oppEPA-OW-OGWDW-17-01-cfda66.424.pdf

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Submission D:20061219143208- 05'00' D:20061219143305- 05'00' Grant Application Package Grants.gov Grant Application Package Grants.gov CFDA Number:

Opportunity Title:

Offering Agency:

Agency Contact:

Opportunity Open Date:

Opportunity Close Date:

CFDA Description:

Opportunity Number:

Competition ID:

Application Filing Name:

Select Forms to Complete Mandatory Optional Instructions About the Application Package.

· This application package is used to apply for the specific Federal funding opportunity referenced in this application package. Please verify that you have downloaded and completed the application package for the correct funding opportunity announcement.

· This application can be completed in its entirety offline using Adobe Reader.

· You can save your application at any time by clicking the "Save" button at the top of your screen.

Using the Application Package.

· The application package is a compilation of forms, such as the SF-424, budget forms, attachment forms, and narratives.

· It is recommended that the SF-424 cover page be the first form completed for the application package. Some data entered on the SF-424 cover page will pre-populate data fields in other subsequent forms in the application package.

· Forms identified as Mandatory are required to be filled out to successfully submit your grant application at a minimum. Optional Forms are used to provide additional support for this application or may be required for specific types of grant activity. Reference the application package instructions for more information regarding Optional Forms.

· Select the check box next to the form's name to add the form to the application package. To navigate to the form in the application package, click on the underlined form name. To remove a form from the application package, uncheck the box next to the form name.

· When you open a form, required fields are highlighted in yellow with a red border. Optional fields and completed fields are displayed in white. If you enter invalid or incomplete information in a field, you will receive an error message.

· Your application will be rejected if you do not follow the Agency and Grants.gov guidance on file naming conventions. Please review the application instructions for this Opportunity Package for specific guidelines and refer to FAQs in the Grants.gov Applicants tab.

Submitting the Application Package.

· You can save the application as you work on it by clicking on the "Save" button.

· Click on the "Check Package for Errors" button to ensure that you have completed all required data fields. Correct any errors. If no errors are found, save the application package. The "Save & Submit" button will also become active.

· You need to be registered with Grants.gov and granted the role of Authorized Organizational Representative by your organization's eBIZ POC in order to successfully submit your application.

· Click on the "Save & Submit" button to begin the application submission process. (You must be connected to the Internet at this time.) You will be taken to the applicant login page to enter your Grants.gov username and password. Follow all onscreen instructions for submission. Upon submission, you will be provided with a Grants.gov Tracking Number.

· You will receive a series of emails after submission: 1. Successful transmission to Grants.gov and your application is undergoing a series of system checks, 2. An email either indicating specific errors in your application OR an email indicating that your submission is being prepared for agency download, and 3. Your application has been retrieved from Grants.gov by the funding agency for further review only after the agency acknowledges the download. If you receive an email with an error, please correct your application and resubmit.

Additional Application Package Information.

· Additional instructions and FAQs about the Application Package can be found in the Grants.gov Applicants tab.

This electronic grants application is intended to be used to apply for the specific Federal funding opportunity referenced here.

If the Federal funding opportunity listed is not the opportunity for which you want to apply, close this application package by clicking on the "Cancel" button at the top of this screen. You will then need to locate the correct Federal funding opportunity, download its application and then apply.

Name- Version Form Tag Name Mandatory Name- Version Form Tag Name Optional Name- Version Form Tag Name SelectedOptional Name- Version Form Tag Name SelectedMandatory Grant Application Package Grants.gov Grant Application Package Grants.gov

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http://www.grants.gov/web/grants/applicants/adobe-software-compatibility.html For more information:

http://www.grants.gov/web/grants/applicants/applicant-faqs.html Also the Grants.gov Contact Center is available for further assistance. The Contact Center is available 24 hours a day, 7 days a week excluding federal holidays.

Email: support@grants.gov Phone: 1-800-518-4726 (local toll free). For international callers, please dial 1-606-545-5035 to speak with a Contact Center representative.

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http://www.grants.gov/web/grants/applicants/applicant-faqs.html Also the Grants.gov Contact Center is available for further assistance. The Contact Center is available 24 hours a day, 7 days a week excluding federal holidays.

Email: support@grants.gov Phone: 1-800-518-4726 (local toll free). For international callers, please dial 1-606-545-5035 to speak with a Contact Center representative.

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

OMB Number: 4040-0002 Expiration Date: 01/31/2019 1.a. Type of Submission:

Other (specify):

1.b. Frequency:

Other (specify):

1.d. Version:

2. Date Received:

3. Applicant Identifier:

4a. Federal Entity Identifier:

4b. Federal Award Identifier:

5. Date Received by State:

6. State Application Identifier:

c. Organizational DUNS:

Department Name:

Division Name:

Street1:

Street2:

City:

County / Parish:

State:

Province:

Zip / Postal Code:

Country:

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

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:

Organizational Affiliation:

Telephone Number:

Fax Number:

Email:

STATE USE ONLY:

7. APPLICANT INFORMATION:

d. Address:

a. Legal Name:

e. Organizational Unit:

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

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

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

Frequency: Select the applicable frequency for the type of submission. This field is required.

Frequency is required: Select the applicable frequency for the type of submission.

1.c. Consolidated Application/Plan/Funding Request?

Consolidated Application/Plan/Funding Request: Indicate if the submission is a consolidated application/plan/funding request.

Version: Select the applicable version for the type of submission. This field is required.

Version is required: Select the applicable version for the type of submission.

8a. TYPE OF APPLICANT:

Other (specify):

b. Additional Description:

9. Name of Federal Agency:

10. Catalog of Federal Domestic Assistance Number:

CFDA Title:

a. Applicant:

b. Program/Project:

a. Start Date:

b. End Date:

a. Federal ($):

b. Match ($):

16. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?

Is Submission Subject to Review: Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. This field is required.

13. CONGRESSIONAL DISTRICTS OF:

14. FUNDING PERIOD:

15. ESTIMATED FUNDING:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

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

11. Descriptive Title of Applicant's Project:

12. Areas Affected by Funding:

Is Submission Subject to Review is required: Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process.

17. Is The Applicant Delinquent On Any Federal Debt?

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:

Organizational Affiliation:

Telephone Number:

Email:

Fax Number:

Signature of Authorized Representative:

Date Signed:

18. 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) Authorized Representative:

Attach supporting documents as specified in agency instructions.

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

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

Is The Applicant Delinquent On Any Federal Debt: This question applies to the applicant organization, not the person who signs as the authorized representative. This field is required.

Is The Applicant Delinquent On Any Federal Debt is required: This question applies to the applicant organization, not the person who signs as the authorized representative.

** I Agree Form Attachments:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

Consolidated Application/Plan/Funding Request Explanation:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

Applicant Federal Debt Delinquency Explanation:

APPLICATION FOR FEDERAL ASSISTANCE SF-424 - MANDATORY

1.

OMB Number: 4040-0007 Expiration Date: 01/31/2019

ASSURANCES - NON-CONSTRUCTION PROGRAMS

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND

IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

NOTE:

Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.

As the duly authorized representative of the applicant, I certify that the applicant:

Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability (including funds sufficient to pay the non-Federal share of project cost) to ensure proper planning, management and completion of the project described in this application.

Act of 1973, as amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee- 3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and, (j) the requirements of any other nondiscrimination statute(s) which may apply to the application.

2.

Will give the awarding agency, the Comptroller General of the United States and, if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives.

3.

Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain.

4.

Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.

5.

Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).

6.

Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to:

(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C.§§1681- 1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Previous Edition Usable Standard Form 424B (Rev. 7-97)Prescribed by OMB Circular A-102 Authorized for Local Reproduction 7.

Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally-assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases.

8.

Will comply, as applicable, with provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds.

Standard Form 424B (Rev. 7-97) Back 9.

12.

Will comply, as applicable, with the provisions of the Davis- Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§327- 333), regarding labor standards for federally-assisted construction subagreements.

Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.

10.

Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.

11.

Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (P.L. 93-523); and, (h) protection of endangered species under the Endangered Species Act of 1973, as amended (P.L. 93- 205).

