RD 4284-1 AIC Application Form.pdf

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Microsoft Word - RD4284-01 Kelli.Kramer 6.5.0.20190320.3.935878 General Information Form RD 4284-1 Form Approved (09-24) OMB No.: 0570-0045 Expires 04/30/2027

AGRICULTURE INNOVATION CENTER PROGRAM

APPLICATION FORM AND INSTRUCTIONS

This form is mandatory for all AIC applications. Thoroughly review 7 CFR Part 4284 Subpart K before completing this form.

Provide general information about the applicant, application, and project below.

1.

Applicant Organization Must match box 8 of the SF-424.

Name:

2.

Project Director Identify the Project Director and the PD’s email address and phone number below.

Name:

Email:

Phone:

3.

Type of Organization Select one entity type, as defined in 7 CFR Part 4284 Subpart K. Note that if your application is selected for funding, you will be required to submit your organization’s legal documents and/or citations to demonstrate your organization type. Examples of required documentation include Articles of Incorporation, Certificates of Good Standing, and legal citations authorizing the establishment of your organization. Individuals are not eligible for assistance.

Commercial Organization (e.g. for-profit business) Indian Tribe Institution of Higher Education Local Government Nonprofit Organization State Government Provide information about the Center’s Board of Directors below.

4.

Board of Directors Role and Approvals Provide information about the responsibilities of the Center’s Board of Directors below.

a. Will the Center’s Board of Directors have approval over the Center’s budget?

Yes No

b. Will the Board of Directors have approval over personnel policies and decisions?

Yes No

c. Will the Board of Directors have approval over procurement policies and decisions?

Yes No

d. Will the Board of Directors have any other roles in the Center’s operation?

Yes No If yes, please describe below:

5.

Board of Directors Members Provide information about the organizations represented on the Center’s Board of Directors and the representatives below. The organizations and representations must already be committed at the time you submit your application.

Their commitment must be in the form of a signed letter on the organization’s letterhead that has been received by you prior to when you submit your application. Note: If your application is selected for funding, you will need to provide signed, written letters of commitment from the organizations identified below that match the information you provide in this application. If the information does not match, RBCS reserves the right to withdraw your award.

Organizatio n Name of Representative Date of Commitment Letter

a. General Agricultural Organization with the Most Members in the State Organization Name:

Number of Members:

Board of Directors

b. General Agricultural Organization with the Second Most Members in the State Organization Name:

Number of Members:

c. State (choose one) State Department of Agriculture, or its equivalent State Legislator District:

d. Commodity Organization Name:

Commodity Represented:

e. Commodity Organization Name:

Commodity Represented:

f. Commodity Organization Name:

Commodity Represented:

g. Commodity Organization Name:

Commodity Represented:

Describe the experience the Center, or its key personnel, have for each type of service listed below. Enter N/A for Name of Key Personnel if you are relying on the Center’s experience for this section, rather than a specific individual. If the Center, or its key personnel, do not have any experience for a type of service, leave that section blank. Note that if the Center, or at least two key personnel, do not have at least three years of experience for a type of service, that type of service is considered unallowable for the project. If the application is selected for funding, resumes for all key personnel must be provided. If the information in the resumes does not match what is provided below, RBCS reserves the right to withdraw the award.

6.

Business Development Name of Key Personnel Time Period Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel Outcomes of the Service Provide d Experience and Evidence of Capability 7.

Market Development Name of Key Personnel Time Period Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel Outcomes of the Service Provide d 8.

Organizational Assistance Name of Key Personnel Time Period Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel 9.

Financial Advisory Services Name of Key Personnel Time Period Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel Outcomes of the Service Provide d Outcomes of the Service Provide d 10.

Process Development Name of Key Personnel Time Period Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel Outcomes of the Service Provide d 11.

Product Development Name of Key Personnel Time Perio d Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel 12.

Value Chain Coordination Name of Key Personnel Time Period Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel Outcomes of the Service Provide d Outcomes of the Service Provide d Financial Capability 13.

