USDA Form AD-1048 experation date 4.30.22.pdf

This form is available electronically. Form Approved - OMB No. 0505-0027 Expiration Date: 04/30/2022

Certification Regarding Debarmen! Suspension,Ineligibility and Yoluntary Exclusion AD-1048 Lower Tier Covered Transactions

USDA

-The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. S 552a, as amended). This certification is required by the regulations implementingExecutiveOrderl2549,DebarmentandSuspension,and2C.F.R.$S180.300, 180.335,Pafticipants'responsibilities. Theregulationswere amendedandpublishedonAugust31,2005,in70Fed.Reg.51865-51880. CopiesoftheregulationsmaybeobtainedbycontactingtheDepaftmentof Agricufture agency offeing the proposed covered transaction.

According to the Papenror* Reduction Act of 1995 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 0505-0027. The time required to complete this information collection is estimated to average 1 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gatheing and maintaining the data needed, and completing and reviewing the collection of information. The provisions of apprcpiate ciminal and civil fraud pivacy, and other statutes may be applicable to the information provided.

(Read instructions on poge two before completing certilication.)

A. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency;

B. Where the prospective lower tier participant is unable to certiff to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

ORGANIZATION NAME PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TrTLE(S) OF AUTHORTZED REPRESENTATTVE(S)

SIGNATURE(S) DATE

ln accordance with Federal civil rights law and U.S. Depadment of Agicufture (USDA) civil rights regulations and policies, the USDA, its agencies, ofices, and emptoyees, and civil rights activity, in any program or activity conducted or funded by USDA (not all basas apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

the responsible agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionatly, program information may be made available in languages other than English.

To file a p,ogram discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found ontine at How to File a Program Discimination Complaint finos:tnww.ascr.usaa.o and at any IJSDA office or wite a tetter addressed to USDA and provide in the tetter att of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mait: lJ.S. Depadment of Agiculture, Ofice of fhe Asg.stant Secrctary for Civil Rights, 1400 lndapendence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442.

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Instructions for Certilicttion

By signing and submitting this form, the prospective lower tier participant is providing the certification set out on page I in accordance with these instructions.

The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. Ifit is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Govemment, the department or agency with which this transaction originated may pursue available remedies, including suspension or debarment.

The prospective lower tier participant shall provide immediate w tten notice to the person(s) to which this proposal is submitted if at any time the prospective lower tier participant leams that its certification was erroneous when submitted or has become erroneous by reason ofchanged circumstances.

The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,rt "participant," "person,r' "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections ofthe rules implementing Executiye Older 12549, at2 C.F.R. Parts 180 and 417. You may contact the deparhnent or agency to which this proposal is being submitted for assistance in obtaining a copy ofthose regulations.

The prospective lower tier participant agrees by submitting this form that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debaned, 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 prospective lower tier participant further agrees by submitting this form that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

A participant in a covered transaction may rely upon a certification ofa prospective participant in a lower tier covered transaction that 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 System for Award Management (SAM) database.

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

Except for transactions authorized under paragraph (5) ofthese instructions, ifa participant in a covered hansaction knowingly enters into a lo]ver tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this tmnsaction, in addition to other remedies available to the Federal Govemment, the department or agency with which this nansaction originated may pursue available remedies, including suspension and/or debarment.

Form AD-1048 (REV lZ18) Page2of2

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