Va Form 40-0895-7 - Certification Regarding Debarment, Suspension, And Other Responsibility Matters - Primary Covered Transactions (State Or Tribal Government)
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2OMB NUMBER: 2900-0559
Respondent Burden: 15 minutes
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
(STATE OR TRIBAL GOVERNMENT) (Title 2 Part 180)
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 document that the State or Tribal government 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.
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 38 CFR, Part 39.
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered
against them for:
(i) commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a
public (Federal, State or local) transaction or in connection with a contract under a public transaction;
(ii) violation of Federal or State antitrust statues; or
(iii) commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
(b) Are not presently indicted for other criminal or civil charges by a governmental entity (Federal, State or local) for
commission of any of the offenses enumerated in paragraph (1)(a) of this certification; and
(c) 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.
(2) 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.
NAME OF ORGANIZATION
PR/AWARD NUMBER
PROJECT FAI (Federal Application Identifier)
NO.
NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE
TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE
DATE (mm/dd/yyyy)
SIGNATURE
NOTE: Before Completing Certification, Read Instructions on page 2.
VA FORM
40-0895-7
PAGE 1 OF 2
OCT 2010
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