13.

Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO 11593(identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§469a-1 et seq.).

14.

Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance.

15.

Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance.

16.

Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead-based paint in construction or rehabilitation of residence structures.

17.

Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, "Audits of States, Local Governments, and Non-Profit Organizations."

18.

Will comply with all applicable requirements of all other Federal laws, executive orders, regulations, and policies governing this program.

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

TITLE

DATE SUBMITTED

APPLICANT ORGANIZATION

Will comply with the requirements of Section 106(g) of the Trafficking Victims Protection Act (TVPA) of 2000, as amended (22 U.S.C. 7104) which prohibits grant award recipients or a sub-recipient from (1) Engaging in severe forms of trafficking in persons during the period of time that the award is in effect (2) Procuring a commercial sex act during the period of time that the award is in effect or (3) Using forced labor in the performance of the award or subawards under the award.

19.

SECTION A - BUDGET SUMMARY

BUDGET INFORMATION - Non-Construction Programs OMB Number: 4040-0006 Expiration Date: 01/31/2019 Grant Program Function or Activity (a) Catalog of Federal Domestic Assistance Number (b) Estimated Unobligated Funds New or Revised Budget Federal (c) Non-Federal (d) Federal (e) Non-Federal (f) Total (g)

5. Totals 4.

3.

2.

1.

Standard Form 424A (Rev. 7- 97) Prescribed by OMB (Circular A -102) Page 1

SECTION B - BUDGET CATEGORIES

7. Program Income

d. Equipment

e. Supplies

f. Contractual

g. Construction

h. Other

j. Indirect Charges

k. TOTALS (sum of 6i and 6j)

i. Total Direct Charges (sum of 6a-6h) (1) Authorized for Local Reproduction Prescribed by OMB (Circular A -102) Page 1A Standard Form 424A (Rev. 7- 97)

GRANT PROGRAM, FUNCTION OR ACTIVITY

(2) (3) (4) (5) Total

6. Object Class Categories

a. Personnel

b. Fringe Benefits

c. Travel Total Total Total Total Total

SECTION D - FORECASTED CASH NEEDS

14. Non-Federal

SECTION C - NON-FEDERAL RESOURCES

(a) Grant Program

(b) Applicant

(d) Other Sources

(c) State (e)TOTALS 8.

9.

10.

11.

12. TOTAL (sum of lines 8-11)

15. TOTAL (sum of lines 13 and 14)

13. Federal Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

FUTURE FUNDING PERIODS (YEARS)

SECTION F - OTHER BUDGET INFORMATION

SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT

Authorized for Local Reproduction 16.

17.

18.

19.

20. TOTAL (sum of lines 16 - 19)

21. Direct Charges:

22. Indirect Charges:

23. Remarks:

(a) Grant Program (b)First

(c) Second

(d) Third

(e) Fourth Standard Form 424A (Rev. 7- 97) Prescribed by OMB (Circular A -102) Page 2 Preaward Compliance Review Report for All Applicants and Recipients Requesting EPA Financial Assistance Note: Read Instructions before completing form.

OMB Number: 2030-0020 Expiration Date: 06/30/2017 I. A. Applicant/Recipient (Name, Address, City, State, Zip Code) Name:

Address:

City:

State:

Zip Code:

B. DUNS No.

II. Is the applicant currently receiving EPA Assistance?

VI. Is the applicant requesting EPA assistance for new construction? If no, proceed to VII; if yes, answer (a) and/or (b) below.

a. If the grant is for new construction, will all new facilities or alterations to existing facilities be designed and constructed to be readily accessible to and usable by persons with disabilities? If yes, proceed to VII; if no, proceed to VI(b).

VII. Does the applicant/recipient provide initial and continuing notice that it does not discriminate on the basis of race, color, national origin, sex, age, or disability in its program or activities? (40 C.F.R 5.140 and 7.95)

a. Do the methods of notice accommodate those with impaired vision or hearing?

b. Is the notice posted in a prominent place in the applicant's offices or facilities or, for education programs and activities, in appropriate periodicals and other written communications?

c. Does the notice identify a designated civil rights coordinator?

