New VA Form 26-0967.pdf

OMB Control Number: 2900-0903 Respondent Burden: 1 hour Expiration Date: 02/28/2025

VA FORM

FEB 2022 26-0967 PAGE 1

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY

AND VOLUNTARY EXCLUSION

CERTIFICATION - THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.

(2) Where the participant is unable to certify to any of the statements in this certification, such prospective participant shall provide an explanation below to this proposal.

(1) The 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.

This certification is required by the regulations implementing 38 U.S.C. 2108, Specially Adapted Housing Assistive Technology Grant Program. Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.

PROJECT DESCRIPTION

PROJECT LOCATION FAI NUMBER

NAME OF COMPANY COMPANY TAX IDENTIFICATION NUMBER

NAME OF AUTHORIZED REPRESENTATIVE TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE SIGNED

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., the authorized release of information to Congress when requested for statistical purposes) as identified in the VA system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and Vendee Loan Applicant Records - VA, and published in the Federal Register. Your obligation to respond is voluntary.

RESPONDENT BURDEN: We need this information to help determine whether VA requirements for a grant award are met. Title 38, U.S.C. section 2108, authorizes collection of this information. We estimate that you will need an average of 1 hour to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

SUPERSEDES VA FORM 26-0967, NOV 2018,

WHICH WILL NOT BE USED.

www.reginfo.gov/public/do/PRAMain

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9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/ or debarment.

Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

A participant in a covered transaction may rely upon a certification of a prospective participant in a transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Non procurement List.

The participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Transactions," without modification, in all covered transactions and in all solicitations for covered transactions.

The participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any transaction with a person who is debarred, suspended declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

The terms "covered transaction," "participant," "person," "primary covered transaction," "principle," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in title 2, Code of Federal Regulations, part

180. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.

The participant shall provide immediate written notice to which this proposal is submitted it any time the participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

The certification in this clause is a material representation of act upon which reliance was placed when this transaction was entered into. If it is later determined that the participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available, remedies, including suspension and/or debarment.

By signing and submitting this proposal, the participant is providing the certification set out below.

INSTRUCTIONS FOR CERTIFICATION

PAGE 2 VA FORM 26-0967, FEB 2022

OMB Control Number: 2900-0903 Respondent Burden: 1 hour Expiration Date: 02/28/2025 OMB Control Number 2900-XXXX, Respondent Burden: 1 hour, Expiration Date: XXXXXXX OMB Control Number 2900-XXXX, Respondent Burden: 1 hour, Expiration Date: XXXXXXX

VA FORM

FEB 2022

26-0967

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY

AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

CERTIFICATION - THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.

(2) Where the participant is unable to certify to any of the statements in this certification, such prospective participant shall provide an explanation below to this proposal.

(2) Where the participant is unable to certify to any of the statements in this certification, such prospective participant shall provide an explanation below to this proposal.

(2) Where the participant is unable to certify to any of the statements in this certification, such prospective participant shall provide an explanation below to this proposal.

(1) The 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.

(1) The 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.

(1) The 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.

This certification is required by the regulations implementing 38 U.S.C. 2108, Specially Adapted Housing Assistive Technology Grant Program. Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.

This certification is required by the regulations implementing XXXXXXX This certification is required by the regulations implementing XXXXXXX ..\logos\FORMLOGO.jpg Department of Veterans Affairs Logo Department of Veterans Affairs Logo

PROJECT DESCRIPTION

Project Description Project Description

PROJECT LOCATION

Project Location Project Location

FAI NUMBER

FAI NUMBER

FAI NUMBER

NAME OF COMPANY

Project Location Project Location

COMPANY TAX IDENTIFICATION NUMBER

Project Location Project Location

NAME OF AUTHORIZED REPRESENTATIVE

Project Location Project Location

TITLE OF AUTHORIZED REPRESENTATIVE

Project Location Project Location

SIGNATURE

Project Location Project Location

DATE SIGNED

Project Location Project Location PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., the authorized release of information to Congress when requested for statistical purposes) as identified in the VA system of records, 55VA26, Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and Vendee Loan Applicant Records - VA, and published in the Federal Register. Your obligation to respond is voluntary.

RESPONDENT BURDEN: We need this information to help determine whether VA requirements for a grant award are met. Title 38, U.S.C. section 2108, authorizes collection of this information. We estimate that you will need an average of 1 hour to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required only to preserve a date of claim for an application that is received within one year of receipt of this form. VA uses your Social Security number to identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the appropriate application and provide it to the claimant.

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required only to preserve a date of claim for an application that is received within one year of receipt of this form. VA uses your Social Security number to identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the appropriate application and provide it to the claimant.

SUPERSEDES VA FORM 26-0967, NOV 2018,

WHICH WILL NOT BE USED.

1.

2.

3.

4.

5.

6.

7.

8.

9.

Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

A participant in a covered transaction may rely upon a certification of a prospective participant in a transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Non procurement List.

The participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion Transactions," without modification, in all covered transactions and in all solicitations for covered transactions.

The participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any transaction with a person who is debarred, suspended declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.

The terms "covered transaction," "participant," "person," "primary covered transaction," "principle," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in title 2, Code of Federal Regulations, part 180. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations.

The participant shall provide immediate written notice to which this proposal is submitted it any time the participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

The certification in this clause is a material representation of act upon which reliance was placed when this transaction was entered into. If it is later determined that the participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available, remedies, including suspension and/or debarment.

By signing and submitting this proposal, the participant is providing the certification set out below.

INSTRUCTIONS FOR CERTIFICATION

VA FORM 26-0967, FEB 2022

2-23-22 N. Kessinger VA Form 26-0967 VBA/Loan Guaranty

FEB 2022

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion