ESBD_File_348251_582-24-85003-AF-Application-Final (acc).pdf

Refueling Infrastructure Project Application Form Alternative Fueling Facilities Program (AFFP)

Texas Commission on Environmental Quality (TCEQ) Texas Emissions Reduction Plan (TERP)

Solicitation No. 582-24-85003-AF

TCEQ invites applications for the AFFP to encourage the construction and reconstruction of alternative fuel facilities in the Clean Transportation Zone (CTZ).

Public Information Notice: Upon submission, all proposals become the property of the State of Texas and subject to the Texas Open Records Act, Texas Government Code, Chapter 552.

How to Submit an Application: If you have questions on how to fill out this form, please contact us at TERP@tceq.texas.gov or 800-919-TERP (8377).

1. Only one refueling infrastructure project at a single location may be submitted per application.

2. Submit a completed and signed application form and the required attachments by emailing AFFP- Apply@tceq.texas.gov, uploading to TCEQ’s File Transfer Protocol Secure (FTPS) site, or submitting the application and associated documents by mail. All applications must be received by TCEQ no later than 5:00 p.m. Central Time, March 22, 2024. Please note: submission via standard email may not be secure. Use TCEQ’s FTPS site to submit your application securely. Learn how to create an account and submit your application via FTPS (FTPS: A Step-by-Step Video Guide).

Application Completeness: TCEQ will review applications for completeness. An application that is not complete will be ineligible for consideration. A complete application must include all pages of the application, all required attachments, applicant’s contact information, all required signatures, and all the information for TCEQ to score and rank the project according to the scoring criteria listed in the Request for Grant Applications (RFGA).

Application Submission Limitations: “Applicant” is defined as an individual or business and all of their associated legal affiliates. Applicants will be subject to application selection limitations as defined in Section 4.3 of this program’s RFGA. Applicants may only include one project site and one alternative fuel type in a single application. A combined compressed natural gas (CNG) and liquified natural gas (LNG) project may be submitted in one application.

Applicants and/or projects that do not meet the AFFP eligibility requirements at the time of application submittal will not be considered for a grant.

Key Events Date and Time

Program Opening Date Jan. 23, 2024

Application Submission Deadline March 22, 2024

TCEQ-20606 (Rev. Jan. 2024) Page 1 of 17 mailto:TERP@tceq.texas.gov mailto:AFFP-Apply@tceq.texas.gov mailto:AFFP-Apply@tceq.texas.gov https://www.tceq.texas.gov/airquality/terp/affp https://www.tceq.texas.gov/airquality/terp/affp https://www.youtube.com/watch?v=GW4eEe_uUwc

Section 1: Applicant Information

1. Legal Name of Entity Applying for the Grant If selected for a grant, the legal name of the applicant will be used for contracting purposes.

Applicant Legal Name:

(Must Match W-9 Form)

2. Business Information All business entities such as corporations or partnerships must have an active registration with the Texas Secretary of State by Jan. 23, 2024, 5:00 p.m. CT. Businesses must maintain an active registration for the contract period.

Ownership / Business Type:

Federal Employer Identification Number

(FEIN/EIN):

Social Security Number:

Individuals and Sole Proprietors only

3. Small Business Information (if applicable) To qualify for funding under the AFFP Small Business allocation, the Small Business entity must be actively registered or certified as a Small Business no later than Jan. 23, 2024, 5:00 p.m. CT.

Does the applicant qualify as a Small Business?

If the applicant is a small business, please select all that are applicable and include documentation as an attachment to the application:

� Applicant is a small business corporation under Subchapter S of the Internal Revenue Code.

� Applicant is a Historically Underutilized Business (HUB) with the Texas Comptroller’s Statewide HUB Program.

� Applicant is an 8(a) Small Business by the U.S. Small Business Administration (SBA).

� Applicant is a Women-Owned Small Business (WOSB) by the U.S. Small Business Administration.

� Applicant is HUBZone Program-Certified by the U.S. Small Business Administration.

� Applicant is a Veteran-Owned Small Business (VOSB) or Service-Disabled Veteran-Owned Small Business through the Department of Veterans Affairs.

� Applicant is a Disadvantaged Business Enterprise (DBE) by the Texas Department of Transportation (TxDOT) or entities that are part of the Texas Unified Certification Program.

