All FOA Attachments.pdf

All FOA Attachments

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SF424_4_0 Page 4 win2k

D:20061002180508- 04'00'

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OMB Number: 4040-0004

Expiration Date: 12/31/2022

* 1. Type of Submission:

* 2. Type of Application:

* 3. Date Received:

4. Applicant Identifier:

5a. Federal Entity Identifier:

5b. Federal Award Identifier:

6. Date Received by State:

7. State Application Identifier:

* a. Legal Name:

* b. Employer/Taxpayer Identification Number (EIN/TIN):

* c. UEI:

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country:

* Zip / Postal Code:

Department Name:

Division Name:

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Telephone Number:

Fax Number:

* Email:

* If Revision, select appropriate letter(s):

* Other (Specify):

State Use Only:

8. APPLICANT INFORMATION:

d. Address:

e. Organizational Unit:

f. Name and contact information of person to be contacted on matters involving this application:

Application for Federal Assistance SF-424

Type of Submission is required. Select one type of submission in accordance with agency instructions.

Type of Submission: Select one type of submission in accordance with agency instructions. One selection is required.

Type of Application: Select one type of application in accordance with agency instructions. One selection is required.

Type of Application is required. Select one type of application in accordance with agency instructions.

* 9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Application for Federal Assistance SF-424

Form Attachments:

* a. Federal

* b. Applicant

* c. State

* d. Local

* e. Other

* f. Program Income

* g. TOTAL

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Telephone Number:

* Email:

Fax Number:

* Signature of Authorized Representative:

* Date Signed:

18. Estimated Funding ($):

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

Authorized Representative:

Application for Federal Assistance SF-424

* a. Applicant

Attach an additional list of Program/Project Congressional Districts if needed.

* b. Program/Project

* a. Start Date:

* b. End Date:

16. Congressional Districts Of:

17. Proposed Project:

E.O. 12372 Review selection is required: Select status of Review.

Application Subject to Review: One selection is required.

Applicant Delinquent on Federal Debt: A selection is required.

Applicant Delinquent on Federal Debt is required: Select an option.

* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

If "Yes", provide explanation and attach

XDPFirstField:

Mandatory:

Type of Submission is required. Select one type of submission in accordance with agency instructions. :

Type of Application is required. Select one type of application in accordance with agency instructions.:

DateEntered1:

DateEntered2:

Submission Type - Preapplication: Select one type of submission in accordance with agency instructions. One selection is required.

Select if the type of submission is a Preapplication.:

Submission Type - Application: Select one type of submission in accordance with agency instructions. One selection is required.

Select if the type of submission is an Application.:

Submission Type - Changed Application: Select one type of submission in accordance with agency instructions. One selection is required.

Select this submission if requested by the agency to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this to submit changes after the closing date.:

Application Type - New: Select one type of application in accordance with agency instructions. One selection is required..

Select New if the application is being submitted to an agency for the first time.:

Application Type - Continuation: Select one type of application in accordance with agency instructions. One selection is required.

Select Continuation if the submission is an extension for an additional funding/budget period for a project with a projected completion date. This can include renewals.:

Application Type - Revision: Select one type of application in accordance with agency instructions. One selection is required.

Select Revision if the submission is a change in the Federal Government’s financial obligation or contingent liability from an existing obligation. :

Revision Type: Select a revision type from the list provided. A selection is required if Type of Application is Revision.:

Other (specify): Please specify the type of revision. This field is required if E. Other is checked.:

Date Received: Enter the date received, if applicable. Enter in the format mm/dd/yyyy. This field is required.:

Applicant Identifier: Enter the applicant's control number, if applicable.:

Federal Entity Identifier: Enter the number assigned to your organization by the Federal agency.:

Federal Award Identifier: For new applications leave blank. For a continuation or revision to an existing award, enter the previously assigned Federal award identifier number. If a changed/corrected application, enter the Federal Identifier in accordance with agency instructions.:

Date Received by State: Enter the date received by the State, if applicable. Enter in the format mm/dd/yyyy.:

State Application Identifier: Enter the identifier assigned by the State, if applicable.:

Organization Name: Enter the legal name of the applicant that will undertake the assistance activity. This field is required.:

EIN/TIN: Enter either TIN or EIN as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444. This field is required.:

UEI: Enter the UEI of the applicant organization. This field is required.:

Street1: Enter the first line of the Street Address. This field is required.:

