Project details
Project description, project location and the FAI number at the top of page 1.
26-0967
Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion
- Agency
- VA
- Revision
- February 2025
- Fillable fields
- 9
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 26-0967: Certification Regarding Debarment, Suspension and Voluntary Exclusion
VA Form 26-0967 is the U.S. Department of Veterans Affairs Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion. The form says the certification is required by the regulations implementing 38 U.S.C. 2108, Specially Adapted Housing Assistive Technology Grant Program. By submitting a proposal, the participant certifies that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from the transaction by any Federal department or agency.
It is completed for the company submitting the proposal, by an authorized representative, and asks for company details rather than a Veteran's personal details. Page 1 holds the project description and location, the FAI number, the two certification statements, space for an explanation, and the company's name, tax identification number and signer. Page 2 holds nine numbered instructions for the certification.
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What's on VA Form 26-0967
Statements (1) and (2)
Statement (1) is the certification on debarment, suspension, proposed debarment, ineligibility and voluntary exclusion. Statement (2) covers a participant that cannot certify and gives space for an explanation.
Company and signer
Name of company, company tax identification number, name and title of the authorized representative, signature and date signed, under a warning that the law provides severe penalties for willful submission of false information.
Instructions for certification
Page 2 lists nine instructions, including that the certification is a material representation and that its terms have the meanings set out in title 2, Code of Federal Regulations, part 180.
Privacy and burden notices
The Privacy Act notice says the obligation to respond is voluntary, and the burden statement estimates 1 hour per respondent, per year.
How to complete VA Form 26-0967
- 1
Describe the project
Enter the project description, project location and FAI number.
- 2
Read the instructions on page 2
They explain that signing and submitting the proposal provides the certification, and what the agency may do if a certification is later found to be knowingly erroneous.
- 3
Add an explanation if needed
If the participant cannot certify to any of the statements, the form says to give an explanation in the space below statement (2).
- 4
Identify the company and sign
Enter the company name and tax identification number, then the authorized representative's name, title, signature and date.
- 5
Include it with the proposal
The form says the participant provides the certification by submission of the proposal. It prints no mailing address.
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Submitting it and other details
Where it goes
The form says the certification is made by submission of the proposal and refers to the person to whom this proposal is submitted. It prints no mailing address or online option.
If the certification changes
Instruction 3 says the participant gives immediate written notice if it learns its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
Companion form
VA Form 26-0967a, Scoring Criteria for SAH Assistive Technology Grants, carries the same OMB control number, 2900-0903.
Edition
The February 2025 edition supersedes the February 2022 edition, which will not be used. It carries OMB Control Number 2900-0903, which expires 02/29/2028.
Related forms
26-0967a
Scoring Criteria for SAH Assistive Technology Grants
6 fields, 6 pages
26-4555
Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant
20 fields, 1 page
26-4555c
Veteran/Servicemember's Supplemental Application for Assistance in Acquiring Specially Adapted Housing
44 fields, 1 page
Who uses VA Form 26-0967?
The form describes the participant, its signer and the person it is submitted to.
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Questions about Form 26-0967
What is VA Form 26-0967 for?
The form says it is the certification required by the regulations implementing 38 U.S.C. 2108, Specially Adapted Housing Assistive Technology Grant Program, that a participant and its principals are not debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded.
Who signs VA Form 26-0967?
An authorized representative of the company, who gives a name and title and signs and dates the form.
What if the company cannot make the certification?
Statement (2) says a prospective participant unable to certify to any of the statements provides an explanation with the proposal.
Where are the terms defined?
Instruction 4 says terms such as covered transaction, participant and proposal have the meanings set out in title 2, Code of Federal Regulations, part 180.
Is checking the Non procurement List required?
Instruction 7 says each participant may, but is not required to, check the Non procurement List.
Is responding voluntary?
The Privacy Act notice on the form says: Your obligation to respond is voluntary.