Appalachian Regional Commission s3

Appalachian Regional Commission West Virginia

Application Forms for FY2013

Area Development Distressed Counties WEST VIRGINIA ARC PROGRAM COVER SHEET

Project Name:

Area Development Distressed Counties

Applicant: Certifying Official: Applicant Title: Address: City/State/Zip Certifying Official Address: Contact: City/State/Zip Contact County: address: City/State/Zip Contact Contact Telephone No. Fax Number: Basic Agency: E-Mail Address:

County(ies) to be served: List each county and its designation (e.g., distressed, transitional)

State Specific Goal and 1 Job Opportunities 2 Strengthen Capacity Strategy Number: (Example: 3 Infrastructure 4 Appalachian Development 1.3.4 from Technical Highway System Assistance Guide)

IJDC project number (for infrastructure projects only):

Purpose:

Description:

Rationale: (Compelling circumstances that show the need for this project to be funded)

Benefit:

Outputs/Outcomes:

Funding: Source Amount ARC $ $ $ TOTAL $

Type of Activities: Construction/Renovation Equipment (Check each activity) Operations Research Access Road Construction Other (specify)

2 Non-Construction Projects: ARC Application Guide

Project applications should be submitted to the state ARC office. Applications should be arranged in the following section sequence and should include the following information.

Applica State SECTION 1 APPLICATION FORMS nt ARC 1) State Transmittal Letter (Indicate source of ARC funding, and identify specific ARC n/a goal and state strategy) 2) Federal Standard Form 424 (SF 424) Totals should include ARC funds and all matching funds. 3) Federal Standard Form 424A: Budget Information. Totals should include ARC funds and all matching funds. 4) Federal Standard Form 424B: Non-Construction Assurances 5) ARC Memorandum of Understanding 6) ARC Form 1 7) Certifications Regarding Debarment, Drug-Free Workplace, and Lobbying SECTION 2 PROJECT PROPOSAL SUMMARY (1 to 2 pages – see recommended format pg. 28) SECTION 3 PROJECT NARRATIVE (suggested length 5-8 pages, please number pages) 1) Goals & Strategies – (refer to state’s Strategy Statement for the current year) a) Identify the primary ARC goal and objective the project will address. b) Identify and quote the primary ARC State Strategy the project will address.

2) Purpose, Description & Rationale- a) Describe specific problems or issues the project will address and how these issues impact the community. b) State in one sentence the main purpose of the project in terms of the goal and strategy being addressed (e.g., To create jobs by providing training for small business owners). c) Provide a detailed description of all major project activities, including: what will be done, who will complete each activity, and a timeline for starting and ending the project. d) Explain why the proposed approach is the most beneficial. e) Describe accomplishments and progress to date if continuing an ongoing program (whether or not ARC funded). f) Illustrate local demand for the project (e.g., letters from key stakeholders, customer data).

3) Relation to Other Local/Regional Activities – Describe how the project meets the priorities of local or regional community or economic development plans, and describe efforts to coordinate the project with other area economic development activities.

4) Geographic Area - a) Describe the project’s anticipated service area including counties and census tracts served. b) Comment on the project’s impact on ARC’s designated distressed areas.

3 c) Attach maps if needed to illustrate the project’s service area.

5) Benefits and Performance Measures - a) State outputs and outcomes in absolute numerical terms (not percents) per ARC’s Performance Measurement Guidelines. b) Attach letters documenting jobs retained, jobs created, and leveraged private investment (LPI) when applicable. c) Describe other project benefits as appropriate, such as the likely impact on future economic development activity in the area, or anticipated spin-off results.

SECTION 3 PROJECT NARRATIVE (continued)

6) Agency Capacity, Staff & Consultant Qualifications, and Procurement Procedures - a) Briefly review the applicant’s capacity to undertake the proposed activity by describing previous experience with relevant activities. b) Describe the qualifications needed for key individuals who will manage and operate the project. Attach position descriptions or brief resumes. c) Describe proposed qualifications for all consultants and subcontractors, and describe the competitive procedures used to select them.

7) Funding Need and Sustainability - a) Identify each funding source for the project and the status of each funding commitment. b) Detail why ARC funding is needed at this time. c) Explain the applicant’s strategy for ensuring the project’s long-term sustainability (once ARC funds are no longer available), including efforts to secure other sources of support for future operations.

SECTION 4 BUDGET INFORMATION and SUPPORTING MATERIALS

1) Detailed budget and budget narrative - a) Provide a detailed budget that includes sources and uses of ARC funds and all non- ARC matching funds. b) Provide a budget narrative that explains expenditures by line items shown on the SF424A.

2) Calculations of match – For multi-county projects with more than one ARC designation (i.e., distressed, transitional, at-risk, competitive, attainment), show calculations to confirm the project meets ARC’s match requirements.

3) Letters of commitment -

4 Include letters citing specific amount of funds committed from all matching fund sources. Provide descriptions of specific in-kind resources including the methods used to determine their value.

4) Clearinghouse documentation (if required by state)

5) Additional documentation - Enclose pertinent supporting materials that will lead to a better understanding of the proposed project. Please do not include form letters, financial audits.

NOTE: For both construction and non-construction projects, it is important to arrange the project information as shown above to ensure timely and careful review of the application. Be specific, and use appropriate page numbers in the spaces provided above (do not use checkmarks). Incomplete applications may not be considered for funding.

Construction Projects: ARC Application Guide

5 Applica State SECTION 1 APPLICATION FORMS nt ARC 1) State Transmittal Letter (Indicate source of ARC funding, and identify specific ARC n/a Project applicationsgoal and should state be strategy) submitted to the state ARC office. Applications should be arranged in the following2) Federal section Standard sequence Form and should 424 (SF include 424) the (including following ARCinformation. and all matching funds) 3) Federal Standard Form 424C: Budget Information 4) Federal Standard Form 424D: Construction Assurances 5) ARC Memorandum of Understanding 6) ARC Form 1 or ARC Form 2 7) Certifications Regarding Debarment, Drug-Free Workplace, and Lobbying SECTION 2 PROJECT PROPOSAL SUMMARY (1 to 2 pages – see recommended format pg. 28) SECTION 3 PROJECT NARRATIVE (suggested length 5-8 pages, please number pages) 1) Goals & Strategies – (refer to state’s Strategy Statement for the current year) a) Identify the primary ARC goal and objective the project will address. b) Identify and quote the primary ARC State Strategy the project will address.

2) Purpose, Description & Rationale- a) Provide a one-sentence statement describing the primary purpose of the project, in terms of the activity and its ultimate outcome, e.g., “To create jobs and encourage future development by extending sewer service to homes and businesses.” b) Describe specific problems or issues the project will address and how these issues impact the community. c) Provide a Preliminary Engineering Report, architect’s report, or other detailed description of all major construction components. Include details such as linear feet to be constructed, square footage built, acreage served, timelines for starting and completing each component. d) Identify who will own improvements and provide maintenance for the completed project. e) Illustrate local demand for the project including letters from key stakeholders, customer data, etc. f) For residential service projects in non-distressed counties, address how the project meets the “Policy for Residential Infrastructure Projects” in ARC’s Project Guidelines. Include letters or other documentation from state health/environmental agencies if relevant. g) For industrial sites or community facilities, describe strategies for marketing the project to potential users and beneficiaries. h) Energy efficient efforts: Describe any energy-efficient features of the project or any efforts that have been made to improve the energy-efficiency of the project. i) If applicable, describe how the project will ensure access to advanced telecommunications services by incorporating telecom features or allowing for future telecom infrastructure.

