Attachment A – Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion Lower Tier Covered Transactions
Guidance Memorandum 4, Revision Date 8/2021 Page 3 of 11
Instructions: Facility to obtain from any potential vendor or existing contractor for all contracts in excess of $25,000.
This form is required each time a bid for goods/services over $25,000 is solicited or when renewing/extending an
existing contract exceeding $25,000 per year.
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 (pages 4722 – 4733). Copies of the regulations may be obtained
by contacting the Department of Agriculture agency with which this transaction originated.
Before Completing Certification, Read Instructions Below
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals
is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency.
(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.
P
otential Vendor or Existing Contractor (Lower Tier Participant):
____________________________________________ Child and Adult Care Food Program
Vendor Name PR/Award Number or Project Name
_________
_______________________________________________________________________________
Vendor Representative Printed Name Title Signature Date
DO NOT SUBMIT THIS FORM. FACILITY TO RETAIN WITH THE APPLICABLE VENDOR AGREEMENT.
Instructions for Certification
1. By signing and submitting this form, the prospective lower tier participant is providing the certification set out on the reverse
side in accordance with these instructions.
2. The certification in this clause is a material representation of fact 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 the person 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,” “debarred,” “suspended,” “ineligible,” “lower tier covered transaction,” “participant,”
“person,” “primary covered transaction,” “principal,” “proposal,” and “voluntarily excluded,” as used in this clause, have th
e
m
eanings 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.
5. The prospective lower tier participant agrees by submitting this form that, should the proposed covered transaction be entere
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to, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declare
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neligible, 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 form that it will include this 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 covere
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ansaction 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 f
aith 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 exclude
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rom 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.
