wic spg concept paper rfa final fy2011.pdf

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FY 2011 WIC SPECIAL PROJECT GRANTS

REQUEST FOR APPLICATIONS FOR

CONCEPT PAPER DEVELOPMENT GRANTS

(APPLICATION B)

Applications Deadline Due: April 29, 2011

OMB Control Number 0584-0512

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SPECIAL SUPPLEMENTAL NUTRITION PROGRAM

FOR WOMEN, INFANTS, AND CHILDREN (WIC)

FY 2011 SPECIAL PROJECT GRANTS

REQUEST FOR APPLICATION (RFA)

CONCEPT PAPER DEVELOPMENT

INTRODUCTION

The USDA Food and Nutrition Service (FNS) expects to have approximately $3,000,000 in fiscal year (FY) 2011 available for Special Project Grants to WIC State agencies, subject to appropriation. Grant funds will be available only to the 90 WIC State agencies responsible for administering WIC in the States, Territories, and Indian Tribal Organizations (ITOs).

There are two types of WIC Special Project Grants: Full Grants and Concept Paper

Development Grants. This RFA (Application B) is for Concept Paper Development Grants only. A separate RFA (Application A) is available for States planning to submit a proposal for a Full Grant.

Up to $98,000 in FY 2011 will be used to develop concept papers into Full Grant proposals for submission for the FY 2012 WIC Special Project Grants application cycle, pending availability of funds. Up to four (4) grants of up to $24,500 each will be awarded to State agencies by September 30, 2011. The actual number of concept paper awards will depend on the quality of the application(s), the availability of funds, and how much of the FY 2011 funds are used to fund the FY 2011 WIC Special Project Full Grants.

FNS reserves the right to cancel this RFA in whole or in part if funds are not available.

The main focus area of interest for FY 2011 Concept Paper Development Grants is on proposals to facilitate cross-program participation between WIC and other assistance programs and services that may benefit WIC participants. This focus area is intended to develop and test innovative strategies by State agencies to increase WIC program participation among those who are eligible and who participate in other assistance programs and to promote participation of WIC participants in other programs and services for which they are eligible, for example, by conveying messages about the potential benefits of making application information available.

Proposals under this focus area may also suggest ways to facilitate WIC program participation through collaboration efforts with other agencies, such as child welfare and housing assistance.

Concept paper proposals will be considered that focus on all WIC-related program areas as they relate to facilitating cross-program participation between WIC and other programs and services (see “Focus Area for Concept Papers” section for more information).

Concept paper proposals with other focus areas will also be considered as long as they suggest ways for State agencies to develop, implement, and evaluate new or innovative methods of service delivery to meet the changing needs of WIC participants.

Concept Paper Grants should:

- Demonstrate national or regional significance.

- Suggest innovative or creative approaches to improving the delivery of WIC services.

- Be transferrable to other WIC Programs in the region or country.

- Upon completion, have the capacity to develop into a significant three year Special

Project Grant.

The most appropriate grant proposals will be those that: (1) include a clear description of the planned project or intervention and how it would address its focus area; (2) include the major goals and clearly defined objectives and outcome measures of the project; (3) explain how the project would be implemented and discuss its sustainability and transferability; and (4) indicate plans for an evaluation component.

State agencies may not submit more than one proposal for a Concept Paper Development

Grant, although they may submit applications for both a Concept Paper Development Grant and a Full Grant in the same year for different projects.

The following steps outline the process of applying for FY 2011 Concept Paper Development

Grants:

State agencies must submit their applications for FY 2011 Concept Paper

Development Grants by April 29, 2011.

The concepts evaluated as most promising will be selected for funding by September

30, 2011.

Each State agency selected for funding should include an individual with experience in designing, developing, implementing and evaluating social or public health research projects.

The person could be a social scientist or someone with a public health nutrition or public health research background from a university, institute, consulting firm or government agency. This person should work with the WIC State agency and any participating local agencies to develop the concept paper into a full grant proposal. FNS prefers, to the extent possible, that this person also be responsible for the evaluation of the Special Project if it is selected for FY 2012 funding. This will help ensure continuity between the development of the grant proposal and subsequent evaluation of the project. State agencies are responsible for entering into and administering any necessary subcontracts and for ensuring that grant proposals are completed in time to submit for FY 2012 Special Project

Grant funds (expected to be around April, 2012).