Street2: Enter the second line of the Street Address.:

City: Enter the City. This field is required.:

County/Parish: Enter the County/Parish.:

State: Select the state, US possession or military code from the provided list. This field is required if Country is the United States.:

Province: Enter the Province.:

Country: Select the Country from the provided list. This field is required.:

ZIP/ Postal Code: Enter the nine-digit Postal Code (e.g., ZIP code). This field is required if the country is the United States.:

Department Name: Enter the name of primary organizational department, service, laboratory, or equivalent level within the organization which will undertake the assistance activity.:

Division Name: Enter the name of primary organizational division, office, or major subdivision which will undertake the assistance activity.:

AOR Prefix: Select the Prefix from the provided list or enter a new Prefix not provided on the list.:

AOR First Name: Enter the First Name. This field is required.:

AOR Middle Name: Enter the Middle Name.:

AOR Last Name: Enter the Last Name. This field is required.:

AOR Suffix: Select the Suffix from the provided list or enter a new Suffix not provided on the list.:

Title: Enter the position title.:

Organizational Affiliation: Enter the organization if different from the applicant organization.:

Telephone Number: Enter the daytime Telephone Number. This field is required.:

Fax Number: Enter the Fax Number.:

Email: Enter a valid Email Address. This field is required.:

TextField1:

ViewBurdenStatement:

Type of Applicant 1: Select the appropriate applicant type. A selection is required.:

Type of Applicant 2: Select the appropriate applicant type.:

Type of Applicant 3: Select the appropriate applicant type.:

Type of Applicant Other: Enter the applicant type here if you selected "Other (specify)" for Type of Applicant.:

Agency Name: Pre-populated from the Application cover sheet.:

CFDA Number: Pre-populated from the Application cover sheet.:

CFDA/Program Title: Pre-populated from the Application cover sheet.:

Opportuntity Number: Pre-populated from the Application cover sheet. This field is required.:

Opportunity Title: Pre-populated from the Application cover sheet. This field is required.:

Competition Number: Pre-populated from the Application cover sheet.:

Competition Title: Pre-populated from the Application cover sheet.:

spacer:

Project Title: Enter a brief, descriptive title of the project. This field is required.:

FileName:

MimeType:

href:

hashAlgorithm:

HashValue_data:

ObjList:

FNList:

AttCount:

Add:

Delete:

View:

Done:

Attachment Check Box: Indicates whether an Attachment is attached:

Additional Project Title - View Attachment Button: Select to view attachment(s).:

Additional Project Title - Delete Attachment Button: Select to delete attachment(s).:

Additional Project Title - Add Attachment Button: Select to add attachment(s).:

Debt Explanation - View Attachment Button: Click here to view the attachment.:

Debt Explanation - Delete Attachment Button: Click here to delete the attachment.:

Debt Explanation - Add Attachment Button: Click here to add the attachment.:

Debt Explanation is required.:

Applicant District: Enter the Congressional District in the format: 2 character State Abbreviation - 3 character District Number. Examples: CA-005 for California's 5th district, CA-012 for California's 12th district.

If outside the US, enter 00-000.

This field is required.:

Program District: Enter the Congressional District in the format: 2 character State Abbreviation - 3 character District Number. Examples: CA-005 for California's 5th district, CA-012 for California's 12th district.

If all districts in a state are affected, enter "all" for the district number. Example: MD-all for all congressional districts in Maryland.

If nationwide (all districts in all states), enter US-all.

If the program/project is outside the US, enter 00-000.

This field is required.:

Additional Congressional Districts:

Additional Congressional Districts - Add Attachment Button: Click here to add the attachment.:

Additional Congressional Districts - Delete Attachment Button: Click here to delete the attachment.:

Additional Congressional Districts - View Attachment Button: Click here to view the attachment.:

Project Start Date: Enter the date in the format MM/DD/YYYY. This field is required.:

Project End Date: Enter the date in the format MM/DD/YYYY. This field is required.:

Federal Estimated Funding: Enter the dollar amount. This field is required.:

Applicant Estimated Funding: Enter the dollar amount. This field is required.:

State Estimated Funding: Enter the dollar amount. This field is required.:

Local Estimated Funding: Enter the dollar amount. This field is required.:

Other Estimated Funding: Enter the dollar amount. This field is required.:

Program Income Estimated Funding: Enter the dollar amount. This field is required.:

