Fillable Ihs-975 FORM IHS 975

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Ihs-975 FORM IHS 975

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
REQUEST FOR RATIFICATION OF UNAUTHORIZED COMMITMENT (UAC)
Federal Acquisition Regulation (FAR) 1.602-3
HHS Acquisition Regulation (HHSAR) 301.602.-3
Purchase Request Number IHS
Amount ($)
Area Office/Service Unit/Program Office or HQ Office/Division
For (Item or Service)
Date of Commitment
To (Vendor/Contractor Name and Address)
The following section are to be completed by
Part I - Description of Commitment and Service Unit/Area or HQ Review
Section A, to be completed by individual who committed UAC
Section B, to be completed by Funds Certifying Official
Section C, to be completed by Immediate Supervisor
Section D, Service Unit CEO or Area/HQ Office Program Director - Review and Concurrence
Section E, Area Office / HQ Executive Officer - Review and Concurrence
Part II - Area or HQ Division of Acquisition's Review/Recommendation
Section A, to be completed by Contracting Officer
Section B, to be completed by Chief of the Contracting Office
Part III - Legal Review, Office of The General Counsel (OGC), Required for $150,000 and Above
Part IV - Approval, Head of the Contracting Activity (HCA)
PART I - SECTION A - COMMITMENT CIRCUMSTANCES
The individual who made the unauthorized commitment shall complete items 1 thru 5 of Part I, Section A, provide detailed facts,
required documentation, electronically sign, date, and forward to the immediate supervisor for completion of Part I - Section B.
1. Describe Circumstances that Led to the Unauthorized Commitment
IHS-975 (05/19)
PSC Publishing Services (301) 443-6740
EF
PAGE 1 of 10
PART I - SECTION A - COMMITMENT CIRCUMSTANCES (Continued)
2. Explain Why Appropriate Acquisition Mechanism Was Not Followed and Why Vendor Was Selected
3. Statement That Funds Are and Were Available at Time of Unauthorized Commitment
4. Describe the Benefits Received by The Government (Give value of benefit and other pertinent facts) and if Service or Goods Have
Been Received
5. List Below and Attach All Relevant Documents (Include orders, invoices, fund availability, requisition and other evidence of the
transaction. Verify accuracy and completeness of documentation)
Signature
Date (mm/dd/yy)
Name, and Title of Individual Who Made the Unauthorized Commitment
IHS-975 (05/19)
PAGE 2 of 10
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PART I - SECTION B - CONTRACTUAL RATIFICATION
The funds certifying official will complete items 6 thru 7 of Part I, Section B, electronically sign, date, and return the form to the individual
who committed UAC.
6. Availability of Funds
Are Unobligated Funds Presently Available for the Amount of the Unauthorized Commitment?
Yes
No
If yes, identify the CAN or approved requisition number
7. Funds Certification
I have Reviewed the Acquisition and Certify that Funds Were Available at the Time of the Occurrance, and Remain Available for
the Project.
Yes
No
Signature
Date (mm/dd/yy)
Funds Certifying Official Name, Title and Area or HQ Office/Service Unit/Program
IHS-975 (05/19)
PAGE 3 of 10
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PART I - SECTION C - CONTRACTUAL RATIFICATION
The Immediate Supervisor Will Complete Items 8 thru 10 of Part I, Section C, Electronically Sign, Date, and Forward to Service Unit
CEO or Area/HQ Office Program Director.
8. Describe Attempts to Resolve Unauthorized Commitment Prior to Requesting Ratification (Such as, returning merchandise, individual
paying from personal funds, etc.)
9. Describe Corrective Action Taken or an Explanation of Why None Was Considered Necessary (Include a description of any
administrative action taken under applicable personnel authority)
10. Describe Action Taken to Prevent Recurrence of Unauthorized Commitments
Signature
Date (mm/dd/yy)
Immediate Supervisor Name, Title and Area or HQ Office/Service Unit/Program
IHS-975 (05/19)
PAGE 4 of 10
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PART I - SECTION D - CONTRACTUAL RATIFICATION
The Service Unit CEO, Area Program Director or HQ Division Director will complete Section D of Part I. (Section B & C, in some
instances, may be the same person.)
Approval of Corrective Action Taken
Yes
No
If no, explain non-concurrence
Approval of Action(s) to Preclude Recurrence of Unauthorized Commitments
Yes
No
If no, explain non-concurrence
I Have Reviewed Sections A and B of Part I, Verified That the Information is Accurate and Complete, That The Government Received a
Benefit and Associated Value from the Unauthorized Commitment, That Certified Funds Were Available at the Time of UAC and
I concur with the ratification of the unauthorized commitment
I do not concur with the ratification of the unauthorized commitment
If no, explain non-concurrence
Completed Purchase Description and Funding Document is Executed and Attached (Required if Ratification is Recommended).
Funding Document Must Specifically State That Funds Were Available at the Time the Unauthorized Commitment Was Made and
These Funds are Still Available.
Yes
No (action will not be ratified)
Signature
Date (mm/dd/yy)
