Form 40-0895-12 - Certification Regarding Debarment, Suspension, Ineligibility And Voluntary Exclusion Lower Tier Covered Transactions - Department Of Veterans Affairs
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1OMB NUMBER: 2900-0559
Respondent Burden: 15 minutes
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
EXCLUSION - LOWER TIER COVERED TRANSACTIONS (Contractor)
Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes. Statutory authority for a State
Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that the contractor has not been debarred, suspended or is
ineligible to participate in the VA grant process and receive Federal funds. VA may not conduct or sponsor and you are not required to respond to
this collection of information unless it displays a valid OMB number. Respond to this collection is voluntary. Send comments regarding the burden
estimate or any other aspects of this collection of information, including suggestions for reducing the burden to VA Clearance Officer (005R1B),
810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications for a grant to this address.
AUTHORITY: This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension,
Title 2 Part 180, Participants' Responsibilities. The regulations were published as Part VII of the May 26, 1988, Federal Register
(pages 19160 - 19211). Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.
CERTIFICATION: The authorized representative certifies, by submission of this form, that neither the representative nor principals
are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this
transaction by any Federal department or agency.
INSTRUCTIONS:
1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.
2. The certification in this clause is a material representation of act 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 and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice 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," "participant," "person," "primary covered transaction," "principle," "proposal," and "voluntarily
excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive
Order 12549. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal 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 proposal that it will include the 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 it 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.
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.
PROJECT FAI (Federal Application Identifier) NO.
NAME AND ADDRESS OF COMPANY:
NAME OF LOWER TIER PARTICIPANT
TITLE OF LOWER TIER PARTICIPANT
SIGNATURE OF LOWER TIER PARTICIPANT
DATE SIGNED (mm/dd/yyyy)
40-0895-12
VA FORM
OCT 2010
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