OMB Control # 1505-0227 1

State Small Business Credit Initiative (SSBCI) Investing in America Small Business Opportunity Program 

(SBOP) Applicant Certifications

U.S. Department of the Treasury

Directions: These certifications are required by the U.S. Department of the Treasury (Treasury) to be submitted in 

connection with each application to Treasury for financial assistance under the SSBCI Investing in America 

SBOP grant program before receipt of award funding. The certifications shall be treated as a material 

representation of fact upon which reliance will be placed when Treasury makes award determinations under the 

SSBCI Investing in America SBOP. The certifications must be signed by an authorized official of the applicant 

who can legally bind the entity and has oversight for the administration and use of SSBCI Investing in America 

SBOP financial assistance.

A. Certification Regarding Debarment, 

Suspension, and Other Responsibility Matters —

Primary Covered Transactions: Instructions for 

Certification 

1. By signing and submitting the application, the 

prospective primary participant (the applicant is 

providing the certification set out below. 

2. The applicant shall submit an explanation of why it 

cannot provide any certification set out below. The 

certification or explanation will be considered in 

connection with Treasury’s approval of the proposed 

application. However, failure of the applicant to 

furnish a certification or an explanation shall 

disqualify such person/entity from participation in 

this transaction. 

3. This certification is a material representation of 

fact upon which reliance is placed when Treasury 

determines to enter into this transaction. If it is later 

determined that the applicant knowingly rendered an 

erroneous certification, in addition to other remedies 

available to the Federal government, Treasury may 

terminate this transaction for cause or default. 

4. The applicant shall provide immediate written 

notice to Treasury if at any time the Applicant learns 

that its certification was erroneous when submitted or 

has become erroneous by reason of changed 

circumstances. 

5. The terms “covered transactions,” “debarred,” 

“suspended,” “ineligible,” “lower tier covered 

transaction,” “participant,” “person,” “primary 

covered transaction,” “principal,” “proposal”, and 

“voluntarily excluded,” as used in this clause 

(certification), have the meanings set out in the 

Definitions and Coverage sections of the rules 

implementing Executive Order 12549. You may 

contact Treasury for assistance in obtaining a copy of 

those regulations (31 CFR Part 19). 

6. The applicant agrees by submitting an application 

under the SSBCI Investing in America SBOP 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 Treasury. 

7. The applicant further agrees by submitting an 

application that it will not award any contract or 

subaward to any entity on the government-wide 

Excluded Parties List System (EPLS) found in the 

System for Award Management (SAM).

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. 

9. Nothing contained in the foregoing shall be 
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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, subject to all other 

remedies available to the Federal Government, and

Treasury may terminate this transaction for cause or 

default. 

B. Certification Regarding Debarment, 

Suspension, and Other Responsibility Matters --

Primary Covered Transactions 

1. Pursuant to Treasury’s regulations on 

nonprocurement debarment and suspension

implemented at 31 CFR Part 19, the prospective 

primary participant (the applicant) in a primary tier 

“covered transaction,” as defined at 31 CFR

§ 19.200(a) certifies to the best of its knowledge and 

belief that neither it nor any of its principals: 

(a) is presently debarred, suspended, proposed for 

debarment, declared ineligible, sentenced to a denial 

of federal benefits by a state or federal court, or 

voluntarily excluded from covered transactions by 

any Federal department or agency; 

(b) has within a three-year period preceding this 

application been convicted of or had a civil judgment 

rendered against it for commission of fraud or a 

criminal offense in connection with obtaining, 

attempting to obtain, or performing a public (federal, 

state, Tribal, or local) or private agreement or

transaction; violation of federal or State antitrust 

statutes; or commission of embezzlement, theft, 

forgery, bribery, falsification or destruction of 

records, making false statements, tax evasion or 

receiving stolen property, making false claims, 

obstruction of justice, or commission of any offense 

indicating a lack of business integrity or business 

honesty that seriously and directly affects its (or its 

principals’) present responsibility; 

(c) is presently indicted for or otherwise criminally or 

civilly charged by a governmental entity (Federal, 

State, tribal, or local) with commission of any of the 

offenses enumerated in paragraph (b) of this 

subsection in the certification; and/or

(d) has within a three-year period preceding this 

application had one or more public transactions 

(Federal, State, tribal, or local) terminated for cause 

or default. 

2. Where the applicant is unable to certify to any of 

the statements in this certification, the applicant shall 

attach an explanation to this Certification form and 

submit it to SSBCI_Information@Treasury.gov.

C. Certification Regarding Drug-Free Workplace 

Requirements 

As required by the Drug-Free Workplace Act of 

1988, as implemented at 31 CFR Part 20, Subpart F, 

for recipients, as defined at 31 CFR § 20.650:

1. The applicant certifies and assures that it will, or 

will continue to, provide a drug-free workplace by: 

(a) Publishing a statement notifying employees that 

the unlawful manufacture, distribution, dispensing, 

possession, or use of a controlled substance is 

prohibited in its workplace and specifying the actions 

that will be taken against the employees for 

violations of such prohibition; 

(b) Establishing an ongoing drug-free awareness 

program to inform employees about: 

(i) The dangers of drug abuse in the workplace; 

(ii) The applicant’s policy of maintaining a drug-free 

workplace; 

(iii) Any available drug counseling, rehabilitation, 

and employee assistance program; and 

(iv) The penalties that may be imposed upon 

employees for drug abuse violations occurring in the 

workplace. 
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(c) Making it a requirement that each employee to be 

engaged in the performance of the award be given a 

copy of the statement required by paragraph (a); 

(d) Notifying the employee in the statement required 

by paragraph (a) that, as a condition of employment 

in such grant, the employee will: 

(i) Abide by the terms of the statement; and 

(ii) Notify the employer in writing of the employee’s 

conviction for a violation of a criminal drug statute

occurring in the workplace no later than five calendar 

days after such conviction; 

(e) Notifying Treasury, in writing, within ten 

calendar days after receiving notice of a conviction 

under paragraph (d)(ii) from an employee or 

otherwise receiving actual notice of such conviction.