A State agency that receives a concept paper development grant must submit a fully developed grant proposal for consideration of FY 2012 Special Project Grants funds by the deadline for such proposals (around April, 2012), and grant funds for FY 2011

Concept Paper Development Grants must be expended by September 30, 2012.

State agencies that do not submit concept papers or whose concept papers are not selected for funding will still be allowed to submit proposals for FY 2012 Special

Project Grants funds.

FNS will use a competitive award process to select grant proposals for funding with

FY 2012 Special Project Grants money. However, grant funding in FY 2012 is not guaranteed.

WHO MAY APPLY

As specified in legislation, these grants are available only to the 90 WIC State agencies responsible for administering WIC in States, Territories, and Indian Tribal Organizations

(ITOs). Concept Paper Development Grants may be awarded to individual State agencies or to a consortium of State agencies. FNS encourages smaller State agencies or ITOs to consider collaborating with other State agencies on concept papers. Each State agency may submit only one concept paper. If a State agency submits a concept paper as part of a consortium of agencies, it may not also submit one individually. State agencies that apply for FY 2011 WIC Special Project Grants (Application A) are also allowed to submit applications for FY 2011 Concept Paper Development funding. State agencies are allowed to receive funding for both Concept Papers and WIC Special Project Grants, but they must be for different projects.

CONCEPT PAPER APPLICATION FORMAT

State agencies should submit a narrative concept paper that provides the following information:

Name, address, and phone number of the appropriate State agency contact person;

A description of the problem that the proposed project addresses and how the expected results of the project can be used to improve program services at either the regional or national level;

Project goals and objectives;

Essential features of the project design including a description of how the project will be accomplished and the goals achieved, A timeline listing key tasks and key personnel responsible.

A description of the proposed concept’s potential impact and sustainability in improving the delivery of WIC services and the proposed concept’s potential to be transferred to or replicated by other WIC State agencies

A description of how the concept paper project will be expanded into a full grant proposal and what oversight will be provided to ensure timely completion of the grant proposal for submission for FY 2012 grant funds.

Concept papers should meet the following formatting guidelines:

five page maximum length, exclusive of any letters of commitment or support and any resumes or curriculum vitas, 8 ½” by 11” paper, single-spaced text, at least 1” margins on top, bottom, and sides, 12 point font size, numbered pages, printing on one side of page only, no color paper, and

Electronic Application Procedure

1. Electronic Application Submission Through Grants.Gov. :

Applicants may only apply for this opportunity directly through the website www.grants.gov. Only WIC State agencies are eligible to apply.

2. The number of pages for the entire Application should be no more than 25 pages, excluding appendices, with narrative in a 12 point font size. Appendices may not exceed 15 pages, for a total application package of not more than 40 pages.

3. State agencies must submit an application package which includes a grant application, a Standard Form 424, APPLICATION FOR FEDERAL ASSISTANCE, Standard

Form 424A, BUDGET SUMMARY, Standard Form 424B, ASSURANCES, and the additional certifications as included in the attachments to this solicitation document.

The regulations governing the attached certification (i.e., Certification Regarding

Lobbying) require that a grantee submit the required certification with each new submission of a grant at the time of application.

4. The complete application package must be uploaded on www.Grants.gov on or before Friday, April 29, 2011 at 5:00 PM, Eastern Daylight Savings time.

Applications received after the deadline date and/or time will be deemed ineligible and will not be reviewed or considered. FNS WILL NOT consider any additions or revisions to applications once they are received. FNS will not accept mailed or hand-delivered applications.

http://www.grants.gov/

5. There is a requirement for applicants of Federal Government awards to have a Data

Universal Numbering System (DUNS) number. If your agency has not yet obtained a number, you will need to contact Dun & Bradstreet at 1-800-234-3867 to register for a number. There is no charge to obtain a DUNS number. The DUNS number will serve as a means of tracking and identifying applications for Federal assistance and is required to be included on all applications for Federal assistance; regardless of the method by which they are submitted. The DUNS number is also required to complete the additional steps to become a registered Grants.gov user. To apply online through http://www.grants.gov/ there are a number of other steps in the registration process that will be required of you before you can submit applications electronically including registering in the Federal Government's Central Contractor Registry (CCR).

We urge you to visit the grants.gov web page (http://www.grants.gov/) and click on the "Getting Started" tab well in advance of the submission deadline to get a thorough understanding of the steps you will need to follow to apply for Federal grant opportunities.