� Applicant certifies to any other certification as a small business enterprise by the state of Texas or local government, regional certification agency, or the U.S. Small Business Administration.

TCEQ-20606 (Rev. Jan. 2024) Page 2 of 17

4. Authorized Official (AO) The applicant or an employee who has legal authority to sign for and speak on behalf of the entity.

AO First Name:

AO Middle Initial:

AO Last Name:

AO Suffix (If applicable):

AO Title:

AO Primary Phone Number:

AO Cell Phone Number:

AO Email Address:

AO Mailing Address (Street or PO Box):

AO City, State, and Zip Code:

5. Designated Project Representative (DPR) The applicant or an employee who will serve as the point of contact for this application.

Is the DPR the same person as the AO?

(If the DPR is the same as the AO, select Yes and continue to

Section 2. Otherwise, enter DPR information)

DPR First Name:

DPR Middle Initial:

DPR Last Name:

DPR Suffix (If applicable):

DPR Title:

DPR Primary Phone Number:

DPR Cell Phone Number:

DPR Email Address:

DPR Mailing Address (Street or PO Box):

DPR City, State, and Zip Code:

TCEQ-20606 (Rev. Jan. 2024) Page 3 of 17

Section 2: Third-Party Preparer Signature Page

1. Third-Party Preparer A third-party preparer is someone other than the applicant or an employee of the applicant. If a third-party preparer was not used in the preparation of an application, select “No” from the dropdown list and proceed to Section 3.

Was this application prepared by a third party?

2. Third-Party Preparer Certification I hereby certify that to the best of my knowledge and belief all information provided in this application and any attachments are true and correct, as represented to me by the applicant. I understand that failure to sign the application will make this application ineligible. I understand that making a false statement may cause the submitted application to be ineligible, may make any resulting contracts voidable, and may subject me to criminal or civil penalties.

Third-Party Preparer Information Third-Party Preparer Printed

Name:

(First, Last)

Title:

Company Name:

Mailing Address:

(Street or PO Box)

City:

State:

Zip Code:

Primary Phone Number:

Cell Phone Number:

Email Address:

Third-Party Preparer Signature*:

Third-Party Signature Date:

*If using an electronic signature instead of a typed signature, please complete the entire application before signing electronically. The ability to edit, add, or remove information will not be available after the application is electronically signed.

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Section 3: Certification of Eligibility to Receive a State-Funded Grant All applicants must complete this section to certify eligibility to receive a grant under this program, even if child support obligations do not apply to the applicant. Failure to complete this section may result in rejection of the application.

Certification Regarding Child Support Obligations Under Section 231.006, Texas Family Code, a child support obligor who is more than 30 days delinquent in paying child support and a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25% is not eligible to receive a state-funded grant or loan.

All applicants must include in the application the name and social security number of the individual or sole proprietor and each partner, shareholder, or owner with an ownership interest of 25% of the business entity submitting the application.

FEDERAL PRIVACY ACT NOTICE: This notice is given pursuant to the Federal Privacy Act. Disclosure of your Social Security Number (SSN) is required under Section 231.006(c) and Section 231.302(c)(3) of the Texas Family Code. The SSN will be used to identify persons that may owe child support. The SSN will be kept confidential to the fullest extent allowed under Section 231.302(e), Texas Family Code.

Please Check Only One of the Following Applicant Options

1. Individual or Sole Proprietor

2. One or more individuals own 25% or more of the business entity

3. No individual owns 25% or more of the business entity

4. Governmental Entity

If Option 1 or 2 is checked above, list the name(s) and social security number(s) below.

Name Social Security Number

Name Social Security Number

Name Social Security Number

Name Social Security Number

Name Social Security Number

Applicant Certification By signing this application in Section 10: Signature Page, under Section 231.006, of the Texas Family Code, the applicant certifies that the individual or business entity named in this application is not ineligible to receive a grant and acknowledges that any grant contract may be terminated, and any payments may be withheld if this certification is inaccurate.

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Section 4: General Certifications This section includes specific requirements and statements for funding under the AFFP. These terms apply to any contract awarded by TCEQ from this application. The AFFP RFGA and the draft contract, located on the AFFP webpage, contain additional terms and conditions that the applicant should review before submitting an application.

