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Annual Subcontractor / Supplier Representations

and Certifications (Government)

BUSINESS NAME: / CONTACT NAME:
DBA: (if different from above)
ADDRESS:
CITY, STATE, ZIP (+4):
REMIT TO: (if different)
CITY, STATE, ZIP (+4):
PHONE: / FAX:
E-MAIL:
TAX ID NUMBER (TIN):
(as req’d on Form W-9) / OR: If Individual or Partnership
SOCIAL SECURITY No.
Dun & Bradstreet Number / D-U-N-S
Check Appropriate Box / Individual/Sole proprietor / Corporation
Partnership / Other / Exempt from backup
withholding
(as req’d on Form W-9) / Limited Liability Company Enter the Tax Classification > > > / Disregarded Entity (LLC) / Corporation (LLC) / Partnership (LLC)

Company Point of Contact NAME to receive PO’s and return acknowledgements:

Company Point of Contact E-MAIL ADDRESS for electronic transmission:

Company Cage Code Number:

Business Size Classification(Check ALL that apply):

Please refer to for classifications defining Small, Socially, and Economically Disadvantaged Businesses:

Small Business (SB) / ITAR (International Traffic in Arms Regulations) ITAR Parts 120-130 (22 CFR 120-130)
Woman-Owned Small Business (WOSB) / We are ITAR compliant Yes No
Small Disadvantaged Business (SDB) (FAR 52.219-22)
Veteran-Owned Small Business (VOSB) / NAICS:
Service-Disabled Veteran-Owned (SDVOSB) / Primary code:
Historically Underutiized Business Zone * (HubZone) / List All Others:
SBA’s 8A Program*
Historically Black College or University (HBCU) / C-TPAT (Customs-Trade Partnership Against Terrorism) Certification
Institution (MI) / Yes No
Large Business (LB)
Government Agency (GA) / COMSEC: We are a COMSEC approved facility
Educational Institution (EI) / COMSEC account number:
Foreign Business (FB) - Suppliers indicating that they are a foreign business need also to answer the following:
(only answer the following if you ARE a Foreign Business)
1. Does the company have a plant in the U.S. which pays taxes to the U.S. and uses American products, materials, or labor? Yes No
2. Is the company incorporated in the U.S.? Yes No
* (Certification Required)
Please list the type of services, processes, products, or commodities that your company provides:
Consultant
Distributor
Sales Representative
Service Provider
Fabricator (QA Approval Req’d on Non-COTS items)
Manufacturer
Contract Manufacturer
Other

Notice: Under 13 CFR 124.6, any person or entity that intentionally misrepresents the business size or status of any concern to obtain contracting opportunities may be subject to fine, imprisonment, or both, administrative remedies, suspension and debarment, and ineligibility for participation in any Federal program.

52.204-10– Reporting Executive Compensation (Jul 2010)

(a)Subcontractor/supplier is exempt from providing the information below under paragraph (b) if at leastone of the following apply: (check each that applies)

Less than 80%of the subcontractor/supplier’s annual gross revenue in the preceding fiscal year was derived from Federal sources; OR

Subcontractor/supplier received less than $25 million in revenue from Federal sources in the preceding year (“Federal sources” includes federal prime- and subcontracts, loans, grants and subgrants, and cooperative agreements); OR

The public has access to this executive compensation information through other sources, such as SEC filings.

(b)If no exception listed above is applicable, list the names, titles and total compensation of each of your five most highly compensated executives for the preceding completed fiscal year.

NameTitleTotal Compensation

1.$

2.$

3.$

4.$

5.$

(c)Please provide the address of the primary performance location:

Street Address
City, State, Country
Nine-digit Zip Code
Congressional District

(d)Did Subcontractor/supplier have at least $300,000 in gross income, from all sources, in the previous tax year?

Yes No

Note: The information required by FAR 52.204-10 will be made public.

52.203-2 – Certificate of Independent Price Determination (Apr 1985)

(a) Subcontractor/supplier certifies that –

(1) The quoted prices were (or “will be” for future orders) 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 quoted prices have not been and will not be knowingly disclosed by the subcontractor/supplier, 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 subcontractor/supplier to induce any other concern to submit or not to submit an offer for the purpose of restricting competition.

(b) Each signature hereto is considered to be a certification by the signatory that the signatory –

(1) Is the person in the subcontractor/supplier’s organization responsible for determining the prices offered, and that the signatory has not participated and will not participate in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision; or

(2)

(i) Has been authorized, in writing, to act as agent for the Subcontractor/supplier principals in certifying that those principals have not participated, and will not participate in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision;

(ii)As an authorized agent, does certify that the principals referred to in subdivision (b)(2)(i) of this provision have not participated, and will not participate, in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision; and

(iii)As an agent, has not personally participated, and will not participate, in any action contrary to subparagraphs (a)(1) through (a)(3) of this provision.

