Ad 1047 Certification Form – Fill Out and Use This PDF

The AD-1047 is a federal certification form from the USDA that confirms the applicant is not debarred, suspended, or excluded from participation in federal programs. It is required for all primary covered transactions under Executive Order 12549 and 2 C.F.R. § 180.335. Use the free PDF editor below to complete and download your AD-1047 Certification Form.

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Ad 1047 Certification Form PDF Details

The AD-1047 Certification Regarding Debarment, Suspension, and Other Responsibility Matters is required for all entities entering primary covered transactions with the USDA. By signing this form, the participant certifies they are in good standing with federal agencies and not currently subject to debarment, suspension, or exclusion from federal programs.

The form requires affirmations on three key compliance points. First, the applicant must not be under active debarment or suspension. Second, there must be no criminal convictions or charges related to fraud within the past three years. Third, no previous federal transaction may have been terminated for cause or default. These requirements come from Executive Order 12549 and 2 C.F.R. § 180.335. All participants at every tier of a covered transaction must meet these standards.

Providing false certification carries serious federal consequences, including termination of the covered transaction and potential criminal liability under 18 U.S.C. § 1001. Keep a signed copy of your completed AD-1047 for your records. Related USDA compliance documents include the Certification Regarding Debarment Form for lower-tier transactions and the USDA Form RD 400-6 for equal opportunity requirements.

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Form Name	Ad 1047 Certification Form
Form Length	2 pages
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Avg. time to fill out	30 sec
Other names	ad 1047 certification debarment, ad 1047, 1047 form pdf, 1047 form

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This form is available electronically.		Form Approved – OMB No. 0505-0027
			Expiration Date: 12/31/2018

	United States Department of Agriculture		AD-1047
	United States Department of Agriculture		AD-1047

AD-1047

Certification Regarding Debarment, Suspension, and Other Responsibility Matters

Primary Covered Transactions

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552(a), as amended). This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, and 2 C.F.R. § 180.335, Participants' responsibilities. The regulations were amended and published on August 31, 2005, in 70 Fed. Reg. 51865-51880. Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the proposed covered transaction.

According to the Paperwork Reduction Act of 1995 an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0505-0027. The time required to complete this information collection is estimated to average 15 minutes 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. The provisions of appropriate criminal and civil fraud privacy, and other statutes may be applicable to the information provided.

(Read Instructions On Page Two Before Completing Certification)

A.The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:

1.Are not presently debarred, suspended, or proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

2.Have not within a three-year period preceding this proposal 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;

3.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 (A.2.) of this certification; and

4.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.

B.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.

ORGANIZATION NAME

PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)

SIGNATURE(S)

DATE

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived

from any public assistance program. (Not all prohibited bases apply to all programs). Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA,

Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at

(866)632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.

Instructions for Certification

(1)By signing and submitting this form, the prospective primary participant is providing the certification set out on page 1 in accordance with these instructions.

(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 on this form. 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 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, at 2 C.F.R. Parts 180 and 417. 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 form 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 form 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 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 System for Award Management (SAM) database.

(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.

Form AD-1047 (REV 12/15)

Page 2 of 2

How to Edit Ad 1047 Certification Form Online for Free

The AD-1047 is a USDA-issued certification form that participants must sign before entering any primary covered transaction with the federal government. A covered transaction is any grant, loan, cooperative agreement, contract, or other financial arrangement with the USDA. The form certifies that the signing party is not debarred, suspended, or otherwise excluded from federal programs at the time of signing.

The requirement comes from Executive Order 12549, Debarment and Suspension, which directs federal agencies to protect government resources by excluding non-responsible parties. The USDA implements this requirement through 2 C.F.R. § 180.335, which lists the specific ineligibility conditions participants must disclose and certify against before federal funds can be awarded.

Who Needs to Complete the AD-1047?

Any individual or organization entering a primary covered transaction with the USDA must complete the AD-1047. Covered parties include recipients of USDA grants, borrowers under USDA loan programs, parties to cooperative agreements, and federal contractors. Both the primary applicant and any sub-recipients involved in lower-tier transactions must certify their compliance status. The federal threshold requiring written certification is 5,000.

State and local government entities, tribes, nonprofit organizations, and private businesses may all be required to submit the AD-1047 depending on the type and amount of the USDA program transaction. Check with the specific USDA agency office handling your application to confirm the exact certification requirements for your program.

