Respondent burden notice
OMB Number 2900-0559, expiration date Oct. 31, 2026, an estimated burden of 15 minutes and the statutory authority 38 U.S.C. 2408.
VA40-0895-12
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion—Lower Tier Covered Transactions
- Agency
- VA
- Revision
- September 2023
- Fillable fields
- 4
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form VA40-0895-12: Certification Regarding Debarment, Lower Tier Covered Transactions
VA Form VA40-0895-12 is the U.S. Department of Veterans Affairs Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion, Lower Tier Covered Transactions (Contractor). The contractor's authorized representative certifies, by submitting it, that neither the representative nor principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in the transaction by any Federal department or agency.
The form says the information is necessary to ensure that the contractor has not been debarred, suspended or is ineligible to participate in the VA grant process and receive Federal funds. It cites the regulations implementing Executive Order 12549, Debarment and Suspension, Title 2 Part 180, and gives the statutory authority for a State Cemetery Grant as 38 U.S.C. 2408. It is a contractor form, not a benefits form.
The form is one page: the authority and certification, nine numbered instructions, and the company and signer fields. VA's form page offers the PDF only. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form VA40-0895-12
Authority
The regulations implementing Executive Order 12549, Debarment and Suspension, Title 2 Part 180, Participants' Responsibilities, published as Part VII of the May 26, 1988, Federal Register.
Certification
The authorized representative certifies that neither the representative nor principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency.
Instructions 1 to 5
The certification as a material representation, remedies for an erroneous certification, written notice of changes, where the defined terms come from, and an agreement not to knowingly deal with excluded persons.
Instructions 6 to 9
Including the clause without modification in lower tier transactions, relying on certifications, the optional Nonprocurement List check, the prudent person standard and remedies.
Company and signer fields
Name and address of the company, the Project FAI (Federal Application Identifier) number, and the name, title and signature of the lower tier participant with the date signed (mm/dd/yyyy).
How to complete VA Form VA40-0895-12
- 1
Read the certification and instructions
The certification and the nine instructions explain what the signer represents and what happens if it is erroneous.
- 2
Enter the company and project
Fill in the name and address of the company and the Project FAI (Federal Application Identifier) number.
- 3
Name the signer
Enter the name and title of the lower tier participant.
- 4
Sign and date it
The lower tier participant signs and enters the date signed as mm/dd/yyyy. Instruction 1 says signing and submitting the proposal provides the certification.
- 5
Report later changes
Instruction 3 says the participant gives immediate written notice to the person to whom the proposal is submitted if it learns the certification was erroneous or has become erroneous.
Why fill Form VA40-0895-12 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes
With the proposal
Instruction 1 says the prospective lower tier participant provides the certification by signing and submitting the proposal. The form prints no mailing address, email or fax number.
Comments only
The burden notice lists the OIRA Desk Officer for VA, 725 17th St NW, Washington, DC 20503, and says SEND COMMENTS ONLY. Please do not send applications for a grant to this address.
Edition
The footer reads VA FORM SEP 2023 40-0895-12, and VA's form page lists a revision date of September 2023. OMB Number 2900-0559 has an expiration date of Oct. 31, 2026.
Related forms
VA40-0895-7
Certification Regarding Debarment, Suspension, and Other Responsibility Matters—Primary Covered Transactions (State or Tribal Government) (Title 2 Part 180)
5 fields, 2 pages
VA40-0895-9
Certification Regarding Lobbying
4 fields, 1 page
VA40-0895-2
Certification of Compliance with Provisions of the Davis-Bacon Act (40 U.S.C. 3141 - 3148)
5 fields, 1 page
VA40-0895-8
Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
10 fields, 2 pages
VA40-0895-10
Certification of Compliance with Federal Requirements State or Tribal Government Construction Grant
4 fields, 1 page
VA40-0895-14
Checklist of Major Requirements for State or Tribal Government Cemetery Construction Grants
93 fields, 2 pages
Who uses VA Form VA40-0895-12?
The form is completed by a contractor in a covered transaction, not by individual Veterans.
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Questions about Form VA40-0895-12
Who completes VA Form VA40-0895-12?
The contractor, as the prospective lower tier participant. The form asks for the company's name and address and the name, title and signature of the lower tier participant.
What does the signer certify?
That neither the representative nor principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in the transaction by any Federal department or agency.
What if the certification turns out to be wrong?
Instruction 3 says the participant gives immediate written notice to the person to whom the proposal is submitted. Instruction 2 says remedies for a knowingly erroneous certification can include suspension and/or debarment.
Does a participant have to check the Nonprocurement List?
Instruction 7 says each participant may, but is not required to, check the Nonprocurement List.
Where are the terms in the form defined?
Instruction 4 says they have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, and that the person to whom the proposal is submitted can help with a copy.
Is VA Form VA40-0895-12 for Veterans or families?
No. The form says it ensures the contractor has not been debarred, suspended or is ineligible to participate in the VA grant process and receive Federal funds.