Attachment 3 Domestic Origin Certificate.pdf
PDF 88 KB Posted
- Solicitation number
- 12-3J14-26-B-0209
About this file
This is a Domestic Origin Certification form required for USDA poultry and poultry product contracts. The form must be completed by an authorized company official or designee for each facility proposed under the RFP and submitted to the USDA Contracting Officer. Each contractor and processing facility must maintain a copy on file.
The form requires certification responses to two key questions: whether the company processes or handles poultry or poultry products from sources outside the United States, its territories, possessions, Puerto Rico, or the Trust Territories of the Pacific Islands; and whether any subcontractors or suppliers process or handle products from non-domestic sources. If either answer is affirmative, the respondent must attach a segregation plan detailing how such products are stored and processed separately from domestic products. The certifying official must attest that all products sold to the Department of Agriculture are 100 percent domestic origin, that all statements are true, and that traceability documentation will be made available to USDA Agricultural Marketing Service representatives upon request. The form includes statutory warnings regarding false statements under 18 U.S.C. Section 1001 and the Perishable Agricultural Commodities Act, which carry penalties of fines, imprisonment up to five years, or license suspension or revocation. The form requires signature, title, date, printed name, and company name from the authorized official.
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EXHIBIT 2 – DOMESTIC ORIGIN CERTIFICATION
This form must be completed by an authorized company official or their designee for each facility proposed under this RFP. The completed form must be presented to the USDA Contracting Officer. If imported product is brought into the facility during the production and shipment of product for this contract, it is the contractor’s responsibility to notify the applicable certification branch. Each contractor and/or processing facility under this contract must have a copy of this form on file.
Solicitation Number: Product:
Does your company process or handle poultry or poultry products originating from sources other than the United States, its territories or possessions, Puerto Rico, or the Trust Territories of the Pacific Islands?
YES NO
If yes, attach a copy of your segregation plan explaining how such product is stored and processed separate from domestic product.
Do any of your Subcontractor/Suppliers process or handle products originating from sources other than the United States, its territories or possessions, Puerto Rico, or the Trust Territories of the Pacific Islands?
YES NO
If yes, attach a copy of each subcontractor’s/supplier’s segregation plan explaining how such product is stored and processed separate from domestic product.
I certify that all products sold to the Department of Agriculture are of 100 percent domestic origin and that all above statements are true. I further certify that traceability documentation will be made available to USDA, Agricultural Marketing Service representatives upon request.
WARNING: 18 U.S.C. Part 1, Chapter 47, Section 1001 states that “Except as otherwise provided in this section, whoever, in any manner within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully
(1) falsifies, conceals, or covers up by any trick, scheme, or devise a material fact; (2) makes any materially false, fictitious or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain materially false, fictitious, or fraudulent statement or entry; shall be fined under this title or imprisoned not more than 5 years, or both.
Knowingly and willingly making false statements may also constitute a violation of the Perishable Agricultural Commodities Act (7 U.S.C., 499a-499t), and may result in monetary penalties or license suspension or revocation.
Signature: Title: Date:
Print Name: Company:
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