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OMB Number: 2900-0661

Estimated Burden: 6 hours

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER

RESPONSIBILITY MATTERS - PRIMARY 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, Section 44.510, Participants' Responsibilities.

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

(a) 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.

(b) Have not within a three-year period preceding this proposal 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 statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making

false statements, or receiving stolen property;

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.

(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.

TITLE 38 CFR 44.510(B)

ORGANIZATION NAME

PR/AWARD NUMBER

PROJECT FAI #

NAME OF AUTHORIZED REPRESENTATIVE

TITLE OF AUTHORIZED REPRESENTATIVE

(mm/dd/yyyy)

SIGNATURE

DATE

NOTE - BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 2

VA FORM

10-0388-7

PAGE 1 OF 2

MAR 2005

Va Form 10-0388-7 - Certification Regarding Debarment, Suspension, And Other Responsibility Matters - Primary Covered Transactions