AD-1047 Certification Regarding Debarment, Suspension, and Other

OMB No. 0572-0121

U.S. DEPARTMENT OF AGRICULTURE

Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and Sus pension, 7
CFR Part 3017, Section 3017.510, Participants' responsibilities. The regulations were published as Part IV of the
January 30, 1989 Federal Register (pages 4722-4733). Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the proposed covered transaction.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)
(1)

(2)

The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a)

are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal department or agency;

(b)

have not within a three -year period preceding this proposal been convicted of or had a
civil judgement 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 Feder
al or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;

(c)

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 (1)(b) of this certification; and

(d)

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.

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

Clear Form

Form AD-1047 (1/92)

Instructions for Certification
1. By signing and submitting this form, the prospective primary participant is providing the certification set out on the reverse
side 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 addit ion 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 whom 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. 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, Ineli gibility 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 Nonprocurement List.
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.
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 0572-0146. The time required to complete this information is estimated to average 10 minutes, including reviewing
instructions, searching existing data sources, gathering and maintaining the data needed.
Form AD-1047 (1/92)
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