Ad 3030

Form Approved - OMB Number: 0505-0025
Expiration Date: 2/29/2016

AD-3030

U.S. DEPARTMENT OF AGRICULTURE

REPRESENTATIONS REGARDING FELONY CONVICTION
AND TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS
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 for USDA Agencies and staff offices is in §738 and 739 of the Agriculture, Rural Development, Food and Drug Administration, and Related
Agencies Appropriation Act, 2012, P.L. 112-55, as amended and/or subsequently enacted. The information will be used to confirm applicant status to
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 and completing and reviewing the collection of information.

1. APPLICANT'S NAME
Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

2. APPLICANT'S ADDRESS (Including Zip Code)
Street1:
Street2:
City:

State:

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 5C. DATE SIGNED (MM/DD/YYYY)
SIGNING IN A REPRESENTATIVE CAPACITY

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