Form AD 1047 AD 1047 Certification Regarding Debarment

OMB No. 0572-0112

Form AD-1047 (1/92)

U. S. DEPARTMENT OF AGRICULTURE

Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension,
7 CFR Part 3017, Section 3017.510, Participants' responsibilities. The regulations were published as Part IV of the
January 30, 1989, Federal Register (pages 4722-4733). Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the proposed covered transaction.

(Before completing certification, read instructions on reverse.)
(1)

(2)

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 from covered transactions 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.

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 AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE

DATE

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Form AD-1047 (1/92) (REVERSE)

INSTRUCTIONS FOR CERTIFICATION
1.

By signing and submitting this form, the prospective primary participant is providing the certification set out
on the reverse side 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
whom 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 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 this 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 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 Nonprocurement List.

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.
According to 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 0572-0112. The time
required to complete this information is estimated to average 10 minutes, including the time for reviewing instructions, searching existing data sources,
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gathering and maintaining the data needed.