By signing this application, you understand and certify compliance with all the statements below, as well as with any state statutes, regulations, policies, guidelines, and requirements as they relate to the application, acceptance, and use of funds for this project. If any of these certifications materially change after submittal of the application, you will provide prompt written notification to TCEQ within three business days of becoming aware of the change. Failure to notify TCEQ and/or any changes to your certifications may make the application ineligible and may make any resulting contracts voidable.

1. Legal Authority. The applicant has legal authority in the State of Texas to apply for the grant. The applicant's governing body has authorized the filing of the application, understands these requirements and certifications, and has authorized the person identified as the Authorized Official to act in connection with the application and to provide such additional information as may be required.

2. Fuel Taxation. The applicant certifies that it complies or will comply with laws, rules, guidelines, and requirements applicable to taxation of fuel provided by the applicant at each fueling facility owned or operated by the applicant.

3. Texas Grant Management Standards. In accordance with Chapter 783, Texas Government Code, if the applicant is a local government, state entity, or political subdivision, it will comply fully with the Texas Grant Management Standards (TxGMS). This includes compliance with the relevant sections of TxGMS when procuring goods and services under a resulting contract. For all other applicants, the selected items of cost of TxGMS apply to any resulting contract. TxGMS is available at: the Grant Management Website of Texas Comptroller of Public Accounts.

4. Procurement of Goods and Services. If this application results in a contract, all procurement transactions made with (or to be reimbursed by) grant funds must be conducted in a manner providing full and open competition. All purchase decisions must be based on sound business decisions and arm’s length bargaining, and purchases must be made without any real or apparent personal or organizational conflicts of interest as described in TxGMS.

5. Conflict of Interest. The applicant has not given, offered to give, nor intends to give any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted application. All purchase decisions must be based on sound business decisions and arm’s length bargaining.

6. Nondiscrimination. The applicant will comply with all state and federal statutes relating to nondiscrimination.

7. Grant Administration. The applicant will maintain an appropriate grant administration system to ensure that all terms,conditions, and specifications of the grant, including these certifications, are met.

8. Audit. Acceptance of funds under this program acts as acceptance of the authority of the State Auditor’s Office (SAO), or any successor agency, to conduct an audit on investigation in connection with those funds. The applicant or other entity that may receive funds directly or indirectly from TCEQ must provide the SAO with access to any information the SAO considers relevant to the investigation or audit.

Applicant will include this clause concerning the authority to audit funds received indirectly and the requirement to cooperate in any subcontract it awards.

9. Debt to the State. The applicant is not indebted to the state and does not have an outstanding tax delinquency. The applicant must comply with all state and federal tax laws and fee requirements and is solely responsible for filing all state and federal tax and fee forms.

TCEQ-20606 (Rev. Jan. 2024) Page 6 of 17 https://www.tceq.texas.gov/airquality/terp/ctt.html https://www.comptroller.texas.gov/purchasing/grant-management/ https://www.comptroller.texas.gov/purchasing/grant-management/

10. Contract. The applicant understands that a PDF of the draft contract may be viewed and downloaded from the AFFP webpage. The draft contract is for reference only and contains terms and conditions which are standard provisions for grants awarded under this program. Any requested changes to the draft contract must be received by TCEQ no later than the date of the submission of this application. However, the applicant further understands that TCEQ will not normally change the contract language in response to individual requests from grant recipients and is under no obligation to do so. TCEQ reserves the right to modify the draft contract terms as necessary due to statutory, rule, or policy changes. Modifications will be posted to the AFFP webpage and the Electronic State Business Daily.

11. Contracting with an Executive of a State Agency. Under Texas Government Code Section 669.003, relating to contracting with an executive head of a state agency, applicant represents that no person who, in the past four years, served as an executive of TCEQ or any other state agency, was involved with or has any interest in this application. If applicant employs or has used the services of a former executive head of TCEQ or other state agency, the applicant shall provide the following information: name of former executive, name of state agency, date of separation from state agency, position with applicant, and date of employment with applicant.

