HomeMy WebLinkAboutFEMA Grant App and Cert DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION
AND OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE O.M.B NO. 1660-0025
REQUIREMENTS Expires September 30, 2017
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1.7 hours per response The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed,and completing, and submitting the form.This
collection of information is required to obtain or retain benefits You are not required to submit to this collection of information unless it displays
a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to:
Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street SW,
Washington, DC 20472-3100,and Paperwork Reduction Project(1660-0025). NOTE: Do not send your completed form to this address.
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 of 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 (Nonprocurement)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 transaction, grant, or cooperative agreement.
1. LOBBYING (a)Are not presently debarred, suspended, proposed for debarment,
declared ineligible, sentenced to a denial of Federal benefits by a State or
As required by section 1352,Title 31 of the U.S. Code, and Federal court, or voluntarily excluded from covered transactions by any
implemented at 44 CFR Part 18,for persons entering,into a grant Federal department or agency;
or cooperating agreement over$ 100,000,as defined at 44 CFR
Part 18,the applicant certifies that: (b) Have not within a three-year period preceding this application been
convicted of a or had a civilian judgment rendered against them for
(a) No Federal appropriated funds have been paid or will be paid, commission of fraud or a criminal offense in connection with obtaining,
by or on behalf of the undersigned,to any person for influencing or attempting to obtain, or perform a public a public(Federal ,State,or local)
attempting to influence an officer or employee of any agency, a transaction or contract under a public transaction; violation of Federal or
Member of Congress, an officer or employee of Congress, or an State antitrust statutes or commission of embezzlement,theft,forgery,
employee of a Member of Congress in connection with the making bribery,falsification or destruction of records, making false statements, or
of any Federal grant,the entering into of any cooperative receiving stolen property;
agreement, and the extension, continuation, renewal, amendment, (c)Are not presently indicted for otherwise criminally or civilly charged
or modification of any Federal grant or cooperative agreement. by a governmental entity(Federal, State, or local)with commission of any
of the offenses enumerated in paragraph (1) (b)of this certification, and
(b) If any other funds than Federal appropriated funds have been (d) Have not within a three-year period preceding this application had
paid or will be paid to any other person for influencing or one or more public transactions (Federal, State, or local)terminated for
attempting to influence an officer or employee of any agency,a cause of default; and
member of Congress, an officer or an employee of Congress, or
employee of a member of Congress in connection with this B.Where the applicant is unable to certify to any of the statements in this
Federal Grant or cooperative agreement,the undersigned shall certification, he or she shall attach an explanation to this application.
complete and submit Stand Form-LLL, "Disclosure of Lobbying 3. DRUG-FREE WORKPLACE(GRANTEE OTHER THAN
Activities,"in accordance with its instructions. INDIVIDUALS)
c)The undersigned shall require that the language of this
certification be included in the award documents for all subawards As required by the Drug-Free Workplace Act of 1988, and implemented at
at all tiers (including subgrants, contracts under grants and 44 CFR Part 17, Subpart F,for grantees, as defined at 44 CFR Part
cooperative agreements, and subcontracts)and that all 17.615 and 17.620-
subrecipients shall certify and disclose accordingly. A. The applicant certifies that it will continue to provide a drug-free
Standard Form-LLL"Disclosure of Lobbying Activities" workplace by;
attached (a) Publishing a statement notifying employees that the unlawful
❑ (This form must be attached to certification if non- manufacture, distribution, dispensing, possession, or use of a controlled
appropriated funds are to be used to influence activities.) substance is prohibited in the grantee's workplace and specifying the
actions that will be taken against employees for violation of such
2. DEBARMENT, SUSPENSION,AND OTHER prohibition;
RESPONSIBILITY MATTERS (DIRECT RECIPIENT) (b) Establishing an on-going drug free awareness program to inform
As required by Executive Order 12549, Debarment and employees about-
Suspension,and implemented at 44 CFR Part 67,for prospective (1)The dangers of drug abuse in the workplace;
participants in primary covered transactions,as defined at 44 CFR
Part 17, Section 17.510-A. (2)The grantee's policy of maintaining a drug-free workplace;
A.The applicant certifies that it and its principals:
FEMA Form 112-0-3C (9/14) Master Page 1 of 2
(3)Any available drug counseling, rehabilitation, (2) Requiring such an employee to participate satisfactorily in a
and employee assistance programs; and drug abuse assistance or rehabilitation program approved for such
purposes by a Federal, State,or local health, law enforcement,or other
(4)The penalties that may be imposed upon employees appropriate agency;
for drug abuse violations occurring in the workplace;
(g) Making a good faith effort to continue to maintain a drug free workplace
(c) Making it a requirement that each employee to be engaged in through implementation of paragraphs(a), (b), (c), (d),
the performance of the grant to be given a copy of the statement (e)and (f).
