College Community School District

AD-3027 OMB Control No: 0508-0002 · Expiration Date: 09/30/2027 · U.S. Department of Agriculture · Complainant Information · First name Middle Initial Last Name · Mailing Address (Include Full City · State and Zip Code) · Primary Phone Number Alternate Phone Number Email · Best way to reach you: ☐ Mail ☐ Phone ☐ Email ☐ Other · If you have difficulty understanding the English language · you may request language assistance services by calling · 866-632-9992. Assistance will be available for individuals who are not proficient in English. Persons with disabilities who · require alternative means of communication (e.g. · braille · large print · American Sign Language) should contact the · responsible State or local Agency that administers the program or contact the United States Department of Agriculture · (USDA) through the Federal Telecommunications Relay Service at 711 (voice TTY). · Representative Information · Do you have a representative? ☐ Yes ☐ No Do you have written authorization from representative? · If so · please attach. ☐ Yes ☐ No · First name Last Name · Mailing address (Include Full City · State and Zip Code) · Complaint Information · (attach additional pages and supporting documentation as needed) · 1. Provide the name of the program you applied for (if known/applicable). · 2. Select the USDA agency that conducts the program or provides Federal financial assistance for the program. · ☐ Agricultural Marketing Service

1989 · Federal Register (pages 4722-4733). Copies of the regulations may be obtained by contacting · the Department of Agriculture agency with which this transaction originated. · (BEFORE COMPLETING CERTIFICATION · READ INSTRUCTIONS BELOW) · (1) The prospective lower tier participant certifies · by submission of this proposal · that neither it nor its · principals is presently debarred · suspended · proposed for debarment · declared ineligible · or voluntarily excluded · from participation in this transaction by any Federal department or agency. · (2) Where the prospective lower tier participant is unable to certify to any of the statements in this · certification · such prospective participant shall attach an explanation to this proposal. · Vendor Organization Name · Vendor Authorized Representative · Signature · Instructions for Suspension and Debarment Certification · 1. By signing and submitting this form · the prospective lower tier participant is providing the certification set out · on the form in accordance with these instructions. · 2. The certification in this clause is a material representation of fact upon which reliance was placed when the · transaction was entered into. If it is later determined that the prospective lower tier participant knowingly · rendered an erroneous certification · in addition to other remedies available to the Federal Government · the · department or agency with which this transaction originated may pursue available remedies