12. Debarment. The applicant certifies that the applying entity and its principals are eligible to participate in this transaction and have not been subjected to suspension, debarment, or similar ineligibility determined by any federal, state, or local governmental entity. The applicant also certifies that it and its principals are not listed on the State of Texas Debarred Vendor List maintained by the Texas Comptroller of Public Accounts, or the System for Award Management (SAM.gov) maintained by the General Services Administration as authorized by Executive Order No. 13224, “Blocking Property and Prohibiting Transactions with Persons Who Commit, Threaten to Commit, or Support Terrorism,” published by the U.S. Department of Treasury, Office of Foreign Assets Control.

13. Abortion Funding Limitation. The applicant represents and warrants it is not an abortion provider or an affiliate of an abortion provider under Texas Government Code, Chapter 2273, Prohibited Transactions.

14. Disclosure Protections for Certain Charitable Organizations. If the applicant is a governmental entity, it represents and warrants that it will comply with Section 2252.906 of the Texas Government Code relating to disclosure protections for certain charitable organizations, charitable trusts, and private foundations.

15. Risk Review. The applicant’s prior performance under other TCEQ contracts; its overall compliance history; and any federal, state, or local enforcement action for violation of environmental laws or permit conditions may be considered in determining eligibility.

16. Texas Public Information Act. Information, documentation, and other material in connection with this solicitation or any resulting contract or grant may be subject to public disclosure pursuant to Chapter 552 of the Texas Government Code. In accordance with Section 2252.907 of the Texas Government Code, applicant is required to make any information created or exchanged with the State pursuant to the contract and grant, and not otherwise excepted from disclosure under the Texas Public Information Act, available in a format that is accessible by the public at no additional charge to the State.

17. Contract Eligibility. Under Section 2155.006 of the Texas Government Code, the applicant certifies that the individual or business entity named in this Application is not ineligible to receive the specified contract.

20. COVID-19 Vaccine Passport Prohibition. Under Section 161.0085 of the Texas Health and Safety Code, the applicant certifies that it is not ineligible to receive funds.

TCEQ-20606 (Rev. Jan. 2024) Page 7 of 17 https://www.tceq.texas.gov/airquality/terp/ctt.html https://www.tceq.texas.gov/airquality/terp/ctt.html

Section 5: Program Certifications

Alternative Fuel Facility Project Certifications For the alternative fuel facility project listed in Section 7, the following certifications apply. By signing this application, you are certifying the applicable eligibility requirements listed herein.

Site Ownership

Is the Applicant the Property Owner?

Applicants are required to be the owner of the site where the equipment is installed unless the applicant establishes permission to install and operate the grant-funded equipment at the site during the contract period.

The information below must be completed by the property owner if the applicant does not own the site where the equipment will be installed.

Property Owner:

Authorized Official of Property Owner:

Title:

Phone Number:

Email Address:

Mailing Address (Street or PO Box):

I, the undersigned owner of the real property located at the address identified in Section 7: Proposed Project Information, consent to the installation of the proposed facility on this property. I understand and agree that the applicant is obligated, unless otherwise approved by TCEQ, to keep the proposed facility in operation and in service for a minimum of three years after installation.

Property Owner Signature*:

Date:

*If using an electronic signature instead of a typed signature, please complete the entire application before signing electronically. The ability to edit, add, or remove information will not be available after the application is electronically signed.

Infrastructure Equipment Ownership

By signing this application, the applicant certifies that it will purchase and own the grant-funded equipment during the contract period subject to the following: Any sale of the grant-funded equipment during the contract period will be subject to approval and consent to assignment by TCEQ in accordance with the contract terms. An entity that purchases the equipment and leases it to another entity may establish eligibility provided that the applicant maintains ownership of the grant-funded equipment during the contract period.

TCEQ-20606 (Rev. Jan. 2024) Page 8 of 17

Section 6: Application Score Tie-Breaking Provisions In the event of a tied score, the following may be used as tiebreakers, along with the small business qualifications in Section 1.3, in no order of preference. Please select all that are applicable and include supporting documentation as an attachment to the application to receive credit:

� Applicant is (or is owned by) a service-disabled veteran who is a Texas resident. (Tex. Gov.

Code 2155.444).

� Applicant is a Texas bidder meaning it is incorporated in this state; has its principal place of business in this state; or has established a physical presence in this state. (Tex. Gov. Code 2155.444).

� Applicant will use USA-produced supplies, materials, or equipment in fulfilling its grant obligations. (Tex. Gov. Code 2155.444).

