The Ohio Specialized Transportation Program for Elderly and Persons with Disabilities

THE OHIO SPECIALIZED TRANSPORTATION PROGRAM FOR ELDERLY AND PERSONS WITH DISABILITIES

(49 U.S.C. SECTION 5310) APPLICATION

APPLICANT INFORMATION 1. Agency Name: 2. Federal Tax ID number: 3. Contract Contact Person (Person authorized to sign contracts.) 4. Address for Contract Contact 5. Application Contact Person 6. Application contact Address 7. City, State Zip 8. County 9. E-Mail 10. Phone Number 11. Fax Number 12. Proposed Service Area (include county)

13. Vehicle 1 Type _____ Replacement Expansion *$ 14. Vehicle 2 Type ___ Replacement Expansion $ 15. Vehicle 3 Type ___ Replacement Expansion $ 16. VEHICLE SUBTOTAL $ 17. Computer Equipment Quantity ______$ 18. Mobility Management Services 19. Total Project Cost $ 20. Federal Share (80%) $

21. 22. Are you a new applicant (have never participated in the Specialized Transportation Program or have not participated since 2001 or before) Yes No

* Total Amount is the total project cost from page 8 for each vehicle, page 9 for computers and page 13 for mobility management. Available in alternate formats on request

PUBLIC NOTICES OR LETTERS TO ALL PRIVATE FOR PROFIT AND NON-PROFIT PROVIDERS IN THE AREA OF THE PROJECT MUST BE DATED BY JANUARY 6, 2009

IF REQUIRED, PUBLIC HEARING MUST ALSO BE HELD BY JANUARY 6, 2009.

Issue Date: Monday, November 17, 2008

1 ACCESS TO TRANSPORTATION AND NEED

1. Check the reason for transportation being unavailable, insufficient or inappropriate in your area. A. There is no public transit system in my area (if checked, go directly to 1B. The public transit system is unable to serve my clients Does not provide service where my clients are located or to destinations needed by clients* Fully booked, unable to handle additional passengers* Hours of service do not match client needs* Does not provide out of county trips* Clients are unable to use transit service because of cognitive or physical disabilities* Other (please provide explanation)

*Note: A letter from the public transit system confirming the above is required. A list of public transit systems is attached as an appendix. B. There are no other private nonprofit agencies or private for-profit organizations in my area that provide transportation service The other providers are unable to serve my clients Do not provide service where my clients are located or to destinations needed by clients Fully booked, unable to handle additional passengers Hours of service do not match client needs Cost of private service is prohibitive Private transportation providers in area do not have lift equipped vehicles Other (provide explanation)

2. Describe your agency’s purpose and programs. What is your target population? Be specific in how your agency will use the requested vehicles or computers to meet transportation needs not currently being met or loss of transportation as a result of not replacing a vehicle. (You may add up to one (1) additional page to answer this question.) The information should be based on your Locally Developed Coordinated Public Transit Human Service Transportation Plan.

2 To assist your agency in answering the number of unduplicated clients and trips. Please read the following example:

During a twenty-eight day (4 week) period John rides the bus to and from work Monday through Friday. Marie takes the bus one day per week to and from the grocery store. May takes the bus one way to see her grandchildren once a month. Once per month, Steve goes to his doctor, the pharmacy, the bank and home. (A trip is counted each time the rider gets on the bus). Unduplicated Riders Trips 1. John 2 trips per day x 5 days per week x 4 weeks = 40 trips 2. Marie 2 trips per day x 1 day per week x 4 weeks = 8 trips 3. May 1 trip per month 1 trip 4. Steve 4 trips per month 4 trips 53 trips The number of unduplicated riders from the example above is 4 (This would be the total current transportation clients in the next question). The number of trips is 53. If all the trips are supplied by this vehicle, this would be the answer used in the vehicle information section.

**Total number of clients currently served by your agency’s transportation program. This is the count of clients who use your transportation service. ______Number of elderly and disabled 60 and over ______Number of disabled (under 60)* ______Other ______Total Current Transportation Clients

Total number of clients proposed to be served by your agency’s expanded transportation program (do not include currently served clients by your transportation service).

______Number of elderly and disabled 60 and over ______Number of disabled (under 60)* ______Other ______Total Additional Clients

*If a client is disabled and over 60, count them as elderly.

3. If you are requesting to expand your service, check the appropriate reasons for service expansion. (must include documented proof of need)

Trip Denials. Number of trips denied last year ______Requests for additional service______Expanding service area based on ______(regional studies, census, locally developed plan, etc.) New Programs______

MANAGERIAL CAPACITY

1. Does your agency currently provide transportation services? Yes No

2. If yes, how long has your agency been providing transportation services?______

3. Describe how you currently or will: (Provide at least one paragraph for items 1 through 5, but no more than two pages for all items.)

1. Hire management employees and drivers (background checks, experience required) 2. Schedule/dispatch vehicles (include experience of dispatchers)

3 3. Conduct a preventive maintenance program 4. Advertise availability of vehicle for transportation 5. Provide adequate storage for vehicle when not in use

4. A copy of your agency’s most recent audit must be included with the application.

ESTIMATED VEHICLE USAGE INFORMATION (Agencies requesting multiple vehicles will receive separate scores for each vehicle requested) Estimated Usage Complete one column for each vehicle requested. Vehicle One Vehicle Two Vehicle Three 1. Type of vehicle requested (SMV, CV, LTN, LTV, MMV) 2. Number of days per week the vehicle will be operated 3. Number of passenger trips* per day to be provided by each vehicle 4. Total number of passenger trips to be provided per year = (number of trips per day x days operated per year) Pass Trips/day x Days/year = Pass Trips/year Veh 1 ______x ______= ______Veh 2 ______x ______= ______Veh 3 ______x ______= ______

5. Miles per day/per vehicle ______6. Total mileage per year (Daily mileage x days operated per year) Daily Mileage x # of days/year = Total Yearly Mileage ______Veh 1______x ______= ______Veh 2______x ______= ______Veh 3______x ______= ______*Passenger trips – a trip is counted every time a passenger boards a vehicle

Use the worksheet on the next page to estimate your agency’s passenger transportation budget.

4 VEHICLE BUDGET WORKSHEET Budget pages 5 through 8 are only to be completed by those agencies applying for vehicles Agency Transportation Budget Information To Be Used To Complete Passenger Transportation Program Budget Information Sheet for 2009 on Page 8 (includes all passenger transportation related revenues and expenses).

ESTIMATED PASSENGER TRANSPORTATION PROGRAM BUDGET INFORMATION FOR 9 1. Estimated Revenue Sources Revenue Sources $ A. Title XX $

B. Local Senior Levy $

C. MRDD Levy $

D. Passenger Revenue $

E. Grants, donations, subsidy from other agency funds $

F. Medicaid Transportation $

Other Revenue (Please list) $ G. $

I. Total Estimated Passenger Transportation Revenue $

Transfer Total Estimated Passenger Transportation Revenue Budget to Page 8, line 1

2. Salaries Classification Hourly Rate Hours Fringe Benefits Yearly Salaries Ex: Driver 10.00 X 2080 X 1.50 = $31,2000

Drivers $ Driver $ Driver $ Driver $ Driver $ Driver $ Driver $ Administrative Functions Dispatcher $ Dispatcher $ Secretary $ Administrator $ Other (Please list) $ $ $ A. Total Salaries $

5 Transfer Total Salaries Expense to Budget Page 8, line 2 Salaries should be calculated using full time equivalent (FTE) i.e. (Two drivers working 20 hours each equal one full time equivalent (40) hour per week employee)). Multiple lines are provided to assist if employees receive varying hourly salaries.

3. Estimated Preventive Maintenance per Year A. Preventive Maintenance* $ Transfer Preventive Maintenance Expense per year to Budget Page 8, line 3 *(If your agency has a record of maintenance expenses, use actual costs, if not, use the estimates provided in ODOT’s “A Guide to Preventive Maintenance”). If you are a new agency applying for a vehicle use $478 per year for new vehicle, the amount ODOT estimates for a year’s maintenance on a new vehicle in “A Guide to Preventive Maintenance.”

4. Fuel Expense per Year Using the table below estimate fuel expenses for 2009

Minivan 19 mpg Modified Minivan 19 mpg Converted Van 10 mpg Light Transit Vehicles 9 mpg Miles per year ÷Miles per gallon = Gallons per year Gallons per year x 3.25 = $Fuel Cost per Year

FUEL ESTIMATE FOR 2009 Complete this table for each requested new vehicle(s that provide elderly and disabled transportation. Type Year Est. ÷ Miles/ = Gallons/ x Cost per Yearly Fuel Example Miles/ Gallon Year Gallon Cost Year Chevrolet MMV 2008 30,000 ÷ 19 = 1578 x $3.25 $5,526

*New Vehicles A. Vehicle One 2009 ÷ = x $3.25 $ B. Vehicle Two 2009 ÷ = x $3.25 $ C. Vehicle Three 2009 ÷ = $3.25 $ D. Total Fuel Expense for New Vehicles Current Fleet (use yearly mileage for each category of vehicle operated) Est. ÷ Miles/ = Gallons/ x Cost per Yearly Fuel Miles/ Gallon Year Gallon Cost Year E. *Standard Minivan ÷ = x $ or Modified Minivans F. *Converted Vans ÷ = x $ G. *Light Transit ÷ = x $ Narrow Bodies H. *Light Transit ÷ = x $ Wide Bodies I. *Cost of fuel for current fleet (Do not include MRDD school bus fleets). $ J. Total Estimated Fuel Costs for 2009 for all vehicles providing passenger transportation. $ (Line 4 + Line 10) Transfer Total Estimated Passenger Transportation Expense to Budget Page 8, line 4 *If vehicles are replacement vehicles, do not include separate fuel costs for new vehicles, they are included as part of your current fuel fleet cost.