Total Estimated Funding: Enter the total dollar amount. This field is required.:

E.O. 12372 Review selection is required: Select status of Review.:

State Review Available: Click to select option.:

State Review Not Selected: Click to select option.:

State Review Not Covered: Click to select option.:

State Review Date: Enter the date in the format MM/DD/YYYY.:

Applicant Delinquent on Federal Debt is required: Select an option.:

Delinquent on Debt: Click to select option.:

Not Delinquent on Debt: Click to select option.:

I Agree checkbox is required: Check I Agree checkbox to provide the required Certifications and Assurances.:

Certification Agree: Check to select. This field is required.:

AOR Title: Enter the position title. This field is required.:

AOR Telephone Number: Enter the daytime Telephone Number. This field is required.:

AOR Fax Number: Enter the Fax Number.:

AOR Email: Enter a valid Email Address. This field is required.:

AORSignature:

DateEntered19:

DateEntered20:

DateSigned:

LastField:

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SFLLL_2_0

pward

D:20061124112418- 05'00'

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10. a. Name and Address of Lobbying Registrant:

9. Award Amount, if known:$

* Street 1

* City

State

Zip

Street 2

* Last Name

Prefix

* First Name

Middle Name

Suffix

DISCLOSURE OF LOBBYING ACTIVITIES

Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352

OMB Number: 4040-0013

Expiration Date: 02/28/2022

1. * Type of Federal Action:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Type of Federal Action is required: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. * Status of Federal Action:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Status of Federal Action is required: Identify the status of the covered Federal action.

3. * Report Type:

Report Type: Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the previously submitted report by this reporting entity for this covered Federal action. This field is required.

For Material Change Only:

year quarter date of last report

4. Name and Address of Reporting Entity:

Reporting Entity: Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. This field is required.

Reporting Entity is required: Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

Tier if known:

* Name

* Street 1

Street 2

* City

State

Zip

Congressional District, if known:

Congressional District, if known:

* Name

* City

State

* Street 1

Street 2

Zip

6. * Federal Department/Agency:

7. * Federal Program Name/Description:

CFDA Number, if applicable:

8. Federal Action Number, if known:

b. Individual Performing Services (including address if different from No. 10a)

Prefix

* First Name

Middle Name

* Street 1

* City

State

Zip

Street 2

11.

* Last Name

Suffix

Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

* Signature:

*Name:

Prefix

* First Name

Middle Name

* Last Name

Suffix

Title:

Telephone No.:

Date:

Federal Use Only:

Authorized for Local Reproduction

Standard Form - LLL (Rev. 7-97)

XDPFirstField:

Mandatory:

Disclosure Statement: Click the button to read the "Review Public Burden Disclosure Statement".:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Contract: Click if the Type of Federal Action is a contract.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Grant: Click if the Type of Federal Action is a grant.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Cooperative Agreement: Click if the Type of Federal Action is a cooperative agreement.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Loan: Click if the Type of Federal Action is a loan.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Loan Guarantee: Click if the Type of Federal Action is a loan guarantee.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Loan Insurance: Click if the Type of Federal Action is a loan insurance.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Bid, Offer, Application: Click if the Status of Federal Action is a bid, an offer or an application.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Initial Award: Click if the Status of Federal Action is an initial award.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Post Award: Click if the Status of Federal Action is a post-award.:

Report Type: Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the previously submitted report by this reporting entity for this covered Federal action. This field is required.

Initial Filing: Click if the Report Type is a initial filing.:

Report Type: Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the previously submitted report by this reporting entity for this covered Federal action. This field is required.

Material Change: Click if the Report Type is a material change.:

Year: If this is a follow up report caused by a material change to the information previously reported, enter the year in which the change occurred.:

Quarter: If this is a follow up report caused by a material change to the information previously reported, enter the quarter in which the change occurred.:

Date of last report: Enter the date of the previously submitted report by this reporting entity for this covered Federal action.:

ReportTypeAttr:

ReportingEntityEntityType:

Reporting Entity: Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. This field is required.

