Form SF 424, SF 424 ins SF 424, SF 424 ins DL&T Grant Program Toolkit

FY 2009 Distance Learning & Telemedicine

Grant Program Toolkit

Telecommunications Program
Rural Development
United State Department of Agriculture

Contents
Page

Application Resources & Tips
SF 424—Application for Federal Assistance
SF 424 Instructions (Combined OMB and RD Instructions)
Survey on Ensuring Equal Opportunity for all Applicants
Budget:
Overall Budget Worksheet
In-Kind Match Worksheet
Other Funds Worksheet

T-ii
T-1
T-3
T-7
T-9
T-11
T-12

Fixed Site Applications Use:
Site Worksheet – Fixed Sites
Rurality Worksheet – Fixed Sites
NSLP Worksheet – Fixed Sites

T-13
T-15
T-17

Non-Fixed Site Applications Use:
Site Worksheet – Non-Fixed Sites
Rurality Worksheet – Non-Fixed Sites
NSLP Worksheet – Non-Fixed Sites

T-19
T-21
T-23
T-25

Leveraging Worksheet
EZ/EC Worksheet
Additional NSLP Worksheet

T-26
T-27

Certifications
Equal Opportunity and Nondiscrimination
Architectural Barriers
Flood Hazard Area Precautions
Uniform Relocation Assistance & Real Property Acquisition Policies Act
Drug-Free Workplace
Debarment, Suspension, and Other Responsibility Matters
Lobbying for Contracts, Grants, Loans, and Cooperative Agreements
Non Duplication of Services
Environmental Impact
T-i

C-1
C-2
C-3
C-4
C-5
C-6
C-7
C-8
C-9

Application Resources & Tips
• APPLICATION GUIDE: Please read and follow the Distance Learning and Telemedicine
Program FY 2009 Grant Application Guide as you fill out the forms, worksheets and
certifications in this Toolkit.
• AS YOU FILL OUT OR SIGN EACH OF THE TOOLKIT ITEMS, place them under the tabs of your
grant application as explained in Section V, “Putting It All Together,” of the Grant
Application Guide.
• FILL THE FORMS OUT COMPLETELY. Missing or inaccurate data on ANY of the forms will
adversely affect our ability to process your application.
• REGULATIONS: The Program’s regulation governs the application process, the Guide and
this Toolkit, but it does not specify application format. Use the FY 2009 Application Guide
for instructions on how to prepare your complete application package. (See the Code of
Federal Regulations, 7 CFR 1703, Subparts D, E, F and G. A copy of the regulations is
posted at the DLT Web page listed below.)
• CATALOG OF FEDERAL DOMESTIC ASSISTANCE (CFDA) Number: 10.855
• DLT PROGRAM:

(202) 720-0413

dltinfo@wdc.usda.gov

• ONLINE RESOURCES
DLT Branch Web page
RUS Staff including
Advanced Service Division
and General Field
Representatives
USDA Rural Development
State Directors

www.rurdev.usda.gov/recd_map.html
www.rurdev.usda.gov/scrty/sdirs.html

EZ/EC/Champion
Community Resources

www.ezec.gov
www.ezec.gov/ezec/mainmap.html
www.ezec.gov/Communit/champions.html

ARC Resources

www.arc.gov

State Single Points of
Contact (SPOC)

www.whitehouse.gov/omb/grants/spoc.html

Grants.gov Information

www.grants.gov

Get a DUNs Number

www.grants.gov/RequestaDUNS

Census 2000 Numbers

factfinder.census.gov/home/saff/main.html?_lang=en

www.usda.gov/rus/telecom/dlt/dlt.htm

www.usda.gov/rus/telecom/staff/index_staff.htm

T-ii

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0575-0096. The time
required to complete this information collection is estimated to average 49 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

T-iii

Reproduction of OMB Number: 4040-004
Expiration Date: 1/31/2009

Application for Federal Assistance SF-424 (page 1 of OMB’s webpage version)
1. Type of Submission:

