Ad-1047

U.S. DEPARTMENT OF AGRICULTURE
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions

This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 7 CFR
Part 3017, Section 3017.510, Participants' responsibilities. The regulations were published as Part IV of the January
30, 1989, Federal Register (pages 4722-4733). Copies of the regulations may be obtained by contacting the Department
of Agriculture agency offering the proposed covered transaction.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 2)
(1)

(2)

The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a)

are not presently debarred, suspended, proposed fo r debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal department or agency;

(b)

have not within a three-year period preceding this certification been convicted of or had a civil judgement
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 statutes 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 or 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;
and

(d)

have not within a three-year period preceding this certification had one or more public transactions
(Federal, State or local) terminated for cause or default.

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.

Organization Name

Award Number or Project Name

Name(s) and Title(s) of Authorized Representative(s)

Signature(s)

Date

1

Form AD-1047 (2/93)

Instructions for Certification
1. By signing and submitting this form, the prospective primary participant is providing the certification set out on page
1, in accordance with these instructions.
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 on this form. 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 if 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 the rules implementing Executive Order 12549. You
may contact the department or agency to which this certification is being submitted for assistance in obtaining a copy
of those regulations.
6. The prospective primary participant agrees by submitting this form 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 form 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..

2

Form AD-1047 (2/93)