Employers of convicted employees must provide 

notice, including position title of any such convicted 

employee to Treasury at 

SSBCI_Information@treasury.gov.

(f) Taking one of the following actions, within 

30 days of receiving notice under paragraph (d)(ii), 

with respect to any employee who is so convicted: 

(i) Taking appropriate personnel action against such 

an employee, up to and including termination, 

consistent with the requirements of the Rehabilitation 

Act of 1973, as amended; or 

(ii) Requiring such employee to participate 

satisfactorily in a drug abuse assistance or 

rehabilitation program approved for such purposes by 

a Federal, State, or local health, law enforcement, or 

other appropriate agency; and 

(g) Making a good faith effort to continue to maintain 

a drug-free workplace through implementation of 

paragraphs (a) through (f). 

D. Certification Regarding Lobbying 

1. As required by 31 U.S.C. § 1352, as implemented 

by 31 CFR Part 21, the applicant certifies and 

assures, to the best of its knowledge and belief that: 

(a) No Federal appropriated funds have been paid or 

will be paid, by or on behalf of the applicant, to any 

person for influencing or attempting to influence an 

officer or employee of an agency, a Member of 

Congress, an officer or employee of Congress, or an 

employee of a Member of Congress in connection 

with making of any Federal grant, and the extension, 

continuation, renewal, amendment, or modification 

of any Federal grant.

(b) If any funds other than Federal appropriated funds 

have been paid or will be paid to any person for 

influencing or attempting to influence an officer or 

employee of any agency, a Member of Congress, an 

officer or employee of Congress, or an employee of a 

Member of Congress in connection with this grant

application, the undersigned shall complete and 

submit the Form SF-LLL, ‘‘Disclosure of Lobbying 

Activities” in accordance with its instructions; and 

(c) The applicant shall require that the language of 

this certification be included in the award documents 

for all its subawards at all tiers and contracts

(including, their subcontracts) and ensure that all 

subrecipients, contractors, and subcontractors shall 

certify and disclose accordingly.

2. This certification regarding lobbying is a material 

representation of fact upon which reliance is placed 

when this transaction is made or entered into. 

Submission of this certification is a prerequisite for 

making or entering into this transaction imposed by 

31 U.S.C. § 1352. Any person who fails to file the 

required certification shall be subject to a civil 

penalty of not less than $10,000 and not more than 

$100,000 for each such failure. 

. 
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I acknowledge that a materially false, fictitious, or fraudulent statement (or concealment or omission of a 

material fact) in this certification, or in the application that it supports, may be the subject of criminal 

prosecution, and also may be subject me and the applicant to civil penalties and administrative remedies for false 

claims under Federal law.

Signature of SSBCI Investing in America SBOP Authorized Official: 

_________________________________________________________

Name: Date: 

Title: Name of Applicant: 

PAPERWORK REDUCTION ACT NOTICE

The information collections discussed in this application will be submitted to the Office of 

Management and Budget (OMB) under OMB control number 1505-0227 in accordance 

with the Paperwork Reduction Act of 1995 (44 U.S.C. chapter 35). OMB approval for this 

information collection is forthcoming and the information will be collected following OMB 

approval. This document will be updated to reflect that approval.

The information collected in this application will be used by the U.S. Department of the Treasury to 

determine whether to approve an applicant for grant funding under the SSBCI Investing in America 

SBOP. 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 control number assigned by the Office of Management and Budget 

(OMB). The estimated burden associated with this collection of information is 6 hours per response. 

Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden 

should be directed to the Office of Privacy, Transparency, and Records, U.S. Department of the Treasury, 

1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send this application form to this 

address.

PRIVACY ACT STATEMENT

The Privacy Act of 1974 (Privacy Act) protects certain information that the federal government has about 

“individuals” (United States citizens and lawfully admitted permanent residents). The Privacy Act does not 

generally apply to businesses, but some federal courts have found that this law applies to sole proprietors (they are 

deemed “individuals” under the Privacy Act).

AUTHORITY: Small Business Jobs Act of 2010 (SBJA), Title III, 12 U.S.C. § 5701 et seq., as amended by the 

American Rescue Plan Act of 2021 (ARPA), section 3301.

PURPOSE: This information is being collected and maintained by Treasury so that it can review and make funding 

decisions regarding applications submitted for grant funding under the SSBCI Investing in America SBOP 

established under the SBJA, as amended by ARPA, and communicate with applicant contacts, and otherwise carry 

out the program.

ROUTINE USE: The information you furnish may be shared in accordance with the routine uses outlined in 

Treasury .013, Department of the Treasury Civil Rights Complaints, Compliance Reviews, and Fairness in Federal 

Programs Files System of Records Notice (SORN); Treasury .015, General Information Technology Access 

Account Records, 85 Fed. Reg. 73353; and Treasury .017, Correspondence and Contact Information, 81 Fed. Reg. 
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78266. For example, one routine use under Treasury .017 allows the disclosure of information to international, 

federal, state, local, tribal, or private entities for the purpose of the regular exchange of business contact information 

in order to facilitate collaboration for official business. More information about this and other routine uses can be 

found in the System of Records Notices (SORNs) listed above, which are posted on Treasury’s website.

DISCLOSURE: Providing this information is voluntary. However, failure to furnish the requested information may 

result in the denial of your application.