3) Relation to Other Local/Regional Activities – Describe the extent of collaboration with other local community, state, regional, or federal partners in the development of the proposal. In what way does the proposed activity represent progress toward fulfillment of a regional strategy (e.g., Comprehensive Economic Development Strategy (CEDS) or county/regional economic development plan)?

4) Geographic Area - 6 a) Identify all counties and census tracts where the project will be physically located. b)Attach area map(s) with the project’s service area clearly marked, diagrams of 5) Benefits and Performance Measures - a) State outputs and outcomes in absolute numerical terms per ARC’s Performance Measurement Guidelines. For infrastructure projects, state number of customers served and how many are residential and/or business customers. b) Attach letters documenting jobs retained, jobs created, and leveraged private investment (LPI) when applicable. c) Describe other project benefits as appropriate, such as the likely impact on future economic development activity in the area, or anticipated spin-off results.

6)Project Sustainability & Grantee Capacity – Describe the applicant’s strategy for ensuring the project’s long-term sustainability (once ARC funds are no longer available) and the grantee’s capacity to manage the project’s long-term operations.

SECTION 4 BUDGET INFORMATION and SUPPORTING MATERIALS

1) Engineer’s budget, detailing line-item project costs. Project total from engineer’s budget should match total on SF 424. *Note that for construction projects only, ARC does not require a breakdown of expenditures by funding source. 2) Funding Sources and Funding Need a) Identify each funding source for the project and the status of each funding commitment. b) Identify each funding source as either: 1) Federal, 2) State, 3) Local or 4) Private. c) Identify each funding source as either 1) grant funds or 2) loan funds. d) Include letters of commitment from each funding source, citing the specific amount of funds committed. Provide descriptions of specific in-kind resources committed, including the methods used to determine their value. e) Detail why ARC funding is needed at this time.

3) Calculations of match – For multi-county projects with more than one ARC designation (i.e., distressed, transitional, at-risk, competitive, attainment), show calculations to confirm the project meets ARC’s matching requirements.

4) Basic agency commitment to administer ARC funds, addressed to ARC. Specific certification forms are required for projects to be administered by CDBG or HUD-Entitlement agencies.

5) Clearinghouse documentation (if required by state)

7 6) IJDC Documentation For infrastructure projects, include copy of WV Infrastructure and Jobs Development Council (IJDC) review letter and all comments by technical review committee.

7) Additional Documentation: Other pertinent supporting materials that will lead to a better understanding of the proposed project. Please do not include form letters, financial audits, or utility rate structure information.

Submit an original and two copies of the application, including any additional material that would help further explain the scope and need for the project. If any of the requested information is not currently available, explain the efforts being undertaken to secure the information.

Send to:

ARC PROGRAM REPRESENTATIVE ATTENTION: CATHY DURHAM WEST VIRGINIA DEVELOPMENT OFFICE CAPITOL COMPLEX BUILDING 6, ROOM 553 CHARLESTON, WEST VIRGINIA 25305-0311 (304) 558-2234 For additional information, please contact our office at [email protected]

All ARC applications must be postmarked on or before January 31, 2013, in order to be considered for funding.

Note: Please complete the Narrative Questions/Checklist with appropriate page number(s).

8 Version 7/03 APPLICATION FOR 2. DATE SUBMITTED Applicant Identifier FEDERAL ASSISTANCE 1. TYPE OF SUBMISSION 3. DATE RECEIVED BY STATE State Application Identifier Application Pre-application Construction Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifer Non-Construction Non-Construction 5. APPLICANT INFORMATION Legal Name: Organizational Unit Department: Organizational DUNS: Division: Address: Name and telephone number of person to be contacted on matters involving this application (give area code) Street: Prefix: First Name:

City: Middle Name:

County: Last Name:

State: Zip Code: Suffix:

Country: Email:

6. EMPLOYER IDENTIFICATION NUMBER (EIN) Phone Number (give area code) Fax Number (give area code) - 8. TYPE OF APPLICATION: 7. TYPE OF APPLICANT: (See back of form for Application New Continuation Revision Types)

If Revision, enter appropriate letter(s) in box(es) (See back of form for description of letters.) Other (specify)

Other (specify) 9. NAME OF FEDERAL AGENCY:

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER 11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT: - TITLE (Name of Program):

12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):

13. PROPOSED PROJECT 14. CONGRESSIONAL DISTRICTS OF: Start Date: Ending Date: a. Applicant b. Project

15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a. Federal $ a. Yes THIS PREAPPLICATON/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON b. Applicant $ DATE: c. State $ d. Local $ b. No PROGRAM IS NOT COVERED BY E. O. 12372 e. Other $ OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW f. Program Income $ 17. IS THE APPLICANT DELINQUENT ON FEDERAL DEBT? g. TOTAL $ Yes If “Yes” attach an explanation. No 18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT. THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED. a. Authorized Representative Prefix First Name Middle Name

Last Name Suffix b. Title c.Telephone Number (give area code) d. Signature of Authorized Representative e. Date Signed

Previous Edition Usable Standard Form 424 (Rev.9-2003) Authorized for Local Reproduction Prescribed by OMB Circular A-102

9 INSTRUCTIONS FOR THE SF-424

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

This is a standard form used by applicants as required face sheet for pre-applications and applications submitted for Federal assistance. It will be used by Federal agencies to obtain applicant certification that States which have established a review and comment procedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given an opportunity to review the applicant’s submission.

Item: Entry: Item: Entry: 1. Select Type of Submission. 11. Enter a brief descriptive title of the project. If more than one program is involved, you should append an explanation on a separate sheet. If appropriate (e.g., construction or real property projects), attach a map showing project location. For preapplications, use a separate sheet to provide a summary description of this project. 2. Date application submitted to Federal agency (or State if 12. List only the largest political entities affected (e.g., State, applicable) and applicant’s control number (if applicable). counties, cities). 3. State use only (if applicable). 13. Enter the proposed start date and end date of the project. 4. Enter Date Received by Federal Agency 14. List the applicant’s Congressional District and any Federal identifier number: If this application is a continuation District(s) affected by the program or project. or revision to an existing award, enter the present Federal Identifier number. If for a new project, leave blank. 5. Enter legal name of application, name of primary organization 15. Amount requested or to be contributed during the first unit (including division, if applicable), which will undertake the funding/budget period by each contributor. Value of in kind assistance activity, enter the organization’s DUNS number contributions should be included on appropriate lines as (received from Dun and Bradstreet), enter the complete applicable. If the action will result in a dollar change to an address of the applicant (including country), and name, existing award, indicate only the amount of the change. For telephone number, e-mail and fax of the person to contact on decreases, enclose the amounts in parentheses. If both matters related to this application. basic and supplemental amounts are included, show breakdown on an attached sheet. For multiple program funding, use totals and show breakdown using same categories as item 15. 6. Enter Employer Identification Number (EIN) as assigned by 16. Applicants should contact the State Single Point of Contact the Internal Revenue Service. (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. 7. Select the appropriate letter in the space provided. 17. This question applies to the applicant organization, not the A. State I. State Controlled person who signs as the authorized representative. B. County Institution of Categories of debt include delinquent audit disallowances, C. Municipal Higher Learning loans and taxes. D. Township J. Private University E. Interstate K. Indian Tribe F. Intermunicipal L. Individual G. Special District M. Profit Organization H. Independent School N. Other (Specify) District O. Not for Profit Organization 8. Select the type from the following list: 18. To be signed by the authorized representative of the  “New” means a new assistance award. applicant. A copy of the governing body’s authorization for  “Continuation” means an extension for an additional you to sign this application as official representative must funding/budget period for a project with a projected be on file in the applicant’s office. (Certain Federal completion date. agencies may require that this authorization be submitted  “Revision” means any change in the Federal as part of the application.) Government’s financial obligation or contingent liability from an existing obligation. If a revision enter the appropriate letter: A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration 9. Name of Federal agency from which assistance is being requested with this application 10. Use the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested. SF-424 (Rev. 7-97) Back

