Va Form 10-0388-12 - Certification Regarding Debarment, Suspension, Ineligibility And Voluntary Exclusion - Lower Tier Covered Transactions
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2OMB Number: 2900-0661
Estimated Burden: 6 hours
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 6
hours 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. We may not collect or sponsor and you are not required to
respond to, a collection unless it has a valid OMB Control Number. This collection of information is collected under the authority of
38 U.S. Code Sections 8133(a) and 8135(a). VA will use this information, along with other documents submitted by the States to
determine the feasibility of the projects for VA participation, to meet VA requirements for a grant award and to rank the projects in
establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize a grant without a
complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 38 CFR Part 44.510,
Participants' Responsibilities. The regulations were published as Part VII of the May 26, 1988, Federal Register (pages 191600-19211).
Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals are presently
debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by
any Federal department or agency.
(2) 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.
NAME OF ORGANIZATION
PR/AWARD NUMBER
PROJECT FAI #
NAME OF AUTHORIZED REPRESENTATIVE
TITLE OF AUTHORIZED REPRESENTATIVE
SIGNATURE
DATE (mm/dd/yyyy)
NOTE - BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 2
VA FORM
10-0388-12
PAGE 1 OF 2
MAR 2005
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