10-0388-7 Certification Regarding Debarment, Suspension, And Other

OMB Number: 2900-0661
Estimated Burden: 1 hour

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
PROJECT DESCRIPTION

PROJECT LOCATION

FAI NUMBER

This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 38 CFR
Part 44, Section 44.510, Participants' Responsibilities.
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) Where the prospective primary participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal;
(b) Have not within a three-year period preceding this proposal 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) transaction or contract
under a public transaction; violation of Federal or State antitrust statues or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements,
or receiving stolen property;
(c) Are not presently indicted for otherwise criminally or civilly charged by a governmental entity (Federal,
State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification;
(d) Have not within a three-year period preceding this application/proposal had one or more public
transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
TITLE 38 CFR 44.510(B)

CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.
I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.
NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE

TITLE OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of this
Act. The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. We may not collect or sponsor and you are
not required to respond to, a collection unless it has a valid OMB Control Number. This collection of information is collected under the authority of 38 U.S. Code Sections
8133(a) and 8135(a). VA will use this information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to
meet VA requirements for a grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to
authorize a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.
VA FORM
DEC 2010

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INSTRUCTIONS FOR CERTIFICATION
1.

By signing and submitting this proposal, the prospective primary participant is providing the certification set out
below.

2.

The inability of a person to provide the certification required below will not necessarily result in denial of
participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot
provide the certification set out below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However, failure of the prospective
primary participant to furnish a certification or an explanation shall disqualify such person from participation in this
transaction.

3.

The certification in this clause is a material representation of fact upon which reliance was placed when the
department or agency determined to enter into this transaction. If it is later determined that the prospective primary
participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for cause or default.

4.

The prospective primary participant shall provide immediate written notice to the department or agency to whom this
proposal is submitted it at any time the prospective primary participant learns that its certification was erroneous
when submitted or has become erroneous by reason of changed circumstances.

5.

The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal" "proposal," and "voluntarily excluded," as used in
this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive
Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in
obtain a copy of those regulations.

6.

The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction
be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred,
suspended declared ineligible, or voluntarily excluded from participation in this covered transaction, unless
authorized by the department or agency entering into this transaction.

7.

The prospective primary participant further agrees by submitting this proposal that it will include the clause titled
"Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered
Transactions," provided by the department or agency entering into this covered transaction, without modification, in
all lower tier covered transactions and in all solicitations for lower tier covered transactions.

8.

A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction
unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it
determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement
List.

9.

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 this clause. The knowledge and information of a participant is not
required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

10.

Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or
voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for cause or default.

VA FORM
MAR 2005

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