Certification Regarding
Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 13 CFR
Part 145. The regulations were published as Part VII of the May 26, 1988
Federal Register
(pages 19160-19211). Copies of
the regulations are available from local offices of the U.S. Small Business Administration.
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)
(1)
Business Name
Date
By
Name and Title of Authorized Representative
Signature of Authorized Representative
SBA Form 1623 (10-88)
Are not presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
Have not within a three-year period preceding this application been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a
public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen
property;
Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this
certification; and
Have not within a three-year period preceding this application had one or more public transactions
(Federal, State, or local) terminated for cause or default.
The prospective primary participant certifies to the best of its knowledge and belief that it and its principals:
Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective primary participant shall attach an explanation to this proposal.
This form was electronically produced by Elite Federal Forms, Inc.
(a)
(b)
(c)
(d)
(2)
INSTRUCTIONS FOR CERTIFICATION
- 2 -
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 is 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 which 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 the rules implementing Executive Order
12549. You may contact the department or agency to which this proposal is submitted for assistance in obtaining a copy
of those regulations (13 CFR Part 145).
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
ineligibility 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.