Form VA Form 26-0967 VA Form 26-0967 Certification Regarding Debarment, Suspension, Ineligibi

OMB Control Number: 2900-0821
Respondent Burden: 1 hour
Expiration Date: XX/XX/XXXX

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION
PROJECT DESCRIPTION

PROJECT LOCATION

FAI NUMBER

This certification is required by the regulations implementing 38 U.S.C. 2108, Specially Adapted Housing Assistive Technology
Grant Program. Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.
(1) The participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department
or agency.
(2) Where the participant is unable to certify to any of the statements in this certification, such prospective participant shall provide
an explanation below to this proposal.

CERTIFICATION - THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.
NAME OF COMPANY

COMPANY TAX IDENTIFICATION NUMBER

NAME OF AUTHORIZED REPRESENTATIVE

TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE

DATE SIGNED

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., the authorized release of information to Congress when requested for statistical purposes) as identified
in the VA system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant
Records, and Vendee Loan Applicant Records - VA, and published in the Federal Register. Your obligation to respond is voluntary.
RESPONDENT BURDEN: We need this information to help determine whether VA requirements for a grant award are met. Title 38, U.S.C. section 2108, authorizes
collection of this information. We estimate that you will need an average of 1 hour to review the instructions, find the information and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this
number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM
XXX XXXX

26-0967

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INSTRUCTIONS FOR CERTIFICATION

1.

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

2.

The certification in this clause is a material representation of act upon which reliance was placed when this transaction
was entered into. If it is later determined that the participant knowingly rendered an erroneous certification, in addition
to other remedies available to the Federal Government, the department or agency with which this transaction originated
may pursue available, remedies, including suspension and/or debarment.

3.

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

4.

The terms "covered transaction," "participant," "person," "primary covered transaction," "principle," "proposal," and
"voluntarily excluded," as used in this clause, have the meanings set out in title 2, Code of Federal Regulations, part
180. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those
regulations.

5.

The participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall
not knowingly enter into any 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 with which this
transaction originated.

6.

The participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding
Debarment, Suspension, Ineligibility, and Voluntary Exclusion Transactions," without modification, in all covered
transactions and in all solicitations for covered transactions.

7.

A participant in a covered transaction may rely upon a certification of a prospective participant in a 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 Non procurement List.

8.

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.

9.

Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction
knowingly enters into a 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 with which this transaction originated may pursue available remedies, including suspension and/
or debarment.

VA FORM 26-0967, XXX XXXX

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