(6) Unit price of contract item.
(7) Number of units.
(8) Total dollar amount of royalties.
(b) Copies of current licenses. In addition, if specifically requested by the Contracting Officer before
execution of the contract, the offeror shall furnish a copy of the current license agreement and an
identification of applicable claims of specific patents.
K-15. Foreign Ownership, Control, or Influence JUN 1998
(a) Notwithstanding the provisions of Section 3 of the NISPOM, the Government intends to secure
services or equipment from firms which are not under foreign ownership, control, or influence (FOCI) or
where any FOCI may, in the opinion of the Government, adversely impact on security requirements.
Accordingly, all Offerors responding to this RFP or initiating performance of a contract are required to
submit a Standard Form 328(formerly known as DD 441 S), Certificate Pertaining to Foreign Interests (or
update a previously submitted Form 328), with their proposal or prior to contract performance, as
appropriate. Standard Form 328 entries should specify, where necessary, the identity, nature, degree, and
impact of any FOCI on their organization or activities, or the organization or activities of a subcontractor.
Notwithstanding the limitation on contracting with an Offeror under FOCI, the Government reserves the
right to contract with such Offerors under appropriate arrangements, when it determines that such contracts
will be in the best interest of the Government.
 Google
Section K -'Reps & Certs.
Page 10 of 13
(b) The Contractor shall, in any case in which it believes that foreign influence exists or is being sought to
be obtained over its affairs, or the affairs of a Subcontractor, promptly notify the Contracting Officer of all
the pertinent facts, even if such influence is not exerted to the degree specified in the NISPOM.
(c) The Contractor shall promptly disclose to the Contracting Officer any information pertaining to any
interest of a FOCI nature in the Contractor or Subcontractor that has developed at any time during the
contract's duration or has subsequently come to the Contractor's attention.
 Google
Section K - Reps & Certs.
Page 11 of 13
(a) The contractor certifies that it will undertake to ensure that any software to be provided or any
Government Furnished Software to be returned, under this contract will be provided or returned free from
computer virus, which could damage, destroy, or maliciously alter software, firmware, or hardware, or
which could reveal to unauthorized persons any data or other information accessed through or processed
by the software.
Security Requirements - Software Certification JUN 1998
(b) The contractor shall immediately inform the Contracting Officer when it has a reasonable suspicion
that any software provided or returned, to be provided or returned, or associated with the production may
cause the harm described in paragraph (a) above.
(c) If the contractor intends to include in the delivered software any computer code not essential to the
contractual requirement, this shall be explained in full detail to the Contracting Officer and Contracting
Officer's Technical Representative (COTR).
(d) The contractor acknowledges its duty to exercise reasonable care, to include the following, in the
course of contract performance:
(1) using on a regular basis current versions of commercially available anti-virus software to
guard against computer viruses when introducing maintenance, diagnostic, or other software into
computers; and
(2) prohibiting the use of non-contract related software on computers, especially from unknown
or unreliable sources.
K-17. 52.230-1 Cost Accounting Standards Notices and Certification. (JUN 2000) - Alternate I (APR 1996)
Note: This notice does not apply to small businesses or foreign governments. This notice is in three parts, identified
by Roman numerals I through III.
Offerors shall examine each part and provide the requested information in order to determine Cost Accounting
Standards (CAS) requirements applicable to any resultant contract.
If the offeror is an educational institution, Part II does not apply unless the contemplated contract will be subject to
full or modified CAS coverage pursuant to 48 CFR 9903.201-2(c)(5) or 9903.201-2(c)(6), respectively.
1. Disclosure Statement - Cost Accounting Practices and Certification
(a) Any contract in excess of $500,000 resulting from this solicitation will be subject to the requirements
of the Cost Accounting Standards Board (48 CFR Chapter 99), except for those contracts which are
exempt as specified in 48 CFR 9903.201-1.
(b) Any offeror submitting a proposal which, if accepted, will result in a contract subject to the
requirements of 48 CFR Chapter 99 must, as a condition of contracting, submit a Disclosure Statement as
required by 48 CFR 9903.202. When required, the Disclosure Statement must be submitted as a part of the
offeror's proposal under this solicitation unless the offeror has already submitted a Disclosure Statement
disclosing the practices used in connection with the pricing of this proposal. If an applicable Disclosure
Statement has already been submitted, the offeror may satisfy the requirement for submission by providing
the information requested in paragraph (c) of Part I of this provision.
 Google
Section K - Reps & Certs.
Page 12 of 13
Caution: In the absence of specific regulations or agreement, a practice disclosed in a Disclosure Statement shall
not, by virtue of such disclosure, be deemed to be a proper, approved, or agreed-to practice for pricing proposals or
accumulating and reporting contract performance cost data.
