Ad 3031

This form is available electronically.

Form Approved – OMB No. 0505-0025
Expiration Date: 02/29/2016

AD-3031

U.S. Department of Agriculture

ASSURANCE REGARDING FELONY CONVICTION
OR TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS
NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 55a – as amended). The authority for requesting the following information for
USDA agencies and offices is in sections 738 and 739 of the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act,
2012, P.L. 112-55, as amended and/or subsequently enacted. The information will be used to document compliance with appropriations restrictions.
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 of this information collection is 0505-0025. The time required to complete this information collection is
estimated to average 3 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 and civil fraud, privacy, and other statutes may be applicable to the
information provided.

This award is subject to the provisions contained in the Agriculture, Rural Development, Food and Drug Administration,
and Related Agencies Appropriations Act, 2012, P.L. 112-55, Division A, Sections 738 and 739, as amended and/or
subsequently enacted for USDA agencies and offices (except Forest Service) regarding corporate felony convictions and
corporate federal tax delinquencies.
Accordingly, by accepting this award the recipient acknowledges that it: (1) does not have a tax delinquency, meaning
that it is not subject to any unpaid Federal tax liability that has been assessed, for which all judicial and administrative
remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with
the authority responsible for collecting the tax liability, and (2) has not been convicted (or had an officer or agent acting
on its behalf convicted) of a felony criminal violation under any Federal or State law within 24 months preceding the
award, unless a suspending and debarring official of the United States Department of Agriculture has considered
suspension or debarment of the recipient corporation, or such officer or agent, based on these convictions and/or tax
delinquencies and determined that suspension or debarment is not necessary to protect the interests of the Government. If
the recipient fails to comply with these provisions, the agency will annul this agreement and may recover any funds the
recipient has expended in violation of the above cited statutory provisions.

_________________________________________________
APPLICANT’S SIGNATURE (BY)

_________________________________________________
TITLE/RELATIONSHIP OF THE INDIVIDUAL IF SIGNING IN A
REPRESENTATIVE CAPACITY
___________________________________________________________________
BUSINESS NAME

_________________________________________________
DATE SIGNED (MM-DD-YYYY)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where
applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s
income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of
discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410,
Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish
Federal-relay). USDA is an equal opportunity provider and employer.
Rev: 11/12 Destroy all previous copies