Subgrant Planning Application

* Application Title:
* Subgrant Applicant:
* Application Number:
* Application Year:
* Grant Type:
* Address:

Applicant Information
Applicant Information
* Name of Applicant  
* State
Congressional District  
* Type of Applicant State Government
Local Government
Indian Tribal Government
Special Governmental District
Private Non-Profit
Other

If Private Non-Profit,

 

Describe the 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
* 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:
(MM-DD-YYYY e.g. 02-05-2003)
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
 If yes, type explanation:

 

 

 

 

* Community:  
Is this a small, impoverished community?
(Note: For PDM-C grants, a response to this question is required.)
Yes   No

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  

* Community Information
Please provide the name of each community that will benefit from this mitigation activity.
County
Code
Community
Name
CID
Number
CRS
Community
CRS
Rating
State
Legislative
District
US
Congressional
District
State
               
               
               
* Community Profile
 


If you would like to make any comments, please enter them below
 


Attachments
 



Mitigation Plan Information
* Is the entity that will benefit from the proposed activity covered by a current
FEMA-approved multihazard mitigation plan in compliance with 44 CFR Part 201?
Yes   No    Not Known
If yes, please answer the following:

* What is the name of the plan?

 



* What is the type of plan?

Local MultiJurisdictional Multihazard Mitigation Plan
Local Multihazard Mitigation Plan
Tribal (Local) MultiJurisdictional Multihazard Mitigation Plan
Tribal (Local) Multihazard Mitigation Plan
Tribal Mitigation Plan

* When was the current multihazard mitigation plan approved by FEMA?

 
If no or not known, please answer the following:

* Does the entity have any other mitigation plans adopted?

Yes   No   Not Known
  If yes, please provide the following information.
Plan Name Plan Type Date Adopted Attachment
       
       
       
Please identify all previous FEMA planning grants received:
Type of Grant  Performance Period  Deliverable Activity  Amount 
Beginning Date  Ending Date 
         
         
Total  $0.00 

* Does the State/Tribe in which the entity is located have a current FEMA-approved mitigation plan in compliance with 44 CFR Part 201?

 Yes  No
If yes, please answer the following:

* What is the name of the plan?

  

* What is the type of plan?

Enhanced State Multi-hazard Mitigation Plan
Enhanced Tribal Multi-hazard Mitigation Plan
Standard State Multi-hazard Mitigation Plan
Standard Tribal Multi-hazard Mitigation Plan
State Mitigation Plan - Pre DMA2000
Tribal Mitigation Plan

* When was the current mitigation plan approved by FEMA?

  

* Describe how the proposed activity relates to or is consistent with the State/Tribe's FEMA-approved mitigation plan.

 



If you would like to make any comments, please enter them below.





 
Attachments:



 


Mitigation Activity Information
* What type of activity are you proposing? (Please choose activities from Appendix A below).
 



* Please select one of the following options to describe the intent of this proposal:
Develop a new plan
Update an existing plan
      * If updating an existing Disaster Mitigation Act of 2000 plan, or modifying a plan adopted
      prior to the Disaster Mitigation Act of 2000, please explain.
     
     


* Title of your proposed activity(should include the type of activity and location):
 
If you would like to make any comments, please enter them below.
   




Attachments:



 

Hazard Information
* Problem Description: Describe the geographic area(s) to be covered by the plan. Attach geographical/topographical maps as necessary.





 
Attachments:



 
Hazard Type
Identify the source(s) of hazards specific to the geographic area to be addressed in the plan.
Hazards Source of Hazard
   
   
   
If you would like to make any comments, please enter them below.
 




Attachments:



 

Scope of Work
* Describe the plan development process. (If updating an existing plan, please indicate here.)





 
If you would like to make any comments, please enter them below.





