Ad 3030 Form PDF Details

In the realm of aligning with federal standards and regulations for corporate entities aiming to engage in contracts, grants, or agreements with the United States Department of Agriculture (USDA), the AD-3030 form emerges as a critical document. Tackling significant concerns related to legal eligibility, the form serves a dual purpose: to verify the absence of felony convictions within the past 24 months among the applicants or their agents acting on the corporation's behalf, and to ensure compliance with federal tax liabilities. Crafted to uphold integrity and lawful conduct among corporations seeking collaboration with the USDA, completion of this form is mandatory for any corporation — spanning for-profit and non-profit sectors and encompassing a diverse range of geographical incorporations from the 50 states to territories like Guam and Puerto Rico. It embodies the USDA's dedication to maintaining a non-discriminatory, inclusive approach across all its programs, enforcing a strict prohibition against discrimination based on a wide array of characteristics from race to religious beliefs. Moreover, the AD-3030 form underscores an adherence to privacy, as outlined in the Privacy Act of 1974, while making explicit the ramifications of non-compliance - rendering applicants ineligible for USDA contracts or agreements. The information solicited through the form, governed by the Paperwork Reduction Act of 1985, aims for efficiency, estimating an average completion time of 15 minutes, which reflects a balanced approach between thoroughness and respect for the applicant’s time.

QuestionAnswer
Form NameAd 3030 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesusda ad 3030 fillable form, ad 3030 usda form, form ad 3030, usda ad 3030

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This form is available electronically.

Form Approved – OMB No. 0505-0025

 

Expiration Date: 12/31/2012

 

 

AD-3030

U.S. DEPARTMENT OF AGRICULTURE

(10-31-12)

 

REPRESENTATIONS REGARDING FELONY CONVICTION

AND TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS

You only need to complete this form if you are a corporation. A corporation is any entity that has filed articles of incorporation in one of the 50 States, the District of Columbia, or the various territories of the United States including American Samoa, Federated States of Micronesia, Guam, Midway Islands, Northern Mariana Islands, Puerto Rico, Republic of Palau, Republic of the Marshall Islands, or the U.S. Virgin Islands. Corporations include both for profit and non-profit entities.

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552(a), as amended). The authority for requesting the following information for USDA Agencies and staff offices is in §738 and 739 of the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act, 2012, P.L. 112-55 and subsequent similar provisions. The information will be used to confirm applicant status concerning entity conviction of a felony criminal violation, and/or unpaid Federal tax liability status.

According to the Paperwork Reduction Act of 1985 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 0505-0025. 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. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

PART A – APPLICANT (You must complete this form if you are a Corporation)

1. APPLICANT’S NAME

2.APPLICANT’S ADDRESS (Including Zip Code)

3.TAX ID NO. (Last 4 digits)

4A. Has the Applicant been convicted of a felony criminal violation under Federal or State law in the 24 months preceding the

 

date of application?

YES

NO

 

 

 

 

4B.

Has any officer or agent of Applicant been convicted of a felony criminal violation for actions taken on behalf of Applicant

 

under Federal or State law in the 24 months preceding the date of application?

YES

NO

4C.

Does the Applicant have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative

 

remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with

 

the authority responsible for collecting the tax liability?

YES

NO

 

 

Providing the requested information is voluntary. However, failure to furnish the requested information will make the applicant ineligible to enter into a contract, memorandum of understanding, grant, loan, loan guarantee, or cooperative agreement with USDA.

PART B – SIGNATURE

5A. APPLICANT’S SIGNATURE (BY)

 

5B. TITLE/RELATIONSHIP OF THE INDIVIDUAL IF

 

5C. DATE SIGNED

 

 

 

 

SIGNING IN A REPRESENTATIVE CAPACITY

 

(MM-DD-YYYY)

 

 

 

 

 

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.

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Filling out segment 1 of usda form ad 3030

2. The next step would be to complete these fields: C Does the Applicant have any, remedies have been exhausted or, YES, Providing the requested, PART B SIGNATURE A APPLICANTS, B TITLERELATIONSHIP OF THE, SIGNING IN A REPRESENTATIVE, C DATE SIGNED MMDDYYYY, and The US Department of Agriculture.

Completing segment 2 of usda form ad 3030

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