AD-1047 (including Certification Regarding Debarment, Suspension, and Other

This form is available electronically.

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

AD-1047
AD-1047

United States Department of Agriculture
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)

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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