2. Type of Application

√

Preapplication

√ Application

New

* If revision, select appropriate letter(s)

_____________________________________

Continuation

Changed Corrected Application

Version 02

* Other (Specify)

Revision ______________________________________

3. Date Received:

4. Applicant Identifier:

5a. Federal Entity Identifier

* 5b. Federal Award Identifier:
_______________________________

___________________________.

6. Date Received by State: __________________________________

7. State Application Identifier.___________________________

State Use Only

8. Applicant Information:
a. Legal Name: __________________________________________________________________________________________________________
b. Employer/Taxpayer Identification Number (EIN/TIN)
____________________________________________

c. Organizational DUNS:
_________________________________________________

d. Address:
* Street 1: _____________________________________________________________________________________________________________
Street 2: _____________________________________________________________________________________________________________
* City:

______________________________________________________________________________________________________________

County: ______________________________________________________________________________________________________________
* State:

_____________________________________________________________________________________________________________

Province: _____________________________________________________________________________________________________________
* Country: _____________________________________________________________________________________________________________
* Zip/Postal Code: _________________________
e. Organizational Unit
Department Name: ________________________________________

Division Name: ____________________________________________

f. Name and contact information for matters involving this application:
Prefix: _________________________ *First Name _______________________________________________________
Middle name: ______________________________________________________________________________________
*Last Name: _______________________________________________________________________________________
Suffix: __________________________
Title:______________________________________________________________________________________________
Organizational Affiliation_______________________________________________________________________________
Telephone Number: ______________________________

Fax Number: ___________________________________

E-mail: ________________________________________________________________

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Application for Federal Assistance SF-424 (pages 2 and 3 of OMB’s webpage version)

Version 02

9, Type of Applicant: #1 ______________________________________
#2 ______________________________________
#3 ______________________________________
Other (Specify)_______________________________________________________________________________
10. Name of Federal Agency: Rural Development Telecommunications Program
11. Catalog of Federal Assistance Number: 10-855
CFDA Title: Distance Learning and Telemedicine Loans and Grants
12. Funding Opportunity Number: RDUP-07-01-DLT
Title: USDA-DLT
13. Competition Identification Number: Leave Blank
Title: Leave Blank
14. Areas affected by Project:

Attach Site Worksheet

15. Descriptive title of Applicant’s Project:

______________________________________________________________________________

Attach supporting documentation as specified in agency instructions:

Attach Site Worksheet. Assemble and Tab Completed Application Package as described in Application Guide
16. Congressional Districts of:
17. Proposed Project:

a. Applicant: ___________b. Program/Project: _______________

a. Start Date: _____________________________

18. Estimated Funding:
a. Federal:

___________________________________

b. Applicant:

___________________________________
a. This application was made available
to the State under the E.O.
12372 process for review on:
_______________________

d. Local leave blank
___________________________________

b. Program is subject to E.O. 12372, but not selected by the State.

f. Program Income: leave blank
g. Total

b. End Date:___________________________________

19. Is Application Subject to Review by State under
Executive Order 12372 Process?

c. State: leave blank
e. Other

Attach Site Worksheet

___________________________________

20. Is the Applicant delinquent on any Federal Debt?

NO

c. Program is not covered by E. O. 12372.

YES (If yes, provide and attach an explanation).

21. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are
true. complete, and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting
terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil or
administrative penalties. (U.S. Code, title 218, Section 1001)
I Agree ** The list of assurances, or an internet site where you may obtain this list, is contained in the announcement or Agency specific instructions.
Authorized Representative: Prefix:: ______________ First name: ___________________________________
Middle Name: ___________________________________
Last Name: ___________________________________ Suffix: ________________
Title:__________________________________________________
Telephone Number: ______________________________________ Fax Number: __________________________________________
e-mail: _________________________________________________________________________________

Signature of Authorized Representative: ________________________________________________ Date: ______________________
Authorized for Local Reproduction

Reproduction of Standard Form 424 (Revised 10/2005)
Prescribed by OMB Circular A-102

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INSTRUCTIONS FOR THE SF-424

These instruction include general instructions provided by OMB (in black) and the additional instructions and
guidance from the Agency (in blue). In many cases, the Agency provides specific instructions or has already
filled in the information making the general OMB instruction less useful. For these, the OMB text is shown in a
small font. General OMB Directions not applicable to the DLT Program are struck through. This is a standard form
(including the continuation sheet) required for use as a cover sheet for submission of preapplications and applications and related information under discretionary
programs. Some of the items are required and some are optional at the discretion of the applicant or the Federal agency (agency). Required items are identified with an
asterisk on the form and are specified in the instructions below. In addition to the instructions provided below, applicants must consult agency instructions to determine
specific requirements. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO
THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

1. We have already checked the “application box” for you. 1. Type of Submission: (Required): Select one type of submission in
accordance with agency instructions. • Preapplication • Application • Changed/Corrected Application – If requested by the agency, check if this submission is to
change or correct a previously submitted application. Unless requested by the agency, applicants may not use this to submit changes after the closing date.
2. We have already checked the “new” box for you. Type of Application: (Required) Select one type of application in accordance with
agency instructions. New – An application that is being submitted to an agency for the first time. Continuation - An extension for an additional funding/budget period
for a project with a projected completion date. This can include renewal. Revision - Any change in the Federal Government’s financial obligation or contingent
liability from an existing obligation. If a revision, enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in text box
provided. A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration E. Other (specify).
3-5. Leave blank for our use. 3. Date Received: Leave this field blank. This date will be assigned by the Federal agency. 4. Applicant Identifier: Enter
the entity identifier assigned by the Federal agency, if any, or the applicant’s control number if applicable. 5a. Federal Entity Identifier: Enter the number assigned to
your organization by the Federal Agency, if any. 5b. Federal Award Identifier: For new applications leave blank. For a continuation or revision to an existing award,
enter the previously assigned Federal award identifier number. If a changed/corrected application, enter the Federal Identifier in accordance with agency instructions.
6-7. Leave blank for state use. 6. Date Received by State: Leave this field blank. This date will be assigned by the State, if applicable. 7. State
Application Identifier: Leave this field blank. This identifier will be assigned by the State, if applicable.
8. There are multiple entries in this block.
a. Enter the legal name of the applicant that will undertake the project funded by the assistance as that name
appears in legal documents such as contracts, i.e., in full without abbreviations or omissions. Applicant Information:
Enter the following in accordance with agency instructions: a. Legal Name: (Required): Enter the legal name of applicant that will undertake the assistance activity.
This is the organization that has registered with the Central Contractor Registry. Information on registering with CCR may be obtained by visiting the Grants.gov
website.

b. Enter the employer or tax identification number assigned by the IRS.

If your organization is not in the US, enter 44-4444444.

c. OMB requires all grant applicants supply a DUNS Number (Dun & Bradstreet Universal Numbering
System). The number is free. To obtain a DUNS number, please call Dun & Bradstreet at 866-705-5711 or
refer to www.whitehouse.gov/omb/grants/duns_num_guide.pdf. c. Organizational DUNS: (Required) Enter the organization’s DUNS or
DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting the Grants.gov website.

d. Enter the complete address as follows: Street address (Line 1 required), City (Required), County, State (Required, if
country is US), Province, Country (Required), Zip/Postal Code (Required, if country is US).
e. Enter the name of the primary organizational unit (and department or division, (if applicable) that will undertake the
assistance activity, if applicable.

