This
form is available electronically.
Form
Approved – OMB No. 0505-0025
Expiration
Date: 2/29/2016
AD-3030-FS
U.S.
DEPARTMENT OF AGRICULTURE
REPRESENTATIONS
REGARDING FELONY CONVICTION
AND
TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS
FY
2012, FY 2013, FY 2014
Note:
You only need to complete
this form if you are a corporation. A corporation includes, but
is not limited to, any entity that has filed articles of
incorporation in one of the 50 States, the District of Columbia,
or the various territories of the United States including
American Samoa, Federated States of Micronesia, Guam, Midway
Islands, Northern Mariana Islands, Puerto Rico, Republic of
Palau, Republic of the Marshall Islands, or the U.S. Virgin
Islands. Corporations include both for profit and non-profit
entities.
The
following statement is made in accordance with the Privacy Act of
1974 (5 U.S.C. 552(a), as amended). The authority for requesting
the following information is sections 433 and 434 of the
Consolidated Appropriations Act, 2012, P.L. 112-74, as amended
and/or subsequently enacted. The information will be used to
confirm applicant status concerning entity conviction of a felony
criminal violation, and/or unpaid Federal tax liability status.
According
to the Paperwork Reduction Act of 1985 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 0505-0025. 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.
1.
APPLICANT’S NAME
2.
APPLICANT’S ADDRESS (Including
Zip Code)
3.
TAX ID NO.
(Last
4 digits)
4A. Has the Applicant been
convicted of a felony criminal violation under Federal law in the
24 months preceding the date of application?
YES NO
4B. Has any officer or
agent of Applicant been convicted of a felony criminal violation
for actions taken on behalf of Applicant under Federal law in the
24 months preceding the date of application?
YES NO
4C.
Does the Applicant have 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?
YES NO
Providing
the requested information is voluntary. However, failure to
furnish the requested information will make the applicant
ineligible to enter into a contract, memorandum of understanding,
grant, loan, loan guarantee, or cooperative agreement with USDA.
PART
B – SIGNATURE
5A.
APPLICANT’S SIGNATURE (BY)
5B.
TITLE/RELATIONSHIP OF THE INDIVIDUAL IF
SIGNING
IN A REPRESENTATIVE CAPACITY
5C.
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.