� Applicant will use products made of recycled, remanufactured, or environmentally sensitive materials in fulfilling its grant obligations. (Tex. Gov. Code 2155.445).

� Applicant will purchase and use energy efficient products in fulfilling its grant obligations. (Tex.

Gov. Code 2155.442).

� Applicant will purchase and use products made by persons with disabilities in fulfilling its grant obligations. (Tex. Gov. Code 2155.441).

� Facility will be located on formerly contaminated property. (Tex. Gov. Code 2155.450).

� Facility will be in an economically depressed or blighted area. (Tex. Gov. Code 2155.449, 2306.004).

TCEQ-20606 (Rev. Jan. 2024) Page 9 of 17

Section 7: Proposed Project Information This project application must be completed by applicants who are requesting grant funds to construct or reconstruct an alternative fuel facility. All grant-funded fuel facilities must be owned, operated, and maintained by the applicant within the Clean Transportation Zone, listed in Appendix A of the RFGA, for the duration of the grantee’s three-year usage reporting requirement. Leased equipment is not eligible.

An applicant may only include one alternative fuel type per application submission, except for applications that include a combined CNG and LNG project. Projects that will be adding a new alternative fueling facility to an existing facility will need to apply for the new alternative fueling facility.

1. Infrastructure Type and Information Select the fuel type from the drop-down box below:

Infrastructure Fuel Type:

Have you previously received a TERP or TxVEMP grant for this project site?

If yes, provide awarded contract number.

Have you applied for or received another grant for alternative fueling at this site?

If yes, please describe.

How many fueling or charging ports will be available?

Number of Fueling or Charging Ports:

2. Fuel Facility Type and Hours of Operation TCEQ considers a facility to be private if the general public’s right to access the facility is restricted in any manner. A public facility must be open and accessible to the public for a minimum of eight hours per day, between the hours of 8:00 a.m. and 6:00 p.m., for at least five days a week.

Select the facility type in the drop-down below.

Alternative Fuel Facility Type:

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For public facilities, please indicate the hours of operation.

Day of Week 24 hrs. Opening Hour Closing Hour

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

3. Proposed Project Location Please list the location of the proposed project.

Physical Address:

City:

State:

Postal/Zip Code:

County:

Latitude:

in decimal degrees to a minimum of five decimal places (e.g., 30.39422)

Longitude:

in decimal degrees to a minimum of five decimal places (e.g., -97.67518)

4. Site Plan The applicant must attach a site plan (including a scaled map which could be a photograph, satellite map, drawing, or similar graphic of the proposed site) that shows the planning and design of its proposed facility (not just an arrow on a map).

The site plan must:

• Demonstrate how the public may access the facility, including driveways and facility access points from public roads; and

• Include the ¼ mile area around the proposed site and show the location of the amenities that are listed in the application.

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5. Ownership Documentation:

The applicant must demonstrate their ability to install, operate and maintain the refueling infrastructure at the proposed site by providing documentation, such as property ownership records, lease agreements or other legal agreements, that can show the following:

• The ability to complete any required construction on the proposed site; and

• The ability to operate on the proposed property for the duration of the contract if awarded a grant.

6. Project Details Please briefly describe the proposed infrastructure project below. If this project will expand existing infrastructure, please indicate this as well.

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7. Amenities Please fill out this section if the proposed facilities in this application will provide amenities or have amenities within ¼ mile. Select all onsite or nearby amenity types that apply. If an amenity type is not provided, please select the “other” type, and provide a brief description below.

Amenity Type Onsite Within ¼ Mile from Proposed

Facility

Restaurants: � �

Hotels: � �

Grocery Stores: � �

Retail Shopping: � �

Entertainment: � �

Parks: � �

Municipal, State, or Federal Buildings: � �

Public Restrooms: � � Other:

(If you chose other, provide explanation in the space below)

Description of other Amenity Type Please provide a brief description of the “other” amenity type that is not listed above. For amenities that do not currently exist, please include definitive documentation with this application that clearly documents the type and location of the future amenities.

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Section 8: Project Budget Categories List all expenses by budget category including a description of each line item and its purpose for the project. Refer to Section 3.2 Eligible Project Costs in the RFGA for descriptions of each budget category. If an eligible cost is shared between multiple fuel types, only list it once. Any cost incurred prior to the program opening date on the cover page of this document will not be eligible for funding. Add additional pages, as necessary.