Producer Grants Name of Key Personnel Time Period Provide d Numbe r of Times Provide d Role of the Center, or Key Personnel Outcomes of the Service Provide d Provide information about the applicant’s financial capability. If the application is selected for funding, the applicant’s audit for its most recent fiscal year must be provided, including the Letter to Managers. If the information in the audit does not match what is provided below, RBCS reserves the right to withdraw the award.

14.

Based on your organization’s most recent audit, what is your organization’s current ratio at the end of your most recent fiscal year? The current ratio is defined as current assets divided by current liabilities.

15.

Based on your organization’s most recent audit, what is your organization’s Cash on Hand at the end of your most recent fiscal year?

Use of Funds Provide information about the support of the agricultural community for the proposed project. The organizations providing support must be primarily agricultural in nature. General business development organizations, community-based organizations, and institutions of higher education are not considered agricultural organizations and their support will not be considered for this section.

16.

Support Letters List the names of the three Agricultural Organizations that have submitted a signed, written letter of support for your project. If your application is selected for funding, you will be required to provide the three letters of support.

The information on the letters must match the information provided in your application, or RBCS reserves the right to withdraw your award.

Name of Agricultural Organization Date of Support Letter Description of Support Provide information about the use of funds and scope of work for the proposed project.

17.

Project Description Briefly describe your project. Make sure you include details about how your project will assist Agricultural Producers with developing and/or marketing a Value-Added Agricultural Product.

Support of the Agricultural Community 18.

Center operation Answer the questions and provide the information requested on Center operations.

Is your Center already in operation?

Yes No If no, describe how your Center will start its operations.

19.

Center services Describe the services will your Center provide in the chart below.

Service (check all that apply) Key Personnel List names of personnel or titles if to-be-hired Description Method of Delivery (e.g. online, workshops, one-on-one) Business development Description:

Method of Delivery:

Market development Description:

Method of Delivery:

Organizational assistance Description:

Method of Delivery:

Financial advisory services Description:

Method of Delivery:

Process development Description:

Method of Delivery:

Product development Description:

Method of Delivery:

Value chain coordination Description:

Method of Delivery:

Grants to Agricultural Producers Description:

Method of Delivery:

20.

Budget Enter the budget information requested below.

Cate g or y of Expense Award Amount Matchin g Amount Total Salaries an d Wages Fringe Benefits Travel Supplies Contractual Othe r Total Direct Charges Indirect Charges Total Charges Program Income a.

Salaries and Wages Expenses Narrative List each employee who will be performing work for the project, including key personnel and administrative personnel, and the amount associated with the work. These costs should be reasonable for the services provided and conform to the established written policy of your organization. If you have more staff than fit in the chart, fill in 10 staff members and aggregate the remaining staff in row 11. If your application is selected for funding, we will request the additional information as part of the award process.

Name Title # of Hours or % FTE Amount by Year Federal Amount Match Amount Total Amount Name:

Title:

Y1:

Y2:

Y3 Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2:

Y3:

Name:

Title:

Y1:

Y2 Y3 Aggregate remaining Y1:

Y2:

Y3:

SALARIES/WAGES TOTAL

b.

Fringe Benefits Expenses Narrative Provide the fringe benefit rates for each of the project’s employees listed above. The costs of the fringe benefits should be reasonable and in accordance with established policies of your organization. If you have more staff than fit in the chart, fill in 10 staff members and aggregate the remaining staff in row 11. If your application is selected for funding, we will request the additional information as part of the award process.

N ame/Title Fringe Benefits Rate Federal Amount Match Amount Total Amount N ame:

Title:

N ame:

Title:

N ame:

Title:

N ame:

Title:

N ame:

Title:

N ame:

Title:

N ame:

Title:

N ame:

Title:

N ame:

Title:

N ame:

Title:

11 Aggregate remaining

FRINGE BENEFITS TOTAL

c.

