U.S. DEPARTMENT OF AGRICULTURE

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Certification Regarding Debarment, Suspension, and Other

Responsibility Matters - Primary Covered Transactions

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This certification is required by the regulations implementing Executive
Order 12549, Debarment and Suspension, 7 CFR Part 3017, Section
3017.510, Participants\' responsibilities. The regulations were
published as Part IV of the January 30, 1989, [Federal
Register]{.underline} (pages 4722-4733). Copies of the regulations may
be obtained by contacting the Department of Agriculture agency offering
the proposed covered transaction.

**(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)**

\(1\) The prospective primary participant certifies to the best of its
knowledge and belief, that it and its principals:

> \(a\) are not presently debarred, suspended, proposed for debarment,
> declared ineligible, or voluntarily excluded from covered transactions
> by any Federal department or agency;

\(b\) have not within a three-year period preceding this proposal been
convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal State or local)
transaction or contract under a public transaction; violation of Fed­eral
or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;

\(c\) are not presently indicted for or otherwise criminally or civilly
charged by a governmental entity (Federal, State or local) with
commission of any of the offenses enumerated in paragraph (1)(b) of this
certification; and

\(d\) have not within a three-year period preceding this
application/proposal had one or more public transactions (Federal, State
or local) terminated for cause or default.

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

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Organization Name PR/Award Number or Project Name

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Name(s) and Title(s) of Authorized Representative(s)

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Signature(s) Date

> Form AD-1047 (1/92)

**[Instructions for Certification]{.underline}**

1\. By signing and submitting this form, the prospective primary
participant is providing the certification

set out on the reverse side in accordance with these instructions.

2\. The inability of a person to provide the certification required
below will not necessarily result in denial

of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the
certification set out on this form. The certification or explanation
will be considered in connection with the department or agency\'s
determination whether to enter into this transaction. However, failure
of the prospective primary participant to furnish a certification or an
explanation shall disqualify such person from participation in this
transaction.

3\. The certification in this clause is a material representation of
fact upon which reliance was placed when the department or agency
determined to enter into this transaction. If it is later determined
that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for
cause or default.

4\. The prospective primary participant shall provide immediate written
notice to the department or agency to whom this proposal is submitted if
at any time the prospective primary participant learns that its
certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.

5\. The terms \"covered transaction," "debarred,\" \"suspended,\"
\"ineligible,\" \"lower tier covered transaction,\" \"participant,\"
\"person,\" \"primary covered transaction,\" \"principal,\"
\"proposal,\" and \"voluntarily excluded,\" as used in this clause, have
the meanings set out in the Definitions and Coverage sections of the
rules implementing Executive Order 12549. You may contact the department
or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.

6\. The prospective primary 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 debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this covered transaction, unless
authorized by the department or agency entering into this transaction.

7\. \'The prospective primary participant further agrees by submitting
this form that it will include the clause titled \"Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -
Lower Tier Covered Transactions,\" provided by the department or agency
entering into this covered transaction, without modification, in all
lower tier covered transactions and in all solicitations for lower tier
covered transactions.

8\. A participant in a covered transaction may rely upon a certification
of a prospective participant in a lower tier covered 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 Nonprocurement List.

9\. 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.

10\. Except for transactions authorized under paragraph 6 of these
instructions, if a participant in a covered transaction knowingly enters
into a lower tier 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 may terminate this transaction for
cause or default.

> Form AD- 1047 (1/92)