5. Casualty and Liability Insurance:

6 A. . Casualty and Liability Insurance for fleet $ Transfer Casualty and Liability Insurance Expense to Budget Page 8, line 5 Total Fleet including additional vehicle, if adding an extra vehicle, obtain quote from insurance vendor.

7 6. Administrative and Other Expenses: All administrative expenses for passenger transportation related activities A Telephone $ .

B Rent $ .

C Utilities $ .

D Other (Please list) $ .

H Total Administrative Expenses $ .

Transfer Total Administrative Expenses to Page 8, line 6

7. Other expenses: (Materials and supplies), page 7 line 6 A Office Supplies $ .

B Other Materials $ .

C Total Other Expenses $ .

Transfer Other Expense to Budget Page 8, line 7

8. Contract Services: (Cleaning services, building maintenance, etc.) page 7, line 7 A. Cleaning Services $ B. Building Maintenance $ C. $ D. Total Contract Services $ Transfer Total Contract Services Expense to Budget Page 8 line 8

9. Total Passenger Transportation Expenses Total lines two through nine Add lines 2 through 8 = Total Expenses for 2009 A. = $ Transfer Total Contract Services Expense to Budget Page 8, line 9

8 10. Net Income for 2009

Total Passenger Transportation Revenue Subtotal Expenses = Net Operating (Line 1) (Line 9) Income - = A Total Contract Services $

Transfer Total Contract Services to Budget Page 8, line 10

9 BUDGET PASSENGER TRANSPORTATION PROGRAM BUDGET INFORMATION FOR 2009 (Use information on pages 5 through 7 to complete this table)

ESTIMATED PASSENGER TRANSPORTATION REVENUE FOR AGENCY REVENUE Worksheet reference 1. Total Estimated Passenger (Page 5, #1, Line I) $ Transportation Revenue EXPENSES 2. Total Salaries (Page 5, #2, Line A) $

3. Preventive Maintenance Expense Per (Page 5, #3, Line A) $ Year 4. Fuel Estimated Expenses for 2009 (Page 6, #4, Line A) $

5. Casualty and Liability Insurance (Page 6, #5, Line A) $

6. Administrative and Other Expenses (Page 7, #6, Line H) $

7. Other Expenses (Page 7 #7, Line C) $

8. Contract Services (Page 7, #8, Line D) $

9. Subtotal Expenses (Page 7, #9, Line A) $

10. Net Operating Income (Page 7, #10, Line A) $

If net operating income is negative, please explain.

Passenger Transportation Operating Fund Sources (Should match or exceed above income figure) Amounts (Calendar Year) Year Year 2008 2009

If there is a significant change (10% or more) in your operating funding sources between years, please provide an explanation.

Local Match Fund Sources for Vehicle(s)/Equipment requested in this application

Identify Source(s) of Local Match AMOUNTS $ $ $

If vehicle is an expansion vehicle, what sources will be used to pay operating expenses for the vehicle? i.e. New Program, New Contract, funds from ????

10 VEHICLE REQUEST (Complete one page for each vehicle requested) Complete a separate page for each vehicle requested, indicating Priority 1, Priority 2, etc. for each vehicle. If your agency operates multiple vehicles, your fleet must be at least 50% accessible before you can apply for a non- accessible vehicle. The accessible percentage of your fleet is determined by the vehicle inventory submitted. PROJECT COSTS - VEHICLE FUNDING REQUEST 1. Project Priority Number (Circle appropriate number) 1 2 3 4 5 6 2. Replacement Vehicle Expansion Vehicle 3. Agency Name: 4. Delivery Address:

5. City, State, Zip: 6. Delivery County: 7. Contact Person: 8. Phone Number: 9. Fax Number: 10. E-mail address: 11. Select Vehicle Type Standard Minivan Converted Van __ CV-12 __ CV-6-1__ CV-4-2__ CV-2-3 Modified Minivan ___with middle seat Light Transit Narrow Body ___LTN-8-2 __LTN-4-3 ___ without middle seat ____LTN- 4-2 Light Transit Wide Body Small ___ LTV-14-1, LTV- 12-2 ____ LTV-0-6 Large ____LTV-15-2 ___LTV-14-2_____LTV-12-3 Unit Quantity Total Cost 12. Base Vehicle (includes base vehicle, lift and mobility positions) Prefer Ricon or Braun Lift (not an option for MMV) Prefer Sure-Loc or Q-Straint tie downs 13. If possible, request vehicle without jump seats Yes

14. Prefer Single or Double jump seats

15. Integrated Child Seat Single Double 17. Flat Floor (LTVs and LTNs only)

18. Driveline Retarder (LTVs only)

19. Slip Resistant Flooring

20. Electric transit Door

21. Total Project Cost

22. Federal Share (80%)

23. Local Share (20%)

11 12 COMPUTER REQUEST

Agency Name: ______

For computer requests two quotes for the equipment requested must be submitted with the application.

