Header and burden statement
OMB Number 2900-0559, an expiration date of Oct. 31, 2026, a respondent burden of 15 minutes, and a note naming 38 U.S.C. 2408 as the statutory authority for a State Cemetery Grant.
VA40-0895-7
Certification Regarding Debarment, Suspension, and Other Responsibility Matters—Primary Covered Transactions (State or Tribal Government) (Title 2 Part 180)
- Agency
- VA
- Revision
- September 2023
- Fillable fields
- 5
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form VA40-0895-7: Debarment and Suspension Certification, Primary Covered Transactions
VA Form VA40-0895-7 is the U.S. Department of Veterans Affairs Certification Regarding Debarment, Suspension, and Other Responsibility Matters for Primary Covered Transactions. The form says the information is necessary to document that the State, Tribal or eligible County government has not been debarred, suspended or is ineligible to participate in the VA grant process and receive Federal funds. It names 38 U.S.C. 2408 as the statutory authority for a State Cemetery Grant.
It is a grant certification signed by a government representative, not a Veteran benefit form. The form says the certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 38 CFR, Part 39. Page 1 holds the certification statements and the signature block, and page 2 holds ten numbered instructions, which the form says to read before completing it.
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What's on VA Form VA40-0895-7
Statement (1)(a): convictions and judgments
That within a three-year period preceding the proposal the participant and its principals have not been convicted of or had a civil judgment rendered against them for fraud tied to a public transaction, antitrust violations, or offenses such as embezzlement, theft, forgery or bribery.
Statements (1)(b) and (1)(c)
That they are not presently indicted for any of those offenses, and have not within a three-year period had one or more public transactions terminated for cause or default.
Statement (2): explanation
Where the prospective primary participant is unable to certify to any statement, it attaches an explanation to the proposal.
Signature block
Name of organization, PR/award number, project FAI (Federal Application Identifier) number, the authorized representative's name and title, signature and date (mm/dd/yyyy).
Page 2: instructions
Ten instructions on the certification as a material representation of fact, immediate written notice if it becomes erroneous, the Executive Order 12549 definitions and lower tier covered transactions.
How to complete VA Form VA40-0895-7
- 1
Read page 2 first
A note on page 1 says to read the instructions on page 2 before completing the certification.
- 2
Review the statements
The prospective primary participant certifies to the best of its knowledge and belief to the paragraph (1) statements for itself and its principals.
- 3
Attach an explanation if needed
If it is unable to certify to any of the statements, the form says to attach an explanation to the proposal.
- 4
Fill in the identifiers
Enter the name of organization, the PR/award number and the project FAI number.
- 5
Sign and date it
The authorized State, Tribal or eligible County government representative enters a name and title, signs and dates the form.
- 6
Submit it with the proposal
Instruction 1 says that by signing and submitting the proposal, the prospective primary participant is providing the certification.
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Where it goes and edition
With the grant proposal
The form does not print a mailing address. Its instructions refer to the department or agency to which the proposal is submitted.
Not to the burden address
Comments on the burden estimate go to OIRA Desk Officer for VA, 725 17th St NW, Washington, DC 20503. The form says to send comments only and not applications for a grant to this address.
Later changes
Instruction 4 says the participant provides immediate written notice to the department or agency if it learns its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
Edition
The PDF footer reads VA FORM SEP 2023. It carries OMB Number 2900-0559, with an expiration date of Oct. 31, 2026.
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Who completes VA Form VA40-0895-7?
The form names the parties it applies to.
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Questions about Form VA40-0895-7
What is VA Form VA40-0895-7 used for?
The form says the information is necessary to document that the State, Tribal or eligible County government has not been debarred, suspended or is ineligible to participate in the VA grant process and receive Federal funds.
Who signs VA Form VA40-0895-7?
The authorized State, Tribal or eligible County government representative, who gives a name and title. The form calls the government the prospective primary participant.
What if the organization cannot certify to every statement?
The form says to attach an explanation to the proposal. The instructions say inability to provide the certification will not necessarily result in denial of participation, but failure to furnish a certification or an explanation disqualifies the participant from the transaction.
Which rules does the form cite?
The regulations implementing Executive Order 12549, Debarment and Suspension, 38 CFR, Part 39. Its title also names Title 2 Part 180.
What does the form say about lower tier transactions?
Instruction 7 says the participant agrees to include the clause titled Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered Transactions, without modification, in all lower tier covered transactions and solicitations for them.
How long does it take to complete?
The form estimates the public reporting burden at an average of 15 minutes.