6. When the applicant submits their application/proposal via www.grants.gov they must send an e-mail to leslie.byrd@fns.usda.gov, advising that their proposal has been submitted through the www.grants.gov portal and that the applicant has received a confirmation notice from www.grants.gov that their application was accepted by the system. This e-mail submission to the FNS Grants Officer must be received no later than 5:00 PM. Eastern Daylight Saving Time on Friday, April 29, 2011.

We strongly recommended that you begin the submission process sufficiently in advance of the due date to ensure your application package is received on or before the deadline in case there are problems with the government-wide website. It is your responsibility to meet the Friday, April 29, 2011, 5:00 PM, Eastern Daylight Saving Time deadline. As noted above, late applications will not be considered in the competition. Also, emailed and faxed applications will not be accepted. Furthermore, we will not consider additions or revisions to applications once they are received by FNS

If there are any questions regarding this Request for Applications for Concept Paper

Development Grants, please contact Leslie Byrd of the Grants & Fiscal Policy Division at

703-305-2867.

mailto:leslie.byrd@fns.usda.gov

TERMS AND CONDITIONS OF AWARD

The Agency is conducting the Women, Infants, and Children (WIC) Special Project Grant as authorized under Public Law 108-447.

The period of performance of the cooperative agreement shall be from the date of the award through September 30, 2012. All expenditures paid with funds provided by the agreement must be incurred for authorized activities which take place during this period, unless stipulated otherwise.

In carrying out the purposes of the cooperative agreement, the grantee shall be responsible for:

1. Managing the cooperative agreement consistent with legislation, administrative rules, regulations, and procedures of the State, including coordination and approval of all accounting procedures and with applicable Federal administrative requirements contained in OMB Circulars A-21, A-87, A-122, and A-133 and the regulations implementing them. Also, adherence is required to the 2 CFR Parts 25, 170, and 175, 7 CFR Parts 15, 3015, 3016, 3017, 3018, 3019, 3021, 3052, 40 CFR Part 31.34, and

41 CFR 1-15.2 (FAR Part 31). A full listing of the applicable documents can be found in Attachment 2, Terms and Conditions of Award.

2. Suspension/Debarment. The grantee agrees to ensure that all sub-grantees are neither excluded nor disqualified under the suspension and debarment rules found at 7 CFR sec. 3017.300 by doing any one of the following:

a) Checking the Excluded Parties List System (EPLS) found at www.epls.gov

b) Collecting a certification that the entity is neither excluded nor disqualified. Since a Federal certification form is no longer available, the grantee or sub-grantee electing this method must devise it own.

c) Including a clause to this effect in the sub-grant agreement and in any procurement contract expected to equal or exceed $25,000, awarded by the grantee or a sub-grantee under its grant or sub-grant.

3. Drug-Free Workplace (DFW) Rules. The grantee agrees to (A) make a good faith effort, on a continuing basis, to maintain a DFW (including taking specific actions described at 7 CFR Sec. 3021.200 through 3021.230); and (B) identify all workplace locations where work under Federal award will be performed (7CFR sec. 3021.200).

Since Federal entities will no longer collect a paper certification, this may include the following:

a) Notifying all sub-grantees and contractors of the Drug Free Workplace rules,

b) Making conforming changes to your internal procedures, directives, training materials, etc.

http://www.epls.gov/

c) Incorporating the new rules into your sub-grantee monitoring practices.

4. The grantee shall submit an original and an electronic copy of the Quarterly progress report to the FNS Program Officer (see address on page 10). The first report should reflect progress up to the end of the first quarter after the effective date of the Grant

Agreement. At a minimum all Quarterly progress reports should include:

A narrative description of the project’s progress, tasks completed, and roadblocks or problems, Identification of tasks or activities initiated, or completed, from proposed timeline with a description and rational for deviations, For each major task, a description of activities performed or completed during the quarter, Identification and description of any major problems or delays encountered, with a discussion of how they will be resolved and/or how they may impact the schedule, outcome measures, budget, or the grantees ability to utilize funds within the specified time period, A description of key tasks and activities planned for the upcoming quarter, and

Any other pertinent information, which may include deliverables.

Any problems, delays or adverse conditions that impair the ability to meet the objectives should be reported to FNS immediately. The notification should include information on any action taken or contemplated.

5. Final Progress Report. The grantee shall submit one original signed and an electronic copy of the final progress report to the FNS Program Officer (see address below) by

December 31, 2012.