Prime: Click to designate the organization filing the report as the Prime Federal recipient.:

SubAwardee: Click to designate the organization filing the report as the SubAwardee Federal recipient. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.:

ReportEntityType:

Tier: Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. :

Reporting Entity Organization Name: Enter the name of reporting entity. This field is required.:

Street 1: Enter the first line of the street address for the Reporting Entity. This field is required.:

Street 2: Enter the second line of the street address for the Reporting Entity.:

City: Enter the city of the Reporting Entity. This field is required.:

State: Select the state for the Reporting Entity's address from this pull down menu.:

Zip / Postal Code: Zip Code (or ZIP+4) of the Reporting Entity.:

Congressional District: If known, the Congressional District of the reporting entity. Should be numeric characters.:

Section5Text:

Prime Organization Name: If the organization filing the report in item 4, checks "Subawardee", enter the full name of the prime Federal recipient.:

Street 1: If the organization filing the report in item 4, checks "Subawardee", enter the address of the prime Federal recipient.:

Street 2: If the organization filing the report in item 4, checks "Subawardee", enter the address of the prime Federal recipient.:

City: If the organization filing the report in item 4, checks "Subawardee", enter the city of the prime Federal recipient.:

State: If the organization filing the report in item 4, checks "Subawardee", select the appropriate state from this pull down menu.:

Zip / Postal Code: If the organization filing the report in item 4, checks "Subawardee", enter the zip code.:

Congressional District: If the organization filing the report in item 4, checks "Subawardee", enter the Congressional District of the prime Federal recipient, if known. Should be numeric characters.:

EntityType:

Federal Department/Agency: Enter the name of the Federal Department or Agency making the award or loan commitment. This field is required.:

Federal Department/Agency: Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments. :

CFDA Number: Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments.:

Federal Action Number: Enter the most appropriate Federal identifying number available for the Federal action, identified in item 1 (e.g., Request for Proposal (RFP) number, invitation for Bid (IFB) number, grant announcement number, the contract, grant, or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001".:

Award Amount: For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment of the prime entity identified in item 4 or 5.:

Prefix: Enter the prefix (e.g., Mr., Mrs., Miss), if appropriate, for the Lobbying Registrant.:

First Name: Enter the first name of Lobbying Registrant. This field is required.:

Middle Name: Enter the middle name of Lobbying Registrant.:

Last Name: Enter the last name of Lobbying Registrant. This field is required.:

Suffix: Enter the suffix (e.g., Jr. Sr., PhD), if appropriate, for the Lobbying Registrant.:

Street 1: Enter the first line of street address for the Lobbying Registrant.:

Street 2: Enter the second line of street address for the Lobbying Registrant.:

City: Enter the city of the Lobbying Registrant.:

State: Select the appropriate state of the Lobbying Registrant.:

Zip / Postal Code: Enter the Zip Code (or ZIP+4) of the Lobbying Registrant.:

DataEntered1:

Prefix: Enter the prefix (e.g., Mr., Mrs., Miss), if appropriate, for the Individual Performing Services.:

First Name: Enter the first name of the Individual Performing Services. This field is required.:

Middle Name: Enter the middle name of the Individual Performing Services.:

Last Name: Enter the last name of the Individual Performing Services. This field is required.:

Suffix: Enter the suffix (e.g., Jr. Sr., PhD), if appropriate, for the Individual Performing Services.:

Street 2: Enter the second line of street address for the Individual Performing Services.:

City: Enter the city of the Individual Performing Services. :

State: Select the state for the address of the Individual Performing Services from this pull down menu.:

Zip / Postal Code: Enter the Zip Code (or ZIP+4) of the Individual Performing Services.:

Street 1: Enter the first line of street address for the Individual Performing Services.:

DataEntered2:

Prefix: Enter the prefix (e.g., Mr., Mrs., Miss), if appropriate, for the Certifying Official.:

First Name: Enter the first name of Certifying Official. This field is required.:

Middle Name: Enter the middle name of the Certifying Official.:

Last Name: Enter the last name of the Certifying Official. This field is required.:

Suffix: Enter the suffix (e.g., Jr. Sr., PhD), if appropriate, for the Certifying Official.:

Title: Enter the title of the Certifying Official.:

Telephone Number: Enter the telephone number of the certifying official.:

LastField:

Signature: Enter the Signature. This field is required.

Date: Enter the date signed. Enter in the format mm/dd/yyyy. This field is required.:

August 2005

U.S. DEPARTMENT OF ENERGY

FINANCIAL ASSISTANCE

CERTIFICATIONS AND ASSURANCES

FOR USE WITH SF 424

Applicant:

Solicitation No.: DE-

The following certifications and assurances must be completed and submitted with each application for financial assistance. The name of the person responsible for making the certifications and assurances must be typed in the signature block on the forms.

