Fillable Printable VA Form 10-0388-12

VA Form 10-0388-12

OMB Number: 2900-0661

Estimated Burden: 1 hour

VA FORM

JUL 2013

10-0388-12

PAGE 1 OF 2

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY

AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS

FAI NUMBER

PROJECT LOCATION

PROJECT DESCRIPTION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of this

Act. The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. We may not collect or sponsor and you are

not required to respond to, a collection unless it has a valid OMB Control Number. This collection of information is collected under the authority of 38 U.S. Code Sections

8133(a) and 8135(a). VA will use this information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to

meet VA requirements for a grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to

authorize a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.

SIGNATURE

DATE (mm/dd/yyyy)

TITLE OF AUTHORIZED REPRESENTATIVE

NAME OF AUTHORIZED REPRESENTATIVE

CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.

(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective

participant shall attach an explanation to this proposal.

(1) The prospective lower tier 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 Executive Order 12549, Debarment and Suspension, 38 CFR Part 44.510,

Participants' Responsibilities. The regulations were published as Part VII of the May 26, 1988, Federal Register (pages 191600-19211).

Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.

NAME OF COMPANY

COMPANY TAX IDENTIFICATION NUMBER

9. Except for transactions authorized under paragraph 5 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 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 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.

The prospective lower tier participant further agrees by submitting this proposal that it will include the 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.

The prospective lower tier participant agrees by submitting this proposal 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 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 the Definitions and Coverage sections of

rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for

assistance in obtaining a copy of those regulations.

The prospective lower tier participant shall provide immediate written notice to which this proposal is submitted it any

time the prospective lower tier 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 prospective lower tier 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 prospective lower tier participant is providing the certification set out below.

INSTRUCTIONS FOR CERTIFICATION

PAGE 2 OF 2

10-0388-12

VA FORM

JUL 2013