6. Quarterly Financial Reports. Each quarterly report should reflect expenditures set forth in the terms and conditions. This report must be certified by the Recipient's chief fiscal officer or an officer of comparable rank.

Grantees will electronically enter their quarterly and final financial status reports (SF-

425) into the FNS Food Programs Reporting System (FPRS). Reporting requirements and instructions will be provided to all awarded grantees.

7. Final Financial Reports. As stated above, grantees are expected to electronically enter the final financial status report (SF-425) into the FNS Food Programs

Reporting System (FPRS), unless otherwise notified. The grantee shall enter its

Final SF-425 data within 90 days of the expiration date of the grant agreement.

This report must be certified by the grantee’s chief fiscal officer or an officer of comparable rank.

8. Application for a WIC Special Project Full Grant in FY 2012. The application for a full grant in FY 2012 shall adhere to the solicitation materials and instructions contained in next year’s Request for Applications.

A signed original and an electronic copy of the Quarterly and Final Progress Reports shall be submitted to:

Melanie Haake

Melanie.Haake@fns.usda.gov

2011 WIC Special Project Grant Program Officer

USDA Food and Nutrition Service

3101 Park Center Drive, 5 th

Floor

Alexandria, VA 22302

FOCUS AREA FOR CONCEPT PAPERS

The main focus area of interest for FY 2011 Concept Paper Development Grants is on proposals to facilitate cross-program participation between WIC and other assistance programs and services that may benefit WIC participants. This focus area is intended to develop and test innovative strategies by State agencies to increase WIC program participation among those who are eligible and who participate in other assistance programs and to promote participation of WIC participants in other programs and services for which they are eligible, for example, by conveying messages about the potential benefits of making application information available.

Proposals under this focus area may also suggest ways to facilitate WIC program participation through collaboration efforts with other agencies, such as child welfare and housing assistance.

Concept Paper proposals will be considered that focus on all WIC-related program areas as they relate to facilitating cross-program participation between WIC and other programs and services with the following two caveats: (1) the concept papers must be able to demonstrate that the proposed concept has the potential to be transferred to or is replicable by other WIC

State agencies and (2) the proposed concept must fall within an allowable area for expenditure of WIC funds. Otherwise, all WIC program areas are open for consideration and may include, but are not restricted to one or more of, the following areas:

Administration

Screening/Eligibility Determination

Referrals

Nutrition Services

Nutrition Risk Assessment

Obesity Prevention

Food Packages

Breastfeeding

Value-Enhanced Nutrition Assessment in WIC (VENA)

Vendor Management

Concept Paper proposals with other focus areas will also be considered as long as they suggest ways for State agencies to develop, implement and evaluate new or innovative methods of service delivery to meet the changing needs of WIC participants.

Concept Paper Grants should:

- Demonstrate national or regional significance.

- Suggest innovative or creative approaches to improving the delivery of WIC services.

- Be transferrable to other WIC Programs in the region or country.

- Upon completion, have the capacity to develop into a significant three year Special

Project Grant.

Multiple WIC State agencies and/or ITOs may join together to submit a concept paper, as long as one of the agencies is designated the lead agency.

The most appropriate grant proposals will be those that: (1) include a clear description of the planned project or intervention and how it would address its focus area, if funded in FY

2012; (2) include the major goals and clearly defined objectives and outcome measures of the project; (3) explain how the project would be implemented and discuss its sustainability and transferability; and (4) indicate plans for an evaluation component.

It is recommended that preparers of applications for Concept Papers Development Grants review the evaluation criteria listed in the RFA for further guidance on what should be included in the application.

EVALUATION OF CONCEPT PAPERS

FNS will convene a panel to review each Concept Paper. The papers will be evaluated using the evaluation criteria and weights specified below:

WEIGHTS: Assign scores using the following scale:

15-Point Scale 1-3 = Unsatisfactory; 4-6 = Fair; 7-9= Satisfactory;

10-12 = Good; 13-15= Excellent.

20-Point Scale 1-4 = Unsatisfactory; 5-8 = Fair; 9-12 = Satisfactory;

13-16 = Good; 17-20 = Excellent

TECHNICAL EVALUATION CRITERIA AND WEIGHTS

1. The significance of the problem to be addressed is 15 demonstrated and specific gaps or weaknesses in regional or national services have been identified and will be addressed through the proposed project.