required by paragraph (a);
B. The grantee may insert in the space provided below the site(s) for the
(d) Notifying the employee in the statement required by paragraph performance of work done in connection with the specific grant:
(a)that,as a condition of employment under the grant,the
employee will-
(1)Abide by the term of the statement;and
(2) Notify the employee in writing of his or her conviction Place of Performance(Street address, City, County, State,Zip code)
for a violation of a criminal drug statute occurring ion the
workplace no later than five calendar days after such convictions;
(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,within 30 calendar days of
receiving notice under subparagraph (d)(2),with respect to any
employee who is convicted- There are workplaces on file that are not identified
(1)Taking appropriate personnel action against such an Sections 17.630 of the regulations provide that a grantee that is a
employee, up to and including termination,consistent with the State may elect to make one certification in each Federal fiscal year.
requirements of the Rehabilitation act of 1973,as amended;or A copy of which should be included with each application for FEMA
funding. States and State agencies may elect to use a state wide
certification.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
MAYvP__
APPLICANT OIP3 NIZATION DATE SUBMITTED
Of Atitk5U►24-J I • 2
FEMA Form 112-0-3C (9/14) Master Page 2 of 2
DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency O.M.B. No. 1660-0025
F,FMA GRANTS APPLICATION Expires September 30, 2017
f'C� .�1(_, I-`f 15 i €�-lei ;r:stc:r �tit� F..��� I 'V 201,5 h.,nui-ig cy(.-.,
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 0.75 per response The burden estimate includes the time for reviewing instructions,searching
existing data sources,gathering and maintaining the data needed,and completing and submitting the form.This collection of information is required to obtain or
retain benefits You are not required to respond to this collection of information unless it displays a valid OMB control number is displayed in the upper right
corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to. Information Collections
Management, Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street,Arlington VA 20598-3005, Paperwork
Reduction Project(1660-0025)NOTE:Do not send your completed form to this address. Please completed fields highlighted in YELLOW.
1.Type of Submission:* 2.Type of Application:* * If Revision, select appropriate letter s
❑ Pre-application New N/A
❑
X Application Continuation *Other(Specify)
❑ Changed/Correct Application Revision
3. Date Received:* 4.Applicant Identifier:
IN/
5a. Federal Entity Identifier: 5b. Federal Award Identifier:*
IN/A N/A
State Use Only:
6. Date Received by State: 7.State Application Identifier:
8.Applicant Information:
a. Legal Name:* City of Auburn
b. Employer/Taxpayer Identification Number EIN/TIN):* c.State DUNS Number see Instruction
1916,001,228 032942575
d.Address:
Street 1:* 25 W Main Street
Street 2:
City* Auburn County/Parish: King
State:* Washington Province: N/A
Country:* USA Zip/Postal Code:*98001
e. Organizational Unit:
Department Name. Innovation&Technology Division:
f. Name and Contact Information of Person to be Contacted on Matters Involving this Application:
Prefix = First Name:*Colin Middle Name: Last Name:*Schmalz
Title. Network Communications Engineer Organizational Affiliation:
Telephone Number: +1 (253)804-5021 Fax Number: E-mail:* c
9. Type of Applicant:
Applicant 1:City or Township Government
Applicant 2:Select Applicant Type
Applicant 3:Select Applicant Type
Other(Specify):
P=Ao r 11o_n_1n 11r)11 AN ^--- ,
10. Catalog of Federal Domestic Assistance(CFDA):
Number: 97.047 Title Pre-Disaster Mitigation
11. Funding Opportunity:*
Number: DHS-I5-MT-047-000-99 Title: FY 15 Pre-Disaster Mitigation
12.Competition Identification: No Competition ID # contained in NOFO.
