APPLIC_1.DOC

FY2025 - FY2027 Applicant Transmittal Cover Page for FTA Section 5310 *No individuals may apply*

AGENCY NAME:

County:

Address:

City/State/Zip Code:

EXECUTIVE DIRECTOR:

Email:

Phone:

FINANCIAL CONTACT:

Email:

Phone:

CHECKLIST OF REQUIRED ITEMS AT SUBMITTAL:

☐ Signed Transmittal Cover Page ☐ Proposal Response Template(s) ☐ Financial Components Workbook ☐ Organizational Chart with staff names, job titles and job descriptions ☐ DHS Pre Award Risk Assessment Form ☐ Copy of liability insurance for all programs and facilities ☐ Cost Share Policy ☐ Client contribution Policy ☐ Complaint Policy and Procedures ☐ Most recent audit’s Financial Statement & Current Budget of Applicant Organization(s) ☐ Three references from entities that have previous or current business relationships with the applicant, wherein the role of the applicant in the relationship is clearly stated

FTA Certifications and Assurances Form

1. The applicant has coordinated or will coordinate to the maximum extent feasible with other transportation providers and users, including social service agencies authorized to purchase transit service;

2. The applicant has or will comply with all terms and requirements listed in the Sub- Recipient Terms and Requirements section of this application;

3. The applicant has complied or will comply with all applicable civil rights requirements, including but not limited to full compliance with Title VI of the Civil Rights Act of 1964 and related statutes and regulations, in all programs and activities (See Appendix III);

4. The applicant has complied or will comply with applicable requirements of U.S. DOT regulations regarding participation of disadvantaged business enterprises in U.S. DOT programs (See Appendix III);

5. The applicant has complied or will comply with all applicable lobbying requirements for each application (per 49 CFR 20.110) exceeding $100,000 (See Appendix III);

6. The applicant will comply with all applicable federal requirements per the FTA Federal Fiscal Year 2015 list of Certifications and Assurances for Federal Transit Administration Grants and Cooperative Agreements, as referenced at: https://www.transit.dot.gov/funding/grantee-resources/certifications-and- assurances/certifications-assurances

Authorized Representative of Applicant

APPLICATION SIGNATURE:

I certify, to the best of my knowledge, that the information submitted in the attached proposal is true and accurate and that this organization has the necessary fiscal, data collection, and managerial capability to implement and manage the services bid on in this proposal in accordance with both federal regulations and Georgia Department of Human Services, Division of Aging regulations.

Signature

Date

Printed Name and Title

FY25 – FY27 FTA Section 5310 Transmittal Cover Page for NOFA | 2 image1.jpg