Travel Expenses Narrative Explain the purpose for each Trip Request. Note that travel costs are limited to those allowed by written procedures for your organization. In the case of air travel, project participants must use the lowest reasonable commercial airfares. For organizations that have no formal travel polity and commercial organizations, allowable travel costs may not exceed those established by the Federal Travel Regulations, issue by GSA, including the maximum per diem and subsistence rates prescribed in those regulations. This information is available at www.gsa.gov . If you have more trips than fit in the chart, fill in 10 trips and aggregate the remaining trips in row 11. If your application is selected for funding, we will request the additional information as part of the award process.

Trip Description Name(s) of Travelers Federal Amount Match Amount Total Amount 1 Destination:

Time Period:

Purpose:

2 Destination:

Time Period:

Purpose:

Destination:

Time Period:

Purpose:

Destination:

Time Period:

Purpose:

5 Destination:

Time Period:

Purpose:

Destination:

Time Period:

Purpose:

Destination:

Time Period:

Purpose:

Destination:

Time Period:

Purpose:

9 Destination:

Time Period:

Purpose:

10 Destination:

Time Period:

Purpose:

11 Aggregate Remaining

TRAVEL TOTAL

d.

Supplies Expenses Narrative List the items that cost less than $5,000 per unit and describe how they will support the project. If you have more supplies than fit in the chart, fill in 10 supplies and aggregate the remaining supplies in the row 11. If your application is selected for funding, we will request the additional information as part of the award process.

Item and Purpose Cost p e r Unit # of Units Purchase Time Period Federal Amount Match Amount Total Amount Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Aggregate remaining

SUPPLIES TOTAL

e.

Contractual Expenses Narrative This section includes all procurement contracts for things like materials, software, and consultants. It also includes subawards, which are the Grants to Producers. If there is more than one contractor/consultant, each must be described separately. The subawards can be listed as an aggregate amount with the purpose of the subawards. See the row 10 of the table below. If you have more contracts than fit in the chart, fill in 10 contracts and aggregate the remaining contracts in the row 11. If your application is selected for funding, we will request the additional information as part of the award process.

Name and Purpose Hourly/Fla t Rate Federal Amount Match Amount Total Amount Name:

Purpose:

Name:

Purpose:

Name:

Purpose:

Name:

Purpose:

Name:

Purpose:

Name:

Purpose:

Name:

Purpose:

Name:

Purpose:

Name:

Purpose:

Name: Grants to Agricultural Producers Purpose:

N A Name: Aggregate remaining Purpose:

N A

TOTAL CONTRACTS

By checking this box, I affirm that my organization followed the same policies and procedures used for procurements from non-Federal sources, which reflect applicable State and local laws and regulations and conform to the Federal laws and standards identified in 2 CFR §

200.317 through § 200.327, as applicable. If the contractor(s)/consultant(s) is/are not already selected, I affirm that my organization will follow the same requirements.

f. Other Expenses Narrative Include any direct expenses not covered in any of the previous budget categories. Examples of expenses that can be included in this section include meetings/conferences, communications, rental expenses, advertisements, publication costs, and data collection, if applicable and allowable. If you have more expenses than fit in the chart, fill in 10 expenses and aggregate the remaining expenses in the row 11. If your application is selected for funding, we will request the additional information as part of the award process.

Item and Purpose Time Period Federal Amount Match Amount Total Amount Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item:

Purpose:

Item: Aggregate of remaining expenses Purpose:

OTHE

R

EXPENSES TOTAL

g.

Indirect Expenses Narrative If you have a Negotiated Indirect Cost Rate Approval (NICRA) from your cognizant agency, list the information below. If you do not have a NICRA, you may choose to charge all expenses as direct expenses identified in the categories above, or you can choose to use the de minimis rate, which is 10% of Modified Total Direct Costs (MTDC). See 2 CFR § 200.414(f) for more information. If you choose the de minimis rate, fill in the chart below with 10% as the Indirect Cost Rate, MTDC as the Base, and include the amounts.

