ANNEX 1a - PHASE 1 App for FY22 RFA.pdf

American Schools and Hospitals Abroad Initiative Solicitation No.: 720DD122RFA00002

ANNEX 1a – PHASE 1 TECHNICAL APPLICATION TEMPLATE Applicants should complete Annex 1 in its entirety and return to ASHA for review. All requested information should be submitted in the spaces provided below.

I. Cover Page (2 pages)

1. Date of submission

2. Name of the applicant USO and address

3. USO’s Unique Entity Identifier (UEI): Please list the UEIs that apply to your organization.

System for Award Management UEI

Dun and Bradstreet Universal Numbering System (DUNS) number

4. The USO’s System for Award Management (SAM) expiration date

5. USO’s Federal Employer/Taxpayer Identification Number (EIN/TIN)

6. Name of the benefiting OSI and address

Check one: School/University Hospital Center Library Center of Excellence

7. Amount of federal funding requested

8. Amount of leveraged funds (if applicable) or cost share (if applicable)

9. The total activity cost

10. Activity Name/Title

11. ASHA Funding Is For

Commodities only Construction/renovation only Construction/renovation with commodities

12. Please describe what the ASHA resources will fund:

13. Project Summary

14. Public Diplomacy Benefit Summary: Please provide a summary of the public diplomacy benefit of this project.

Optional: Applicants may also include a photo or sketch in the space below (does not count against the page limit):

II. Eligibility (4 pages)

Please see Section C Eligibility Criteria of the RFA for instructions. By completing each question, the applicant affirms that they meet each eligibility criteria. Failure to complete any of these questions will render the application ineligible.

1. Is the Applicant a U.S. not-for-profit non-governmental entity (e.g. “NGOs,” foundations, and similar)?

Yes No

2. Is the USO/OSI Applicant partnership’s work primarily focused in the Middle East? For purposes of this RFA, the Middle East includes the following countries and territories: Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Syria, Tunisia, West Bank & Gaza, Israel, and Yemen. Yes No

If “Yes”:

Are you applying for the Middle East Set-Aside? Yes No

Does the USO have ten or more years of experience in the Middle East region? Yes No

Has the USO had a relationship with the OSI for at least the past ten years? Yes No

3. Does the application identify one USO and one OSI only? Yes No

4. Do the USO an OSI share the same name? Yes No

5. Are the USO and OSI the “same legal entity”? Yes No

6. If the USO and OSI are the “same legal entity,” does the Applicant have proof that it is registered as a legal entity in the U.S. and is authorized to operate in the foreign country? Yes No If “No,” provide a succinct explanation:

7. Is the OSI founded or sponsored (sponsored refers to support provided) by United States citizens?

Yes No

If “Yes,” does the USO have a continuing and supportive relationship with the OSI that has lasted at least two years prior to the date of application1? Yes No

Please provide a brief narrative in the space provided addressing the USO’s relationship with the OSI:

8. Administrative Status & Audits:

Is the USO active in SAM? Yes No

Does it have any active exclusion? Yes No

Does it have any delinquent Federal debt? Yes No

Will the USO and OSI have independently audited financial statements from 2019 or later by the full proposal deadline2? Yes No

9. Is the OSI located outside the United States? Yes No

10. Is the OSI under the control or management of a foreign government or any of its agencies as defined in Section C: Eligibility Information? Yes No

11. OSI Eligibility by type

a. If the OSI is a school:

i. Does it provide English language instruction or use English as the language of instruction in at least one course? Yes No Not Applicable

ii. Does it provide post-secondary education or secondary education that serve students at the equivalent of a U.S. sixth grade level or higher? Yes No Not Applicable

b. If the OSI is a hospital, does it provide medical education or conduct medical research?

Yes No Not Applicable

c. If the OSI is a library, does it advance learning and understanding on issues of import to the U.S.

and demonstrate promotion of English language and literature?

Yes No Not Applicable

d. If the OSI is a Center of Excellence, does it advance learning and understanding on issues of importance to the U.S., and model American best practices and values?

Yes No Not Applicable

12. For construction or renovation activities, will the OSI or USO have an official copy of a title, lease or similar official documentation recognized within the country where implementation will take place prior to submitting full application3? Yes No Not Applicable

13. Do the USO and OSI agree not to discriminate against any beneficiaries in the implementation of the award on the basis of race, color, religion, sex, national origin, disability, age, sexual orientation, gender identity, pregnancy, genetic information, marital status, parental status, political affiliation, and veteran’s status, or any other factor not expressly stated in the application?

Yes, we agree No, we do not agree

Eligibility Section Footnotes

1 A continuing relationship MUST include significant financial support and may include technical support, joint ventures, exchange programs, volunteer placement programs, faculty exchanges, fundraising, or other arrangements, and may include in-kind contributions.

Partnerships and mutual collaborations alone are insufficient; the USO must support the OSI.

2 If the USO and OSI are separate entities, then each entity should submit an independently audited financial statement. If the USO and OSI are one entity, then one independently audited financials can be submitted. The financial statements need to be audited by an “independent” audit firm. “Independent” refers to the fact that the auditor/CPA is not an employee of the USO or OSI entity but instead is retained through a contract for services, and hence is “independent.”

Please see Annex 6 of the solicitation for more information on the audit requirements.

3 If the applicant is asked to submit a full application for a project that involves construction or renovation activities, the applicant must submit with the Phase 2 application, an official copy of a title, lease or similar official documentation recognized within the country where implementation will take place. The documentation must demonstrate a legal right to the land (to build, renovate, retrofit according to current building codes), ideally for a period of at least 20 years from the date of the application, as well as an English translation of the lease or title, if the official copy is not in English. Applications involving a legal right to the land of 20 years (or more) will be given a greater preference, although USAID is willing to consider applications that include a title, lease or similar official documentation covering a shorter period of time; such applications will be reviewed on a case-by-case basis.

SAM.GOV SCREENSHOT

Copy and paste a screenshot of the Applicant's current SAM account on this page.

III. Response to Phase 1 Technical Application Criterion (not to exceed 3 pages) - Please insert the public diplomacy response below, in accordance with the instructions in Section E.2.a of this RFA.

Phase 1 Public Diplomacy Criterion Response: Page 1 of 3

Phase 1 Public Diplomacy Criterion Response: Page 2 of 3

Phase 1 Public Diplomacy Criterion Response: Page 3 of 3

IV. Response to Phase 1 Past Project Impact Statement – ONLY for Applicants applying for the 30% Middle East set-aside (not to exceed 3 pages). Please insert the Past Performance Impact Statement below, in accordance with the instructions in Section E.2.a of this RFA.

Phase 1 Past Performance Impact Response: Page 1 of 3

Phase 1 Past Performance Impact Response: Page 2 of 3

Phase 1 Past Performance Impact Response: Page 3 of 3