Certifications Regarding Lobbying; Debarment, Suspension and Other Responsibility

Matters; and Drug Free Workplace Requirements

DOE F 1600.5, Assurance of Compliance Nondiscrimination in Federally Assisted

Programs

CERTIFICATIONS REGARDING LOBBYING;

DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS;

AND DRUG FREE WORKPLACE REQUIREMENTS

Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the instructions for certification included in the regulations before completing this form. Signature of this form provides for compliance with certification requirements under 10 CFR Part 601 "New Restrictions on Lobbying," 10 CFR Part 606 "Governmentwide Debarment and Suspension (Nonprocurement) and 10 CFR Part 607 “Governmentwide Requirements for Drug-Free Workplace (Grants)."

The certifications shall be treated as a material representation of fact upon which reliance will be placed when the Department of Energy determines to award the covered transaction, grant, or cooperative agreement.

1. LOBBYING

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into.

Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code.

Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

2. ADDITIONAL LOBBYING REPRESENTATION

Applicant organizations which are described in section 501(c)(4) of the Internal Revenue Code of 1986 and engage in lobbying activities after December 31, 1995, are not eligible for the receipt of Federal funds constituting an award, grant, or loan.

As set forth in section 3 of the Lobbying Disclosure Act of 1995 as amended, (2 U.S.C. 1602), lobbying activities are defined broadly to include, among other thins, contacts on behalf of an organization with specified employees of the Executive Branch and Congress with regard to Federal legislative, regulatory, and program administrative matters.

Check the appropriate block:

The applicant is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986? Yes No

If you checked “Yes” above, check the appropriate block:

The applicant represents that after December 31, 1995 it has has not engaged in any lobbying activities as defined in the Lobbying Disclosure Act of 1995, as amended.

3. DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS

(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery; falsification or destruction of records, making false statements, or receiving stolen property;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or 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 application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default.

(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

4. DRUG-FREE WORKPLACE

This certification is required by the Drug-Free Workplace Act of 1988 (Pub.L. 100-690, Title V, Subtitle D) and is implemented through additions to the Debarment and Suspension regulations, published in the Federal Register on January 31, 1989, and May 25, 1990.

ALTERNATE I (GRANTEES OTHER THAN INDIVIDUALS)

(1) The grantee certifies that it will or will continue to provide a drug-free workplace by:

(a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be taken against employees for violation of such prohibition;

(b) Establishing an ongoing drug-free awareness program to inform employees about:

(1) The dangers of drug abuse in the workplace;

(2) The grantee's policy of maintaining a drug-free workplace;

(3) Any available drug counseling, rehabilitation, and employee assistance programs; and

(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

(c) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a);

(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will:

(1) Abide by the terms of the statement; and

(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace not later than five calendar days after such conviction;

(e) Notifying the agency, in writing, within ten calendar days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant;

(f) Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted:

(1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or

(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State or local health, law enforcement, or other appropriate agency;

(g) Making a good faith effort to continue to maintain a drug- free workplace through implementation of paragraphs

(a),(b),(c),(d),(e), and (f).

(2) The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant:

Place of Performance: (Street address, city, county, state, zip code)

Check if there are workplaces on file that are not identified here.

ALTERNATE II (GRANTEES WHO ARE INDIVIDUALS)

(1) The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant.

(2) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant.

5. SIGNATURE

As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications.

Name of Applicant:

Printed Name and Title of Authorized Representative:

SIGNATURE DATE

DOE F 1600.5 U.S. Department of Energy OMB Control No.

(06-94) All Other Editions are Obsolete Assurance of Compliance

1910-0400

Nondiscrimination in Federally Assisted Programs

OMB Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of Information Resources Management Policy, Plans, and Oversight, Records Management Division, HR- 422 - GTN, Paperwork Reduction Project (1900-0400), U.S. Department of Energy, 1000 Independence Avenue, S.W., Washington, DC 20585; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1900-0400), Washington, DC 20503.