Computer Hardware and/or Software All computer hardware and software requested for Specialized Transportation Program funding must be used primarily for serving the transportation needs of the elderly and individuals with disabilities.

Total Project Cost: Applicants must attach at least two (2) cost estimates for the entire project, listing costs for computer hardware and software separately:

Computer Equipment (specify) Number Unit Cost Total Cost 1.

2. Total Project Cost

3. Federal Share (80%)

4. Local Share (20%)

5. Computer equipment will be used for:

Billing Scheduling/dispatching Driver scheduling Maintenance records Reports

6. Number of vehicles computer will be used to schedule ______

7. Explain how the requested computer equipment will be used to support the transportation service. Describe the current method of collecting and tracking transportation service information. Discuss any expected improvements in service delivery or coordination and any reduction in the cost to provide service. If you are making a request for a new computer based on the “inadequacy” of your old equipment, please include a description of the computer to be replaced (e.g. age, memory capacity) stating why it is unable to use specific software that would make your operations, scheduling and routing more efficient.

For ODOT use only: Computer Approved: _____ Yes ____ No Assigned project number: 2009/______PNP - ______

13 MOBIITY MANAGEMENT SERVICES

Agency Name: ______

I. PROJECT SUMMARY –

Using Times New Roman, 12pt. font, please provide a detailed project description no more than two pages in length. Attached documents (i.e. brochures, pamphlets, etc.) will not be accepted.

II. PROJECT OUTCOMES

Please provide both quantitative and qualitative information on each of the following measures based on your proposed project: 1) Transportation service improvement for clients 2) Mobility barriers eliminated by the project 2) Coordination efforts that will be developed between agencies (funding, billing, scheduling, dispatching, customers, etc. ) 4) Additional goals established by agency for mobility management project.

List measurable project outcomes that will be used to demonstrate the success of this proposal. Goals for the program measurements must include unduplicated clients, passenger trip counts for those over 60, disabled under 60 and other clientele that were assisted by the Mobility Management project.

III. COORDINATION

Explain how this project integrates with current coordination efforts. How does this project improve current coordination efforts? Include a complete list of all project coordinating agencies and stakeholders and their role(s) in the project.

IV. ADMINISTRATIVE AND FISCAL CAPACITY

Describe your agency’s ability to manage the financial needs of this project. List all key staff involved in the project and their specific tasks. Additionally, please describe the processes to be used in collecting the data to support the outcomes listed in Section II. A proposed project budget must be attached.

V. MARKETING AND OUTREACH

14 Describe how the project will be marketed to serve the targeted agencies and populations.

VI. SUSTAINABILITY

What efforts are in place to continue this project beyond the grant period? What potential funding sources are available for sustaining this project? Clearly indicate all funding sources if there are more than one.

15 Applicant:______Date:______MOBILITY MANAGEMENT PROGRAM PROPOSED BUDGET SUMMARY NON- ELIGIBLE ELIGIBLE TOTAL EXPENSES EXPENSES EXPENSES Labor-Management and Supervision $ - Total Labor $ - Fringe Benefits $ - Office Supplies $ - Utilities $ - Insurance - Vehicle Liability $ - Other $ - Other $ - Taxes $ - Miscellaneous Expenses: Dues and Subscriptions $ - Travel and Meetings $ - Marketing $ - Other Misc Expenses $ - Leases and Rentals: Other Costs $ - $ - Subtotals $ - Total Operating Costs $ -

16 COORDINATION

List the organizations with which you have coordination arrangements, agreements or relationships. Appendix 5 is enclosed to assist you in completing this section. Backup documentation from the agencies listed below must be provided. A brief letter describing the relationship from the other agency receiving the service from your agency or providing the service to your agency is required. Do not include copies of contracts!

1. SHARING TRIPS

Provides trips to other agencies (Your agency provides trips as requested by other agencies, doctor’s offices, hospitals, social service agencies, retirement homes, etc) Purchases or receives trips from other agencies (Other agencies call your agency to provide trips as needed for their clients, doctor’s offices, social service agencies, retirement homes, etc.)

1. ______2. ______3. ______4. ______

2. SCHEDULING

Scheduling occurs when two agencies work together to schedule trips for clients.

Schedules trips for other agencies (Other agencies contact your agency to schedule trips for their clients.) Uses other agencies to schedule trips. (Your agency contacts another agency to schedule client trips.)

