State Government
Local Government
Indian Tribal Government
Special Governmental District
Private Non-Profit
Other
If Private Non-Profit,
Legal status, function, and facilities owned:
State Tax Number: (e.g. 11-111111)
Federal Tax Number: (e.g. 11-111111)
If Other, please specify:
*
Federal Employer Identification Number (EIN). If Indian
Tribe, this is Tribal Identification Number.
* What is your DUNS Number?
*
Are you the application preparer?
Yes No
*
Does your organization have a Smartlink account?
Yes No
* Is the application preparer the Point of Contact?
Yes No
*
Is application
subject to review by Executive Order 12372 Process?
Yes.
This preapplication/application was made available
to the Executive Order 12372 Process for review on:
No.
Program is not covered by E.O. 12372
Or program has not been selected by state for review
* Is the applicant delinquent on any Federal debt?
Yes No
Explanation:
Contact Information
Point of Contact Information
Title
Mr.
Ms.
Mrs.
Dr.
*
First Name
Middle Initial
*
Last Name
Title
*
Agency/Organization
*
Address 1
Address 2
*
City
*
State
*
ZIP
*
Phone
Fax
*
Email
Alternate Point of Contact Information
Title
Mr.
Ms.
Mrs.
Dr.
First Name
Middle Initial
Last Name
Title
Agency/Organization
Address 1
Address 2
City
State
ZIP
Phone
Fax
Email
Subgrant Applications
Rank
Application Number
Application Title
Name
Non-Federal Share
Federal Share
Federal Share %
Plan Schedule
Subgrant Applicant
Total Duration
Unit of Time
Title of your proposed activity
Proposed Period of Performance
Overall duration of the grant
Unit of Time
Day(s)
Week(s)
Month(s)
Year(s)
Budget
File Name
Date Attached
Subgrant Applicant
Requested Amount
Total
$
Assurances and Certifications
Forms
Status
Part I: FEMA Form 20-16A, Assurances Non-Construction
Programs.
Incomplete/Complete
Not Applicable
Part II: FEMA Form 20-16C, Certifications Regarding
Lobbying; Debarment, Suspension and Other Responsibilities Matters;
and Drug-Free Workplace Requirements.
Incomplete/Complete
Part III: SF-LLL, Disclosure of Lobbying
Activities (Complete only if applying for a
grant of more than $100,000 and have lobbying activities using Non-Federal
funds. See Form 20-16C for lobbying activities definition.)
Incomplete/Complete
Not Applicable
FEMA Form 20-16A, Assurances-Non-Construction Programs
Note: Certain of these assurances
may not be applicable to your project or program. If you have questions,
please contact the awarding agency. Further, certain Federal awarding
agencies may require applicants to certify to additional assurances.
If such is the case, you will be notified.
As the duly authorized representative of the applicant, I certify
that the applicant:
1.
Has the legal authority to apply for Federal
assistance, and the institutional, managerial and financial
capability (including funds sufficient to pay the non-Federal
share of project costs) to ensure proper planning, management
and completion of the project described in this application.
2.
Will give the awarding agency, the Comptroller
General of the United States, and if appropriate, the State,
through any authorized representative, access to and the
right to examine all records, books, papers, or documents
related to the award; and will establish a proper accounting
system in accordance with generally accepted accounting
standards or agency directives.
3.
Will establish safeguards to prohibit employees
from using their positions for a purpose that constitutes
or presents the appearance of personal or organizational
conflict of interest, or personal gain.
4.
Will initiate and complete the work within
the applicable time frame after receipt of approval of the
awarding agency.
5.
Will comply with the Intergovernmental Personnel
Act of 1970 (42 USC Section 4728-4763) relating to prescribed standards
for merit systems for programs funded under one of the nineteen
statutes or regulations specified in Appendix A of OPM's
Standards for a Merit System of Personnel Administration
(5 CFR 900, Subpart F).
6.
Will comply with all Federal statutes relating
to nondiscrimination. These include but are not limited
to: (a) Title VI of the Civil Rights Act of 1964 (PL 88-352)
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education Amendments
of 1972, as amended (20 USC Section 1681-1683, and 1685-1686),
which prohibits discrimination on the basis of sex; (c)
Section 504 of the Rehabilitation Act of 1973, as amended
(29 USC Section 794), which prohibits discrimination on the basis
of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 USC Section 6101-6107), which prohibits discrimination
on the basis of age; (e) The Drug Abuse Office and Treatment
Act of 1972 (PL 92-255), as amended, relating to nondiscrimination
on the basis of drug abuse; (f) The Comprehensive Alcohol Abuse
and Alcoholism Prevention, Treatment and Rehabilitation Act
of 1970 (PL 91-616), as amended, relating to nondiscrimination
on the basis of alcohol abuse or alcoholism; (g) Sections 523
and 527 of the Public Health Service Act of 1912 (42 USC
290-dd-3 and 290-ee-3), as amended, relating to confidentiality
of alcohol and drug abuse patient records; (h) Title VIII
of the Civil Rights Act of 1968 (42 USC Section 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental
or financing of housing; (i) Any other nondiscrimination
provisions in the specific statute(s) under which application
for Federal assistance is being made; and (j)The requirements
of any other nondiscrimination statute(s) which may apply
to the application.