(Hereinafter called the “Applicant”) HEREBY AGREES to comply with Title VI of the Civil Rights Act of 1964 (Pub. L.88-352), Section 16 of the Federal Energy Administration Act of 1974 (Pub.L.93-275), Section 401 of the Energy Reorganization Act of 1974 (Pub.L.93-438), Title IX of the Education Amendments of 1972, as amended (Pub.L.92-318, Pub.L.93-568, and Pub.L.94-482), Section 504 of the Rehabilitation Act of 1973 (Pub.L.93-112), the Age Discrimination Act of 1975 (Pub.L.94-135), Title VIII of the Civil Rights Act of 1968 (Pub.L.90-284), the Department of Energy Organization Act of 1977 (Pub.L.95-91), and the Energy Conservation and Production Act of 1976, as amended (Pub.L.94-385) and Title 10, Code of Federal Regulations, Part 1040. In accordance with the above laws and regulations issued pursuant thereto, the Applicant agrees to assure that no person in the United States shall, on the ground of race, color, national origin, sex, age, or disability, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity in which the Applicant receives Federal assistance from the Department of Energy.

Applicability and Period of Obligation

In the case of any service, financial aid, covered employment, equipment, property, or structure provided, leased, or improved with Federal assistance extended to the Applicant by the Department of Energy, this assurance obligates the Applicant for the period during which Federal assistance is extended. In the case of any transfer of such service, financial aid, equipment, property, or structure, this assurance obligates the transferee for the period during which Federal assistance is extended. If any personal property is so provided, this assurance obligates the Applicant for the period during which it retains ownership or possession of the property. In all other cases, this assurance obligates the Applicant for the period during which the Federal assistance is extended to the Applicant by the Department of Energy.

Employment Practices

Where a primary objective of the Federal assistance is to provide employment or where the Applicant's employment practices affect the delivery of services in programs or activities resulting from Federal assistance extended by the Department, the Applicant agrees not to discriminate on the ground of race, color, national origin, sex, age, or disability, in its employment practices. Such employment practices may include, but are not limited to, recruitment advertising, hiring, layoff or termination, promotion, demotion, transfer, rates of pay, training and participation in upward mobility programs; or other forms of compensation and use of facilities.

Subrecipient Assurance

The Applicant shall require any individual, organization, or other entity with whom it subcontracts, subgrants, or subleases for the purpose of providing any service, financial aid, equipment, property, or structure to comply with laws cited above. To this end, the subrecipient shall be required to sign a written assurance form, however, the obligation or both recipient and subrecipient to ensure compliance is not relieved by the collection or submission of written assurance forms.

Data Collection and Access to Records

The Applicant agrees to compile and maintain information pertaining to programs or activities developed as a result of the Applicant's receipt of Federal assistance from the Department of Energy. Such information shall include, but is not limited to, the following: (1) the manner in which services are or will be provided and related data necessary for determining whether any persons are or will be denied such services on the basis of prohibited discrimination; (2) the population eligible to be served by race, color, national origin, sex, age, and disability; (3) data regarding covered employment including use or planned use of bilingual public contact employees serving beneficiaries of the program where necessary to permit effective participation by beneficiaries unable to speak or understand English; (4) the location of existing or proposed facilities connected with the program and related information adequate for determining whether the location has or will have the effect of unnecessarily denying access to any person on the basis of prohibited discrimination; (5) the present or proposed membership by race, color, national origin, sex, age, and disability, in any planning or advisory body which is an integral part of the program; and (6) any additional written data determined by the Department of Energy to be relevant to its obligation to assure compliance by recipients with laws cited in the first paragraph of this assurance.

DOE F 1600.5 OMB Control No.

(06-94)

All Other Editions are Obsolete 1910-0400

The Applicant agrees to submit requested data to the Department of Energy regarding programs and activities developed by the Applicant from the use of Federal assistance funds extended by the Department of Energy, Facilities of the Applicant (including the physical plants, building, or other structures) and all records, books, accounts, and other sources of information pertinent to the Applicant's compliance with the civil rights laws shall be made available for inspection during normal business hours on request of an officer or employee of the Department of Energy specifically authorized to make such inspections. Instructions in this regard will be provided by the Director, Office of Civil Rights, U.S.

Department of Energy.

This assurance is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts (excluding procurement contracts), property, discounts or other Federal assistance extended after the date hereto, to the Applicants by the Department of Energy, including installment payments on account after such data of application for Federal assistance which are approved before such date. The Applicant recognizes and agrees that such Federal assistance will be extended in reliance upon the representation and agreements made in this assurance and that the United States shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Applicant, the successors, transferees, and assignees, as well as the person(s) whose signature appears below and who are authorized to sign this assurance on behalf of the Applicant.

