AD-1048 Certification Regarding Drug-Free Workplace Requirements

This form is available electronically.

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

United States Department of Agriculture

AD-1048

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier 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.
§§ 180.300, 180.355, 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 lower tier participant certifies, by submission of this proposal, that neither it nor its principals is
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency;
B. Where the prospective lower tier 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 lower tier participant is providing the certification set out on
page 1 in accordance with these instructions.
(2) The certification in this clause is a material representation of fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an
erroneous certification, in addition to other remedies available to the Federal Government, the department or agency
with which this transaction originated may pursue available remedies, including suspension or debarment.
(3) The prospective lower tier participant shall provide immediate written notice to the person(s) to which this proposal is
submitted if at any time the prospective lower tier participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
(4) 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.
(5) The prospective lower tier 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 with which this transaction originated.
(6) The prospective lower tier participant further agrees by submitting this form that it will include this clause titled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered
Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered
transactions.
(7) 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.
(8) 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.
(9) Except for transactions authorized under paragraph (5) 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 with which this transaction originated may pursue available remedies,
including suspension and/or debarment.

Form AD-1048 (REV 12/15)
Page 2 of 2