1. ______2. ______3. ______4. ______

17 3. REFERRALS

Referrals occur when an agency refers a client to a transportation service.

Receive referrals from other agencies (Clients are referred to your agency by other agencies, social service agencies, senior citizens organizations, disabled organizations, etc.)

Refers clients to other agencies. (Your agency refers clients to other agencies who may be able to meet their transportation needs. 1. ______2. ______3. ______4. ______5. ______6. ______7. ______8. ______

4. BACKUP SERVICE

Your agency provides back up service for other agencies,

Back up service is supplied to other agencies (Your agency picks up additional clients for other agency when they are overbooked, due to vehicle breakdowns, or you provide your vehicle or vehicle and driver when needed by other agencies.)

Purchases or receive back up service from other agency. (Your agency uses another agency to meet high demand times, or you rent or borrow a vehicle or drivers from another agency to meet demand.)

1. ______2. ______3. ______4. ______

Are drivers of other agencies allowed to drive your vehicles? Yes No Do you allow your drivers to drive vehicles of other agencies? Yes No Do you pick up additional passengers as needed by other agencies? Yes No

18 5. TRAINING

Supplies the training for our agency and other agencies (Your agency offers training courses which other agency may participate i.e. First Aid, Drive training, CPR, Passenger Assistance, Sensitivity, Bloodborne Pathogens, Wheelchair Securement, Lift Maintenance classes.)

Purchases or shares the training with other agencies. (Your organization attends training courses offered by other agencies, i.e. i.e. First Aid, Drive training, CPR, Passenger Assistance, Sensitivity, Bloodborne Pathogens, Wheelchair Securement, Lift Maintenance classes or shares the expense of training with other agencies)

(A class roster showing the names and organizations represented at the training may be attached to obtain credit, (credit is not given for training the staff of your agency by your staff.) Name of Class Sponsor Organization: 1. ______2. ______3. ______4. ______5. ______6. ______

6. MAINTENANCE

Supplies maintenance to other agencies (Your agency provides maintenance service to other organizations)

Purchases or shares maintenance services with other agency (Your agency’s purchases or receives maintenance services from other agencies, the city, county or public transit agency does your vehicle maintenance work or a joint maintenance program has been developed.) 1. ______2. ______

7. PROCUREMENT

Supplies the services listed (Your agency is the lead agency an allows other agencies to join you in purchasing supplies, paper products, gasoline, etc.)

Purchases or shares the services listed. (Your agency joins with another agency to purchase supplies, paper products, gasoline, maintenance services, training classes.) Agency Items Procured 1. ______2. ______3. ______4. ______

8. STORAGE FACILITIES

19 Supplies storage area for other agencies (Your agencies allows other agencies to store vehicles in a secure parking area at your facility).

Purchases or shares storage area with other agency(ies). (Your agency stores vehicles on another agencies property (i.e. city property, police lot, other agency’s lot).

1. ______2. ______3. ______4. ______

9. INSURANCE

Sponsor of an insurance pool that allows additional agencies on policy Buy into an insurance pool sponsored by other agency (Name agency with whom insurance is shared) i.e. you purchase insurance jointly with another agency or insurance is provided through the township, city, county, school board, MRDD or another agency.) 1. ______2. ______

10. RADIO OR TRANSMITTER

Allows other agencies to use radio or transmitter Uses other agencies radio or transmitter Share radio frequency & monitor for emergencies and other assistance 1. ______2. ______

11. PUBLIC TRANSIT SYSTEM

Refers clients to public transit system (if unable to transport client you refer and work with public transit agency to supply needed trip). Accepts referrals from public transit systems. (The local public transit system sends clients it is unable to serve to your agency.) 1. ______2. ______

12. OTHER (Additional pages may be added as necessary to describe relationship, but no more than one page per item.)

1. ______2. ______

I certify the above information listed in the coordination section of this application is true to the best of my knowledge.

20 ______Signature

______Date

21 VEHICLE INVENTORY

Please complete the information on the table below for each vehicle used to transport passengers. Please list replacement vehicles first.

1 2 3 4 5 6 7 8 9

Specialized Program Vehicles only Total One VIN Way 12 Month Replace (Last 6 digits) for Passenger Passenger Maintenance Yes or currently active vehicles Capacity Date Trips Per & No purchased through Ambulatory or Current Purchased or Year Repair Year Vehicle Make Specialized Program Wheelchair Mileage Leased Costs EX 2003 El Dorado Yes 654321 5-2 150,000 6/1/2025 2,222 $4,000 0 1. 2. 3. 4.