Indirect Cost Rate (%) Base (e.g. MTDC, Salaries & Fringe) Federal Amount Match Amount Total Amount h.

Matching Funds Narrative List the sources, purpose, and amounts of matching funds below. If you have more than 3 sources, you can use the third line to aggregate the remaining amounts, and we will request more specific information if your application is selected for funding. Note that if one or more third parties will be contributing matching funds and your application is selected for funding, you will be required to submit letters from the third parties that identify the amount contributed, the allowable used of funds, and the time period of availability. These letters verifying the Matching funds must be provided to your organization prior to submitting your application. They must be on the organization's letterhead and signed. The information in the letters must match the information provided in your application, or RBCS reserves the right to withdraw your application.

Source (Name of Organization) Purpose Amoun t

MATCHING FUNDS TOTAL

i.

Program Income Narrative Enter a description of how program income will be calculated and earned, if applicable. Note that if you are charging fees for services provided, you must address program income.

Provide the information for the evaluation criteria below. This is the information that RBCS will use to evaluate the merit of your application. See 7 CFR § 4284.1040(c) for more information.

21.

Federal Award Management Describe up to five Federal awards your organization has received in the table below. This information will be evaluated in accordance with 7 CFR § 4284.1040(c)(1). RBCS will search USASpending.gov, or its successor system, to verify the awards listed below and SAM.gov, or its successor system, and USDA internal systems to check for performance deficiencies. If the award cannot be verified or there is a performance deficiency, it will not be counted for scoring purposes.

a. Federal Award 1 Title:

Program Name:

Agency Name:

Federal Awar d Identification Number:

Period of Performance:

Start Date:

End Date:

Purpose of Award:

Evaluation Criteria b . Federal Award 2 Title:

Program Name:

Agency Name:

Federal Awar d Identification Number:

Period of Performance:

Start Date:

End Date:

Purpose of Award:

c. Federal Award 3 Title:

Program Name:

Agency Name:

Federal Awar d Identification Number:

Perio d of Performance:

Start Date:

End Date:

Purpose of Award:

d. Federal Award 4 Title:

Program Name:

Agency Name:

Federal Awar d Identification Number:

Period of Performance:

Start Date:

End Date:

Purpose of Award:

e. Federal Award 5 Title:

Program Name:

Agency Name:

Federal Awar d Identification Number:

Period of Performance:

Start Date:

End Date:

Purpose of Award:

22.

Qualifications of Key Personnel Provide information about the project’s key personnel below. We will only evaluate information for up to four key personnel, regardless of how many are assigned to the project, so we recommend that you choose the key personnel that demonstrate the best qualifications if you have more than four.

a. Name of Key Personnel Is this person currently employed by the applicant organization or on contract?

Yes No Description of Qualifications fo r this Project Service Provided Number of Times Dates Provided Role Outcomes Business Development Market Development Process Development Product Development Organizational Assistance Financial Advisory Services Value Chain Coordination Producer Grants b . Name of Key Personnel Is this person currently employed by the applicant organization or on contract?

Yes No Description of Qualifications fo r this Project Service Provided Number of Times Dates Provided Role Outcomes Business Development Market Development Process Development Product Development Organizational Assistance Financial Advisory Services Value Chain Coordination Producer Grants

c. Name of Key Personnel 3 Is this person currently employed by the applicant organization or on contract?

Yes No Description of Qualifications fo r this Project Service Provided Number of Times Dates Provided Role Outcomes Business Development Market Development Process Development Product Development Organizational Assistance Financial Advisory Services Value Chain Coordination Producer Grants

d. Name of Key Personnel Is this person currently employed by the applicant organization or on contract?

Yes No Description of Qualifications fo r this Project Service Provided Number of Times Dates Provided Role Outcomes Business Development Market Development Process Development Product Development Organizational Assistance Financial Advisory Services Value Chain Coordination Producer Grants 23.