2. Uniqueness and innovation of project goals, objectives, and 10 design.

3. Potential contribution of the project to facilitate cross-program 20 participation between WIC and other assistance programs and services that may benefit WIC participants or the project’s potential contribution to improving methods of service delivery to meet the changing needs of WIC participants.

4. Project goals and objectives are clearly identified and appropriate. 20

Objectives are linked to project goals and measurable.

5. Project design and implementation tasks follow directly from 20 project goals and objectives and the necessity for the tasks are adequately explained.

6. Appropriateness of the description of how the concept paper 15 project will be expanded into a full grant proposal.

APPLICATION PROCEDURES

The complete application package must be submitted via www.grants.gov no later than 5:00

PM Eastern Daylight Saving Time, Friday, April 29, 2011. The following forms should be included in the submission:

STANDARD FORMS

_____ Standard Form 424, Application for Federal Assistance

_____ Standard Form 424A, Budget Summary

_____ Standard Form 424B, Assurances - Non-Construction Programs

CERTIFICATION

_____ SF-LLL Certification Regarding Lobbying - Contracts, Grants, Loans, and

Cooperative Agreements

REQUIRED FORMS FOR STATE AGENCIES ONLY

1. AD-1047- CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND

OTHER RESPONSIBILITY MATTERS

2. AD-1048- CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNTARY EXCLUSION- LOWER TIER COVERED

TRANSACTIONS

3. AD-1052- CERTIFICATION REGARDING DRUG-FREE WORKPLACE

REQUIREMENTS, STATE AND STATE AGENCIES

ALL APPLICATIONS MUST BE RECEIVED BY FNS

NO LATER THAN 5:00 PM EASTERN DAYLIGHT SAVING TIME ON

FRIDAY, APRIL 29, 2011

FAXED AND E-MAILED APPLICATIONS WILL NOT BE ACCEPTED

LIST OF ATTACHMENTS

1. TERMS AND CONDITIONS OF AWARD

2. STANDARD FORMS AND REQUIRED DOCUMENTS

3. TIMELINE

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ATTACHMENT 1

TERMS AND CONDITIONS OF AWARD

This grant will be awarded and administered in accordance with the regulations and OMB grant circulars, as described below. Copies of these documents are available from the

Grants Officer upon request.

2 CFR Part 25: “Universal Identifier and Central Contractor Registration”

2 CFR Part 170: “Reporting Subaward and Executive Compensation Information”

2 CFR Part 175: “Trafficking Victims Protection Act”

7 CFR Part 15: “Regulation Prohibiting Discrimination in Programs Receiving

Federal Financial Assistance from USDA”

7 CFR Part 3015: “Uniform Federal Assistance Regulations”

7 CFR Part 3016: “Uniform Administrative Requirements for Grants and Cooperative

Agreements to State and Local Governments”

7 CFR Part 3017: Subparts A-E “Government-wide Debarment and Suspension (Non-procurement)”

7 CFR Part 3018: “New Restrictions on Lobbying”

7 CFR Part 3019: “Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education, Hospitals and Other Non-Profit

Organizations”

7 CFR Part 3021: “Government-wide Requirements for a Drug-free Workplace (Financial

Assistance)”

7 CFR Part 3052: “Audits of States, Local Governments and Non-Profit Organizations”

40 CFR Part 31.34: “Copyrights”

41 CFR 1-15.2 (FAR Part 31): Cost Principles for For-Profit Organizations.

Code of Federal Regulation Cost Principles:

2 CFR, Subtitle A, Chapter II, Part 225 State, Local, and Indian Tribal

2 CFR, Subtitle A, Chapter II, Part 220 Education Institutions

2 CFR, Subtitle A, Chapter II, Part 230- Non Profit Organizations

OMB Circular A-133: Audits of State, Local Governments and Nonprofit Organizations.

40 CFR Part 31.34 - Copyrights

The Federal awarding agency reserves a royalty-free, nonexclusive, and irrevocable license to reproduce, publish or otherwise use, and to authorize others to use, for Federal

Government purposes:

(a) The copyright in any work developed under a grant, subgrant, or contract under a grant or subgrant; and

(b) Any rights of copyright to which a grantee, subgrantee or a contractor purchases ownership with grant support.