What Does the AD-1047 Certify?

Signing the AD-1047 certifies three specific compliance conditions. You confirm that you are not currently debarred, suspended, or voluntarily excluded from covered transactions. You also confirm that you have not been convicted of fraud or a related criminal offense within the past three years. Finally, you certify that no public transaction has been terminated against you for cause or default within the same period. All three conditions must be true at the time you sign.

How Do You Fill Out the AD-1047 Certification Form?

The AD-1047 is a straightforward form, but accuracy is critical. Errors or omissions can delay USDA application processing or trigger a compliance review. Follow these steps to complete it correctly.

Step 1: Verify Your Debarment Status

Before signing the AD-1047, search for your organization at SAM.gov. The System for Award Management Exclusions database lists all currently debarred and suspended parties. Confirm your organization is not listed before proceeding. Checking this takes less than two minutes and protects you from unknowingly submitting an inaccurate certification.

Step 2: Read Each Certification Statement Carefully

Each statement in the AD-1047 covers a specific compliance area. If you are uncertain about whether a particular statement applies to your situation, contact the relevant USDA program office or your legal counsel before signing. Do not sign any statement that does not accurately reflect your current legal status.

Step 3: Complete All Required Fields

Enter your full legal name, the name of your organization, and your official title. Include the transaction or program reference number if the application requires it. Make sure the name on the AD-1047 matches the legal name used on your other application documents. Inconsistencies between forms can cause processing delays.

Step 4: Sign and Date the Form

Your signature is a legal attestation that all information is accurate and complete as of the signing date. Submitting knowingly false information is a federal crime under 18 U.S.C. § 1001 and may result in termination of your program participation and additional legal consequences. Keep a copy of the signed form for your records before submitting it.

Common Mistakes to Avoid When Completing the AD-1047

Several errors commonly delay USDA application processing. The most frequent issue is using an informal or abbreviated organization name instead of the full legal name. Another common mistake is signing the form without first checking SAM.gov, leaving applicants uncertain whether they are eligible at the time they certify.

Applicants sometimes also forget to attach the AD-1047 to the final application package. This causes the application to be returned as incomplete. Some USDA program offices require original wet signatures on the certification form rather than photocopies or electronic signatures. Confirm the submission format requirements with your program officer before sending the package.

Failing to keep a signed copy is another avoidable error. If a discrepancy arises later about the terms of your certification, having your own copy is essential. Date your copy the same day you sign the original.

Related USDA and Federal Certification Forms

Many USDA applications require multiple certification forms alongside the AD-1047. The SF-424 Federal Grant Application is the standard application form for USDA grant funding and is submitted alongside the AD-1047 in most grant packages. The USDA Form RD 1980-21 is used for agricultural credit applications and also requires debarment certification from borrowers. The RD 400-1 Fair Housing Certification applies to USDA Rural Development programs and must be completed alongside the AD-1047 when equal opportunity requirements apply.

Common Questions About the AD-1047 Form

Is the AD-1047 required for every USDA transaction?

The AD-1047 is required for primary covered transactions above 5,000 with the USDA. This includes most grants, loans, and cooperative agreements. Smaller transactions may require only a verbal certification, but written certification is standard for most USDA program applications.

What happens if I made an error on the AD-1047 after submitting?

Contact the USDA program office or contracting officer right away. You may be able to submit a corrected form. Review all fields carefully before submitting to prevent delays and compliance issues. Keep a copy of every version you submit.

How long does a federal debarment period last?

Debarment periods typically last up to three years but can be extended based on the severity of the violation. Before completing the AD-1047, verify your organization status at SAM.gov to confirm you are eligible to enter covered transactions.

Is the AD-1047 specific to USDA programs only?

Yes. The AD-1047 is issued by and applies exclusively to USDA-covered transactions. Other federal agencies use comparable debarment certification forms as part of their own application packages. The non-procurement common rule at 2 C.F.R. Part 180 governs debarment standards across all federal agencies.

Where can I check if a party is currently debarred from federal programs?

The SAM.gov Exclusions database is the authoritative source for checking debarment and suspension status in federal programs. All federal agencies, including the USDA, use this system to verify participant eligibility. Checking this database before signing the AD-1047 protects both the applicant and the program officer handling the application.