10 Catalog of Federal Domestic Assistance

Programs from Appalachian Regional Commission

Program # Agency Title

23.001 ARC Appalachian Regional Development

23.002 ARC Appalachian Area Development

23.003 ARC Appalachian Development Highway System

23.008 ARC Appalachian Local Access Roads

23.009 ARC Appalachian Local Development District Assistance

23.011 ARC Appalachian State Research, Technical Assistance, and Demonstration Projects

11 OMB Approval No. 0348-0044 BUDGET INFORMATION – Non-Construction Programs SECTION A – BUDGET SUMMARY Grant Program Catalog of Estimated Unobligated Funds New or Revised Budget Function or Federal Domestic Activity Assist. Number (a) (b) Federal Non-Federal Federal Non-Federal Total (c) (d) (e) (f) (g)

1. $ $ $ $ $ 2. 3. 4. 5. TOTALS SECTION B – BUDGET CATEGORIES 6. OBJECT CLASS CATEGORIES GRANT PROGRAM, FUNCTION OR ACTIVITY Total (5) (1) (2) (3) (4) a. Personnel $ $ $ $ b. Fringe Benefits c. Travel d. Equipment e. Supplies f. Contractual g. Construction h. Other i. Total Direct Charges (sum of 6a-6h) j. Indirect Charges k. TOTALS (sum of 6i and 6 j)

7. PROGRAM INCOME Standard Form 424A (Rev. 4-92) Previous Edition Usable Authorized for Local Reproduction Prescribed by OMB Circular A-102

12 Standard Form 424A (Rev 4-92)

SECTION C – NON FEDERAL RESOURCES (a) Grant Program (b) Applicant (c) State (d) Other Sources (e) Totals 8. 9. 10. 11. 12. TOTALS (sum of lines 8 and 11) SECTION D – FORECASTED CASH NEEDS Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 13. Federal 14. Non Federal 15. TOTAL (sum of lines 13 and 14) SECTION E – BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT (a) Grant Program FUTURE FUNDING PERIODS (YEARS) (b) First (c) Second (d) Third (e) Fourth 16. 17. 18. 19. 20. TOTALS (sum of lines 16 – 19) SECTION F – OTHER BUDGET INFORMATION (Attach Additional Sheets if Necessary) 21. Direct Charges: 22. Indirect Charges: 23. Remarks: SF424A (Rev. 4-92) Page 2 Prescribed by OMB Circular A-102

Authorized for Local Reproduction

13 INSTRUCTIONS FOR THE SF 424A

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, including suggestions for reducing this burden, to the Office of Management and Budget. Paperwork Reduction Project (0348-0043), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

General Instructions Lines 1-4, Columns (c) through (g)

This form is designed so that application can be made for For new applications, leave Columns (c) and (d) blank. For funds from one or more grant programs. In preparing the each line entry in Columns (a) and (b), enter in Columns (e), budget, adhere to any existing Federal grantor agency (f), and (g) the appropriate amounts of funds needed to guidelines which prescribe how and whether budgeted support the project for the first funding period (usually a year). amounts should be separately shown for different functions or For continuing grant program applications, submit these forms activities within the program. For some programs, grantor before the end of each funding period as required by the agencies may require budgets to be separately shown by grantor agency. Enter in Columns (c) and (d) the estimated function or activity. For other programs, grantor agencies may amounts of funds which will remain unobligated at the end of require a breakdown by function or activity. Sections A, B, C, the grant funding period only if the Federal grantor agency and D should include budget estimates for whole project instructions provide for this. Otherwise, leave these columns except when applying to assistance which requires Federal blank. Enter in Columns (e) and (f) the amount of funds authorization in annual or other funding period increments. In needed for the upcoming period. The amount(s) in Column (g) the latter case, Sections A, B, C, and D should provide the should be the sum of amounts in Columns (e) and (f). budget for the first budget period (usually a year) and Section E should present the need for Federal assistance in the For supplemental grants and changes to existing grants, do subsequent budget periods. All applications should contain a not use Columns (c) and (d). Enter in Column (e) the amount breakdown by the object class categories shown in Lines a-k for the increase or decrease of Federal funds and enter in of Section B. Column (f) the amount of the increase or decrease of non- Federal funds. In Column (g) enter the new total budgeted Section A. Budget Summary Lines 1-4, Columns (a) and amount (Federal and non-Federal) which includes the total (b) previous authorized budgeted amounts plus or minus, as appropriate, the amounts shown in Columns (e) and (f). The For applications pertaining to a single Federal grant program amount(s) in Column (g) should not equal the sum of amounts (Federal Domestic Assistance Catalog number) and not in Columns (e) and (f). requiring a functional or activity breakdown, enter on Line 1 under Column (a) the catalog program title and the catalog Line 5 – Show the total for all columns used. number in Column (b). Section B. Budget Categories For applications pertaining to a single program requiring budget amounts by multiple function or activities, enter the In the column headings (1) through (4), enter the titles of the name of each activity or function on each line in Column (a), same programs, functions, and activities shown in Lines 1-4, and enter the catalog number in Column (b). For applications Column (a), Section A. When additional sheets are prepared pertaining to multiple programs where none of the programs for Section A, provide similar column headings on each sheet. require a breakdown by function or activity, enter the catalog For each program, function or activity, fill in the total program title on each line in Column (a) and the respective requirements for funds (both Federal and non-Federal) by catalog number of each line in Column (b). object class categories.

For applications pertaining to multiple programs where one or Lines 6a-i – Show the totals of lines 6a to 6h in each column. more programs require a breakdown by function or activity, prepare a separate sheet for each program requiring the Line 6j – Show the amount of indirect cost. breakdown. Additional sheets should be used when one form does not provide adequate space for all breakdown of data Line 6k – Enter the total of amounts on Lines 6i and 6j. For all required. However, when more than one sheet is used, the first applications for new grants and continuation grants the total page should provide the summary totals by program. amount in Column (5), Line 6k, should be the same as the total shown in Section A, Column (g), Line (5). For supplemental grants and changes to grants, the total amount of the increase or decrease as shown in Columns (1)-(4), Line 6k, should be the same as the sum of the amounts in Section A, Columns (e) and (f) on Line 5.