52.222-48 – Exemption from Application of the Service Contract Act to Contracts for Maintenance, Calibration, or Repair of Certain Equipment Certification (Feb 2009)

(a)Subcontractor/supplierdoescertify that

(1) The items of equipment serviced or to be serviced are used regularly for other than Government purposes, and are sold or traded by the subcontractor/supplierin substantial quantities to the general public in the course of normal business operations;

(2) The services have been and will be furnished at prices which are, or are based on, established catalog or market prices for the maintenance, calibration, or repair of equipment.

(i) An “established catalog price” is a price included in a catalog, price list, schedule, or other form that is regularly maintained by the manufacturer or the subcontractor/supplier, is either published or otherwise available for inspection by customers, and states prices at which sales currently, or were last, made to a significant number of buyers constituting the general public.

(ii) An “established market price” is a current price, established in the usual course of trade between buyers and sellers free to bargain, which can be substantiated from sources independent of the manufacturer or offeror; and

(3) The compensation (wage and fringe benefits) plan for all service employees performing work under the contract are the same as that used for these employees and equivalent employees servicing the same equipment of commercial customers.

Or N/A (FAR 52.222-48 is not applicable because Subcontractor / Supplier does not and will not provide services for maintenance, calibration or repair of relevant equipment. Further, Subcontractor / Supplier acknowledges that if FAR 52.222-48 is later determined to be applicable, then a purchase order cannot be placed for such services when “N/A” is checked; and at ViaSat’s sole election, Subcontractor / Supplier may be provided an opportunity to submit a new representation and certification.)

52.222-22 – Previous Contracts and Compliance Reports (Feb 1999)

Subcontractor/supplier represents that –

(a) It has, has not participated in a previous contract or subcontract subject to the Equal Opportunity clause of this subcontract; and

(b)It has, has not filed all required compliance reports.

52.222-25 – Affirmative Action Compliance(Apr 1984)

Subcontractor/supplier 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 has notpreviously had contracts subject to the written affirmative action programs requirement of the rules and regulations of the Secretary of Labor.

52.209-5 – Certification Regarding Responsibility Matters (Apr 2010)

(a)Subcontractor/supplier certifies, to the best of its knowledge and belief, that Subcontractor/supplier and any of its Principals –

(1)Are are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

(2)Have have not, within a three-year period preceding this certification, 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; and

(3)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 paragraph (1)(B) of this certification; and

(4)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.

(5)Have have not, within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal agency.

(b)Subcontractor/supplier will provide immediate written notice to ViaSat Supply Chain Management if, at any time prior to subcontract award, the subcontractor/supplier learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

252.225-7049 – Prohibition on Acquisition of Commercial Satellite Services from certain Foreign Entities

(a)Subcontractor/supplier represents that –

(1)It is is nota foreign entity in which the government of a covered foreign country has an ownership interest that enables the government to affect satellite operations;

(2)It is is notaforeign entity that plans to provide or use launch or other satellite services under the contract from a covered foreign country;

(3)It is is notoffering commercial satellite services provided by a foreign entity in which the government of a covered foreign country has an ownership interest that enables the government to affect satellite operations; and

(4)It is is not offering commercial satellite services provided by a foreign entity that plans to or is expected to provide or use launch or other satellite services under the contract from a covered foreign country.

52.203-11 – Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions (Sep 2007)

Subcontractor/supplier certifies that to the best of its knowledge and belief 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 any ViaSat order or contract.

Subcontractor/supplier certifies that it does not utilize forced, prison, or indentured labor, or subject workers to any form of compulsion or coercion. Subcontractor/supplier further certifies that all labor used in the creation of its products comply with laws regarding slavery and human trafficking in the countries in which subcontractor/supplier is doing business.

Should there be any changes whatsoever, I will inform ViaSat immediately. If a Business Size Classification change occurs I will submit new Representations and Certifications. If Business is certified by SBA I have attached a copy of the certification.

By completing and signing this form, I certify that the information given in these Representations and Certifications are current, complete, and accurate as of the date signed.

PRINT NAME: / TITLE:
SIGNATURE: / DATE:

Return Completed Form to:ViaSat, Inc.

