AD- 3031-FS Assurance Regarding Felony Conviction or Tax Delinquent Status

Form Approved – OMB No. 0505-0025
Expiration Date: 04/30/2019

This form is available electronically.

AD-3031-FS

U.S. Department of Agriculture

ASSURANCE REGARDING FELONY CONVICTION
OR TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS
FY 2012, FY 2013, FY 2014
NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 55a – as amended). The authority for requesting the following information for
Forest Service is in sections 433 and 434 of the Consolidated Appropriations Act 2012, P.L. No. 112-74, as amended and/or subsequently enacted. The information will be
used to document compliance with appropriations restrictions.
According to the Paperwork Reduction Act of 1995 an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number of this information collection is 0505-0025. The time required to complete this information collection is
estimated to average 3 minutes 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the
information provided.

This award is subject to the provisions contained in the Consolidated Appropriations Act, 2012, P.L. No. 112-74,
Division E, Sections 433 and 434, as amended and/or subsequently enacted regarding corporate felony convictions
and corporate federal tax delinquencies.
Accordingly, by accepting this award the recipient acknowledges that it: (1) does not have a tax delinquency, meaning

that it is not subject to any unpaid Federal tax liability that has been assessed, for which all judicial and
administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner
pursuant to an agreement with the authority responsible for collecting the tax liability, and (2) has not been
convicted (or had an officer or agent acting on its behalf convicted) of a felony criminal violation under any
Federal law within 24 months preceding the award, unless a suspending and debarring official of the United
States Department of Agriculture has considered suspension or debarment of the recipient corporation, or such
officer or agent, based on these convictions and/or tax delinquencies and determined that suspension or
debarment is not necessary to protect the interests of the Government. If the recipient fails to comply with these
provisions, the awarding agency will annul this agreement and may recover any funds the recipient has
expended in violation of the above cited statutory provisions.

_________________________________________________
APPLICANT’S SIGNATURE (BY)

_________________________________________________
TITLE/RELATIONSHIP OF THE INDIVIDUAL IF SIGNING IN A
REPRESENTATIVE CAPACITY
___________________________________________________________________
BUSINESS NAME

_________________________________________________
DATE SIGNED (MM-DD-YYYY)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where
applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s
income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of
discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410,
Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish
Federal-relay). USDA is an equal opportunity provider and employer.
Rev: 11/12 Destroy all previous copies