SF 424A (Rev. 4-92) page 1

14 INSTRUCTIONS FOR THE SF 424A (continued)

Line 7 – Enter the estimated amount of income, if any, Section E. Budget Estimates for Federal Funds Needed for expected to be generated from this project. Do not add or Balance of the Project subtract this amount from the total project amount. Show under the program narrative statement the nature and source Lines 16-19 – Enter in Column (a) the same grant program of income. The estimated amount of program income may be titles shown in Column (a), Section A. A breakdown by function considered by the federal grantor agency in determining the or activity is not necessary. For new applications and total amount of the grant. continuation grant applications, enter in the proper columns amounts of Federal funds which will be needed to complete Section C. Non-Federal Resources the program or project over the succeeding funding periods (usually in years). This section need not be completed for Lines 8-11 – Enter amounts of non-Federal resources that will revisions (amendments, changes, or supplements) to funds for be used on the grant. If in-kind contributions are included, the current year of existing grants. provide a brief explanation on a separate sheet. If more than four lines are needed to list the program titles, Column (a) – Enter the program titles identical to Column (a), submit additional schedules as necessary. Section A. A breakdown by function or activity is not necessary. Line 20 – Enter the total for each of the Columns (b)-(e). Column (b) – Enter the contribution to be made by the When additional schedules are prepared for this Section, applicant. annotate accordingly and show the overall totals on this line. Column (c) – Enter the amount of the State’s cash and in-kind contribution if the applicant is not a State or State agency. Section F. Other Budget Information Applicants which are a State or State agencies should leave this column blank. Line 21 – Use this space to explain amounts for individual Column (d) – Enter the amount of cash and in-kind direct object-class categories that may appear to be out of the contributions to be made from all other sources. ordinary or to explain the details as required by the Federal Column (e) – Enter totals in Columns (b), (c), and (d). grantor agency.

Line 12 – Enter the total for each of Columns (b)-(e). The Line 22 – Enter the type of indirect rate (provisional, amount in Column (e) should be qual to the amount on Line 5, predetermined, final or fixed) that will be in effect during the Column (f), Section A. funding period, the estimated amount of the base to which the rate is applied, and the total indirect expense. Section D. Forecasted Cash Needs Line 23 – Provide any other explanations or comments Line 13 – Enter the amount of cash needed by quarter from deemed necessary. the grantor agency during the first year.

Line 14 – Enter the amount of cash from all other sources needed by quarter during the first year.

Line 15 – Enter the totals of amounts on Lines 13 and 14.

SF 424A (Rev. 4-92) page 2

15 OMB Approval No. 0348-0041

BUDGET INFORMATION – Construction Programs

Note: Certain Federal assistance programs require additional computations to arrive at the Federal share of project costs eligible for participation. If such is the case you will be notified.

COST CLASSIFICATION a. Total Cost b. Costs Not Allowable c. Total Allowable Costs for Participation 1. Administrative and legal expenses

A 2. Land, structures, rights-of-way, appraisals, etc. 3. Relocation expenses and payments 4. Architectural and engineering fees 5. Other architectural and engineering fees 6. Project inspection fees 7. Site work 8. Demolition and removal 9. Construction 10. Equipment 11. Miscellaneous 12. SUBTOTAL (sum of lines 1-11) 13. Contingencies 14. SUBTOTAL 15. Project (program) income 16. TOTAL PROJECTS COSTS (subtract #15 from #14) FEDERAL FUNDING

16 17. Federal assistance requested, calculate as follows: Enter eligible costs from line 16c Multiply X % (Consult Federal agency for Federal percentage share.) Enter the resulting Federal share. Standard Form 424C (Rev. 7-97) Prescribed by OMB Circular A-102

17 INSTRUCTIONS FOR THE SF-424C Public reporting burden for this collection of information is estimated to average 180 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0041), Washington, DC 20503.

This sheet is to be used for the following types of applications: (1) “New” (means a new [previously unfunded] assistance award); (2) “Continuation” (means funding in a succeeding budget period which stemmed from a prior agreement to fund); and (3)“Revised” means any changes in the Federal government’s financial obligations or contingent liability from an existing obligation). If there is no change in the award amount there is no need to complete this form. Certain Federal agencies may require only an explanatory letter to effect minor (no cost) changes. If you have questions please contact the Federal Agency.

Column a. -If this is an application for a “new” project, enter the Line 12 - Total of items 1 through 11. total estimated cost of each of the items listed on lines 1 through 16 (as applicable) under “COST CLASSIFICATONS.” Line 13 - Enter estimated contingency costs. (Consult the Federal Agency for the percentage of the estimated If this application entails a change to an existing award, enter construction cost to use.) the eligible amounts approved under the previous award for the items under “COST CLASSIFICATIONS.” Line 14 - Enter the total of lines 12 and 13.

Column b. -If this is an application for a “New” project, enter Line 15 - Enter estimated program income to be earned during that portion of the cost of each item in Column a. which is not the grant period., e.g., salvaged materials, etc. allowable for Federal assistance. Contact the Federal agency for assistance in determining the allowability of specific costs. Line 16 - Subtract line 15 from line 14.

If this application entails a change to an existing award, enter Line 17 - This block is for the computation of the Federal the adjustment [+ or (-)] to the previously approved costs (from share. Multiply the total allowable project costs from line 16, column a.) reflected in this application. column “c.” by the Federal percentage share (this may be up to 100 percent; consult Federal agency for Federal percentage Column c -This is the net of lines 1 through 16 in columns “a.” share) and enter the project on line 17. and “b.”

Line 1 - Enter estimated amounts needed to cover administrative expenses. Do not include costs which are related to the normal functions of government. Allowable legal costs are generally only those associated with the purchase of land which is allowable for Federal participation and certain services in support of construction of the project.

Line 2 - Enter estimated site and right(s)-of-way acquisition costs (this includes purchase, lease, and/or easements).

Line 3 - Enter estimated costs related to relocation advisory assistance, replacement housing, relocation payments to displaced persons and businesses, etc.

Line 4 - Enter estimated basic engineering fees related to construction (this includes start-up services and preparation of project performance work plan).

Line 5 - Enter estimated engineering costs, such as surveys, tests, soil borings, etc.

Line 6 - Enter estimated engineering inspection costs.

Line 7 - Enter estimated costs of site preparation and restoration which are not included in the basic construction contract.

Line 8 – NOTE: INSTRUCTIONS NOT PROVIDED FOR THIS LINE.

Line 9 - Enter estimated cost of the construction contract. SF-424C (Rev. 7-97) Back

Line 10 - Enter estimated cost of office, shop, laboratory, safety equipment, etc., to be used at the facility, if such costs are not included in the construction contract.

Line 11 - Enter estimated miscellaneous.

18 Appalachian Regional Commission 1666 Connecticut Avenue, NW, Suite 700 Phone 202- Program Operations Division 884-7750 Washington, DC 20009-10068 Fax 202-884-7682

ARC FORM 1 CONSTRUCTION AND/OR EQUIPMENT PROJECT APPLICATION

Submit three (3) copies of project application to State ARC Office.

IDENTIFICATION Project Title Location

FEDERAL DATA Basic Federal Agency Federal Agency Program ARC Project No. (assigned by ARC Washington Office)

FUNDING (Specify Source) INITIAL CHANGE* REVISED* % TOTAL ARC Funds Other Federal Assistance: (list sources)

State Funds Other Funds (Non Federal) Total Eligible Project Cost Total Ineligible Project Cost Total Project Cost

*Use these columns only if requesting a revision to an ARC application previously submitted.