VIII. Does the applicant/recipient maintain demographic data on the race, color, national origin, sex, age, or handicap of the population it serves? (40 C.F.R. 7.85(a)) IX. Does the applicant/recipient have a policy/procedure for providing access to services for persons with limited English proficiency? (40 C.F.R. Part 7, E.O. 13166) For the Applicant/Recipient I certify that the statements I have made on this form and all attachments thereto are true, accurate and complete. I acknowledge that any knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law. I assure that I will fully comply with all applicable civil rights statutes and EPA regulations.

A. Signature of Authorized Official B. Title of Authorized Official C. Date For the U.S. Environmental Protection Agency I have reviewed the information provided by the applicant/recipient and hereby certify that the applicant/recipient has submitted all preaward compliance information required by 40 C.F.R. Parts 5 and 7; that based on the information submitted, this application satisfies the preaward provisions of 40 C.F.R. Parts 5 and 7; and that the applicant has given assurance that it will fully comply with all applicable civil rights statures and EPA regulations.

A. *Signature of Authorized EPA Official B. Title of Authorized Official C. Date

* See Instructions Instructions for EPA FORM 4700-4 (Rev. 06/2014)

General. Recipients of Federal financial assistance from the U.S. Environmental Protection Agency must comply with the following statutes and regulations.

Title VI of the Civil Rights Acts of 1964 provides that no person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. The Act goes on to explain that the statute shall not be construed to authorize action with respect to any employment practice of any employer, employment agency, or labor organization (except where the primary objective of the Federal financial assistance is to provide employment). Section 13 of the 1972 Amendments to the Federal Water Pollution Control Act provides that no person in the United States shall on the ground of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under the Federal Water Pollution Control Act, as amended. Employment discrimination on the basis of sex is prohibited in all such programs or activities. Section 504 of the Rehabilitation Act of 1973 provides that no otherwise qualified individual with a disability in the United States shall solely by reason of disability be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. Employment discrimination on the basis of disability is prohibited in all such programs or activities. The Age Discrimination Act of 1975 provides that no person on the basis of age shall be excluded from participation under any program or activity receiving Federal financial assistance. Employment discrimination is not covered. Age discrimination in employment is prohibited by the Age Discrimination in Employment Act administered by the Equal Employment Opportunity Commission. Title IX of the Education Amendments of 1972 provides that no person in the United States on the basis of sex shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving Federal financial assistance. Employment discrimination on the basis of sex is prohibited in all such education programs or activities. Note: an education program or activity is not limited to only those conducted by a formal institution. 40 C.F.R. Part 5 implements Title IX of the Education Amendments of 1972. 40 C.F.R. Part 7 implements Title VI of the Civil Rights Act of 1964, Section 13 of the 1972 Amendments to the Federal Water Pollution Control Act, and Section 504 of The Rehabilitation Act of 1973. The Executive Order 13166 (E.O. 13166) entitled; "Improving Access to Services for Persons with Limited English Proficiency" requires Federal agencies work to ensure that recipients of Federal financial assistance provide meaningful access to their LEP applicants and beneficiaries.

Items “Applicant” means any entity that files an application or unsolicited proposal or otherwise requests EPA assistance. 40 C.F.R. §§ 5.105, 7.25. “Recipient” means any entity, other than applicant, which will actually receive EPA assistance. 40 C.F.R. §§ 5.105, 7.25. “Civil rights lawsuits and administrative complaints” means any lawsuit or administrative complaint alleging discrimination on the basis of race, color, national origin, sex, age, or disability pending or decided against the applicant and/or entity which actually benefits from the grant, but excluding employment complaints not covered by 40 C.F.R. Parts 5 and 7. For example, if a city is the named applicant but the grant will actually benefit the Department of Sewage, civil rights lawsuits involving both the city and the Department of Sewage should be listed. “Civil rights compliance review” means any review assessing the applicant’s and/or recipient’s compliance with laws prohibiting discrimination on the basis of race, color, national origin, sex, age, or disability. Submit this form with the original and required copies of applications, requests for extensions, requests for increase of funds, etc. Updates of information are all that are required after the initial application submission. If any item is not relevant to the project for which assistance is requested, write “NA” for “Not Applicable.” In the event applicant is uncertain about how to answer any questions, EPA program officials should be contacted for clarification. * Note: Signature appears in the Approval Section of the EPA Comprehensive Administrative Review For Grants/Cooperative Agreements & Continuation/Supplemental Awards form.

