Form AD-1047 Certification Regarding Debarment, Suspension, and Other

This form is available electronically.

Form Approved - OMB No. 0505-0027
Expiration Date: 12/31/2018

United States Department of Agriculture

AD-1047

Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions
The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552(a), as amended). This
certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, and 2 C.F.R.
§ 180.335, Participants' responsibilities. The regulations were amended and published on August 31, 2005, in 70 Fed. Reg.
51865-51880. Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the
proposed covered transaction.
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 for this
information collection is 0505-0027. 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. The provisions of appropriate
criminal and civil fraud privacy, and other statutes may be applicable to the information provided.

(Read Instructions On Page Two Before Completing Certification)
A. The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
1. Are not presently debarred, suspended, or proposed for debarment, declared ineligible, or voluntarily excluded
from covered transactions by any Federal department or agency;
2. 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;
3. 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 (A.2.) of this certification; and
4. 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.
B. 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(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title:
SIGNATURE(S)

DATE

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.

Instructions for Certification
(1) By signing and submitting this form, the prospective primary participant is providing the certification set out on page
1 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 which 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, at 2 C.F.R. Parts 180 and 417. 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 the 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 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 System for Award Management
(SAM) database.
(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.

Form AD-1047 (REV 12/15)
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