2 CFR Part 25 – Universal Identifier and Central Contractor Registration

Effective October 1, 2010, all grant applicants must obtain a Dun and Bradstreet (D&B) Data

Universal Numbering System (DUNS) number as a universal identifier for Federal financial assistance applicants, as well as active grant recipients and their direct subrecipients of a subgrant award. To request a DUNS number visit http://fedgov.dnb.com/webform

The grant recipient must register its DUNS number into the Central Contractor Registration

(CCR) as the repository for standard information about applicants and recipients, and the registration must be maintain in the CCR throughout the performance period of the grant award. To register a DUNS number and or maintain a CCR registration visit ww.ccr. gov.

OMB requires grant recipients DUNS number registered in CCR be current in order to access

(usaspending.gov) the federal prime grant recipient reporting website.

FNS may not make an award to an entity until the entity has complied with the requirements described in 2 CFR 25.200 to provide a valid DUNS number and maintain an active CCR registration with current information.

2 CFR Part 170—Reporting Subaward and Executive Compensation

As required by the Federal Funding Accountability and Transparency Act of 2006 (Pub. L.

109–282), as amended by section 6202 of Public Law 110–252, hereafter referred to as “the

Transparency Act”, requirements for recipients' reporting of information on subawards and executive total compensation.

Prime grant recipients awarded a new federal grant greater than or equal to $25,000 as of october 1, 2010 are subject to FFATA subaward reporting. The prime recipient is required to file a FFATA subaward report by the end of the month following the month in which the prime recipient awards any sub-grant greater than $25,000. The grants subaward reporting http://fedgov.dnb.com/webform data must be entered into the federal subaward reporting system (FSRS) available at www.fsrs.gov. Specific OMB award terms and conditions will be included in all grant awards.

https://www.fsrs.gov/

ATTACHMENT 2

The following forms and documents are included in this attachment:

STANDARD FORM 424 - APPLICATION FOR FEDERAL ASSISTANCE

(FOR NON-CONSTRUCTION)

INSTRUCTIONS FOR COMPLETING STANDARD FORM 424

STANDARD FORM 424a - BUDGET SUMMARY

STANDARD FORM 424b – ASSURANCES – NON CONSTRUCTION

PROGRAMS

CERTIFICATION REGARDING LOBBYING

DISCLOSURE OF LOBBYING ACTIVITIES

REQUIRED FORMS FOR STATE AGENCIES ONLY

1. AD-1047- CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND

2. AD-1048- CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

3. AD-1052- CERTIFICATION REGARDING DRUG-FREE WORKPLACE

STANDARD FORM 424

Version 7/03

APPLICATION FOR

FEDERAL ASSISTANCE

2. DATE SUBMITTED

Applicant Identifier

1. TYPE OF

SUBMISSION:

Application Construction

Non-Construction

Pre-application

Non-

3. DATE RECEIVED BY STATE

State Application Identifier

4. DATE RECEIVED BY FEDERAL

AGENCY

Federal Identifier

5. APPLICANT INFORMATION

Legal Name:

Organizational Unit:

Department:

Organizational DUNS:

Division:

Address: Name and telephone number of person to be contacted on matters involving this application (give area code)

Street:

Prefix:

First Name:

City: Middle Name:

County:

Last Name:

State:

Zip Code:

Suffix:

Country:

Email:

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

Phone Number (give area code)

Fax Number (give area code)

8. TYPE OF APPLICATION:

New Continuation

Revision If Revision, enter appropriate letter(s) in box(es)

(See back of form for description of letters.)

Other ( specify)

7. TYPE OF APPLICANT: (See back of form for Application Types)

Other (specify)

9. NAME OF FEDERAL AGENCY:

10 CATALOG OF FEDERAL DOMESTIC ASSISTANCE

NUMBER:

TITLE (Name of Program):

11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:

12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc):

13. PROPOSED PROJECT 14. CONGRESSIONAL DISTRICTS OF:

Start Date:

Ending Date: a. Applicant b. Project

15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE

EXECUTIVE ORDER 12372 PROCESS?

a. Federal $ a. Yes THIS PREAPPLICATION/APPLICATION WAS MADE

AVAILABLE TO THE STATE EXECUTIVE ORDER 12372

PROCESS FOR REVIEW ON

DATE:

b. No PROGRAM IS NOT COVERED BY E. O. 12372

OR PROGRAM HAS NOT BEEN SELECTED BY STATE

FOR REVIEW

b. Applicant $

c. State $

d. Local $

e. Other $

f. Program Income $ 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL

DEBT?

Yes If “Yes” attach an explanation. No

g. TOTAL $

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT.

THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY

WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.

a. Authorized Representative

Prefix

First Name

Middle Name

Last Name

Suffix

b. Title

c. Telephone Number (give area code)

d. Signature of Authorized Representative

e. Date Signed

Previous Edition Usable Standard Form 424 (Rev. 9-2003) Authorized for Local Reproduction Prescribed by OMB Circular A-102

INSTRUCTIONS FOR THE SF-424

Public reporting burden for this collection of information is estimated to average 45 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 (0348-0043), 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.

This is a standard form used by applicants as a required face sheet for pre-applications and applications submitted for Federal assistance. It will be used by Federal agencies to obtain applicant certification that States which have established a review and comment procedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given an opportunity to review the applicant’s submission.

Item: Entry: Item: Entry:

1. Select Type of Submission. 11. Enter a brief descriptive title of the project. If more than one program is involved, you should append an explanation on a separate sheet. If appropriate (e.g., construction or real property projects), attach a map showing project location. For preapplications, use a separate sheet to provide a summary description of this project.

2. Date application submitted to Federal agency (or State if applicable) and applicant’s control number (if applicable)

12. List only the largest political entities affected (e.g., State, counties, cities).

3. State use only (if applicable). 13. Enter the proposed start date and end date of the project.

4. Enter Date Received by Federal Agency Federal identifier number: If this application is a continuation or revision to an existing award, enter the present Federal Identifier number. If for a new project, leave blank.

14. List the applicant’s Congressional District and any District(s) affected by the program or project

5. Enter legal name of applicant, name of primary organizational unit (including division, if applicable), which will undertake the assistance activity, enter the organization’s DUNS number (received from Dun and Bradstreet), enter the complete address of the applicant (including country), and name, telephone number, e-mail and fax of the person to contact on matters related to this application.

15. Amount requested or to be contributed during the first funding/ budget period by each contributor.

Value of in kind contributions should be included on appropriate lines as applicable. If the action will result in a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parentheses. If both basic and supplemental amounts are included, show breakdown on an attached sheet. For multiple program funding, use totals and show breakdown using same categories as item 15.

6. Enter Employer Identification Number (EIN) as assigned by the Internal Revenue Service.

16. 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.

7. Select the appropriate letter in the space provided.

A. State I. State Controlled

Institution B. County of Higher Learning.

C. Municipal J. Private University

D. Township K. Indian Tribe E. Interstate L. Individual

F. Intermunicipal M. Profit Organization

G. Special District N. Other (Specify) H. Independent School District O. Not for Profit

Organization

17. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of debt include delinquent audit disallowances, loans and taxes.

8. Select the type from the following list:

“New” means a new assistance award.

“Continuation” means an extension for an additional funding/budget period for a project with a projected completion date.

“Revision” means any change in the Federal Government’s financial obligation or contingent liability from an existing obligation. If a revision enter the appropriate letter:

A. Increase Award B. Decrease Award

C. Increase Duration D. Decrease Duration

18. To be signed by the authorized representative of the applicant. A copy of the governing body’s authorization for you to sign this application as official representative must be on file in the applicant’s office. (Certain Federal agencies may require that this authorization be submitted as part of the application.)

9. Name of Federal agency from which assistance is being requested with this application.

10. Use the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested.

SF-424 (Rev. 7-97) Back

STANDARD FORM 424A - BUDGET SUMMARY

} BUDGET INFORMATION - Non-Construction Programs OMB Approval No. 0348-0044

SECTION A - BUDGET SUMMARY

Grant Program Function or

Activity

Catalog of Federal

Domestic Assistance

Estimated Unobligated Funds New or Revised Budget

(a) Number

(b)

Federal

(c)

Non-Federal

(d)

Federal

(e)

Non-Federal

(f)

Total

(g)

1. ANA SEDS 93-612 $ $ $ 0.00 $ 0.00 $ 0.00

2. 0.00

3. 0.00

4. 0.00

5. TOTALS $ 0.00 $ 0.00 $0.00 $ 0.00 $ 0.00

SECTION B - BUDGET CATEGORIES

6. OBJECT CLASS CATEGORIES GRANT PROGRAM, FUNCTION OR ACTIVITY Total (5)

(1) ANA SEDS (2) (3) (4)