Number: I I Title: N/A
13.Areas Affected by Projects (Cities, Counties, States,etc.) if more space needed please use continuation sheet:
Auburn,WA
14. Descriptive Title of Applicants Project:*
City of Auburn Seismic Retrofit
15. Congressional Districts of:*
Applicant:18 Project:8
16. Proposed Project:*
Start Date: 01/04/2016 End Date: 10/31/2018 Date from NOFO.
17. Estimated Funding ($):* NUMERIC values only - no $ sign.
Federal: 27,257.29 1 Applicant:
State: Other:
Local: 9,085.76 Program Income:
Total: 36,343.05
18. Is Application Subject to Review by State Under Executive Order(EO) 12372 Process?:*
a.This application was made available to the State under EO 12372 Process for Review on:
❑ b. Program is Subject to EO 12372, but has not been selected by the State for review.
❑X c. Program is not covered under EO 12372. Change this as needed.
19. Is the Applicant Delinquent on Any Federal Debt?(If Yes, Provide an Explanation in Attachment):* ❑ Yes ZX No
20. By signing this application, I certify (1)to the statements contained in the list of certifications**and (2)the statements herein are
true,complete and accurate to the best of my knowledge. I also provide the required assurances**and agree to comply with any
resulting terms if I accept an award. I am aware any false,fictitious or fraudulent statements or claims may subject me to criminal,
civil, or administrative penalties. (US Code,Title 218, Section 1001)*
[V I Agree
Authorized Representative:
Prefix: First Name:*Nancy Middle Name Last Name:*Backus
Title:* Mayor Organizational Affiliation:
Telephone Number:* +1 (253)931-3008 Fax Number: E-mail:* nbackus @auburnwa.gov
Signature of Authorized Representative:* fJ1,�� Date Signed:* �. 27'15
Areas Affected by Projects(continuation sheet):
Applicant Federal Debt Delinquency Explanation:
The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debit. Try to avoid extra spaces
and carriage returns to maximize the availability of space.
GGf1IlA P- 11')_!1_1(1 11011X11
INSTRUCTIONS
This form (including the continuation sheet) is required for use as a cover sheet for submission of pre-applications, applications and related
information under discretionary programs. Some of the items are required and some are optional. Required items are identified with an asterisk
on the form and are specified in the instructions below.
Items Number Entry
Type of Submission(Required): Select one type of submission:
• Pre-application
1 •Application
•Changed/Corrected Application—check if the submission is to change or correct a previously submitted application. Unless
requested by the Agency, do not use this to submit changes after the closing date.
Type of Application (Required): Select one type of application:
• New-an application being submitted for the first time.
•Continuation-an extension for additional funding/budget period for a project with a projected completion date. This can
include renewals
2 • Revision-any change in the Federal Government's financial obligation or contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be selected. If"Other" is selected, please specify in the text box
provided.
A. Increase Award B. Decrease Award
C. Increase Duration D. Decrease Duration
E. Other(Specify)
3. Date Received: Leave this field blank,the date will be assigned by the Agency.
4. Applicant Identifier: Enter the entity identifier assigned by FEMA.
5a. Federal Entity Identifier: Enter the number assigned to your organization by FEMA, if any.
Federal Award Identifier: For new applications, leave blank. For a continuation or revision to an an existing award, enter the
5b. previously assigned Federal Award Identifier number If a changed/corrected application, enter the Federal Identifier in
accordance with Agency instructions.
6 Date Received by State: Leave this field blank,this date will be assigned by the State (if applicable).
7 State Application Identifier: Leave this field blank,this identifier will be assigned by the State(if applicable).
8 Applicant Information: Enter the following:
Legal Name(Required): Enter the legal name of the applicant that will undertake the assistance activity This is the name
a. that the organization has registered with the Central Contractor Registry(CCR). Information on registering with CCR may be
obtained by visiting the Grants gov website
b Employer/Taxpayer Number(EIN/TIN (Required)): Enter the EIN/TIN as assigned by the Internal Revenue Service. If your
organization is not in the US, enter 44-4444444.
Organization DUNS(Required): Enter the organizations DUNS or DUNS+4 number received from Dun and Bradstreet.