Applicant Certification

The Applicant certifies that it has complied, or that, within 90 days of the date of the grant, it will comply with all applicable requirements of 10 C.F.R. § 1040.5 (a copy will be furnished to the Applicant upon written request to DOE).

Designated Responsible Employee

Name and Title (Printed to Typed) Telephone Number

Signature Date

Applicant’s Name Telephone Number

Address: Date

Authorized Official:

President, Chief Executive Officer or Authorized Designee

Name and Title (Printed to Typed) Telephone Number

Signature Date viewer may not be able to display this type of document.

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RR_OtherProjectInfo mhughes

D:20061211095927- 05'00'

D:20061211095927- 05'00'

1. Are Human Subjects Involved?

IRB Approval Date:

Human Subject Assurance Number:

2. Are Vertebrate Animals Used?

IACUC Approval Date:

Animal Welfare Assurance Number:

4.b. If yes, please explain:

4.c. If this project has an actual or potential impact on the environment, has an exemption been authorized or an environmental assessment (EA) or environmental impact statement (EIS) been performed?

4.d. If yes, please explain:

6. Does this project involve activities outside of the United States or partnerships with international collaborators?

6.b. Optional Explanation:

7. Project Summary/Abstract

11. Equipment

8. Project Narrative

12. Other Attachments

RESEARCH & RELATED Other Project Information

Is the IACUC review Pending?

If no, is the IRB review Pending?

2.a.

If YES to Vertebrate Animals

3. Is proprietary/privileged information included in the application?

4.a. Does this Project Have an Actual or Potential Impact - positive or negative - on the environment?

6.a. If yes, identify countries:

9. Bibliography & References Cited

10. Facilities & Other Resources

Are Human Subjects Involved is required.

Are Human Subject Involved: If activities involving human subjects are planned at any time during the proposed project at any performance site. Check yes even if the proposed project is exempt from Regulations for the Protection of Human Subjects. If no, skip the rest of block 1.

This field is required.

1.a.

If YES to Human Subjects

Is the Project Exempt from Federal regulations is required.

Is the Project Exempt from Federal regulations?

Is the IRB review Pending is required.

Is the IRB review Pending?

If yes, check appropriate exemption number.

Are Vertebrate Animals Used is required.

Are Vertebrate Animals Used? If activities involving vertebrate animals are planned at any time during the proposed project at any performance site, check yes. If no, skip the rest of block 2.

Is the IACUC review Pending is required.

Is the IACUC review Pending? Indicate if an Institutional Animal Care and Use Committee (IACUC) review is pending.

Is proprietary/privileged information included in the application is required.

Is proprietary/privileged information included in the application: Patentable ideas, trade secrets, privileged or confidential commercial or financial information, disclosure of which may harm the applicant, should be included in applications only when such information is necessary to convey an understanding of the proposed project. If the application includes such information, check yes and clearly mark each line or paragraph on the pages containing the proprietary/privileged information with a legend similar to: "The following contains proprietary/privileged information that (name of applicant) requests not be released to persons outside the Government, except for purposes of review and evaluation." This field is required.

Does this project have an actual or potential impact - positive or negative - on the environment is required.

Does this project have an actual or potential impact on the environment: Indicate if this project has an actual or potential impact on the environment? This field is required.

Does this project involve activities outside of the United States or partnerships with international collaborators is required.

Does this project involve activities outside of the United States or partnerships with international collaborators? Indicate whether this project involve activities outside of the United States or partnerships with international collaborators. This field is required.

Form Attachments:

Is the Project Exempt from Federal regulations?

5. Is the research performance site designated, or eligible to be designated, as a historic place?

Is the research performance site designated, or eligible to be designated, as a historic place is required.

Is the research performance site designated, or eligible to be designated, as a historic place?: If any research performance site is designated or eligible to be designated as a historic place, if Yes, check the Yes box and then provide an explanation in the box provided in 5.a. Otherwise, check the No box.

5.a. If yes, please explain:

OMB Number: 4040-0001

Expiration Date: 12/31/2022

Optional Explanation: Enter an explanation for involvement with outside entities (optional).:

Mandatory:

Is proprietary/privileged information included in the application? - Yes:

Patentable ideas, trade secrets, privileged or confidential commercial or financial information,…