(c) Check the appropriate box below:
[[ ]] (1) Certificate of Concurrent Submission of Disclosure Statement. The offeror hereby certifies that, as a part of
the offer, copies of the Disclosure Statement have been submitted as follows:
(i) Original and one copy to the cognizant Administrative Contracting Officer (ACO) or
cognizant Federal agency official authorized to act in that capacity (Federal official), as
applicable; and
(ii) One copy to the cognizant Federal auditor.
(Disclosure must be on Form No. CASB DS-1 or CASB DS-2, as applicable. Forms may be obtained from the
cognizant ACO or Federal official and/or from the loose-leaf version of the Federal Acquisition Regulation.)
Date of Disclosure Statement: [Name and Address of Cognizant ACO or Federal Official Where Filed:]
The offeror further certifies that the practices used in estimating costs in pricing this proposal are consistent with the
cost accounting practices disclosed in the Disclosure Statement.
[[ ]] (2) Certificate of Previously Submitted Disclosure Statement. The offeror hereby certifies that the required
Disclosure Statement was filed as follows:
Date of Disclosure Statement: [ ]
Name and Address of Cognizant ACO or Federal Official Where Filed: [ ]
The offeror further certifies that the practices used in estimating costs in pricing this proposal are consistent with the
cost accounting practices disclosed in the applicable Disclosure Statement.
[[ ]] (3) Certificate of Monetary Exemption. The offeror hereby certifies that the offeror, together with all divisions,
subsidiaries, and affiliates under common control, did not receive net awards of negotiated prime contracts and
subcontracts subject to CAS totaling $50 million or more in the cost accounting period immediately preceding the
period in which this proposal was submitted. The offeror further certifies that if such status changes before an award
resulting from this proposal, the offeror will advise the Contracting Officer immediately.
[[ ]] (4) Certificate of Interim Exemption. The offeror hereby certifies that (i) the offeror first exceeded the monetary
exemption for disclosure, as defined in (3) of this subsection, in the cost accounting period immediately preceding
the period in which this offer was submitted and (ii) in accordance with 48 CFR 9903.202-1, the offeror is not yet
required to submit a Disclosure Statement. The offeror further certifies that if an award resulting from this proposal
has not been made within 90 days after the end of that period, the offeror will immediately submit a revised
certificate to the Contracting Officer, in the form specified under subparagraph (c)(1) or (c)(2) of Part I of this
provision, as appropriate, to verify submission of a completed Disclosure Statement.
[[ ] ] (5) Certificate of Disclosure Statement Due Date by Educational Institution. If the offeror is an educational
institution that, under the transition provisions of 48 CFR 9903.202-1(f), is or will be required to submit a
Disclosure Statement after receipt of this award, the offeror hereby certifies that (check one and complete):
[[ ]] (i) A Disclosure Statement Filing Due Date of [ ] has been established with the cognizant Federal agency.
[[ ]] (ii) The Disclosure Statement will be submitted within the 6-month period ending [ ] months after receipt of
this award.
 Google
Section K - Reps & Certs.
Page 13 of 13
Name and Address of Cognizant ACO or Federal Official Where Disclosure Statement is to be Filed: [ ]
Caution: Offerors currently required to disclose because they were awarded a CAS-covered prime contract or
subcontract of $50 million or more in the current cost accounting period may not claim this exemption (4). Further,
the exemption applies only in connection with proposals submitted before expiration of the 90-day period
following the cost accounting period in which the monetary exemption was exceeded.
II. Cost Accounting Standards - Eligibility for Modified Contract Coverage
If the offeror is eligible to use the modified provisions of 48 CFR 9903.201-2(b) and elects to do so, the offeror
shall indicate by checking the box below. Checking the box below shall mean that the resultant contract is subject
to the Disclosure and Consistency of Cost Accounting Practices clause in lieu of the Cost Accounting Standards
clause.
[[ ]] The offeror hereby claims an exemption from the Cost Accounting Standards clause under the provisions of 48
CFR 9903.201-2(b) and certifies that the offeror is eligible for use of the Disclosure and Consistency of Cost
Accounting Practices clause because during the cost accounting period immediately preceding the period in which
this proposal was submitted, the offeror received less than $50 million in awards of CAS-covered prime contracts
and subcontracts. The offeror further certifies that if such status changes before an award resulting from this
proposal, the offeror will advise the Contracting Officer immediately.
Caution: An offeror may not claim the above eligibility for modified contract coverage if this proposal is expected
to result in the award of a CAS-covered contract of $50 million or more or if, during its current cost accounting
period, the offeror has been awarded a single CAS-covered prime contract or subcontract of $50 million or more.
III. Additional Cost Accounting Standards Applicable to Existing Contracts
The offeror shall indicate below whether award of the contemplated contract would, in accordance with
subparagraph (a)(3) of the Cost Accounting Standards clause, require a change in established cost accounting
practices affecting existing contracts and subcontracts.
[[ ]] yes [[ ]] no