Debartment - Form AD 1047

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1.

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

2.

The inability of a person to provide the certification required below will not necessarily result in
denial of participation in the covered transaction. The prospective participant shall submit an
explanation of why it cannot provide the certification set out below. 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. 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 proposal that, should the proposed
covered transaction be entered into, it shall not knowingly enter into any lower tier covered
transactions with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4,
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 proposal that it will include
the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion - Lower Tier Covered Transaction,” 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.

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 for this information collection is 0572-0032. The time
required to complete this information collection is estimated to average 30 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.

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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 proposed for debarment under 48 CFR part 9, subpart
9.4, 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 List of Parties Excluded from Federal Procurement and Nonprocurement Programs.

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
proposed for debarment under 48 CFR part 9, subpart 9.4, 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.

CERTIFICATION
(1)

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 for debarment, declared ineligible, or voluntarily
excluded by any Federal department or agency;

(b)

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;

(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 application/proposal had one or more public
transactions (Federal, State or local) terminated for cause or default.

(2)

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 or Project Name

Name and Title
Signature

Date

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