22 Ohio Medical Transportation Board Requirements REQUIREMENTS OF PROGRAM: Those agencies successful in obtaining vehicles through this program will be required to: 1. Obtain driver’s Ohio Bureau of Motor Vehicles record/abstract for all new drivers 2. Complete criminal background check for all new drivers 3. Obtain a signed statement from a licensed physician declaring driver applicant does not have a medical condition or physical condition, including vision impairment that cannot be corrected, that could interfere with safe driving, passenger assistance, and emergency treatment activity or could jeopardize the health and welfare of a client or the general public 4. Conduct pre-employment drug and alcohol testing for new drivers 5. Have a substance abuse policy 6. All drivers must: a. Take a Defensive Driving Class every three years b. Take a course on assisting elderly and persons with disabilities c. Take a first aid course d. Take a course on bloodborne pathogens e. Take a CPR class f. Know how to secure a wheelchair g. If required due to vehicle size, have a commercial driver’s license h. Complete a pre-trip vehicle inspection sheet for each day or shift 7. Vehicles must have a. A formal preventive maintenance plan b. An annual inspection by a certified mechanic or an annual inspection by highway patrol, if vehicle size requires it

______Signature of Authorized Official

______

23 PUBLIC PARTICIPATION AND PRIVATE SECTOR INVOLVEMENT:

1. Label and insert the affidavit of publication and the original public notice; or

2. Label and insert a dated copy of the letter(s) mailed and the address list.

3. Label and insert the minutes or summary of the public hearing (public bodies only).

4. Correspondence or Service Proposals and Responses for coordination or private sector initiatives resulting from the public notice or letters must be included.

24 CERTIFICATION OF PROJECT DERIVED FROM A LOCALLY DEVELOPED, COORDINATED PUBLIC TRANSIT – HUMAN SERVICES TRANSPORTATION PLAN

The ______(name of agency) project is derived from the Locally Developed Public Transit – Human Service Transportation Plan for our ______(area, city, region or county).

The name of the plan is the: ______

______. This plan is for the following county(ies) ______. This requested project is included on page ______as part of the overall strategy or is named as a specific project.

The lead agency for the plan is: ______.

______Signature

______Date

25 TITLE VI GENERAL REPORTING REQUIREMENTS

Agency Name: ______

1. List active lawsuits or complaints against the transit provider alleging discrimination on the basis of race, color or national origin with respect to service or other transit benefits. (This question is only for the transit portion of the grantee.)

2. Describe all pending applications for financial assistance currently provided by other Federal agencies to the grantee. (This question is for the grantee, which includes the entire agency, county or city.

3. Summarize all civil rights compliance reviews conducted by other local, state or federal agencies during the last three years. (This question is for the grantee, which includes the entire agency, county or city.)

4. List the date of the most recent signing of the Annual Certification and Assurances included in this application.

26 5. FY 2009 FEDERAL AND STATE CERTIFICATIONS AND ASSURANCES FOR THE SPECIALIZED TRANSPORTATION PROGRAM:

Name of Applicant: ______

1. The Applicant has or will have the legal, financial, and technical capacity to carry out its proposed program of projects, including safety and security aspects of that program; 2. the Applicant has or will have satisfactory continuing control over the use of project equipment and facilities 3. the Applicant will adequately maintain the project equipment and facilities; 4. the Applicant has or will have available and will provide the amount of funds required by 49 U.S.C. 5310(c), and if applicable by section 3012b(3) and (4), for the local share, and that those funds will be provided from approved non-Federal sources except as permitted by Federal law; 5. the Applicant will comply with: 49 U.S.C. 5301(a) (requirements for public transportation systems that maximize the safe, secure, and efficient mobility of individuals, minimize environmental impacts, and minimize transportation-related fuel consumption and reliance on foreign oil); 49 U.S.C. 5301(d) (special efforts to design and provide public transportation for elderly individuals and individuals with disabilities); and 49 U.S.C. 5303 through 5306 (planning and private enterprise requirements); 6. The applicant certifies that, before it transfers funds to a project funded under 49 U.S.C. 5336, that project will has been or will have been coordinated with private nonprofit providers of services under 49 U.S.C. 5310; 7. The applicant certifies that, before it transfers funds to a project funded under 49 U.S.C. 5336, that project will has been or will have been coordinated with private nonprofit providers of services under 49 U.S.C. 5310; 8. Will give FTA, the Comptroller General of the United States, and, if appropriate, the State (ODOT), 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; 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; 9. The agency is an Equal Employment Opportunity employer; 10. The agency has a complaint procedure in place ; 11. The agency is not on the U.S. Government Wide Debarment and Suspension list; 12. If the agency operates vehicles that require a Commercial Driver’s license, those drivers have Commercial Driver’s Licenses. 13. If any private transportation providers proposals are received , the proposal and the review of the proposal are submitted with the grant. 14. Restrictions on Lobbying 15. Disadvantage Business Enterprise

27 The agency agrees these federal funds will not be used for lobbying Congressional Representatives or Senators directly or indirectly, such as by contributing to a lobbying organization or funding a grass-roots campaign to influence legislation (31 U.S.C. 1352). Agencies may provide information to legislators about the services a recipient provides in the community

Standard Assurances

The Applicant ensures that it will comply with all applicable Federal statutes and regulations in carrying out any project supported by an FTA grant or cooperative agreement. The Applicant agrees that it is under a continuing obligation to comply with the terms and conditions of the grant agreement or cooperative agreement issued for its project with FTA/ODOT. The Applicant recognizes that Federal laws and regulations may be modified from time to time and those modifications may affect project implementation. The Applicant understands that Presidential executive orders and Federal directives, including Federal policies and program guidance may be issued concerning matters affecting the Applicant or its project. The Applicant agrees that the most recent Federal laws, regulations, and directives will apply to the project, unless FTA issues a written determination otherwise.

Nondiscrimination Assurance

As required by 49 U.S.C. 5332 (which prohibits discrimination on the basis of race, color, creed, national origin, sex, or age, or and prohibits discrimination in employment or business opportunity), by Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d, and by U.S. DOT regulations, "Nondiscrimination in Federally-Assisted Programs of the Department of Transportation--Effectuation of Title VI of the Civil Rights Act," 49 CFR part 21 at 21.7, the Applicant ensures that it will comply with all requirements imposed by or issued pursuant to 49 U.S.C. 5332, 42 U.S.C. 2000d, and 49 CFR part 21, so that no person in the United States, on the basis of race, color, national origin, creed, sex, or age will be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination in any program or activity (particularly in the level and quality of transportation services and transportation-related benefits) for which the Applicant receives Federal assistance awarded by the U.S. DOT or FTA. Specifically, during the period in which Federal assistance is extended to the project, or project property is used for a purpose for which the Federal assistance is extended or for another purpose involving the provision of similar services or benefits, or as long as the Applicant retains ownership or possession of the project property, whichever is longer, the Applicant ensures that: (1) Each project will be conducted, property acquisitions will be undertaken, and project facilities will be operated in accordance with all applicable requirements imposed by or issued pursuant to 49 U.S.C. 5332, 42 U.S.C. 2000d, and 49 CFR part 21, and understands that this assurance extends to its entire facility and to facilities operated in connection with the project. (2) It will promptly take the necessary actions to effectuate this assurance, including notifying the public that complaints of discrimination in the provision of transportation-related services or benefits may be filed with U.S. DOT or FTA. Upon request by U.S. DOT or FTA, the Applicant ensures that it will submit the required information pertaining to its compliance with these provisions.

28 (3) It will include in each subagreement, property transfer agreement, third party contract, third party subcontract, or participation agreement adequate provisions to extend the requirements imposed by or issued pursuant to 49 U.S.C. 5332, 42 U.S.C. 2000d and 49 CFR part 21 to other parties involved therein including any subrecipient, transferee, third party contractor, third party subcontractor at any level, successor in interest, or any other participant in the project. (4) The United States has a right to seek judicial enforcement with regard to any matter arising under the Act, regulations, and this assurance. (5) It will make any changes in its Title VI implementing procedures as U.S. DOT or FTA may request to achieve compliance with the requirements imposed by or issued pursuant to 49 U.S.C. 5332, 42 U.S.C. 2000d, and 49 CFR part 21.

Assurance of Nondiscrimination on the Basis of Disability

As required by U.S. DOT regulations, "Nondiscrimination on the Basis of Handicap in Programs and Activities Receiving or Benefiting from Federal Financial Assistance," at 49 CFR 27.9, the Applicant ensures that, as a condition to the approval or extension of any Federal assistance awarded by FTA to construct any facility, obtain any rolling stock or other equipment, undertake studies, conduct research, or to participate in or obtain any benefit from any program administered by FTA, no otherwise qualified person with a disability shall be, solely by reason of that disability, excluded from participation in, denied the benefits of, or otherwise subjected to discrimination in any program or activity receiving or benefiting from Federal assistance administered by the FTA or any entity within U.S. DOT. The Applicant ensures that project implementation and operations so assisted will comply with all applicable requirements of U.S. DOT regulations implementing the Rehabilitation Act of 1973, as amended, 29 U.S.C. 794, et seq., and the Americans with Disabilities Act of 1990, as amended, 42 U.S.C. 12101 et seq., and implementing U.S. DOT regulations at 49 CFR parts 27, 37, and 38, and any other applicable Federal laws that may be enacted or Federal regulations that may be promulgated.

School Transportation

Under the FTA Section 5310 Program, Specialized Transportation Program vehicles may not be used for exclusive school transportation. Further, any use of these vehicles for incidental transportation of students to school or school-related events may only be provided in accordance with the Ohio Department of Education=s (ODE) Ohio Pupil Transportation Operation and Safety Rules and the Ohio Revised Code.

Charter Service

Charter service is transportation provided by a recipient at the request of a third party for the exclusive use of a bus or van for a negotiated price. The following features may be characteristic of charter service:  A third party pays the transit provider a negotiated price for the group;  Any fares charged to individual members of the group are collected by a third party;  The service is not part of the transit provider’s regularly scheduled service, or is offered for a limited period of time; or  A third party determines the origin and destination of the trip as well as

29 scheduling; or  Transportation provided by a recipient to the public for events or functions that occur on an irregular basis or for a limited duration and:  A premium fare is charged that is greater than the usual or customary fixed route fare; or  The service is paid for in whole or in part by a third party.

Agency’s engaging in any of the above activities must observe FTA’s Charter Regulations 49 CFR Part 604. A summary and explanation of the regulations is posted on ODOT’s web site (http://www.dot.state.oh.us/Divisions/Local/Transit/Documents/Programs/Federal %20Compliance/Charter%20Manual%202008.pdf) “FTA’s Charter Regulations: A Compliance Guide for Ohio’s Rural Public Transit Systems”,

Limited English Proficiency (LEP) The applicant agrees to ensure that the level and quality of transportation service is provided without regard to race, color, national origin, including minority and low income populations. That the applicant encourages input and participation from all affected populations in decisions, prevents the denial, reduction or delay in benefits related to programs that benefit minority and low income populations, and ensures meaningful access to programs and activities by persons with limited English proficiency. The Applicant must either conduct an assessment of the number or proportion of LEP persons or have access to an assessment document which contains the number or proportion of the LEP population in the eligible service area. The Applicant must have a plan to address the needs of LEP persons using its services. (FTA C 4702.1A, Title VI and Title VI – Dependent Guidelines for Federal Transit Administration Recipients)

Alcohol Misuse And Prohibited Drug Use

The Applicant is required to certify that it has established and implemented an alcohol misuse and anti-drug program (or substance abuse prevention program). If driver’s hold Commercial Driver’s Licenses the applicant will comply with the Federal Motor Carrier Safety Administration (FMCSA) rule for employees who hold Commercial Driver’s Licenses (49 CR part 382). Section 5310 applicants who receive funding under one of the covered FTA programs should include any safety-sensitive employees funded under Section 5310 projects in their testing program. Any subrecipient of Section 5310 funds from a designated recipient under another FTA program (such as 5307 or 5311) should also be included in the designated recipient’s testing program.

As a result of the regulations passed the Ohio Medical Transportation Board, ODOT requires the Specialized Transportation Program Applicants conduct a pre-employment drug and alcohol screening for all new drivers.

30 RESOLUTION OF AUTHORIZING BOARD:

WHEREAS, the , is submitting an application for the Federal Transit Administration (FTA) Specialized Transportation Program; and WHEREAS, this program provides eighty percent (80%) Federal funds for the purchase of vehicles to provide transportation to elderly persons and persons with disabilities or for other eligible items for the Specialized Transportation Program as defined in the Criteria; and

WHEREAS, twenty percent (20%) matching funds will be provided by the applicant from non Federal Transit or Highway sources.

WHEREAS, this project is derived from a Locally Developed, Coordinated Public Transit-Human Services Transportation Plan.

NOW THEREFORE, be it resolved that authorization is given to ______, Agency Representative to submit this application to the Ohio Department of Transportation (ODOT), acting for the FTA, for the aforementioned capital grant program.

Signature of Authorized Official

______Title

Attest

I certify that the information supplied in this application is true to the best of my knowledge. ______(Typed Name of Agency Representative Authorized to Sign Contracts, must match name on first page of application)

______Signature ______Date

31 RESOLUTION FOR CERTIFICATION OF A PUBLIC BODY

OPTION I

The ______(Agency Name), certifies that we are a governmental authority and that no nonprofit corporation or associations are readily available in the proposed service area to provide the service.

______(Area MPO) agrees with the statement that there are no nonprofit corporations or associations that are readily available in the area to provide the service proposed by the above agency.

OPTION II

OHIO COORDINATION GRANTEE:

The ______(Agency Name) is a grantee designated by the State of Ohio as an Ohio Coordination Grantee and is currently receiving funding through the Ohio Coordination Program.

NOW THEREFORE, be it resolved that the above name grantee, has determined that there are no nonprofit corporations or associations readily available in the area to provide the service or that the agency has been currently designated by the State of Ohio as a lead coordination agency in the Ohio Coordination Program.

Signature of Authorized Official

______Title

Attest

32 ADDENDUM FOR MOBILITY MANAGEMENT PROJECTS

DESIGNATED GRANTEE

Attach letter, from County Commissioners, designating your agency as applicant and potential grantee for the Ohio Specialized Transportation Program Mobility Management Project.