SSBCI-Investing-in-America-SBOP-Applicant-Certifications-Template

State Small Business Credit Initiative (SSBCI) Investing in America Small Business Opportunity Program
(SBOP) Applicant Certifications
U.S. Department of the Treasury
Directions: These certifications are required by the U.S. Department of the Treasury (Treasury) to be submitted in
connection with each application to Treasury for financial assistance under the SSBCI Investing in America
SBOP grant program before receipt of award funding. The certifications shall be treated as a material
representation of fact upon which reliance will be placed when Treasury makes award determinations under the
SSBCI Investing in America SBOP. The certifications must be signed by an authorized official of the applicant
who can legally bind the entity and has oversight for the administration and use of SSBCI Investing in America
SBOP financial assistance.

A. Certification Regarding Debarment,
Suspension, and Other Responsibility Matters —
Primary Covered Transactions: Instructions for
Certification
1. By signing and submitting the application, the
prospective primary participant (the applicant is
providing the certification set out below.

transaction,” “participant,” “person,” “primary
covered transaction,” “principal,” “proposal”, and
“voluntarily excluded,” as used in this clause
(certification), have the meanings set out in the
Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may
contact Treasury for assistance in obtaining a copy of
those regulations (31 CFR Part 19).

2. The applicant shall submit an explanation of why it
cannot provide any certification set out below. The
certification or explanation will be considered in
connection with Treasury’s approval of the proposed
application. However, failure of the applicant to
furnish a certification or an explanation shall
disqualify such person/entity from participation in
this transaction.

6. The applicant agrees by submitting an application
under the SSBCI Investing in America SBOP 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 Treasury.

3. This certification is a material representation of
fact upon which reliance is placed when Treasury
determines to enter into this transaction. If it is later
determined that the applicant knowingly rendered an
erroneous certification, in addition to other remedies
available to the Federal government, Treasury may
terminate this transaction for cause or default.

7. The applicant further agrees by submitting an
application that it will not award any contract or
subaward to any entity on the government-wide
Excluded Parties List System (EPLS) found in the
System for Award Management (SAM).

4. The applicant shall provide immediate written
notice to Treasury if at any time the Applicant learns
that its certification was erroneous when submitted or
has become erroneous by reason of changed
circumstances.
5. The terms “covered transactions,” “debarred,”
“suspended,” “ineligible,” “lower tier covered
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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.
9. Nothing contained in the foregoing shall be
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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, subject to all other
remedies available to the Federal Government, and
Treasury may terminate this transaction for cause or
default.
B. Certification Regarding Debarment,
Suspension, and Other Responsibility Matters -Primary Covered Transactions
1. Pursuant to Treasury’s regulations on
nonprocurement debarment and suspension
implemented at 31 CFR Part 19, the prospective
primary participant (the applicant) in a primary tier
“covered transaction,” as defined at 31 CFR
§ 19.200(a) certifies to the best of its knowledge and
belief that neither it nor any of its principals:
(a) is presently debarred, suspended, proposed for
debarment, declared ineligible, sentenced to a denial
of federal benefits by a state or federal court, or
voluntarily excluded from covered transactions by
any Federal department or agency;
(b) has within a three-year period preceding this
application been convicted of or had a civil judgment
rendered against it for commission of fraud or a
criminal offense in connection with obtaining,
attempting to obtain, or performing a public (federal,
state, Tribal, or local) or private agreement or
transaction; violation of federal or State antitrust
statutes; or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of
records, making false statements, tax evasion or
receiving stolen property, making false claims,
obstruction of justice, or commission of any offense
indicating a lack of business integrity or business
honesty that seriously and directly affects its (or its
principals’) present responsibility;
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(c) is presently indicted for or otherwise criminally or
civilly charged by a governmental entity (Federal,
State, tribal, or local) with commission of any of the
offenses enumerated in paragraph (b) of this
subsection in the certification; and/or
(d) has within a three-year period preceding this
application had one or more public transactions
(Federal, State, tribal, or local) terminated for cause
or default.
2. Where the applicant is unable to certify to any of
the statements in this certification, the applicant shall
attach an explanation to this Certification form and
submit it to SSBCI_Information@Treasury.gov.
C. Certification Regarding Drug-Free Workplace
Requirements
As required by the Drug-Free Workplace Act of
1988, as implemented at 31 CFR Part 20, Subpart F,
for recipients, as defined at 31 CFR § 20.650:
1. The applicant certifies and assures that it will, or
will continue to, provide a drug-free workplace by:
(a) Publishing a statement notifying employees that
the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is
prohibited in its workplace and specifying the actions
that will be taken against the employees for
violations of such prohibition;
(b) Establishing an ongoing drug-free awareness
program to inform employees about:
(i) The dangers of drug abuse in the workplace;
(ii) The applicant’s policy of maintaining a drug-free
workplace;
(iii) Any available drug counseling, rehabilitation,
and employee assistance program; and
(iv) The penalties that may be imposed upon
employees for drug abuse violations occurring in the
workplace.