I hereby request Appalachian Act grant funds in the amount identified above and if provided, agree to apply these funds in accordance with applicable Federal laws, including Sections 224(b) and 402 of the Appalachian Act.

Legal Name of Applicant Signature of Responsible Officer Date

Name/Title of Responsible Officer

STATE APPROVAL This Application has been evaluated and approved as meeting the requirements for assistance under the Appalachian Regional Development Act of 1965, as amended; and, where required by Executive Order No. 12372 and implementing regulations, the appropriate project review clearinghouses were given an opportunity to review the project and comment:

E.O. No. 12372 Comments Attached E.O. No. 12372 Comments Not Made E.O. No. 12372 Not Applicable

______SIGNATURE OF STATE ARC ALTERNATE DATE

Revised 5/2000 19 ARC FORM 1 – Instructions

The ARC Form 1 is a standard form which must be completed by applicants requesting assistance from the Appalachian Regional Commission for construction projects. Applicants must complete ARC Form 1 as follows:

Identification Section

1. Project Title. This title should be the same as the title used on the basic agency application. 2. Location: Identify only the largest political subdivisions affected (e.g., county, city).

Federal Data Section

1. Basic Federal Agency: Identify the federal basic agency that will administer this project for ARC (e.g., U.S. Department of Commerce, U.S. Department of Agriculture, U.S. Department of Housing and Urban Development, U.S. Department of Transportation). 2. Federal Agency Program: Identify the basic agency program for the project (e.g., Economic Development Administration, Rural Development, Community Development Block Grant, Federal Highway Administration). 3. ARC Project Number: Fill in if known, otherwise leave blank and this number will be assigned by ARC Washington Office.

Funding Section

1. Source column: Identify each source of funding involved in the project beside the appropriate category. 2. Initial column: In this column, identify the dollar amount to be provided by each source of funding involved in the project. 3. Change and Revised column: Do not enter anything in these two columns unless you are completing a revised ARC full application. If you are submitting such, identify the original dollar amount in the Initial column, and identify the dollar amount of change for each funding source and the revised total amount for each funding source in the revised column. 4. Percent Total: Identify the percent of the total project cost each funding source represents. If you are submitting a revision, provide the percentages for the revised budget (not the initial).

Bottom Section

1. Legal Name of Applicant: Self-explanatory. 2. Signature of Responsible Officer and Date: The signature of an authorized representative of the applicant organization, and the date signed, should be provided. 3. Name and Title of Responsible Officer: Type the name and title of the authorized representative of the applicant organization. 4. State Approval: Leave blank. This will be completed by the ARC office.

20 Appalachian Regional Commission Program Operations Division 1666 Connecticut Avenue, NW, Suite 700 Phone 202-884-7750 Washington, DC 20009-1068 Fax 202-884-7682

ARC FORM 2 – LOCAL ACCESS ROAD PROJECT APPLICATION ARC Project No.:______(assigned by ARC Washington Office) Send three (3) copies of project application to State ARC Office.

1. Proposed Local Access Road: State County From: Location To: Location 2. New Construction Reconstruction No. of Lanes Projected ADT Miles Total Cost Per Mile Federal Cost Per Mile Fed % 3 Prelim. Eng. Right-of-Way Construction Total % Total Schedule (Fiscal Year) FY FY FY Requested Federal Funds State and/or Local Funds Estimated Total Cost

Applicant hereby requests Appalachian Act grant funds in the amount identified above and if provided, agrees to apply these funds in accordance with applicable Federal laws, including the Appalachian Act.

Legal Name of Applicant Signature of Responsible Officer Date

STATE APPROVAL

The State hereby requests Appalachian Act funds for the local access road project in the amount described in this application, and agrees to comply with (1) applicable Federal laws, including Section 224(b)* of the Appalachian Regional Development Act of 1965 and Title VI of the Civil Rights Act of 1955, and (2) Chapter B2 of the Appalachian Regional Commission Code, including Section 201B-6.4. The local access road will be constructed in accordance with; “the design criteria in the State’s secondary road plan approved by the Federal Highway Administration;” exceptions to such criteria approved by the Federal Highway Administration’s Division Engineer. The project has been evaluated and approved as meeting the requirements for assistance under such Act and Appalachian Regional Commission Code. The State has acquired or will acquire the necessary right-of-way and will construct and maintain the road as public highway, or it will provide therefore by appropriate arrangements with a local government unit, in accordance with Federal aid highway procedures administered by the Federal Highway Administration. Where required by Executive Order No. 12372 and implementing regulations, the appropriate project review clearinghouses were given an opportunity to review the project and comment:

E.O. No. 12372 Comments Attached E.O. No. 12372 Comments Not Made E.O. No. 12372 Not Applicable

SIGNATURE OF STATE ARC ALTERNATE DATE

21 ARCForm 2 Revised 5/2000

22 ARC FORM 2 – Instructions

The ARC Form 2 is specifically designed for completion by local access road project applicants requesting ARC Access Road Program funds. Other ARC construction project applicants do not need to complete ARC Form 2

ARC Project Control Number Leave blank. This number is assigned by the ARC Washington office upon receipt of the full application.

Number 1 I. State/County: Identify the State and County(ies) in which the project will take place. II. From/To: Clearly identify the location from which the project will begin and the location to which the project will end. The From and To locations identified for the project should include the entire scope of work to be completed through all funds related to the project.

Number 2 I. New Construction/Reconstruction: Identify if the project is a new road to be constructed or the rehabilitation of an existing roadway (e.g., road widening). II. No. of Lanes: Record the number of lanes to be constructed. Projected ADT: Identify the projected average daily traffic (ADT) count upon completion of the project. The ADT may be obtained from your engineer and/or the state Department of Transportation. III. Miles; Record the total number of miles to be constructed and/or improved. This can be found on the Engineer’s Cost Estimate. IV. Total Cost Per Mile: To calculate the total cost per mile, applicants must divide the total project cost by the total miles. Example: A 1.9 mile improvement at a total cost of $650,000. $650,000 divided by 1.9 = $342,105 cost per mile. V. Federal Cost Per Mile: This item must include ARC plus any other federal sources contributing to the project (e.g., Federal Highway Adm.). Take the total federal share and divide by the total miles. Example: The above referenced 1.9 mile project has $450,000 federal contributions. $450,000 divided by 1.9 = $236,842 federal cost per mile. VI. Federal Percent: Take the total Federal participating share and divide by the total project cost. Example: The project above has $450,000 federal contributions and a total project cost of $650,000. $450,000 divided by $650,000 = 69% federal dollar percentage. Total federal participation in a project cannot exceed 80%.

Number 3 I. Budget & Anticipated Construction Start Dates: Access road projects must use the state Department of Transportation, or other state designated agency, as the basic agency. Construction activities may be delayed due to the state’s plan review and approval timelines. It is recommended to record three separate Fiscal Years in each of the outlined areas (e.g., FY97 Preliminary Engineering, FY98 Right-Of-Way, FY99 Construction). II. The budget must show the sum of all federal funds participating in the project under the Requested Federal Funds line. At a minimum, the ARC funding request must be recorded on this line. All other sources participating (State and/or Local) must also be summed and recorded on the budget accordingly. III. Projected costs for each construction area – preliminary engineering, right-of-way, and construction – must be prorated and recorded based upon the construction cost estimate. The Estimated Total Cost line for each area when totaled must equal the total cost reflected on the Engineer’s Cost Estimate. IV. If ARC will not be participating in the funding for the preliminary engineering and/or right-of-way portions of the project, do not include these items in the ARC total project costs. Only include construction costs for the project. V. Legal Name of Applicant: Self-explanatory. VI. Signature of Responsible Officer and Date: The signature of an authorized representative of the applicant organization, and the date signed, should be provided.