Certification for Contracts, Grants, Loans, and Cooperative Agreements

(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 of Lobbying Activities,'' 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.

If any 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 commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions. Submission of this statement 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 statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

* APPLICANT'S ORGANIZATION

* SIGNATURE:

* DATE:

* PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

Suffix:

Middle Name:

* Title:

* First Name:

* Last Name:

Prefix:

CERTIFICATION REGARDING LOBBYING

(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 an 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.

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

Statement for Loan Guarantees and Loan Insurance The undersigned states, to the best of his or her knowledge and belief, that:

OMB Number: 4040-0010 Expiration Date: 10/31/2019

* Applicant Organization Name:

Key Contacts Form Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Street1:

Street2:

* City:

County:

* State:

Province:

* Country:

* Zip / Postal Code:

* Telephone Number:

Fax:

* Email:

Enter the individual's role on the project (e.g., project manager, fiscal contact).

Enter the individual's role on the project (for example, project manager, fiscal contact).

Other Attachment File(s)

* Mandatory Other Attachment Filename:

To add more "Other Attachment" attachments, please use the attachment buttons below.

Form Attachments:

Project Narrative File(s)

* Mandatory Project Narrative File Filename:

To add more Project Narrative File attachments, please use the attachment buttons below.

Form Attachments:

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 Approved by OMB 4040-0013

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)

EPA estimates public reporting burden for the preparation of this form to average 30 minutes per response. This estimate includes the time for reviewing instructions, gathering and maintaining the data needed and completing and reviewing the form. Send comments regarding the burden estimate, including suggestions for reducing this burden, to U.S. EPA, Attn: Collection Strategies Division (MC 2822T), Office of Information Collection, 1200 Pennsylvania Ave., NW, Washington, D.C. 20460; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

The information on this form is required to enable the U.S. Environmental Protection Agency to determine whether applicants and prospective recipients are developing projects, programs and activities on a nondiscriminatory basis as required by the above statutes and regulations.:

Application: Select if the type of submission is an Application.:

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

Plan: Select if the type of submission is a Plan.:

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

Funding Request: Select if the type of submission is a Funding Request.:

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

Other: Select "Other" if submission is not an application, plan, or funding request.:

Annual: Select if the frequency of the submission is Annual.:

Frequency: Select the applicable frequency for the type of submission. This field is required.

Quarterly: Select if the frequency of the submission is Quarterly.:

Frequency: Select the applicable frequency for the type of submission. This field is required.

Other: Select "Other" if the frequency of the submission is other than quarterly or annual.:

Yes: Select if the submission is a consolidated application/plan/funding request.:

Consolidated Request: Indicate if the submission is a consolidated application/plan/funding request.

No: Select if the submission is not a consolidated application/plan/funding request.:

Version: Select the applicable version for the type of submission. This field is required.

Update: Select if this is a change to an accepted or approved submission.:

the person to contact on matters related to this application.:

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.:

Project: 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.:

State Review Available: Select if this submission was made available to the State Executive Order 12372 process for review.:

Is Submission Subject to Review: Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. This field is required.

State Review not selected: Select if the program is subject to E.O. 12372 but has not been selected by State for review.:

Is Submission Subject to Review: Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. This field is required.

State Review not needed: Select if the program is not covered by E.O. 12372.:

View Mandatory Project Narrative File:

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Delete Mandatory Project Narrative File:

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Yes: Select if the applicant is delinquent on any Federal debt.:

Is The Applicant Delinquent On Any Federal Debt: This question applies to the applicant organization, not the person who signs as the authorized representative. This field is required.

No: Select if the applicant is not delinquent on any Federal debt.:

Click here to view optional Project Narrative File:

Delete Optional Project Narrative File:

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Add Optional Project Narrative File:

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