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(c) Making it a requirement that each employee to be
engaged in the performance of the award be given a
copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required
by paragraph (a) that, as a condition of employment
in such grant, the employee will:
(i) Abide by the terms of the statement; and
(ii) Notify the employer in writing of the employee’s
conviction for a violation of a criminal drug statute
occurring in the workplace no later than five calendar
days after such conviction;
(e) Notifying Treasury, in writing, within ten
calendar days after receiving notice of a conviction
under paragraph (d)(ii) from an employee or
otherwise receiving actual notice of such conviction.
Employers of convicted employees must provide
notice, including position title of any such convicted
employee to Treasury at
SSBCI_Information@treasury.gov.
(f) Taking one of the following actions, within
30 days of receiving notice under paragraph (d)(ii),
with respect to any employee who is so convicted:
(i) Taking appropriate personnel action against such
an employee, up to and including termination,
consistent with the requirements of the Rehabilitation
Act of 1973, as amended; or
(ii) Requiring such employee to participate
satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by
a Federal, State, or local health, law enforcement, or
other appropriate agency; and

(a) No Federal appropriated funds have been paid or
will be paid, by or on behalf of the applicant, to any
person for influencing or attempting to influence an
officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection
with making of any Federal grant, and the extension,
continuation, renewal, amendment, or modification
of any Federal grant.
(b) If any funds other than Federal appropriated funds
have been paid or will be paid to any person for
influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a
Member of Congress in connection with this grant
application, the undersigned shall complete and
submit the Form SF-LLL, ‘‘Disclosure of Lobbying
Activities” in accordance with its instructions; and
(c) The applicant shall require that the language of
this certification be included in the award documents
for all its subawards at all tiers and contracts
(including, their subcontracts) and ensure that all
subrecipients, contractors, and subcontractors shall
certify and disclose accordingly.
2. This certification regarding lobbying is a material
representation of fact upon which reliance is placed
when this transaction is made or entered into.
Submission of this certification is a prerequisite for
making or entering into this transaction imposed by
31 U.S.C. § 1352. Any person who fails to file the
required certification shall be subject to a civil
penalty of not less than $10,000 and not more than
$100,000 for each such failure.

(g) Making a good faith effort to continue to maintain
a drug-free workplace through implementation of
paragraphs (a) through (f).
D. Certification Regarding Lobbying
1. As required by 31 U.S.C. § 1352, as implemented
by 31 CFR Part 21, the applicant certifies and
assures, to the best of its knowledge and belief that:

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I acknowledge that a materially false, fictitious, or fraudulent statement (or concealment or omission of a
material fact) in this certification, or in the application that it supports, may be the subject of criminal
prosecution, and also may be subject me and the applicant to civil penalties and administrative remedies for false
claims under Federal law.

Signature of SSBCI Investing in America SBOP Authorized Official:
_________________________________________________________
Name:

Date:

Title:

Name of Applicant:

PAPERWORK REDUCTION ACT NOTICE

The information collections discussed in this application will be submitted to the Office of
Management and Budget (OMB) under OMB control number 1505-0227 in accordance
with the Paperwork Reduction Act of 1995 (44 U.S.C. chapter 35). OMB approval for this
information collection is forthcoming and the information will be collected following OMB
approval. This document will be updated to reflect that approval.
The information collected in this application will be used by the U.S. Department of the Treasury to
determine whether to approve an applicant for grant funding under the SSBCI Investing in America
SBOP. 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 control number assigned by the Office of Management and Budget
(OMB). The estimated burden associated with this collection of information is 6 hours per response.
Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden
should be directed to the Office of Privacy, Transparency, and Records, U.S. Department of the Treasury,
1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send this application form to this
address.
PRIVACY ACT STATEMENT
The Privacy Act of 1974 (Privacy Act) protects certain information that the federal government has about
“individuals” (United States citizens and lawfully admitted permanent residents). The Privacy Act does not
generally apply to businesses, but some federal courts have found that this law applies to sole proprietors (they are
deemed “individuals” under the Privacy Act).
AUTHORITY: Small Business Jobs Act of 2010 (SBJA), Title III, 12 U.S.C. § 5701 et seq., as amended by the
American Rescue Plan Act of 2021 (ARPA), section 3301.
PURPOSE: This information is being collected and maintained by Treasury so that it can review and make funding
decisions regarding applications submitted for grant funding under the SSBCI Investing in America SBOP
established under the SBJA, as amended by ARPA, and communicate with applicant contacts, and otherwise carry
out the program.
ROUTINE USE: The information you furnish may be shared in accordance with the routine uses outlined in
Treasury .013, Department of the Treasury Civil Rights Complaints, Compliance Reviews, and Fairness in Federal
Programs Files System of Records Notice (SORN); Treasury .015, General Information Technology Access
Account Records, 85 Fed. Reg. 73353; and Treasury .017, Correspondence and Contact Information, 81 Fed. Reg.

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78266. For example, one routine use under Treasury .017 allows the disclosure of information to international,
federal, state, local, tribal, or private entities for the purpose of the regular exchange of business contact information
in order to facilitate collaboration for official business. More information about this and other routine uses can be
found in the System of Records Notices (SORNs) listed above, which are posted on Treasury’s website.
DISCLOSURE: Providing this information is voluntary. However, failure to furnish the requested information may
result in the denial of your application.

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