a. Personnel $ 0 $ $ $ $ 0

b. Fringe Benefits 0 0

c. Travel 0 0

d. Equipment 0 0

e. Supplies 0 0

f. Contractual 0 0

g. Construction 0 0

h. Other 0 0

i. Total Direct Charges (sum of 6a - 6h) 0 0.00 0.00 0.00 0

j. Indirect Charges 0 0

k. TOTALS (sum of 6i and 6j) $ 0 $0.00 $0.00 $ 0.00 $ 0

7. Program Income $ 0.00 $ $ $ $ 0.00

} SECTION C - NON-FEDERAL RESOURCES

(a) Grant Program (b) Applicant (c) State (d) Other Sources (e) TOTALS

8. ANA SEDS $ 0.00 $ 0.00 $ 0.00 $ 0.00

9. 0.00

10. 0.00

11. 0.00

12. TOTAL (sum of lines 8 and 11) $ 0.00 $ 0.00 $ 0.00 $ 0.00

SECTION D - FORECASTED CASH NEEDS

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

$ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00

14. NonFederal 0.00 0.00 0.00 0.00 0.00

15. TOTAL (sum of lines 13 and 14) $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00

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

(a) Grant Program FUTURE FUNDING PERIODS (Years)

(b) First (c) Second (d) Third (e) Fourth

16. ANA SEDS $ 0.00 $ 0.00 $0.00 $ 0.00

17.

18.

19.

20. TOTALS (sum of lines 16 - 19) $ 0.00 $ 0.00 $ 0.00 $ 0.00

SECTION F - OTHER BUDGET INFORMATION

(Attach additional sheets if Necessary)

21. Direct Charges: $ 0.00 22. Indirect Charges: $ 0.00

23. Remarks:

SF 424A (4-88) Page 2

Prescribed by OMB Circular A-102

AUTHORIZED FOR LOCAL REPRODUCTION

Previous Edition Usable Standard Form 424B (Rev. 7-97) Authorized for Local Reproduction Prescribed by OMB Circular A-102

OMB Approval No. 0348-0040

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:

1. 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.

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 -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

-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.

handicaps; (d) the Age Discrimination Act of 1975, as

-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

Pub -3 and

290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil 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.

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 the provisions of the Hatch

-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.

9. Will comply, as applicable, with the provisions of the Davis-

-7), the Copeland Act (40

-333), regarding labor standards for federally assisted construction subagreements.

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 conformity of Federal actions to State (Clear Air) Implementation Plans under

Section 176(c) of the Clear Air Act of 1955, as amended (42 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).

12 Will comply with the Wild and Scenic Rivers Act of 1968 potential components of the national wild and scenic rivers system.

13. Will assist the awarding agency in assuring compliance with

Section 106 of the National Historic Preservation Act of and protection of historic properties), and the Archaeological

-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 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 -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, -Profit

18. Will comply with all applicable requirements of all other

Federal laws, executive orders, regulations and policies governing this program.

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

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

TITLE

APPLICANT ORGANIZATION

DATE SUBMITTED

CERTIFICATION REGARDING LOBBYING

CERTIFICATION FOR CONTRACTS, GRANTS, AND COOPERATIVE

AGREEMENTS

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

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 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.

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-

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including sub-contracts, sub-grants, and contracts under grants, loans and cooperative agreements) and that all sub-recipients 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.

By Date:

(Signature of Official [Executive Director] Authorized to Sign Application)

By Date:

(Signature of Official (Chief Financial Officer) Authorized to Sign Application)

For Name of Grantee

Title of Grant Program

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046

(See reverse for public burden disclosure)

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

2. Status of Federal Action:

a. bid/offer/application

b. initial award

c. post-award

3. Report Type:

a. initial filing

b. material change

For material change only:

Year _______ quarter _______

Date of last report___________

4. Name and Address of Reporting Entity:

Prime Subawardee

Tier______, if known:

Congressional District, if known:

5. If Reporting Entity in No. 4 is

Subawardee, Enter Name and Address of Prime:

Congressional District, if known:

6. Federal Department/Agency: 7. Federal Program Name/Description: Federal Program Name/Description:

CFDA Number, if applicable: __________________

8. Federal Action Number, if known: 9. Award Amount, if known: Award Amount, if known:

10. a. Name and Address of Lobbying Registrant

(if individual, last name, first name, MI):

a. Individuals Performing Services (including address if different from No. 10a)

(last name, first name, MI):

11. 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 this 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: ______________________________________

Print Name:_____________________________________

Title:__________________________________________

Telephone No.: _________________ Date: ___________

Federal Use Only

Authorized for Local Reproduction Standard Form - LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required within 30 days of each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. 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.