State Approval and Application for Funds Leave blank. This will be completed by the state ARC office.

ARC Form 2 Revised 5/2000

23 Appalachian Regional Commission Program Operations Division 1666 Connecticut Avenue, NW, Suite 700 Phone 202-884-7750 Washington, DC 20009-1068 Fax 202-884-7682

Memorandum of Understanding For ARC Projects

Project Name: State: Federal Agency:

The Following Conditions Apply to all ARC Projects

Deadline: The Commission may revoke or revise its approval of any project if work intended to be assisted is not underway within 18 months after the date of approval of such project. Davis Bacon Davis Bacon wage rates (as determined by the Department of Labor for your respective Wages: area) must be paid for all construction projects in accordance with Section 402 of the Appalachian Regional Development Act of 1965, as amended. ARC Underrun Each disbursement of funds for a project receiving assistance from more than one Federal Policy: source will be deemed to be a proportional disbursement from each source. In the event of an underrun, the ARC will be entitled to recover its proportionate share of the underrun. Additional Funds It is understood that if the applicant receives additional funding from any new source towards Added to the the eligible cost of this project after the ARC approval, these funding sources should not be Project After ARC used to reduce the amount of local funds pledged. If new funds are made available to this Approval: project, the ARC and the Basic Federal Agency, if any, should be notified immediately. ARC reserves the right to reconsider the level of its funding approval in such an eventuality. Changes in Scope: It is understood that a change-in-scope may not be implemented without prior written approval from the ARC and the Basic Federal Agency, if any. A change of scope is any major change to the project design, the type of project to be completed, capacity of the system, size of project, the number and/or type of customers served or equipment items purchased. Close Working It is understood that the applicant must work closely with the Basic Federal Agency identified Relationship With in the ARC application, if any, and follow bidding and contract award procedures to insure Basic Federal that all pertinent Federal laws are complied with. Coordination with the Federal agency Agency: begins with filing an application with the basic Federal agency. Restrictions on ARC funds shall not be used for: a. any form of assistance to relocating industries; b. Assistance: recruitment activities that place a state in competition with other state or states; and c. projects that promote unfair competition between businesses within the same immediate service area. Cornerstone or Any facility constructed in whole or in part by funds provided under the ARDA shall include a Plaque: cornerstone, or plaque appropriately acknowledging the assistance provided through the ARC program, provided that such an item not be required if it would be prohibited as an eligible project cost under the basic federal program through which the ARDA assistance is provided.

Applicant/Authorized Representative Date

24 OMB Approval No. 0348-0042 ASSURANCES – CONSTRUCTION PROGRAMS Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0042), Washington, DC 20503

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 assistance 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:

funded under one of the nineteen statutes or 1. Has the legal authority to apply for Federal regulations specified in Appendix A of OPM’s assistance, and the institutional, managerial and Standards for a Merit System of Personnel financial capability (including funds sufficient to pay Administration (5 C.F.R. 900, Subpart F). the non-Federal share of project costs) to ensure 9. Will comply with the Lead-Based Paint Poisoning proper planning, management and completion of the Prevention Act (42 U.S.C. §§ 4801 et seq.) which project described in this application. prohibits the use of lead based paint in construction or 2. Will give the awarding agency, the Comptroller rehabilitation of residence structures. General of the United States, and if appropriate, the 10. Will comply with all Federal statutes relating to State, through any authorized representative, access nondiscrimination. These include but are not limited to and the right to examine all records, books, papers, to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88- or documents related to the assistance; and will 352) which prohibits discrimination on the basis of establish a proper accounting system in accordance race, color or national origin; (b) Title IX of the with generally accepted accounting standards or Education Amendments of 1972, as amended (20 agency directives. U.S.C. §§ 1681-1683, and 1685-1686), which 3. Will not dispose of, modify the use of, or change the prohibits discrimination on the basis of sex; (c) terms of the real property title, or other interest in the Section 504 of the Rehabilitation Act of 1973, as site and facilities without permission and instructions amended (29 U.S.C. § 794) which prohibit from the awarding agency. Will record the Federal discrimination on the basis of handicaps; (d) the Age interest in the title of real property in accordance with Discrimination Act of 1975, as amended (42 U.S.C. awarding agency directives and will include a §§ 6101-6107) which prohibits discrimination on the covenant in the title of real property acquired in whole basis of age; (e) the Drug Abuse Office and on in part with Federal assistance funds to assure Treatment Act of 1972 (P.L. 92-2S5), as amended, nondiscrimination during the useful life of the project. relating to nondiscrimination on the basis of drug 4. Will comply with the requirements of the assistance abuse; (f) the Comprehensive Alcohol Abuse and awarding agency with regard to the drafting, review Alcoholism Prevention, Treatment and Rehabilitation and approval of construction plans and specifications. Act of 1970 (P.L. 91-616), as amended, relating to 5. Will provide and maintain competent and adequate nondiscrimination on the basis of alcohol abuse or engineering supervision at the construction site to alcoholism; (g) §§ 523 and 527 of the Public Health ensure that the complete work conforms with the Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee- approved plans and specifications and will furnish 3), as amended, relating to confidentiality of alcohol progress reports and such other information as may and drug abuse patient records; (h) Title VIII of the be required by the assistance awarding agency or Civil Rights Act of 1968 (42 U.S.C. §3601 et seq.), as State. amended, relating to non-discrimination in the sale, 6. Will initiate and complete the work within the rental or financing of housing; (i) any other applicable time frame after receipt of approval of the nondiscrimination provisions in the specific statute(s) awarding agency. under which application for Federal assistance is 7. Will establish safeguards to prohibit employees from being made; and (j) the requirements of any other using their positions for a purpose that constitutes or nondiscrimination statute(s) which may apply to the presents the appearance of personal or organizational application. conflict of interest, or personal gain. 11. Will comply, or has already complied, with the 8. Will comply with the Intergovernmental Personnel Act requirements of Titles II and 111 of the Uniform of 1970 (42 U.S.C. §§4728-4763) relating to Relocation Assistance and the Real Property prescribed standards for merit systems for programs Acquisition Policies Act of 1970 (P.L. 91-646) which 25 provide for fair and equitable treatment of persons consistency with the approved State management displaced or whose property is acquired as a result of program developed under the Coastal Zone Federal or federally assisted programs. These Management Act of 1972 (16 U.S.C. §§ 1451 et seq.); requirements apply to all interests in real property (f) conformity of Federal actions to State (Clear Air) acquired for project purposes regardless of Federal Implementation Plans under Section 176(c) of the participation in purchases. Clear Air Act of 1955, as amended (42 U.S.C. § 7401 12. Will comply with the provisions of the Hatch Act (5 et seq.); (g) protection of underground sources of U.S.C. §§ 1501-1508 and 7324-7328) which limit the drinking water under the Safe Drinking Water Act of political activities of employees whose principal 1974, as amended, (P.L. 93-523); and (h) protection employment activities are funded in whole or in part of endangered species under the Endangered with Federal funds. Species Act of 1973, as amended (P.L. 93-205). 13. Will comply, as applicable, with the provisions of the 16. Will comply with the Wild and Scenic Rivers Act of Davis-Bacon Act (40 U.S.C. §§ 276a to 276a 7), the 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting Copeland Act (40 U.S.C. §§ 276c and 18 U.S.C. §§ components or potential components of the national 874), and the Contract Work Hours and Safety wild and scenic rivers system. Standards Act (40 U.S.C. §§ 327-333) regarding labor 17. Will assist the awarding agency in assuring standards for federally assisted construction compliance with Section 106 of the National Historic subagreements. Preservation Act of 1966, as amended (16 U.S.C. 14. Will comply with flood insurance purchase 470), EO 11593 (identification and preservation of requirements of Section 102(a) of the Flood Disaster historic properties), and the Archaeological and Protection Act of 1973 (P.L. 93234) which requires Historic Preservation Act of 1974 (16 U.S.C. 469a-1 recipients in a special flood hazard area to participate et seq.). in the program and to purchase flood insurance if the 18. Will cause to be performed the required financial and total cost of insurable construction and acquisition is compliance audits in accordance with the Single Audit $10,000 or more. Act of 1984. 15. Will comply with environmental standards which may 19. Will comply with all applicable requirements of all be prescribed pursuant to the following: (a) institution other Federal laws, Executive Orders, regulations and of environmental quality control measures under the policies governing this program. National Environmental Policy Act of 1969 (P.L. 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