Outreach Plan a.

Goals List the Goals and performance metrics for your proposed project. Note that atleast one goal must be related to increasing and improving the ability of Local Agricultural Producers to market Value-Added Agricultural Products.

Goal Metric Baseline Tar g et b.

Identified Need Describe the need(s) your proposed project will address in your service area and connect it to the Goals you described above. If applicable, describe how the need(s) are in an underserved/distressed area.

c.

Customer identification Describe your plan for identifying customers. If applicable, describe how the plan will identify customers in an underserved/distressed area.

24.

Coordination, collaboration, and partnerships with other organizations Describe your coordination, collaboration, and partnerships with other organizations for the proposed project. If applicable, include a description of how the coordination, collaboration, or partnership connects the proposed project to an underserved/distressed area.

a.

Organization 1 Name:

Description of relationship an d services to be provided Gaps filled by relationship How does the coordination, collaboration, or partnership connect the proposed project to an underserved/distressed area?

b.

Organization 2 Name:

Description of relationship an d services to be provided Gaps filled by relationship How does the coordination, collaboration, or partnership connect the proposed project to an underserved/distressed area?

c.

Organization 3 Name:

Description of relationship an d services to be provided Gaps filled by relationship How does the coordination, collaboration, or partnership connect the proposed project to an underserved/distressed area?

d.

Organization 4 Name:

Description of relationship an d services to be provided Gaps filled by relationship How does the coordination, collaboration, or partnership connect the proposed project to an underserved/distressed area?

25.

Scope of the Project a.

Service area.

Number of counties in the State the Center is located:

Number of counties in the State that the Center will serve:

b.

Types of services.

Check the boxes for the services you will provide to Agricultural Producers. Note that services can only be provided to Agricultural Producers. They may not be provided to processors, manufacturers, distributors, aggregators, marketers, or customers.

Business development services, such as feasibility studies, business plans, and other types of technical assistance that supports business development.

Market development services, such as marketing plans, branding, and customer identification.

Organizational assistance, such as legal and technical advisory services related to the development, expansion, or operation of a business.

Financial advisory services related to the development, expansion, or operation of a business, such as assistance with obtaining credit for operating costs, training on using financial management software, and guidance on use of cash flow.

Process development services, such as engineering services, scale production assessments, systems development.

Product development, such as idea generation, concept testing, feasibility and cost analysis, product taste-testing, demographic and other types of consumer analysis, production analysis, recipe development, and evaluation of packaging and labeling options.

Value chain coordination, such as connecting an Agricultural Producer to a distribution system, processing facility, or commercial kitchen.

Grants to Agricultural Producers for any of the above services c.

Agricultural Commodities.

Describe the proposed project’s capacity to provide services to support Value-Added Agricultural Products from multiple Agricultural Commodities in addition to the four represented on the Board of Directors.

d.

Unique services Describe how the proposed project will contribute unique services in the proposed service area. Unique means that the services are not already provided in the service area.

e.

Physical location Describe the locations at which services will be provided.

Describe how your project meets up to two Rural Development priorities, as described on the program website and in the annual notice at the time of application.

Priority 1 Priority 2 Rural Development Priorities Below is a list of the standard documents that will be required if your application is selected for an award.

Additional documents may be required at the discretion of the Agency.

Evidence of legal incorporation Resumes for key personnel Written commitments for the Center’s Board of Directors Applicant’s independent audit from its most recent fiscal year Agricultural community support letters Additional budget information, if needed Summary of Documentation for an Award A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 0570-0045. Public reporting for this collection of information is estimated to be approximately 40 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

All responses to this collection of information are voluntary. However, in order to obtain or retain a benefit, the information in this form is required 7 CFR 4284 subpart K. Rural Development has no plans to publish information collected under the provisions of this program. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Rural Development Innovation Center, Regulations Management Division at ICRMTRequests@usda.gov