Please note that a grantee must identify in the request for reimbursement any financial incentive received for the project, such as tax credits or deductions, other grants, or any other public financial assistance.

The grant reimbursement amount plus the financial incentive amount cannot exceed 100% of the total cost of the project.

Full Description and Detailed Purpose: Category: Estimated Cost:

Total Eligible Project Costs:

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Section 9: Proposed Project Grant Amount For refueling infrastructure projects, applicants must submit with the grant application an estimated budget outlining the eligible project costs. Please list the total cost for each budget category from Section 8.

Equipment Total:

Supplies and Materials Total:

Construction Total:

Contract Services Total:

Total Eligible Project Costs:

Grant Amount Requested:

Requested grant amount may not exceed:

• For a CNG or LNG project, 100% of Eligible

Project Costs or $400,000, whichever is less.

• For a combined CNG and LNG project, 100% of

Eligible Project Costs or $600,000, whichever is less.

• For fuels other than Natural Gas, 50% of Eligible Project Costs or $600,000, whichever is less.

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Section 10: Signature Page

Authorized Official The applicant or an employee of the applicant who has the legal authority to sign on behalf of the entity.

I hereby certify to the best of my knowledge and belief that all information provided in this application and any attachments is true and correct, including any representations made by a third-party preparer. My signature also constitutes acceptance of the certifications in Sections 3, 4 and 5 of this application, the terms of the RFGA, and any other changes posted through addenda on the Electronic State Business Daily.

I understand that failure to sign the application will make this application ineligible. I understand that making a false statement may make the submitted application ineligible, may make any resulting contracts voidable, and may subject me to criminal or civil penalties.

Printed Name of Authorized Official:

Authorized Official Title:

Signature of Authorized Official*:

Date of Signature:

*If using an electronic signature instead of a typed signature, please complete the entire application before signing electronically. The ability to edit, add, or remove information will not be available after the application is electronically signed.

The application, signed by the Authorized Official, must be received by the application deadline or the application will not be accepted.

Upon submission, all proposals become the property of the State of Texas and as such become subject to the Texas Public Information Act, Texas Government Code Chapter 552.

Personal Information Policy: Individuals are entitled to request and review their personal information that the agency gathers on its forms. Individuals may request to have their provided personal information updated. To review such information, contact TERP program staff at TERP@tceq.texas.gov or 800-919-TERP (8377).

TCEQ-20606 (Rev. Jan. 2024) Page 16 of 17 mailto:TERP@tceq.texas.gov

Section 11: Application Checklist All applications for funding must be submitted within the application submission period listed on the cover page of the RFGA. A complete application must include:

• All pages of the application;

• All required attachments;

• Applicant’s contact information;

• All required signatures; and

• All the information for TCEQ to review the application for selection according to the program requirements list in the RFGA.

Section 1: Applicant Information Please fill out entirely.

Section 2: Third-Party Preparer Signature Page

Please fill out entirely if application was prepared by a third party. Signature Required.

Section 3: Certification of Eligibility Please fill out entirely.

Section 4: General Certifications Please read and include with application.

Section 5: Program Certifications If the applicant is not the site owner, please fill out entirely. Signature Required

Section 6: Application Score Tie-Breaking Provisions Please fill out entirely (if applicable).

Section 7: Proposed Project Information Please fill out entirely.

Section 8: Project Budget Categories Please fill out entirely.

Section 9: Proposed Project Grant Amount Please fill out entirely.

Section 10: Signature Page Please fill out entirely. Signature Required.

Section 11: Application Checklist Please read and include with the application.

Attachments Checklist

IRS Form W-9 Download, fill out entirely. Signature Required.

Copy of all applicable small business certifications

(if applicable)

Please refer to Section 1 for a list of certifications that may apply and attach to application

Application Score Tie-Breaking Documentation (if applicable)

Please provide documentation of all selected criteria from Section 6.

Site Plan Please refer to Section 7 for requirements.

TCEQ-20606 (Rev. Jan. 2024) Page 17 of 17 https://www.irs.gov/pub/irs-pdf/fw9.pdf