Fillable Printable VA Form 40-0895-7
Fillable Printable VA Form 40-0895-7
VA Form 40-0895-7
OMB NUMBER: 2900-0559
Respondent Burden: 15 minutes
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
(STATE OR TRIBAL GOVERNMENT) (Title 2 Part 180)
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 document that the State or Tribal government 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.
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 38 CFR, Part 39.
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered
against them for:
(i) commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a
public (Federal, State or local) transaction or in connection with a contract under a public transaction;
(ii) violation of Federal or State antitrust statues; or
(iii) commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
(b) Are not presently indicted for other criminal or civil charges by a governmental entity (Federal, State or local) for
commission of any of the offenses enumerated in paragraph (1)(a) of this certification; and
(c) 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.
NAME OF ORGANIZATION PR/AWARD NUMBER PROJECT FAI (Federal Application Identifier)
NO.
NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE
SIGNATURE DATE (mm/dd/yyyy)
NOTE: Before Completing Certification, Read Instructions on page 2.
VA FORM
OCT 2010
40-0895-7
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INSTRUCTIONS FOR CERTIFICATION
1.
By signing and submitting this proposal, the prospective primary participant is providing the certification set out
below.
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 below. 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 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 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 entering into this transaction.
7.
The prospective primary 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," 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.
VA FORM
OCT 2010
40-0895-7
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