Fillable Printable VA Form 40-0895-12

VA Form 40-0895-12

OMB NUMBER: 2900-0559

Respondent Burden: 15 minutes

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY

EXCLUSION - LOWER TIER COVERED TRANSACTIONS (Contractor)

Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes. Statutory authority for a State

Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that the contractor has not been debarred, suspended or is

ineligible to participate in the VA grant process and receive Federal funds. VA may not conduct or sponsor and you are not required to respond to

this collection of information unless it displays a valid OMB number. Respond to this collection is voluntary. Send comments regarding the burden

estimate or any other aspects of this collection of information, including suggestions for reducing the burden to VA Clearance Officer (005R1B),

810 Vermont Avenue NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications for a grant to this address.

AUTHORITY: This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension,

Title 2 Part 180, Participants' Responsibilities. The regulations were published as Part VII of the May 26, 1988, Federal Register

(pages 19160 - 19211). Copies of the regulations may be obtained by contacting the person to whom this proposal is submitted.

CERTIFICATION: The authorized representative certifies, by submission of this form, that neither the representative nor principals

are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this

transaction by any Federal department or agency.

INSTRUCTIONS:

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.

2. 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.

3. The prospective lower tier participant shall provide immediate written notice to which this proposal is submitted if at any time the

prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of

changed circumstances.

4. 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 whom this proposal is submitted for assistance in obtaining a copy of those regulations.

5. 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.

6. 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.

7. 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.

8. 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.

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.

NAME AND ADDRESS OF COMPANY: PROJECT FAI (Federal Application Identifier) NO.

NAME OF LOWER TIER PARTICIPANT TITLE OF LOWER TIER PARTICIPANT

SIGNATURE OF LOWER TIER PARTICIPANT DATE SIGNED (mm/dd/yyyy)

VA FORM

OCT 2010

40-0895-12