6155 El Camino Real

Carlsbad, CA 92009-1699

Attention: Subcontracts Department

The Box Below is for ViaSat Internal Use Only:
Requestor (print name): / Signature: / Date:
Approval (print name): / Signature: / Date:

PR000129 Rev027 (06/04/15)Page 1 of 8

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Instructions for Completing Form

PR000129 Forms are renewed every year.

All sections must be completed.

Supplier shall include on the Supplier Representations and Certifications form (PR000129)

(Please complete all sections.)

  1. Business Name
  2. Contact Name
  3. Doing Business As (DBA) Name (if different from A)
  4. Business Street Address
  5. City, State and Zip (+4)
  6. Remit to address if different than business address (D)
  7. Remit to City, State and Zip (+4)
  8. Business phone number
  9. Business fax number
  10. Email address for contact
  11. Tax ID number (TIN) (as required on Form W-9) unless Individual or Partnership
  12. Social Security No. if individual or partnership
  13. Dun & Bradstreet Number/D-U-N-S
  14. Check appropriate box (as required on W-9 form)

1)Individual/Sole proprietor

2)Corporation

3)Partnership

4)Other

5)Exempt from backup withholding

6)Limited Liability company (enter the Tax Classification)

  1. Disregarded Entity (LLC)
  2. Corporation (LLC)
  3. Partnership (LLC)
  1. Company Point of Contact Name to receive Purchase Orders and return acknowledgements
  2. Company Point of Contact E-Mail Address for electronic transmission
  3. Business size classification – check all that apply. Refer to for classifications defining Small, Socially and Economically Disadvantaged Businesses Select Small Business or Large Business and any other classifications that apply. If business is medium size, select Large Business.

1)Small Business (SB)

2)Woman-Owned Small Business (WOSB)

3)Small Disadvantaged Business (SDB) (FAR 52.219-22)

4)Veteran-Owned Small Business (VOSB)

5)Service-Disabled Veteran-Owned (SDVOSB)

6)Historically Underutilized Business Zone (HubZone) – certification is required

7)SBA’s 8A Program – certification is required

8)Historically Black College or University (HBCU)

9)Institution (MI)

10)Large Business (LB)

11)Government Agency (GA)

12)Foreign Business (FB) (select if Foreign business or if owned by Foreign business)

13)Educational Institution (EI)

  1. North American Industry Classification Systems (NAICS): If needed, look up code at

1)List primary code

2)List all other codes

  1. International Traffic in Arms Regulation (ITAR) - select response
  2. COMSEC: Check if you are a COMSEC approved facility

1)If checked, enter COMSEC account number

  1. Customs-Trade Partnership Against Terrorism (C-TPAT) Certification ( )

– select yes or no

  1. List the type of services, processes, products, or commodities that your company provides.

1)Select box in first column where appropriate

2)Add details in this column for type of service, processes, products or commodities

  1. 52.204-10 – Reporting Executive Compensation

1)Fill out section (a) or (b) and complete (c) if the primary performance location is other than listed at the top of the form.

2)For Section (d) select Yes or No

  1. 52.203-2 Certificate of Independent Price Determination (Apr 1985) - Review and confirm you are complying
  2. 52.222-48 – Exemption from Application of the Service Contract Act to Contracts for Maintenance, Calibration, or Repair of Certain Equipment Certification (Feb 2009)

1)Select response that applies: Supplier does certify paragraphs 1-3 or NA (FAR 22.222-48 is not applicable)

  1. 52.222.22 – Previous Contracts and Compliance Reports (Feb 1999)

1)Select box that applies for (a) and (b)

  1. 52.222-25 – Affirmative Action Compliance (Apr 1984)

1)Select box that applies for both (a) & (b)

  1. 52.209-5 –Certification Regarding Responsibility Matters (Apr 2010)

1)Select response for all questions (1-5)

  1. 252.225-7049 - Prohibition on Acquisition of Commercial Satellite Services from certain Foreign Entities

1)Respond to all boxes

  1. 52.203.11 – Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions (Sep 2007)

1)Review and confirm company complies.

  1. Signature that information provided on the Representation and Certification form is complete and accurate. Please note that all forms must be completed and signed by a senior manager in your company.

1)Print Name

2)Print Title

3)Sign Form

4)Date Form

Return the form to ViaSat using one of the options below:

  • E-mail or fax to ViaSat contact requesting the form
  • E-mail to:
  • Fax to: (760) 893-3121. Please verify your fax is received by sending email to
  • Mail to: ViaSat Purchasing Dept., 6155 El Camino Real, Carlsbad, CA 92009-1699

PR000129 Rev027 (06/04/15)Page 1 of 8