AD_3030 for application.pdf

PDF 157 KB Posted May 16, 2018

Attached to: Program Funding (APF) for Conservation Implementation Acceleration Technician Positions Federal grant opportunity
Opportunity number: USDA-NRCS-CON-KY-18-01
Issued by: Department of Agriculture

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AD-3030

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Form Approved - OMB Number: 0505-0025 Expiration Date: 2/29/2016

AD-3030 U.S. DEPARTMENT OF AGRICULTURE

REPRESENTATIONS REGARDING FELONY CONVICTION

AND TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS

Note: You only need to complete this form if you are a corporation. A corporation includes, but is not limited to, any entity that has filed articles of incorporation in one of the 50 States, the District of Columbia, or the various territories of the United States including American Samoa, Federated States of Micronesia, Guam, Midway Islands, Northern Mariana Islands, Puerto Rico, Republic of Palau, Republic of the Marshall Islands, or the U.S. Virgin Islands. Corporations include both for profit and non-profit entities.

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552(a), as amended). The authority for requesting the following information for USDA Agencies and staff offices is in §738 and 739 of the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriation Act, 2012, P.L. 112-55, as amended and/or subsequently enacted. The information will be used to confirm applicant status to concerning entity conviction of a felony criminal violation, and/or unpaid Federal tax liability status.

According to the Paperwork Reduction Act of 1985 an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0505-0025. The time required to complete this information collection is estimated to average 15 minutes 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.

1. APPLICANT'S NAME

Prefix: First Name: Middle Name:

Last Name: Suffix:

2. APPLICANT'S ADDRESS (Including Zip Code)

Street1:

Zip Code:

State:City:

Street2:

3. TAX ID NO. (Last 4 digits)

4A. Has the Applicant been convicted of a felony criminal violation under Federal law in the 24 months preceding the date of application? YES NO

4B. Has any officer or agent of Applicant been convicted of a felony criminal violation for actions taken on behalf of Applicant under Federal law in the 24 months preceding the date of application? YES NO

4C. Does the Applicant have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability? YES NO

Providing the requested information is voluntary. However, failure to furnish the requested information will make the applicant ineligible to enter into a contract, memorandum of understanding, grant, loan, loan guarantee, or cooperative agreement with USDA.

PART B - SIGNATURE

5A. APPLICANT'S SIGNATURE (BY) 5B. TITLE/RELATIONSHIP OF THE INDIVIDUAL IF

SIGNING IN A REPRESENTATIVE CAPACITY

5C. DATE SIGNED (MM/DD/YYYY)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S. W., Stop 9410, Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or

(866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.

Rev: 11/12 Destroy all previous copies

AD_3030

Information Analysis, Inc.

D:20061108145517- 05'00' D:20061108145517- 05'00' Form Approved - OMB Number: 0505-0025Expiration Date: 2/29/2016

AD-3030

U.S. DEPARTMENT OF AGRICULTURE

REPRESENTATIONS REGARDING FELONY CONVICTION

AND TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS

1. APPLICANT'S NAME

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

2. APPLICANT'S ADDRESS (Including Zip Code) Street1:

Zip Code:

State:

City:

Street2:

3. TAX ID NO. (Last 4 digits) 4A. Has the Applicant been convicted of a felony criminal violation under Federal law in the 24 months preceding the date of application?

Has the Applicant been convicted of a felony criminal violation under Federal law in the 24 months preceding the date of application?: One selection is required.

Has the Applicant been convicted of a felony criminal violation under Federal law in the 24 months preceding the date of application is required.

4B. Has any officer or agent of Applicant been convicted of a felony criminal violation for actions taken on behalf of Applicant under Federal law in the 24 months preceding the date of application?

Has any officer or agent of Applicant been convicted of a felony criminal violation for actions taken on behalf of Applicant under Federal law in the 24 months preceding the date of application?: One selection is required.

Does the Applicant have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability?: One selection is required.

PART B - SIGNATURE

5A. APPLICANT'S SIGNATURE (BY)

5B. TITLE/RELATIONSHIP OF THE INDIVIDUAL IF SIGNING IN A REPRESENTATIVE CAPACITY

5C. DATE SIGNED (MM/DD/YYYY)

Rev: 11/12 Destroy all previous copies

Mandatory:

Applicant's Prefix: Select the Prefix from the provided list or enter a new Prefix not provided on the list.:

Applicant's First Name: Enter the First Name. This field is required.:

Applicant's Middle Name: Enter the Middle Name.:

Applicant's Last Name: Enter the Last Name. This field is required.:

Applicant's Suffix: Select the Suffix from the provided list or enter a new Suffix not provided on the list.:

Applicant's Address Street1: Enter the first line of the Street Address. This field is required.:

Applicant's State: Select the state, US possession or military code from the provided list. This field is required.:

Applicant's City: Enter the City. This field is required.:

Applicant's Address Street2: Enter the second line of the Street Address.:

Applicant's Zip Code: Enter the Zip Code. This field is required.:

TAX ID Number: Enter the last four digits of the Tax ID Number. This field is required.:

Yes: Select this option for Yes.:

No: Select this option for No.:

Yes: Select this option for Yes.:

No: Select this option for No.:

Applicant's Signature: Enter the applicant's signature. This is a required field.:

Title: Enter the title. This is a required field.:

Date Signed: Enter the date signed. This is a required field.:

XDPFirstField:

LastField:

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