omb certification.pdf
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- VA-SAHAT-17-02
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Department of Veterans Affairs
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VA Form- 26-0967: Certification
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CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION
OMB Control Number: 2900-0821 Respondent Burden: 1 hour Expiration Date: 12/31/2018
VA FORM
DEC 2015 26-0967 PAGE 1
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.
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, DEC 2015
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION
OMB Control Number: 2900-0821 Respondent Burden: 1 hour Expiration Date: 12/31/2018 OMB Control Number 2900-0821, Respondent Burden: 1 hour, Expiration Date: XXXXXXX OMB Control Number 2900-0821, Respondent Burden: 1 hour, Expiration Date: XXXXXXX
VA FORM
DEC 2015
26-0967 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.
..\logos\FORMLOGO.jpg Department of Veterans Affairs Logo Department of Veterans Affairs Logo
PROJECT DESCRIPTION
PROJECT LOCATION
Project Location Project Location
FAI NUMBER
FAI NUMBER
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.
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4.
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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, DEC 2015
| Enter Name of Authorized Representative: |
| Enter location of the project: |
| Enter explanation that the participant is unable to certify to any statements in this certification.: |
| Enter the F.A.I. Number: |
| CERTIFICATION - THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION. Enter Name of Company: |
| Enter Company Tax ID Number: |
| Enter Title of Authorized Representative: |
| Enter Date Signed. 2 digit month, 2 digit day, and 4 digit year: |
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