   
Attachments:



 


Enter Work Schedule
Description Of Task Starting Point Unit Of Time Duration Unit Of Time Work Complete By
           
           
           
* Estimate the total duration of the proposed activity:   Day(s)
Week(s)
Month(s)
Year(s)  


* Cost Estimate
Item Name Grant
Budget Class
Subgrant
Budget Class
Unit
Quantity
Unit of
Measure
Unit Cost ($) Cost
Estimate ($)
             
             
             
* Total Cost Estimate

Match Sources
Activity Cost Estimate  
Federal Share Percentage  
Non-Federal Share Percentage  
  Dollars Percentage
* Proposed Federal Share $ % 
* Proposed Non-Federal Share
$ % 
* Matching Funds
Source Agency Name of
Source Agency
Funding Type Amount ($)
       
       
       
Grand Total $
If you would like to make any comments, please enter them below.
 




Attachments:



 

Cost Effectiveness Information
Amendment Number  
Community  
Net Present Value of Project Benefits (A) $
Total Project Cost Estimate (B) $
Benefit Cost Ratio (A/B)   
Analysis Type Exempt
Exempt Type Plans
Reviewer's Name   
BCA Performed by   
Analysis Date   
Comments




  


Evaluation Information
By checking the Not Applicable box and not providing the information in this section, I understand that this application may not be selected for the Pre-Disaster Mitigation - Competitive Grant Program. Incomplete/Complete
Not applicable


Evaluation Information (Part 1 of 4)
* Is the recipient participating in the Community Rating System (CRS)?  Yes  No
          If yes, what is their CRS rating? 1   2   3   4
5   6   7   8
9   10
* Is the recipient a Cooperating Technical Partner (CTP)?  Yes  No
* Is the recipient a Firewise Community?  Yes  No
          If yes, please provide their Firewise Community number.   
* Has the recipient adopted building codes consistent with the International Codes?  Yes  No
* Has the recipient adopted the National Fire Protection Association (NFPA) 5000 Code?  Yes  No
* Have the recipient's building codes been assessed on the Building Code Effectiveness Grading Schedule (BCEGS)?  Yes  No
         If yes, what is their BCEGS rating? 1   2   3   4
5   6   7   8
9   10
* Is the recipient a Disaster Resistant University?  Yes  No
* Is the recipient a Historically Black College or University / Tribal College or University?  Yes  No

Evaluation Information (Part 2 of 4)
* Describe how this planning activity will benefit your constituents.
 




* Describe the strategy for completing this planning activity, including the review process, adoption, and FEMA’s approval.

  

 


 

* Describe how you will manage the costs and schedule, and how you will ensure successful performance.
 




* Describe the staff and resources needed to implement this mitigation activity and the applicant's ability to provide these resources.





  
* If applying for multiple mitigation activities, how do these activities relate?





  

Evaluation Information (Part 3 of 4)
* How will this mitigation activity leverage involvement of partners to enhance its outcome?
 




* What outreach activities are planned relative to this mitigation activity (e.g., signs, press releases, success stories, developing package to share with other communities, losses avoided analysis) and/or how will this mitigation activity serve as a model for other communities (i.e., Do you intend to mentor other communities, Tribes or States? Do you intend to prepare a description of the process followed in this activity so that others may learn from the example?)?
 






Evaluation Information (Part 4 of 4)
* Please provide an assessment of the frequency (high, moderate, low, very low, not applicable) and severity (catastrophic, extensive, serious, minor) of an event for each of the following hazards:
Hazard Frequency Severity
Coastal storms Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Earthquake Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Windstorms Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Fire Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Flood Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Freezing Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Hurricane Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Mud/landslide Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Hazard Frequency Severity
Severe ice storms Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Severe storms Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Snow Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Tornado Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Tsunami Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Typhoon Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
Volcano Not Applicable
Very Low
Low
Moderate
High
Minor
Serious
Extensive
Catastrophic
     
Comments:





 
Attachments:



 

Environmental/Historic Preservation Information
* Is CATEX review applicable?   Yes  No
     If yes, why is CATEX review applicable?  
* Is CATEX review completed?  Yes  No
     If yes, when was CATEX review completed?  


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 _______________.




Note: Fields marked with an * are required.

Appendix A