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

APPLICANT ORGANIZATION DATE SUBMITTED

SF424D (Rev. 4/88) Back

26 OMB Approval No. 0348-0040 ASSURANCES—NON-CONSTRUCTION PROGRAMS

Public reporting burden for this collection of information is estimated to average 45, minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget. Paperwork Reduction Project (0348-0043), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

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 U.S.C. §§ 1681-1683, and 1685-1686), which assistance, and the institutional, managerial and prohibits discrimination on the basis of sex; (c) financial capability (including funds sufficient to pay Section 504 of the Rehabilitation Act of 1973, as the non-Federal share of project costs) to ensure amended (29 U.S.C. § 794), which prohibits proper planning, management and completion of the discrimination on the basis of handicaps; (d) the Age project described in this application. Discrimination Act of 1975, as amended (42 U.S.C. §§ 6101-6107), which prohibits discrimination on the 2. Will give the awarding agency, the Comptroller basis of age; (e) the Drug Abuse Office and General of the United States, and if appropriate, the Treatment Act of 1972 (P.L. 92-2S5), as amended, State, through any authorized representative, access relating to nondiscrimination on the basis of drug to and the right to examine all records, books, abuse; (f) the Comprehensive Alcohol Abuse and papers, or documents related to the award; and will Alcoholism Prevention, Treatment and Rehabilitation establish a proper accounting system in accordance Act of 1970 (P.L. 91-616), as amended, relating to with generally accepted accounting standards or nondiscrimination on the basis of alcohol abuse or agency directives. alcoholism; (g) §§ 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 3. Will establish safeguards to prohibit employees from ee-3), as amended, relating to confidentiality of using their positions for a purpose that constitutes or alcohol and drug abuse patient records; (h) Title VIII presents the appearance of personal or of the Civil Rights Act of 1968 (42 U.S.C. § 3601 et organizational conflict of interest, or personal gain. seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (i) any other 4. Will initiate and complete the work within the nondiscrimination provisions in the specific statute(s) applicable time frame after receipt of approval of the under which application for Federal assistance is awarding agency. being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the 5. Will comply with the Intergovernmental Personnel application. Act of 1970 (42 U.S.C. §§ 4728-4763) relating to prescribed standards for merit systems for programs 7. Will comply, or has already complied, with the funded under one of the nineteen statutes or requirements of Titles II and 111 of the Uniform regulations specified in Appendix A of OPM’s Relocation Assistance and Real Property Acquisition Standards for a Merit System of Personnel Policies Act of 1970 (P.L. 91-646) which provide for Administration (5 C.F.R. 900, Subpart F). fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or 6. Will comply with all Federal statutes relating to federally assisted programs. These requirements nondiscrimination. These include but are not limited apply to all interests in real property acquired for to: (a) Title VI of the Civil Rights Act of 1964 (P.L. project purposes regardless of Federal participation 88-352) which prohibits discrimination on the basis in purchases. of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 27 8. Will comply with the provisions of the Hatch Act (5 Endangered Species Act of 1973, as amended, (P.L. U.S.C. §§ 1501-1508 and 7324-7328) which limit the 93-205). political activities of employees whose principal employment activities are funded in whole or in part 12. Will comply with the Wild and Scenic Rivers Act of with Federal funds. 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting components or potential components of 9. Will comply, as applicable, with the provisions of the the national wild and scenic rivers system. Davis-Bacon Act (40 U.S.C. §§ 276a to 276a7), the Copeland Act (40 U.S.C. § 276c and 18 U.S.C. §§ 13. Will assist the awarding agency in assuring 874), and the Contract Work Hours and Safety compliance with Section 106 of the National Historic Standards Act (40 U.S.C. §§ 327-33.3), regarding Preservation Act of 1966, as amended (16 U.S.C. labor standards for federally assisted construction 470), EO 11593 (identification and protection of subagreements. historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 10. Will comply, if applicable, with flood insurance et seq.). purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93234) 14. Will comply with P.L. 93-348 regarding the protection which requires recipients in a special flood hazard of human subjects involved in research, area to participate in the program and to purchase development, and related activities supported by this flood insurance if the total cost of insurable award of assistance. construction and acquisition is $10,000 or more. 15. Will comply with the Laboratory Animal Welfare Act 11. Will comply with environmental standards which may of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131 et be prescribed pursuant to the following: (a) seq.) pertaining to the care, handling, and treatment institution of environmental quality control measures of warm blooded animals held for research, under the National Environmental Policy Act of 1969 teaching, or other activities supported by this award (P.L. 91-190) and Executive Order (EO) 11514; (b) of assistance. notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 16. Will comply with the Lead-Based Paint Poisoning 11990; (d) evaluation of flood hazards in floodplains Prevention Act (42 U.S.C. §§ 4801 et seq.) which in accordance with EO 11988; (e)assurance of prohibits the use of lead based paint in construction project consistency with the approved State or rehabilitation of residence structures. management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§ 1451 17. Will cause to be performed the required financial and et seq.); (f) conformity of Federal actions to State compliance audits in accordance with the Single (Clear Air) Implementation Plans under Section Audit Act of 1984 or OMB Circular No. A-133, Audits 176(c) of the Clear Air Act of 1955, as amended (42 of Institutions of Higher Learning and other Non- U.S.C. § 7401 et seq.); (g) protection of underground profit Institutions. sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and 18. Will comply with all applicable requirements of all (h) protection of endangered species under the other Federal laws, executive orders, regulations and policies governing this program. SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

APPLICANT ORGANIZATION DATE SUBMITTED

Standard Form 242B (Rev. 4/92) back FORM CD-511 UNITED STATE DEPARTMENT OF COMMERCE (7-91)

