Sba Form 1623 - Certification Regarding Debarment, Suspension, And Other Responsibility Matters
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1
2Certification Regarding
Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 13 CFR
Part 145. The regulations were published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211). Copies of
the regulations are available from local offices of the U.S. Small Business Administration.
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)
(1) 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 disbarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) Have not within a three-year period preceding this application 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;
(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 had one or more public transactions
(Federal, State, or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective primary participant shall attach an explanation to this proposal.
Business Name
By
Date
Name and Title of Authorized Representative
Signature of Authorized Representative
SBA Form 1623 (10-88)
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