Form AD-1047 Certification Regarding Debarment, Suspension, and Other

OMB Control No. 0505-0027
Expiration Date: 04/30/2022

This form is available electronically.

Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions

AD-1047

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552a, as amended). This certification is required by the regulations
implementing Executive Order 12549, Debarment and Suspension, and 2 C.F.R. § 180.335, Participants' responsibilities. The regulations were amended
and published on August 31, 2005, in 70 Fed. Reg. 51865-51880. Copies of the regulations may be obtained by contacting the Department of Agriculture
agency offering the proposed covered transaction.
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 information required is mandatory by statute ( 41 U.S.C. 8101). The valid OMB control
number for this information collection is 0505-0027. The time required to complete this information collection is estimated to average 15 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, civil, fraud, privacy, and other statutes may be applicable to the information
provided.

(Read instructions on page two before completing certification.)
A. The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
1. Are not presently debarred, suspended, or proposed for debarment, declared ineligible, or voluntarily excluded from
covered transactions by any Federal department or agency;
2. 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 statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen property;
3. 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 (A.2.) of this certification; and
4. 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.
B. 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

PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title:
SIGNATURE(S)

DATE

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and
employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex,
gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance
program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all
programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language,
etc.) should contact the responsible agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at
(800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program
Discrimination Complaint (https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer) and at any USDA office or write a letter addressed to
USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed
form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington,
D.C. 20250-9410; (2) fax: (202) 690-7442.

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 which 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, at 2 C.F.R. Parts 180 and 417. You may contact the department or agency to which this proposal 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 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 System for Award Management
(SAM) database.
(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.

Form AD-1047 (REV 12/18)
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