28 CERTIFICATIONS REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS; DRUG-FREE WORKPLACE REQUIREMENTS AND LOBBYING

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 15 CFR Part 26, “Governmentwide Debarment and Suspension (Nonprocurement)” and Governmentwide requirements for Drug-Free Workplace” and 15 CFR Part 28, “New Restrictions on Lobbying.” The certifications shall be treated as a material representation of fact upon which reliance will be placed when the Department of Commerce determines to award the covered transaction, grant or cooperative agreement. convicted employees must provide notice, including position title, to 1. DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY the Director, Office of Federal Assistance, Office of Federal MATTERS Assistance and Management Support, HCHB Room 6054, U.S. As required by Executive Order 12549, Debarment and Suspension, Department of Commerce, Washington, DC 20230. Notice shall and implemented at 15 CFR Part 26, for prospective participants in include the identification number(s) of each affected grant; primary covered transactions, as defined at 15 CFR Part 26, Sections (f) Taking one of the following actions, within 30 calendar days of 26.105 and 26.110. receiving notice under subparagraph (d)(2), with the respect to any (1) The prospective primary participant certifies to the best of its employee who is so convicted: knowledge and belief, that it and its principals: (1) Taking appropriate personnel action against such an (a) Are not presently debarred, suspended, proposed for employee, up to and including termination, consistent with debarment, declared ineligible, or voluntarily excluded the requirements of the Rehabilitation Act of 1973, as from covered transactions by a Federal department or amended; or agency; (2) Requiring such employee to participate satisfactorily in a (b) Have not within a three-year period preceding this drug abuse assistance or rehabilitation program approved proposal been convicted of or had a civil judgment for such purposes by Federal, State, or local health law rendered against them for commission of fraud or a enforcement, or other appropriate agency. criminal offense in connection with obtaining, attempting (g) Making a good faith effort to continue to maintain a drug-free to obtain, or performing a public (Federal, State or local) workplace through implementation of paragraphs (a), (b), (c), (d), (e), transaction or contract under a public transaction; and (f). violation of Federal or State antitrust statutes or B. The grantee shall insert in the space provided below the site(s) for commission of embezzlement, theft, forgery, bribery, the performance of work done in connection with the specific grant: falsification or destruction or records, making false statements, or receiving stolen property: Place of Performance: (Street address, city, county, state, zip code): (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) 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 Check if there are workplaces on file that are not identified here. application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default. Alternate II. Grantees Who Are Individuals (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective As required by the Drug-Free Workplace Act of 1988, and implemented at 15 participant shall attach an explanation to this proposal. CFR 26, Subpart F, for grantees, as defined at 15 CFR Part 26, Sections 26.605 and 26.610: 2. DRUG-FREE WORKPLACE REQUIREMENTS (A) The grantee certifies that, as a condition of the grant, he Alternate I. Grantee Other Than Individuals or she will not engage in the unlawful manufacture, As required by the Drug-Free Workplace Act of 1988, and distribution, dispensing, possession, or use of a controlled implemented at 15 CFR Part 26, Subpart F, for grantees, as defined substance in conducting any activity within the grant; at 15 CFR Part 26, Sections 26.605 and 26.610. (B) If convicted of a criminal drug offense resulting from a A. The grantee certifies that it will or will continue to provide a violation occurring during the conduct of any grant drug-free workplace by: activity, he or she will report the conviction, in writing, (a) Publishing a statement notifying employees that the unlawful within 10 calendar days, of the conviction, to the director, manufacture, distribution dispensing, possession, or use of a Office of Federal Assistance, Office of Federal Assistance controlled substance is prohibited in the grantee’s workplace and and Management Support, HCHB Room 6054, U.S. specifying the actions that will be taken against employees for Department of Commerce, Washington, DC 20230. When violation of such prohibition; the notice is made to such a central point, it shall include (b) Establishing an ongoing drug-free awareness program to inform the identification number(s) of each affected grant. employees about: (1)The dangers of drug abuse in the workplace: 3. LOBBYING (2)The grantee’s policy of maintaining a drug-free workplace; (3)Any available drug counseling, rehabilitation, and employee As required by Section 1352, Title 31 of the U.S. Code, and assistance programs; and implemented at 15 CFR Part 28, for persons entering into a grant (4)The penalties that may be imposed upon employees for drug cooperative agreement or contract over $100,000. Or loan or loan abuse violations occurring in the workplace; guarantee over $150,000, as defined at 15 CFR Part 28, Sections (c) Making it a requirement that each employee to 28.105 and 28.110, the applicant certifies that to the best of his or her be engaged in the performance of the grant be given a copy of the knowledge and belief, that: statement required by paragraph (a); (1) No Federal appropriated funds have been paid or will be (d) Notifying the employee in the statement paid, by or on behalf of the undersigned, to any person for required by paragraph (a) that as a condition of employment under influencing or attempting to influence an officer or the grant, the employee will: employee of Congress, or an employee of a member of (1) Abide by the terms of the statement; and Congress in connection with the awarding of any Federal (2) Notify the employer in writing of his or her conviction for a violation contract, the making of any Federal grant, the making of of a criminal drug statute occurring in the workplace no later than any Federal loan, the entering into of any cooperative five calendar days after such conviction; agreement, and the extension, continuation, renewal, (e) Notifying the agency in writing, within ten calendar days after amendment, or modification of any Federal contract, grant receiving notice under subparagraph (d)(2) from an employee or loan, or cooperative agreement. otherwise receiving actual notice of such conviction. Employers of 29 (2) If any funds other than Federal appropriated funds have to a civil penalty of not less than $10,000 and not more than been paid or will be paid to any person for influencing or $100,000 for each such failure. attempting to influence an officer or employee of Congress, or an employee of a member of Congress in Statement for Loan Guarantees and Loan Insurance connection with this Federal contract, loan, or cooperative agreement, the undersigned shall complete and submit The undersigned states, to the best of his or her knowledge and belief, that: standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. If any funds have been paid to any person for influencing or attempting to (3) The undersigned shall require that the language of this influence an officer or employee of any agency, a Member of Congress, an certification be included in the award documents for all officer or employee of Congress, or an employee of a Member of Congress in subawards at all tiers (including subcontract, subgrants, connection with this commitment providing for the United States to insure or and contracts under grants, loans and cooperative guarantee loan, the undersigned shall complete and submit Standard Form-LLL, agreements) and that all subrecipients shall certify and “Disclosure Form to Report Lobbying,” in accordance with its instructions. disclose accordingly. Submission of this statement is a prerequisite for making or entering into this This certification is a material representation of fact upon which transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to reliance was placed when this transaction was made or entered into. file the required statement shall be subject to a civil penalty of not less than Submission of this certification is a prerequisite for making or entering $10,000 and not more than $100,000 for each such failure. into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above applicable certification(s).

NAME OF APPLICANT AWARD NUMBER AND/OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZIED REPRESENTATIVE

SIGNATURE DATE

30 PROJECT SUMMARY FORMAT: (2 page maximum)

Project Title:

Project Grantee:

County(ies) Served:

Basic Agency:

Goal/Strategy (Identify and quote the primary ARC State Strategy the project will address):

Funding:

Purpose:

Description:

Rationale:

Benefits:

Outputs/Outcomes: