UNITED STATES
/ ENVIRONMENTAL
PROTECTION
AGENCY
? . . '...«*
APPLICATION ICIT FOR
ASSISTANCE
Januaiy 1998
-------
-------
Dear Applicant:
An application kit for submitting a request for Federal Assistance to the Environmental Protection
Agency (EPA) is attached. Please complete all application procedures as instructed in this kit and
refer to the enclosed checklist to ensure your application is complete prior to submission.
Please consider whether your proposal is for acquisition or assistance. The Federal Grant and
Cooperative Agreement Act requires Federal agencies to use a contract to acquire property or
services that directly benefit the Federal government. A grant or cooperative agreement must
be used to transfer money, property, services, or anything else of value, that supports or
stimulates an activity to accomplish a public purpose of assistance authorized by Federal statute.
The SF-424 is only used for submitting proposals for Federal assistance.
The direct beneficiary is the determining factor as to whether a proposal is for acquisition or
assistance. If the direct beneficiary is a state or local government or other recipient, and the
purpose of the support or stimulation is authorized by Federal statute, then a grant or cooperative
agreement is the proper legal instrument to use. If the direct beneficiary is EPA, then a contract is
the appropriate legal instrument to use, and an SF-424 is not appropriate
Please direct questions about completing your application, or general inquiries about EPA's
assistance program, to the Grants Administration Division (GAD) at (202) 564-5305.
Grants Administration Division
-------
TABLE OF CONTENTS
Applicable EPA Regulations and Description.
Supplemental Information: Application For Federal Assistance 6
(Standard Form 424)
Checklist Of Application Items To Be Submitted 10
Application Receipt Letter. 11
Key Contact List 12
SF-424 "Application For Federal Assistance"; including Instructions
And Assurances (SF 424A and SF 424B)
Certification Regarding Debarment and Suspension
Certification Regarding Lobbying, Including Disclosure of Lobbying Activities
Preaward Compliance Review Report
MBE\WBE Utilization Under Federal Grants
EPA Mailing Address
-------
ENVIRONMENTAL PROTECTION AGENCY REGULATIONS AND DESCRIPTION
40 CFR Parts 7 and 12 - APPLICABLE TO ALL APPLICANTS
NONDISCRIMINATION IN PROGRAMS RECEIVING FEDERAL ASSISTANCE FROM
THE ENVIRONMENTAL PROTECTION AGENCY
This rule implements statutes which prohibit discrimination on the grounds of race, color,
national origin, sex and handicap.
This rule stipulates that no person shall be excluded from participation in, be denied the benefits
of or be subjected to discrimination under any program or activity receiving EPA assistance on
the basis of race, color, national origin, or on the basis of sex or handicap in any program or
activity receiving EPA assistance.
40 CFR Part 29-APPLICABLE TO ALL APPLICANTS
INTERGOVERNMENTAL REVIEW OF THE ENVIRONMENTAL PROTECTION AGENCY
PROGRAMS AND ACTIVITIES
These regulations implement Executive Order 12373, "Intergovernmental Review of Federal
Programs". These regulations apply to all EPA programs.
You must contact your State's Single Point of Contact to find out if the program was selected for
coverage by the State process and, if the program was selected, to receive information about your
State's review process requirements and procedures. If you don't know who your Single Point of
Contact is, please call (202) 564-5305.
40 CFR Part 30-APPLICABLE TO OTHER THAN STATE AND LOCAL
GOVERNMENTAL APPLICANTS
GENERAL REGULATION FOR ASSISTANCE PROGRAMS FOR ALL APPLICANTS
OTHER THAN STATE AND LOCAL GOVERNMENTS
These regulations inform applicants, other than state and local governments, how to apply for and
manage an EPA project, describes EPA involvement in the process, and identifies recipient's
responsibilities.
-------
40 CFR Part 31 - APPLICABLE TO ALL STATE AND LOCAL GOVERNMENT
APPLICANTS
UNIFORM ADMINISTRATIVE REQUIREMENTS FOR GRANTS AND COOPERATIVE
AGREEMENTS TO STATE AND LOCAL GOVERNMENTS
This part establishes uniform administrative rules for federal grants and cooperative agreements to
State, local and Indian Tribal governments.
40 CFR Part 32 - APPLICABLE TO ALL APPLICANTS
GOVERNMENT WIDE DEB ARMENT AND SUSPENSION (NONPROCUREMENT) AND
GOVERNMENTWIDE REQUIREMENTS FOR DRUG-FREE WORKPLACE (GRANTS)
Subpart A - General
Executive Order 12549 provides for a govemmentwide system of nonprocurement (grants and
cooperative agreements) debarment and suspension. A person who is debarred or suspended is
excluded from federal financial and nonfinancial assistance and benefits under federal programs
and activities. Debarment or suspension of a participant in a program by one agency has
govemmentwide effect.
Subpart F - Drug-Free Workplace Requirements (Grants)
The Drug-Free Workplace Act of 1988 requires that all grantees receiving grants from any federal
agency certify to that agency that they will maintain a drug-free workplace, or, in the case of a
grantee who is an individual, certify to the agency that his or her conduct of grant activity will be
drug-free. This government-wide rule implements the statutory requirements. It directs that
grantees take steps to provide a drug-free workplace in accordance with the Act.
40 CFR Part 34 - APPLICABLE TO ALL APPLICANTS
NEW RESTRICTIONS ON LOBBYING
This interim final rule is in response to section 319 of Public Law 101-121. Section 319 prohibits
recipients of Federal contracts, grants, and loans from using appropriated funds for lobbying the
Executive or Legislative Branches of the Federal Government in connection with a specific
contract, grant, or loan.
-------
40 CFR Part 40 - APPLICABLE TO ALL APPLICANTS APPLYING FOR
RESEARCH AND DEMONSTRATION GRANTS
This part establishes mandatory policies and procedures for all EPA research and demonstration
grants. The provisions of this part supplement the EPA general grant regulations and procedures
(40 CFR part 30).
40 CFR Part 45 - APPLICABLE TO ALL APPLICANTS APPLYING FOR
TRAINING ASSISTANCE
This part establishes the policies and procedures for the award of training assistance by EPA.
Assistance agreements are awarded under this part to support students through traineeships for
occupational and professional training, and to develop career-oriented personnel qualified to work
in occupations involving environmental protection and pollution abatement and control.
40 CFR Part 46 - APPLICABLE TO ALL APPLICANTS APPLYING FOR
FELLOWSHIPS
This part establishes the policies and procedures for all Environmental Protection Agency
fellowships. Fellowships awarded under this part are intended to enhance the capability of State
or local agencies responsible for environmental pollution control or other agencies with similar
pollution control responsibilities; provide educational renewal opportunities for their career
oriented personnel to achieve additional knowledge through academic professional training and to
bring new people into the environmental control field.
40 CFR Part 47 - APPLICABLE TO ALL APPLICANTS APPLYING FOR
NATIONAL ENVIRONMENTAL EDUCATION ACT GRANTS AND COOPERATIVE
AGREEMENTS
This part codifies policy and procedures for the award of grants or cooperative agreements under
section 6 of the NEE A. Grants awarded under this part are educational activities and training
activities involving elementary, secondary, and postsecondary students, as such terms are defined
in the State in which they reside, and environmental education personnel, but does not include
technical training activities directed toward environmental management professionals or activities
primarily directed toward the support of noneducational research and development.
Should you need copies of the above cited regulations please call (202) 564-5305 or you may
access a copy through the World Wide Web at: http://www.epa.gov/ogd/regs.htm.
-------
SUPPLEMENTAL INFORMATION:
APPLICATION FOR FEDERAL ASSISTANCE (STANDARD FORM 424)
Please refer to the SF 424 instructions. The following discusses items that require
additional attention.
Item 5: If die individual you list under "Name and telephone number of the person to be
contacted for matters involving this application", is not the Project Manager, please
provide the Project Manager's name, title, address, telephone number, and facsimile
machine number on the key contact list.
Additionally, please submit a biographical sketch for the Project Manager. The
biographical sketch should include educational and background information, and other
qualifying experience relevant to the project. Also, list other key personnel engaged in the
project, and detail each person's training or discipline. Identify the Project Manager's
other projects, and the amount of time that he or she devotes to each project. Provide
employment summaries for the Project Manager and the key personnel. The employment
summaries should include contracts and consultancies for the present and for the past two
years.
Item 9: List EPA personnel who have provided you with preapplication assistance along
with their telephone number and the program office.
Item 10: List the Catalog of Federal Domestic Assistance (CFDA) Number and Title. If
you do not know the CFDA Number and Title, leave this item blank.
Item 13: The "Start Date" and "Ending Date" should represent the time frame in which
the entire scope of work detailed in the application will be completed, and during which
the recipient may expend or obligate Federal funds.
Item 15: List the estimated funding amounts for the entire project and for each proposed
budget period. The "Estimated Funding" amounts should include the amount requested
from EPA, and your organization's cost sharing amount, if required.
Item 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. '
Item 18: The authorized representative listed here will receive an official award agreement
if EPA awards a grant or cooperative agreement in response to your application.
-------
DESCRIPTION OF PROJECT: Include a section which addresses the following:
Objective:
(1) Describe the primary and secondary project objectives.
(2) Identify relevant physical, economic, social, financial, institutional, or other
problems.
(3) Include supporting documentation from concerned interests other than the
applicant
(4) Include and footnote relevant data based on planning studies.
Results or benefits expected:
Identify results and benefits that will accrue to the project. Include the benefits that will
accrue to the recipient, the population served, the public, and the environment For
example, compliance with water quality standards, or ambient air quality standards,
advancements in the state of the art of pollution abatement, etc.
Approach:
(1) Provide a work plan detailing how the scope of work will be accomplished, and
detailing the proposed project. Cite factors that could potentially accelerate or decelerate
the work. Indicate why this approach has been chosen rather than alternative approaches.
Describe any unusual project features such as design or technological innovations, cost or
time reductions, or extraordinary social and community involvement.
(2) Describe all available facilities for carrying out the project.
(3) List all non-Federal funds sources and facilities to be used to perform the proposed
project.
(4) Provide a chronological schedule of accomplishments, progress, and milestones that
are anticipated over the project's duration.
(5) Indicate who will carry out each of the work plan's elements. Include supporting
agencies, consultants, and contractors.
(6) Describe sampling and data collection procedures, analytical methods, and methods to
evaluate the project's results
-------
General Project Information:
(1) Identify the kinds of data to be collected and maintained, and discuss the evaluation
criteria for the project's results. Indicate whether research or demonstration will
involve human subjects or research animals.
(2) Discuss this project's effect on or relationship to work planned, anticipated, or in
process, by the grantee, or Government agencies. Discuss the Federal, state, and local
programs with which the work will be coordinated, and describe the extent and nature of
the coordination.
QUALITY ASSURANCE:
If your project involves environmentally related measurements or data generation, you
must develop and implement quality assurance practices. These practices must sufficiently
produce quality data to adequately meet project objectives, and to minimize data loss due
to uncontrolled conditions or malfunctions. State, local, or Indian tribal government
applicants should refer to EPA regulation 40 CFR 31.45. All other applicants should refer
to EPA regulation 40 CFR 30.54.
BUDGET:
The application includes Standard Form 424 A: "Budget Information - Non-Construction
Programs". Please complete only Section B: "Budget Categories", and Section F: "Other
Budget Information" on Standard Form 424 A. If you have budgeted indirect costs in
Section B, please attach a copy of your indirect cost rate agreement which has been
negotiated with a cognizant Federal agency. Please indicate under "remarks" in Section F,
that your indirect cost rate is attached.
Guidance for completing a Detailed Budget to Supplement Standard Form 424A
In addition to completing Standard Form 424A, a separate, detailed budget is required.
Please follow the guidelines listed below.
Detailed Itemization of Costs:
Personnel: List all project participants' titles. Indicate the time percentage that each
individual will devote to this project during the entire project period. The budgeted cost
should be derived as follows: multiply each person's time percentage by his or her annual
salary. Indicate this calculation for each personnel member. The sum of each person's
costs should be reflected as total personnel costs. Record total on Standard Form 424A,
Section B, Line A.
-------
Travel: Indicate the budgeted travel's purpose and the destination of each trip and
indicate the number of travelers. Record toted on Standard Form 424A, Section B, Line C
Equipment: Provide a list of equipment to be purchased. Record total on Standard Form
424A, Section B, Line D.
Supplies: Itemize budgeted supplies unless their total represents less than two percent of
total costs. Record total on Standard Form 424A, Section B, Line E.
Contractual: Specify the nature and cost of contractual services. EPA may review the
contracts for personal services before the contracts are executed, to assure that all costs
are reasonable and necessary to the project. Record total on Standard Form 424A,
Section B, Line F.
Construction: If your budget includes construction costs, contact the Grants
Administration Division for additional instructions while completing your application.
Record total on Standard Form 424A, Section B, Line G.
Other: Itemize all costs included here. Include items here which can not be scheduled in
the more specific categories. If you are applying for a training project, the itemization
should include a cost breakdown of trainee tuition and fees, book allowances, stipends,
and travel. Record total on Standard Form 424A, Section B, Line H,
Indirect Costs: Please indicate how indirect charges were calculated for this project, and
remember to attach a copy of your current indirect cost rate agreement. Record total on
Standard Form 424A, Section B, Line J. If an organization has not previously established
an indirect cost rate with another Federal Agency, please specify on Standard Form 424A,
Section B, Line J. _ 7
Program Income: If any income is expected to be generated from this project, insert the
estimated income amount here. Do not add or subtract this amount from the total project
amount. Your detailed direct cost itemization should show this income's nature and
source. Record total on Standard Form 424A, Section B, Line 7.
-------
-------
CHECKLIST OF APPLICATION
ITEMS TO BE SUBMITTED
SF-424 APPLICATION FOR FEDERAL ASSISTANCE, with original signature,
(including Assurances for Non-construction Programs)
NUMBER OF COPIES: Original and 2 copies
ASSURANCES NON-CONSTRUCTION PROGRAMS CERTIFICATION
DEBARMENT AND SUSPENSION CERTIFICATION
CERTIFICATION REGARDING LOBBYING (if over $100,000)
and SF LLL if applicable
EPA FORM 4700-4 PREAWARD COMPLIANCE REVIEW REPORT
NARRATIVE STATEMENT (WORK PLAN)
QUALITY ASSURANCE NARRATIVE STATEMENT, if applicable
DETAILED ITEMIZED BUDGET
__' COPY OF NEGOTIATED INDIRECT COST RATE AGREEMENT
. .KEY CONTACT LIST
BIOGRAPHICAL SKETCH
APPLICATION RECEIPT LETTER, with your address filled in
ADDITIONAL INFORMATION TO BE SUBMITTED IF APPLICABLE
(1) If you are submitting your application under the Federal Demonstration Project, please
indicate it in block 11.
(2) If your project requires an Environmental Impact Statement or Environmental Assessment, or
both, please indicate it on a separate sheet of paper.
(3) If your project involves human testing studies, please indicate it on a separate sheet of paper.
(4) If your project involves animal testing studies, please indicate it on a separate sheet of paper.
10
-------
-------
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460
OFFICE OF
ADMINISTRATION
AND RESOURCES
MANAGEMENT
Application Receipt Letter
Dear
The U.S. Environmental Protection Agency's Grants Operations Branch has received your
application. The EPA identification number assigned to your project is
is this project's Grants Specialist. If you have any questions,
please contact your grants specialist at (202) 564-
Sincerely,
Barbara Rochon
Grants Administration Division
11
Recyct»
-------
-------
KEY CONTACTS
Authorized Representatives: Original awards and amendments will be sent to this individual for review and
acceptance, unless otherwise indicated.
Name:_
Title:
Complete Address:.
Phone Number: Fax:_
E-Mail Address:
Payee: Individual authorized to accept payments.
Name:
Title:
Complete Address:.
Phone Number: Fax':_
E-Mail Address:
Administrative Contact: Individual from Sponsored Programs Office to contact concerning administrative
matters (i.e., indirect cost rate computation, rebudgeting requests, etc.)
Name:
Title:
Complete Address:
Phone Number: ; __ Fax:_
E-Mail Address:
Project Manager: Individual responsible for the technical completion of the proposed work.
Name:
Title:
Complete Address:.
Phone Number: Fax:.
E-Mail Address: ,
12
-------
-------
OMB Approval No. 034*4043
APPLICAIION rOH 2. OATC SUWMTTCO Applicant id*mi(w<
FEDERAL ASSISTANCE ^^
1. rVPCOrtUMIISSION:
O Construction Q Consln
Q Non-Constfucnon Q Non-Co
jOATiHccciVEOav STATE su(a Applicaiwn ictendiw
4 DATCRECCtVCOavrEDCRALAOENCV Fadoal Uontilior
». A»PUCANr INFOMIAT1OM
LagatNama:
Address ftp** erty. county. jfara. and op codaj:
*. etanovniocMnncArnNMUMamccw
1 1 l-l
1 III
Q Haw Q Continuation ' Q Aavision
n tovtaon. antar appropriaw lattarft) in bo»(«s): Q Q
A Incraaaa Award a Oacraaaa Award C tocraaM Duration
O Darraaia Ouratwn Othar /spaory>:
it. cATALOOomociUt.aoMcsne
TITLE:
1 1.1 II
«. AMASArFCCTEOCVMiajfCT (totos. caunuws. *»«•<. OfC.):
11. fMPOKD ••OJCJCf: I
SUM Data Ending Data «
15. ESTtMATEO rUNDtNa
a Fadaral f
b. Appfccant f
c SUM f
d Local 1,
Organisational Unit:
NaAw and tolaphona numbar of lha panon to ba contaclad on mattar* nvornxi
this application (gn» «v>a cooaj
7. TVPf orA*njCAOT: 1 J
A. SUM H. mdapandant School Oiat
a County . 1. Stata Ovmolad Inttitution o« Highar Laammg
w MufNCBpfll J. Pnvflto vfMpWty
0. Townanip K Indian Triba
E. kuorvtala . * I, Indrviiliial . ;
F. tmarmumapal U Profit Organization
G. Soacial Dinnct N. Othar (SoaoM:
1. MAM CV MORAL AMMOr.
4. CONaMCSSIONAI.PISnilCrSOF:
. .Applicant . b. Pioiact
irr5Ai>nj(UTioNSUucCTTOMevifwivsTATCixECvnv«oMpeii»n mocntt
00 «• TES THI$PREAPPUCATIC«VAPPU(MTIONWASUAOEAVAaAeU1O1»«l
STATE EXECUnvB ORDER I2JT2 PROCESS POR REVCW ON:
•G0 - DATE
•w ^
b NO. C
| PROGRAM iS NOT COVERED BY E.O. 12372
00
Q OR r^OQRAM HAS NOT BCB* SELECTED BY STATE FOR REWEW
•°"1" ' •°°
f. Program meoma $
g TOTAL I
.00 17. ItTHIAPHJI
.« V"
If *Yaa,* attach an axplanation. Q No
1C 10 TW KST Of IK KNOVUOW AM laJV. AU MTA tM THO) AafUU
AMTNOMZro «V THC OOVCRNIMQ MOAT W TM AI>fUCAOT AIM INC APtH^^
Ia Typed Nama o> Authormd Raprasantaihra
.
b. Trtta C Tataphona ngmbar
d Signatura ot Authoruad Hapraaantativ* •• Data Signad
Authorized for Local Reproduction
-------
INSTRUCTIONS FOR THE SF 424
This is a standard form used by applicants is a required facesheet for preapplications 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: Entrv: Item: Entrv:
1. Self-explanatory.
2. Date application submitted to Federal agency (or
State if applicable) & applicant's control number
(if applicable).
3. State use only (if applicable).
4. If-this application is to continue or revise an
existing award, enter present Federal identifier
number. If for a new project, leave blank.
5. Legal name of applicant, name of primary
organizational unit which will undertake the
assistance activity, complete address of the
applicant, and name and telephone number of the
person to contact on matters related to this
application.
6. Enter Employer Identification Number (BIN) as
assigned by the Internal Revenue Service.
7. Enter the appropriate letter in the space
provided.
8. Check appropriate box and enter appropriate
letteKs) in the space(s) provided:
—"New" means ft 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.
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.
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 preappUcations, use a separate sheet to
provide a summary description of this project.
12. List only the largest political entities affected
(e.g.. State, counties, cities).
13. Self-explanatory.
14. List the applicant's Congressional District and
any Districts) affected by the program " project.
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 a,n 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 IS.
16. Applicants should contact the State Single Point
of Contact (SPOC) for Federal Executive :. '
12372 to determine whether the application is
subject to the State intergovernmental review
process.
17. This question applies to the applicant organi-
zation, not the person who signs as the
authorized representative. Categories of debt
include delinquent audit disallowances, loans
andtaxes.
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.)
«4 (REV 4-Ml feck
-------
i
I
i
c
o
t?
o
V
i
3
<•
-------
|A
S
K
U
'
1
«
^
I
X
J
Z
2
S
v»
w
„
m
»
0
s
w
«
p
]
TOTALS (sum of lints
ri
m
a
2
3
fl
D> FORECASTED <
1
•
i
i
i
!
1
I
1
1
S
I
I
«
w
•»
I
5
5
i
«*
w
M
V.
9
1
_<
s
u
c
S
•
p
i
i
R
s
s
s
c
u
C
u
u
.
•'
IDERAL FUNDS*
S
ET ESTIMATES OF
O
I
§
(4
i
i
t
c
1
1
*•«
*
*••
i
3
€
(
i
o
?
V.
•t
s
C
S
2
*.
'^
?
TOTAIS (sum of lines
o
Q
Ii
o s
2 Z
OTHER BUDGET 1
[h additional Sheets if
SECTION F.
(Atta
i
-g
m
I
^
|
I
•*
IM «t
,i
'
rinrtlnn
S
o
J
1
Authorli
1
-------
INSTRUCTIONS FOR THE SF-424A
General Instructions
This form is designed so that application can be made
for funds from one or more grant programs. In pre-
paring the budget, adhere to any existing Federal
grantor agency guidelines which prescribe how and
whether .budgeted amounts should be separately
shown for different functions or activities within the
program. For some programs, grantor agencies may
require budgets to be separately shown by function or
activity. For other programs, grantor agencies may
require a breakdown by function or activity. Sections
A.B.C, and D should include budget estimates for the
whole project except when applying for assistance
which requires Federal authorization in annual or
other funding period increments. In the latter case.
Sections A.B, C, an^ D should provide the budget for
the first budget period (usually a year) and Section E
should present the need for Federal assistance in the
subsequent, budget periods. All applications should
contain a breakdown'by the object class categories
shown in Lines a-k of Section B.
Section A. Budget Summary
Lines 1-4, Columns (a) and (b)
For applications pertaining to a single Federal grant
program (Federal Domestic Assistance Catalog
number) and not requiring a functional or activity
reakdown, enter on Line 1 under Column (a) the
catalog program title and the catalog number in
Column (b).
For applications pertaining to a single program
requiring budget amounts by multiple functions or
activities, enter the name of each activity or function
on each line in Column (a), and enter the catalog num-
ber in Column (b). For applications pertaining to mul-
tiple programs where none of the programs require a
breakdown by function or activity, enter the catalog
program title on each line in Column (a) and the
respective catalog number on each line in Column (b).
For applications pertaining to multiple programs
where one or more programs require a breakdown by
function or .activity, prepare a separate sheet for each
program requiring the breakdown. Additional sheets
should be used when one form does not provide
adequate space for all breakdown of data required.
However, when more than one sheet is used, the first
page should provide the summary totals by programs.
Lines 1*4, Columns (c) through (g.)
For new applications, leave Columns (c) and (d) blank.
For each line entry in Columns (a) and (b), enter in
Columns (e), (0, and (g) the appropriate amounts of
jfunds needed to support the project for the first
lunding period (usually a year).
Lines 1-4, Columns (c) through (g.) (continued)
For continuing grant program applications, submit
these forms before the end of each funding period as
required by the grantor agency. Enter in Columns (c)
and (d) the estimated amounts of funds which will
remain unobligated at the end of the grant funding
period only if the Federal grantor agency instructions
provide for this. Otherwise, leave these columns
blank. Enter in columns (e) and (0 the amounts of
funds needed for the upcoming period. The amount(s)
in Column (g) should be the sum of amounts in
Columns (e) and (0.
For supplemental grants and changes to existing
grants, do not use Columns (c) and (d). Enter in
Column (e) the amount of the increase or decrease of
Federal funds and enter in Column (0 the amount of
the increase or decrease of non-Federal funds. In
Column (g) enter the new total budgeted amount
(Federal and non-Federal) which, includes the total
previous authorized budgeted amounts plus or minus,
as appropriate; the amounts shown in Columns (e) and
(f). The amount(s) in Column (g) should not equal the
sum of amounts in Columns (e) and (f).
Line 5 — Show the totals for all columns used.
Section B Budget Categories
In the column headings (1) through (4), enter the titles
of the same programs, functions, and activities shown
on Lines 1-4, Column (a), Section A. When additional
sheets are prepared for Section A, provide similar
column headings on each sheet. For each program,
.function or activity, fill in the total requirements for
funds (both Federal and non-Federal) by object class
categories.
Lines 6a-i — Show the totals of Lines 6a to 6h in each
column.
Line 6j - Show the amount of indirect cost.
Line. 6k - Enter the total of amounts on Lines 6i and
6j. For all applications for new grants and
continuation* grants the total amount in column (5),
Line 6k, should be the same as the total amount shown
in Section A, Column (g). Line 5. For supplemental
grants and changes to grants, the total amount of the
increase or decrease as shown in Columns (1M4), Line
6k should be the same as the sum of the amounts in
Section A, Columns (e) and (f) on Line 5.
S5 424A
-------
INSTRUCTIONS FOR THE SF-424A (continued)
Line 7 * Enter the estimated amount of income, if any,
expected to be generated from this project Do not add
or subtract this amount from the total project amount.
Show under the program narrative statement the
nature and source of income. The estimated amount of
program income may be considered by the federal
grantor agency in determining the total amount of the
grant
Section C. Non-Federal-Resources
Lone* 8-11 - Enter amounts of non-Federal resources
that will be used on the grant. If in-kind contributions
are included, provide a brief explanation on a separate
sheet
Column (a) - Enter the program titles identical
to Column (a). Section A. A breakdown by
.function or activity is not necessary.
Column (b) - Enter the contribution to be made
by the applicant.
Column (c) - Enter the amount of the State's
cash and in-kind contribution if the applicant is
not a State or State agency. Applicants which are
a State or State agencies should leave this
column blank.
Column (d) - Enter the amount of cash and in-
kind contributions to be made from all other
sources.
Column (e) - Enter totals of Columns (b), (c). and
(d).
Line 12 — Enter the total for each of Columns (b)-(e).
The amount in Column (e) should be equal to the
amount on Line 5, Column (0, Section A.
Section D. Forecasted Cash Needs
Line 13 - Enter the amount of cash needed by quarter
from the grantor agency during the first year.
9ine
I
Line 14 - Enter the amount of cash from all othe
sources needed by quarter during the first year.
Line IS - Enter the totals of amounts on Lines 13'
14.
Section E. Budget Estimates of Federal Fund
Needed for Balance of the Project
Lines 16 - 19 - Enter in Column (a) the same gran
program titles shown in Column (a). Section A. /
breakdown by function or activity is not necessary. Foi
new applications and continuation grant applications
enter in the proper columns amounts of Federal funds
which will be needed to complete the. program 01
project over the succeeding funding mriods (usually in
years). This section need not be completed for revisions
(amendments, changes, or supplements) to funds for
the current year of existing grants.
If more than four lines are needed to list the program
titles, submit additional schedules as necessary.
Line 20 - Enter the total for each of the Columns (bi-
te). When additional schedules are prepared for this
Section, annotate accordingly and show the overall
totals on this line.
Section F. Other Budget Information
Line 21 - Use this space to explain amounts for
individual direct object-class cost categories that
appear to be out of the ordinary or to explain
details as required by the Federal grantor agency.
Line 22 - Enter the type of indirect raU ^ru. .^ional,
predetermined, final or fixed) that will be in effect
during the funding period, the estimated amount of
the base to which the rate is applied, and the total
indirect expense.
Line 23 - Provide any other explanations or comments
deemed necessary.
-------
I.
OMB Appro** Mo. 0348-0040
ASSURANCES — NON-CONSTRUCTION PROGRAMS
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:
(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; (0
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) 55 523 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 non-
discrimination 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.
3.
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 costs) to
ensure proper planning, management and com-
pletion of the project described in this application.
WUi 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.
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. 55 4728-4763)
relating to prescribed standards for merit systems
for programs funded under one of the nineteen
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. 55 1681-1683, 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. § 794), which prohibits dis-
crimination on the basis of handicaps; (d) the Age
Discrimination Act of 1975, as amended (42
U.S C 55 6101-6107), which prohibits discrim-
ination on the basis of age;
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 with the provisions of the Hatch Act
(5 U.S.C. 55 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.
9. Will comply, as- applicable, with the provisions of
the Davis-Bacon Act (40 U.S.C. 55 276a to 276a-
7), the Copeland Act (40 U.S.C. $ 276c and 18
U.S.C. $5 874), and the Contract Work Hours and
Safety Standards Act (40 U.S.C. 55 327-333),
regarding labor standards for federally assisted
construction subagreements.
Slanted Fan* 4240 <«•*•>
P*t»ibad by OMB Cwcdir A-102
Authorized for Local Reproduction
-------
10. Will comply, if applicable, with Hood 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 andto 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. §5 1451 et seq.); (0
conformity of Federal actions to State (Clear Air)
Implementation Plans under Section I76(c) of the
Clear 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).
12. Will comply with the Wild and Scenic Rivers Act
.of 1968 (16 U.S.C. §5 1271 et seq.) related to
protecting components or 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 1966, as amended
U.S.C. 470), EO 11593 (identification an
protection of historic properties), and
Archaeological and Historic Preservation Act of
'1974 (16 U.S.C. 469a-l 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 of 1984.
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
APPLICANT ORGANIZATION
DATE SUBMITTED
SF 4248 (4-S8I
-------
EPA Project Control Number
United States Environmental Protection Agency
Washington, DC 20460
Certification Regarding
Debarment, Suspension, and Other Responsibility Matters
The prospective participant certifies to the best of its knowledge and belief that it and the principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) Have not within a three year period preceding this proposal been convicted of or had a civil judgement
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public
transaction: violation of Federal or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen
property:
(C) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal,
State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this
certification; and
(d) Have not within a three-year period preceding this application/proposal had one or more public
transactions (Federal, State, or local) terminated for cause or default
I understand that a false statement on this certification may be grounds for rejection of this proposal or
termination of the award. In addition, under 18 USC Sec. 1001, a false statement may result in a fine of
up to $10,000 or imprisonment for up to 5 years, or both.
Typed Name & Title of Authorized Representative
Signature of Authorized Representative ' Date
|| I am unable to certify to the above statements. My explanation is attached.
PA Form 5700-49 (11-88)
-------
Instructions
Under Executive Order 12549, an individual or organization debarred or excluded from
participation in Federal assistance or benefit programs may not receive any assistance award under
a Federal program or a subagreement thereunder for $25,000 or more.
Accordingly, each prospective recipient of an EPA grant, loan, or cooperative agreement and any
contract or subagreement participant thereunder must complete the attached certification or provide
an explanation why they cannot For further details, see 40 CFR 32.510, Participants'responsibilities,
in the attached regulation.
Where To Submit
The prospective EPA grant, loan, or cooperative agreement recipient must return the signed
certification or explanation with its application to the appropriate EPA Headquarters or Regional office,
as required in the application instructions.
A prospective prime contractor must submit a completed certification or explanation to the individual
or organization awarding the contract
Each prospective subcontractor must submit a completed certification or explanation to the prime
contractor for the project
How To Obtain Forms:
EPA includes the certification form, instructions, and a copy of its implementing regulation (40 CFR
Part 32) in each application kit Applicants may reproduce these materials as needed and provide them
to their prospective prime contractor, who, in turn may reproduce and provide them to prospective
subcontractors.
Additional copies/assistance may be requested from:
Suspension and Debarment Division
Grants Administration Division (3903R)
U.S. Environmental Protection Agency
401 M Street, SW
Room 51288
Washington, DC 20460
(Telephone: 202/564-5305)
EPA Form 670049 (11-88)
-------
EPA PROJECT CONTROL NUMBER
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTACTS/ GRANTS,
LOANS, AND COOPERATIVE AGREEMENTS
The Undersigned certifies, to the best of his or her
knowledge and belief, that:
(1) No Federal appropriated funds have been 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 any 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.
(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, 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 Form to Report Lobbying," in
accordance with its instructions.
(3) The undersigned shall require that the language of this
certification be included in the award of 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.
TYPED NAME & TITLE OF AUTHORIZED REPRESENTATIVE
SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE
-------
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTTVITliS
This disclosure torn shall be completed by the reporting entity, Aether tubawardee of prime Federal recipient at the
initiation or rweipt of a covered Federal action, or a material change to a previous filing, pursuant to tide 31
section 1352. Tne filing of a form is required for each payment or agreement to make paymenttoany lobtrpn,
influencing or attempting to influence an officer or employee of any agency, « Member of Con«« an o
employe,, of Congress, or an employee of a Member of Congress in connection with * covered FedX a«"n ui
SF.LU-A Continuation Sheet for additional information if the space on the form it inadequate Comokte M hJm? .kS
apply for both the initial filing and material change report. Refer to the implement^ g^fdal« pubSSSd by** SScfo
Management and Budget for additional information. ^ f puoiitneo oy we otnce of
Identify the type of covered Federal action for which lobbying activity i, and/or has been secured to influence the
outcome of a covered Federal action. ^ »^».««™ iw mnuence me
1
2. Identify the status of the covered Federal action.
. u e overe eera acon.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to me
•nformatjon previously reported enter (he year and quarter in which the change occunW EnUf *• daTeof the l«t
previously submitted report by this reponing entity for this covered Federal action.
'
*
, state and
. ««« ana
S. If the organization filing the report in item.4 checks "Subawardee-. then enter the full name,
np code of the pnme Federal recipient. Include Congressional District if known.
6. Enter the name of the Federal agency making the award or loan commitment, include at least on* organizational
level below agency name, if known. For example. Department of Transportation. United States Coast Cuanl
rt e n °f 'k*0?'!?" for th« covered f^*'*1 *«• « kno*«. «ter the full
Catalog of Federal Domest.c Ass-stance (CFDA) number for grants, cooperative agreement!, few, anT ban
commitments.
Enter the most *PP'Opriate Federal identifying number available for the Federal action identified to item 1 (e^,
Request for Proposal (RFP) number Imitation for Bid
-------
V
DISCLOSURE: OF LOBBYING ACTlVniES
Complete thicforii»t*djidotc lobbying activities pursuant to 31 U.5.C. 13S2
.
-------
DISCLOSURE OF LOBBYING ACTIVITIES
CONTINUATION SHEET
Entity-
-------
y*""*, UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
f 4% \ WASHINGTON, DC 20460
1 53J2£ J Preaward Compliance Review Report For All Applicants
^•t****^ Requesting Federal Financial Assistance
Form Approved
OMB No. 2090-00 14
Expires 4-30-99
Note: Read instructions on reverse side before completing form.
I. A. Applicant (Name, City, State)
B. Recipient
(Name, City, State)
C. EPA Project No.
II. Brief description of proposed project, program or activity.
III. Are any civil rights lawsuits or complaints pending against applicant and/or recipient?
If "yes", list those complaints and the disposition of each complaint
YES NO
IV. Have any civil rights compliance reviews of the applicant and/or recipient been conducted
by any Federal agency during the two years priorto this Application for activities which
would receive EPA assistance?
If "yes", list those compliance reviews and status of each review.
YES NO
j V. Is any other Federal financial assistance being applied for or is any other Federal financial
assistance being applied to any portion of this project, program or activity?
I If "yes", list the other Federal Agency(s), describe the associated work and the dollar amount
i of assistance.
YES NO
VI. If entire community under the applicant's jurisdiction is not served under the existing facilities'
services, or will not be served under the proposed plan, give reasons why.
VII. Population Characteristics
1. A. Population of Entire Service Area
; B. Minority Population of Entire Service Area
: 2. A. Population Currently Being Served
i B. Minority Population Currently Being Served
3. A. Population to be Served by Project, Program or Activity
B. Minority Population to be Served by Project, Program or Activity
4. A. Population to Remain Without Service
B. Minority Population to Remain Without Service
Number of People
VIII. Will all new facilities or alterations to existing facilities financed by these funds be designed
and constructed to be readily accessible to and usable by handicapped persons?
If "No", explain how a regulatory exception applies (40 CFR 7.70).
YES
NO
IX. Give the schedule for future projects, programs or activities (or of future plans), by which service will be
provided to all beneficiaries within applicant's jurisdiction. If there Is no schedule, explain why.
X. 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.
A. Signature of Authorized Official
B. Title of Authorized Official
C. Date
For the U.S. Environmental Protection Agency
Approved
Disapproved
Authorized EPA Official
Date
iPA Form 4700-4 (Rev 1-90) Previous editions ore obsolete
Printed on Recycled Paper
-------
Instructions
General IA.
Recipients of Federal financial assistance from the U.S. Envi-
ronmental Protection Agency must comply with the following
statutes.
Title VI of the Civil Rights Act 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 pro-
gram or activity receiving Federal financial assistance. The
Act goes on to explain that the title shall not be construed to
authorize action with respect to any employment practice or
any employer, employment agency, or labor organization (ex-
cept where the primary objective of the Federal financial assis-
tance is to provide employment).
Section 13 of the 1972 Amendments to the Federal Water Pol-
lution 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. Em-
ployment 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 handicapped individual shall solely by rea-
son of handicap be excluded from participation in, be denied
the benefit of or be subjected to discrimination under any pro-
gramoractivityreceivingFederalfinanceassistance. Employ-
ment discrimination on the basis of handicap 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 Em-
ployment Act administered by the Equal Employment Opportu-
nity Commission.
TMe IX of the Education Amendments-of 1972 provides that no
person on the basis of sex shall be excluded from participation
in, be denied the benefit of, or be subjected to discrimination
under any education program or activity receiving Federal fi-
nancial 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.
ITEMS
"Applicant" means any entity that files an application or un-
solicited proposal or otherwise rquests EPA assistance.
IB. •Recipient1' means any entity, other than applicant, which will
actually receive EPA assistance.
1C. Self-explanatory.
II. Self-explanatory.
III. "Civil rights lawsuits" means any lawsuit or complaint alleg-
ing discrimination on the basis of race, color, national origin,
sex, age or handicap pending against the applicant and/or
entitywhich actually benefits from thegranL For example, if
a city is the named applicant but the grant will actually benefit
the Dept of Sewage, civil rights lawsuits involving both the
ctty and the Dept of Sewage should be listed.
Jv*. "Civil rights compliance review" means any review assess-
ing the applicant's and/or recipient's compliance with laws
prohibiting discrimination on the basis efface, color, national
origin, sex, age or handicap. If any part of the review covered
the entity which will actually benefit from the grant, it should
be listed.
V. Self-explanatory.
VI. The word "carrimunitv" refers to the area underthe applicants
and/or recipient's jurisdiction. The "community" might be a
university or laboratory campus, ora community within a large
city. If there is a significant disparity between minority and
. nonminority populations to receive serve, not otherwise sat-
isfactorily explained, the Regional office may require a map
which indicates the minority and non-minority population
served by this project, program or activity.
VII. Thisinfbmrationfe required so that reviewers may determine
If a disparity in the proposed provision of services will exist hi
theeventthe application is approved for funding. G we popu-
lation of recipient's jurisdiction, broken out by categories as
In the event the applicant cannot provide the requested infor-
mation because the funds will be distributed over a wide de-
mographic area which is yet to be determined, an explana-
tion may be provided on a separate sheet For example, a
State applying for a capitalization grant under the State Re-
volving Fund program may not know which cities and coun-
ties wfll apply for, and receive, SRF loans.
The information on this forni is required to enable the U.S.
Environmental Protection Agency to determine whether appli-
cants and prospedivenxapients are developing projects, pro- DC
grams and activities on a nondiscriminatory basis as required
by the above statutes.
Submit this form with the original and required copies of appli-
cations, 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 "MA: for-Not Applicable."
In the event applicant is uncertain about how to answer certain
questions, EPA program officials should be contacted for clari-
fication.
VIII. Self-explanatory.
"Jurisdiction'' means the geographical area over which appli-
cant has the authority to provide service.
Self-explanatory.
"Burden Disclosure Statement" .
EPA eitr-n 'Jt*, uMic reporting burden tar the preparation of (hi* torn to ew-
ege 30 minute* per resporae. This ectimeta incudes «he time tar reviewing
tfutfuctions. gathering and niemtftviing Ine date needed, end (xunptotirig end
reviewing the (arm. Send comments regarding Bits burden eitimate or any
ottw eapect d (his collection of information, Including eugge»lion« far reduc-
ing Ihe burden, to U.S. Environmental Protection Agency. Chief. >tfuu«tiai
Poecy Branch (PM-Z23). 401M. Street. S.W.. Wtohinglon, O.C. 20460: endto
the Paperwork Reduction Project. Office o« Information and R*giattery Alfeir*.
Office of Management end Budget. Wuhingtan. O.C. 20503.
EPA FORM 4700-4 (Rev. 1/90) Reverse
-------
PREAWARD COMPLIANCE REVIEW REPORT
FOR ALL APPLICANTS REQUESTING FEDERAL
FINANCIAL ASSISTANCE
If you have any questions regarding this form, please contact the
appropriate person for your region, listed below:
Region 1
Region D
CT
ME
MA
NH
RI
VT
NJ
NY
PR
VI
Region m DE
DC
MD
PA
VA
WV
Region IV AL
FL
CA
KV
MS
NC
sc
Region V IL
IN
MI
MN
" OH
WI
Region VI AR
LA
NM
OK
TX
Region VH IA
KS
MO
NE
Region Vm CO
MX
ND
SD
UT
WY
Region K AZ
CA
ra
NV
AS
GU
Region X AK
ID
OR
WA
EEO Officers
Region I
Region II
Region III
Region IV
Region V
Region VI
Region VII
Region VIII
Region IX
Region X
James Younger
Dana Williams
Cynthia Burrows
Rafael Santamaria
Robert Thayer
Nellie Roblez
Joe Solis
Bobby Hodges
Rebecca Tudisco
Cecilia Contreras
(617) 565-3427
(212)637-3531
(215) 566-5326
(404)562-8312
(312)353-5138
(214) 665-6505
(913)551-7203
(303)312-6782
(415) 744-1699
(206) 553-2899
-------
-------
RETURN COMPLETED APPLICATION TO;
OFFICIAL MAILING ADDRESS;
U.S. ENVIRONMENTAL PROTECTION AGENCY
OFFICE OF GRANTS AND DEBARMENT
401 M. STREET, SW (3903R)
ROOM5128S
WASHINGTON, D.C. 20460
COURIER MAILING ADDRESS;
U.S. ENVIRONMENTAL PROTECTION AGENCY
1300 PENNSYLVANIA AVENUE, NW (3903R)
FIFTH FLOOR, ROOM 51288
WASHINGTON, D.C. 20004
-------
i
------- |