C. Information on obtaining a DUNS number may be obtained by visiting the Grants.gov website.
d Address: Enter the complete address as follows: Street Address(Line 1 Required), City(Required), County, State
(Required, if country is US), Province, Country (Required),Zip/Postal Code(Required, if country is US)
Organizational Unit: Enter the name of the primary organizational unit(and Department or Division, (if applicable)that will
e' undertake the assistance activity(if applicable).
Name and Contact Information of Person to be Contacted on Matters Involving this Application: Organizational
f affiliation (if affiliated with an organization other on: Enter the name (First and Last,than the application organization
(Required)),Telephone Number(Required), Fax Number, and E-mail Address of the person to contact on matters related to
this application (Required).
FEMA Form 112-0-10, (11/13) DRAFT
97GFt A6 r: 117_!-1(1 11 M1 AN
Type of Applicant(Required): Select up to three applicant type(s)
A. State Government B. County Government C City or Township Government
D. Special District Government E. Regional Organization F. US Territory or Possession
G. Independent School District H. Public/State Controlled Institution of I Indian/Native American Tribal
Government Higher Education
J. Indian/Native American Tribal K. Indian/Native American Tribally L. Public/Indian Housing Authority
Government(Other than Federally Designated Organization
9. Recognized)
M. Non-profit with 50CS IRS Status N. Non-profit without 501 CS IRS Status O. Private Institution of Higher
Education
P. Individual Q. For Profit Organization (Other than R. Small Business
Small Business)
S. Hispanic-serving Institution T. Historically Black Colleges and U.Tribally Controlled Colleges and
Universities (HBCUs) Universities
V.Alaska Native and Native W. Non-Domestic(non-US) Entity X. Other(Specify)
Hawaiian Serving Institutions
10. Catalog of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic Assistance Number and
Title of the Program under which assistance is requested, as found in the program announcement(if applicable).
11. Funding Opportunity Number/Title(Required): Enter the Funding Opportunity Number and Title of the opportunity under
which assistance is requested, as found in the program announcement.
12 Competition Identification Number/Title: Enter the Competition Identification Number and Title of the competition under
which assistance is requested (if applicable).
13. Areas Affected by Project: List the areas or entities using the categories (e.g., cities, counties, states, etc.). Use the
continuation sheet to enter additional areas(if needed).
Descriptive Title of Applicant's Project(Required): Enter a brief descriptive title of the project. If appropriate, attach a map
14. showing the project location (e.g., construction or real property projects) For pre-applications, attach a summary description
of the project.
Congressional Districts of(Required): Enter the applicant's Congressional District, and enter the District(s)affected by the
program or project. Enter in the format: 2 characters State Abbreviation-3 characters District Number(e.g., CA-005 for
15. California 5th District). If all Congressional Districts in a State are affected, enter"All"for the District Number(e.g., MD-All for
all of the Congressional Districts in Maryland). If nationwide (i.e. all Districts within All States are affected),enter US-All If the
program or project is outside the US, enter 00-000.
16 Proposed Projected Start and End Dates (Required): Enter the proposed start and end date of the project.
Estimated Funding (Required): Enter the amount requested or to be contributed during the first funding/budget period by
17 each contributor.Value of in-kind contributions should be included on appropriate lines, as applicable. If the action will result in
a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in
parentheses.
Is the Application Subject to Review by the State Under Executive Order(EO) 12372 Process?Applicants should
18 contact the State Single Point of Contact(SPOC)for Federal EO 12372 to determine whether the application is subject to the
State intergovernmental review process. Select the appropriate box. If"a." is selected, enter the date the application was
submitted to the State.
Is the Applicant Delinquent on Any Federal Debit(Required)?Select the appropriate box. This question applies to the
19. applicant organization, not the person who signs as the authorized representative. Categories of debit include: delinquent
audit disallowances, loans and taxes. If yes, please include an explanation on the continuation sheet.
Authorized Representative(Required): To be signed and dated by the authorized representative of the applicant
organization. Enter the name (First and Last(Required)), Title(Required),Telephone number(Required), Fax number, and E-
20. mail Address of the person authorized to sign for the applicant(Required). A copy of the governing body's authorization for
you to sign this application as the official representative must be on file in the applicant's office. -- Does l-F1AA require this
rtt31l7r�rizx�iian l:c:„s. ? ittt,t4 g�z��t c�i"tt�;a€ r�iicxst; ; ":> Sub-Applicant MUST SUBMIT TO GRANTEE.
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