7.
Will comply, or has already complied, with
the requirements of Titles II and III of the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of
1970 (PL 91-646) which provide for fair and equitable treatment
of persons displaced or whose property is acquired as a result
of Federal or federally assisted programs. These requirements
apply to all interests in real property acquired for project
purposes regardless of Federal participation in purchases.
8.
Will comply with the provisions of the Hatch
Act (5 USC Section 1501-1508 and 7324-7328) which limit the political
activities of employees whose principal employment activities
are funded in whole or in part with Federal funds.
9.
Will comply, as applicable, with the provisions
of Davis-Bacon Act (40 USC Section 276a to 276a-7), Copeland Act
(40 USC Section 276c and 18 USC 874), and the Contract Work Hours
and Safe Standards Act (40 USC Section 327-333), regarding labor standards
for federally assisted construction subagreements.
10.
Will comply, if applicable, with flood insurance
purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires recipients
in a special flood hazard area to participate in the program
and to purchase flood insurance if the total cost of insurable
construction and acquisition is $10,000 or more.
11.
Will comply with environmental standards
which may be prescribed pursuant to the following: (a) institution
of environmental quality control measures under the National
Environmental Policy Act of 1969 (PL 91-190) and Executive
Order (EO) 11514; (b) notification of violating facilities
pursuant to EO 11738; (c) protection of wetlands pursuant
to EO 11990; (d) evaluation of flood hazards in floodplains
in accordance with EO 11988; (e) assurance of project consistency
with the approved State management program developed under
the Coastal Zone Management Act of 1972 (16 USC Section I' 1451
et seq.); (f) conformity of Federal actions to State (Clear
Air) Implementation Plans under Section 176(c) of the Clear
Air Act of 1955, as amended (42 USC Section I 7401 et seq.);
(g) protection of underground source of drinking water under
the Safe Drinking Water Act of 1974, as amended, (PL 93-523);
and (h) protection of endangered species under the Endangered
Special Act of 1973, as amended, (PL 93-205).
12.
Will comply with the Wild and Scenic Rivers
Act of 1968 (16 USC Section 1271 et seq.) related to protecting
components or potential components of the national wild
and scenic rivers system.
13.
Will assist the awarding agency in assuring
compliance with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 USC Section 470), EO 11593 (identification
and protection of historic properties), and the Archaeological and
Historic Preservation Act of 1974 (16 USC Section 469a-1 et seq.)
14.
Will comply with PL 93-348 regarding the protection
of human subjects involved in research, development, and
related activities supported by this award of assistance.
15.
Will comply with the Laboratory Animal Welfare
Act of 1966 (PL 89-544, as amended, 7 USC 2131 et seq.) pertaining
to the care, handling, treatment of warm blooded animals
held research, teaching, or other activities supported by this
award of assistance.
16.
Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 USC Section 4801 et seq.) which prohibits
the use of lead based paint in construction or rehabilitation
of residence structures.
17.
Will cause to be performed the required
financial and compliance audits in accordance with the Single
Audit Act of 1984.
18.
Will comply with all applicable requirements
of all other Federal laws, executive orders, regulations and policies
governing this program.
19.
It will comply with the minimum wage and
maximum hours provisions of the Federal Fair Labor Standards
Act (29 USC Section 201), as they apply to employees of institutions
of higher education, hospitals, and other non-profit organizations.
I, ______________________________, hereby sign this form as of _______________.
FEMA Form 20-16C
Applicants should refer to the regulations
cited below to determine the certification to which they are required
to attest. Applicants should also review the instructions for certification
included in the regulations before completing this form. Signature
on this form provides for compliance with certification requirements
under 44 CFR Part 18, "New Restrictions on Lobbying; and 28 CFR
Part 17, "Government-wide Debarment and suspension (Non-procurement)
and Government-wide Requirements for Drug-Free Workplace (Grants)."
The certifications shall be treated as a material representation of
fact upon which reliance will be placed when the Federal Emergency
Management Agency (FEMA) determines to award the covered transaction,
grant, or cooperative agreement.
1. LOBBYING
A. As required by the section 1352, Title 31 of the US Code, and implemented
at 44 CFR Part 18 for persons entering into a grant or cooperative agreement
over $100,000, as defined at 44 CFR Part 18, the applicant certifies
that:
(a) No Federal appropriated funds have been paid or will be paid,
by or on behalf of the undersigned, to any person for influencing
or attempting to influence an officer or employee of any agency,
a Member of Congress, an officer or employee of congress, or an
employee of a Member of Congress in connection with the making
of any Federal grant, the entering into of any cooperative agreement
and extension, continuation, renewal, amendment, or modification
of any Federal grant or cooperative agreement;
(b) If any other funds than Federal appropriated funds have been
paid or will be paid to any person for influencing or attempting
to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of
a Member of Congress in connection with this Federal
grant or cooperative agreement, the undersigned
shall complete and submit Standard Form LLL, "Disclosure
of Lobbying Activities", in accordance with its instructions;
Standard Form LLL Disclosure of Lobbying Activities Attached
(c) The undersigned shall require that the language of this certification
be included in the award documents for all the sub awards at all
tiers (including subgrants, contracts under grants and cooperative
agreements, and subcontract(s)) and that all subrecipients shall
certify and disclose accordingly.
2. DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS (DIRECT RECIPIENT)
As required by Executive Order 12549, Debarment and Suspension,
and implemented at 44 CFR Part 67, for prospective participants in primary covered
transactions, as defined at 44 CFR Part 17, Section 17.510-A. The
applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, sentenced to a denial of Federal benefits
by a State or Federal court, or voluntarily excluded from covered
transactions by any Federal department or agency;
(b) Have not within a three-year period preceding this application
been convicted of or had a civilian judgment rendered against
them for commission of fraud or a criminal offense in connection
with obtaining, attempting to obtain, or perform a public (Federal,
State, or local) transaction or contract under a public transaction;
violation of Federal or State antitrust statutes or commission
of embezzlement, theft, forgery, bribery, falsification or destruction
of records, making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or
civilly charged by a governmental entity (Federal, State, or locally)
with commission of any of the offenses enumerated in paragraph
(1)(b) of this certification; and
(d) Have not within a three-year period preceding this application
had one or more public transactions (Federal, State, or local)
terminated for cause or default; and
B. Where the applicant is unable to certify to any of the statements
in this certification, he or she shall attach an explanation to
this application.
Explanation:
3. DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented
at 44 CFR Part 17, Subpart F, for grantees, as defined at 44 CFR
part 17, Sections 17.615 and 17.623:
(A) The applicant certifies that it will continue to provide
a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful
manufacture, distribution, dispensing, possession, or use of
a controlled substance is prohibited in the grantee's workplace
and specifying the actions that will be taken against employees
for violation of such prohibition;
(b) Establishing an on-going drug free awareness program to
inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation and employee
assistance programs; and
(4) The penalties that may be imposed upon employees for drug
abuse violations occurring in the workplace;
(c) Making it a requirement that each employee to be engaged in
the performance of the grant to be given a copy of the statement
required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph
(a) that, as a condition of employment under the grant, the employee
will:
(1) Abide by the terms of the statement; and
(2)Notify the employee in writing of his or her conviction
for a violation of a criminal drug statute occurring in the
workplace no later than five calendar days after such conviction.
(e) Notifying the agency, in writing within 10 calendar days after
receiving notice under subparagraph (d)(2) from an employee or
otherwise receiving actual notice of such conviction. Employers
of convicted employees must provide notice, including position
title, to the applicable FEMA awarding office, i.e. regional office
or FEMA office.
(f) Taking one of the following actions against such an employee,
within 30 calendar days of receiving notice under subparagraph
(d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an
employee, up to and including termination, consistent with
the requirements of the Rehabilitation Act of 1973, as amended;
or
(2) Require such employee to participate satisfactorily in
a drug abuse assistance or rehabilitation program approved
for such purposes by a Federal, State, or local health, law
enforcement or other appropriate agency.
(g) Making a good effort to continue to maintain a drug free workplace
through implementation of paragraphs (a), (b), (c), (d), (e),
and (f).
(B) The grantee may insert in the space provided below the site(s)
for the performance of work done in connection with the specific
grant:
*
Place of Performance
Street
City
State
Zip
Section 17.630 of the
regulations provide that a grantee that is a State may elect to make one certification
in each Federal fiscal year. A copy of which should be included with each
application for FEMA funding. States and State agencies may elect to use a
Statewide certification.
I, ______________________________, hereby sign this form as of _______________.
Standard Form LLL: Disclosure of Lobbying Activities
*
1. Type of Federal Action
a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance
*
2. Status of Federal Action
a. bid/offer/application
b. initial award
c. post award
*
3. Report Type
a. initial filling
b. material change
For Material Change Only :
year :
quarter :
date of last report :
4.
*
Name and Address of Reporting Entity:
Reporting Entity Type:
Prime Subawardee
Tier, if known:
Congressional District, if known:
5. If Reporting
Entity in No.4 is a Subawardee, Enter Name and Address of Prime:
Congressional District, If known:
*
6.
Federal Department/Agency
*
7. Federal
Program Name/Description
CFDA Number, if applicable:
8.
Federal Action Number, if Known:
9.
Award Amount, if Known: $
10a.
Name and address of Lobbying Registrant: (if individual, last name, first name, MI)
10b. Individuals
Performing Services: (including address if different from No.10a)
(last name, first name, MI)
11. Information requested
through this form is authorized by title 31 U.S.C. section 1352. This
disclosure of lobbying activities is a material representation of
fact upon which reliance was placed by the tier above when this transaction
was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352.
This will be reported to the Congress semi-annually
and will be available for public inspection. Any person who fails
to file the required disclosure shall be subject to a civil penalty
of not less than $10,000 and not more than $100,000 for each such
failure.
I, ______________________________, hereby sign this form as of _______________.