DOT 2309-1 Form Certification Regarding Debarment, Suspension Form

OMB NO. 2105-0555

DOT F 2309-1

EXPIRATION DATE: MM/DDYYY

OFFICE OF SMALL AND DISADVANTAGED BUSINESS UTILIZATION

U.S. DEPARTMENT OF TRANSPORTATION

SHORT TERM LENDING PROGRAM

Certification Regarding Debarment, Suspension

This certification is required the Office of Budget and Management (OMB) Circular No. A-129, Revised, Policies for Federal Credit Programs, and Non-Tax Receivables.

The participating lender certifies, by submission of this document, that neither it nor its principals are presently debarred, suspended, proposed for debarment, or declared ineligible from participation in a Government contract or delinquent on a Government debt.

Participating Lender: ________________________________________

Date: ____________________ By: ____________________________________

Name and Title of Authorized Representative

___________________________________________

Signature of Authorized Representative

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

A Federal agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. The OMB Control No. for this information collection is 2105-0555. The information requested on this form is being collected and disseminated by the U.S. Department of Transportation, Office of the Secretary as a courtesy to the public. Public burden reporting for this collection of information is estimated to be 15 minutes per response, including time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection are mandatory. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Office, US Department of Transportation, Office so Small and Disadvantaged Business Utilization, Financial Assistance Division, 1200 New Jersey Ave., S.E., 5^th Floor, W56-448, Washington, DC 20590.

PRIVACY ACT STATEMENT

The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this form is solicited under the authority of Title 49 U.S.C. 332(b)(3)(4)(5) which authorizes DOT OSDBU to assist Disadvantage Business Enterprises and Small and Disadvantaged Businesses in acquiring access to working capital and to debt financing, in order to obtain transportation related contracts funded by DOT. STLP loans are provided through lenders that serve as STLP Participating Lenders (PL). The PLs enter into a Cooperative Agreement with DOT’s OSDBU. The STLP is subject to budgeting and accounting requirements of the Federal Credit Reform Act of 1990 (FCRA). The PL must carry out processes to activate, monitor, service and close out STLP loans. To fulfill the requirements of FCRA, the PL submits reports and the forms to OSDBU. Provisions of the requested information are voluntary; however it is a requirement of the Cooperative Agreement.

Rev. 5/12 OPI:  Office of Small Disadvantage Business Utilization