Service Unit CEO, Area Program Director or HQ Division Director Name, Title and Service Unit/Office.
IHS-975 (05/19)
PAGE 5 of 10
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PART I - SECTION E - CONTRACTUAL RATIFICATION
The Area Executive Officer or HQ Office Director will complete Section E of Part I.
Approval of Corrective Action Taken
Yes
No
If no, explain non-concurrence
Approval of Action(s) to Preclude Recurrence of Unauthorized Commitments
Yes
No
If no, explain non-concurrence
I Have Reviewed Sections A and B of Part I, Verified That the Information is Accurate and Complete, That The Government Received a
Benefit and Associated Value from the Unauthorized Commitment, That Certified Funds Were Available at the Time of UAC and
I concur with the ratification of the unauthorized commitment
I do not concur with the ratification of the unauthorized commitment
If no, explain non-concurrence
Completed Purchase Description and Funding Document is Executed and Attached (Required if Ratification is Recommended).
Funding Document Must Specifically State That Funds Were Available at the Time the Unauthorized Commitment Was Made and
These Funds are Still Available.
Yes
No (action will not be ratified)
Signature
Date (mm/dd/yy)
Area Executive Officer or HQ Office Director Name.
IHS-975 (05/19)
PAGE 6 of 10
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PART II - SECTION A - CONTRACTING OFFICER'S REVIEW
FAR 1.602.3 AND HHSAR 301.602-3
THE CONTRACTING OFFICER SHALL REVIEW THE FILE AND PROCEED AS FOLLOWS:
Determine the adequacy of all facts, records, and documents furnished, and obtain any additional material required.1.
State whether the ratification is in accordance with any other limitations prescribed under agency procedures.3.
2. Prepare a summary of facts to include a recommendation as to whether or not the transaction should be ratified and reasons for
the recommendation. A recommendation not to ratify must include a recommendation as to whether or not the matter should be
processed under FAR part 50 and (Pub. L. 85-804) as a Government Accountability Office (GAO) claim or in some other
appropriate way.
4. Determine whether supplies or services have been provided to and accepted by the Government, or the Government otherwise
has obtained or will obtain as a result from performance of the unauthorized commitment.
The ratifying official has the authority to enter into a contractual commitment.
6. Determine whether the resulting contract would otherwise have been proper if made by an appropriate Contracting Officer.
5. The ratifying official has the authority to enter into a contractual commitment.
7. State whether the price is considered fair and reasonable and indicate how that determination was made.
8. Indicate whether or not the Contracting Officer recommends payment and legal counsel concurs in the recommendation, unless
Agency procedures expressly do not require such concurrence.
Determine that sufficient funds are available, and were available at the time the unauthorized commitment was made.
9.
Contracting Officer's Review
If more space is required, CO's statement may be attached; signature and date required below and on attachment).
Signature
Date (mm/dd/yy)
Name of Contracting Officer
IHS-975 (05/19)
PAGE 7 of 10
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PART II - SECTION B - RECOMMENDATION/APPROVAL
SECTION A
(Completed by the Chief of the Contracting Office)
ACTION VALUED AT ANY VALUE
Based on the foregoing determination, ratification of unauthorized commitment is recommended for approval.
Based on the foregoing determination, ratification of unauthorized commitment is recommended for disapproval (Explain below).
Signature
Date (mm/dd/yy)
Name Chief of the Contracting Office
IHS-975 (05/19)
PAGE 8 of 10
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PART III - LEGAL REVIEW
(To be completed by Office of the General Counsel for all requests $150,000 and above, per HHS Acquisition Alert 2017-02)
Determine Whether the Acquisition is Ratifiable Under FAR 1.602-3 and HHSAR 301.602-3 or Whether the Matter Should be
Processed Under (Public Law 85-804), as a GAO Claim, or Recommend Other Appropriate Disposition. (Return to the Head of the
Contracting Activity for final approval or non-approval).
If more space is required, legal opinion may be attached; signature and date required below and on attachment)
Signature
Date (mm/dd/yy)
Name of Legal Advisor, Title, and Organization
IHS-975 (05/19)
PAGE 9 of 10
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PART IV - APPROVAL
(Completed by the IHS, Head of the Contracting Activity)
ALL ACTIONS REGARDLESS OF DOLLAR VALUE
Based on the foregoing determination, ratification of unauthorized commitment is recommended for approval.
Based on the foregoing determination, ratification of unauthorized commitment is recommended for disapproval (Explain below).
Signature
Date (mm/dd/yy)
Name of Head of the Contracting Activity (HCA)
IHS-975 (05/19)
PAGE 10 of 10
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Ihs-975 FORM IHS 975

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Completed 28 February 2020

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