f. This information will be used for all contact and correspondence. Please complete carefully and in full.
Attach a sheet if you want to provide additional contacts. It is crucial that we have accurate information, in
particular, a fax number. If you do not have a fax, you must provide a reliable e-mail address to receive
correspondence promptly. Otherwise, it will go by regular US mail. Given that response deadlines are based
on the date of our correspondence, using mail effectively shortens your time to respond. If any of you contact
information changes after you submit your application, please inform us.
If you wish to delegate someone not in your organization to act on your behalf, attach a letter to the SF
424 listing the person’s name, organization, contact info, and relationship to your organization. Make sure the
letter states the scope of the delegation and any time limit you wish to apply to their authority. The letter of
delegation must be signed by the same authorized person who signs the SF 424 in Block 21. Remember, if
you delegate someone, that person is responsible for responding to any date-sensitive request from us. Faxes
T-3

(or e-mails) will be sent to that contact. We also send a copy to the applicant, but that correspondence goes by
mail. If you designate someone to act, but also wish to receive such correspondence as promptly as possible,
make that clear and provide contact info for both. Name (required), organizational affiliation (if affiliated with another organization than the
applicant organization, enter the name (First and last name), telephone number (Required), fax number, and email address (Required) of the person to contact on matters related
to this application.

9. Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions.
For example, a public university that if identified as an Historically Black Coolege could enter “H,T” Use the
following designations. Many are self-explanatory.
A. State Government. Do not include state supported institutions of higher learning.
B. County Government. Exclude supported institutions of primary, secondary, or post secondary learning.
C. City or Township Government. Also include boroughs or other forms of local municipal government.
Exclude supported institutions of higher learning or post secondary education.
D. Special District Government. According to the Census, special district governments are independent,
special purpose governmental units that exist as separate entities with substantial administrative and fiscal
independence from general purpose governments. This excludes school district governments. Special
district governments provide specific services, usually only one, not supplied by general purpose
governments. The services range from hospitals and fire protection to mosquito abatement and cemetery
upkeep. It covers a wide variety of entities, most of which are officially called districts or authorities.
However, not all so named represent separate governments. Many “districts” or “authorities” are so
closely related to county, municipal, or state governments that they are classified as subordinate agencies
of those governments. In order to be considered a special district government, an entity must possess
three attributes - existence as an organized entity, governmental character, and substantial autonomy.
E. Regional Organization. An organization affiliated with more than one state or local government, but
without the governmental character of a Special District Government.
F. U.S. Territory or Possession.
G. Independent School District. Includes public primary & secondary districts (K-12), regardless of their
specific relationship to states, counties, municipalities, or overlap with other public school districts.
H. Public/State Controlled Institution of Higher Learning
I. Indian/Native American Tribal Government – Federally Recognized
J. Indian/Native American Tribal Government – Other than Federally Recognized.
K. Indian/Native American Tribally Designated Organization.
L. Public Housing Authority/Indian/Native American Housing Authority.
M. Nonprofit (Secular) with 501C3 IRS Status (Other than Institution of Higher Education.)
N. Nonprofit (Secular) without 501C3 IRS Status (Other than Institution of Higher Education.)
O. Private Institution of Higher Education.
P. Individual. Individuals are not eligible for the DLT Grant Program.
Q. For-Profit Organization other than Small Business.
R. Small Business
S. Hispanic-Serving Institution.
T. Historically Black Colleges and Universities (HBCUs).
U. Tribally Controlled Colleges and Universities (TCCUs).
V. Alaska Native and Native Hawaiian Serving Institutions.
W. Non-domestic (non-US) Entity. Not eligible. Only domestic areas (US and certain territories) qualify for
DLT Funding.
X. Other. (specify)
Y. Nonprofit. (Faith-Based – with or without 501C3 IRS Status)
T-4

10-13. We have entered the required information in blocks 10-12. Leave Block 13 blank. 10. (Required) Enter the name
of the Federal agency from which assistance is being requested with this application. 11. Enter the Catalog of Federal Domestic Assistance number and title of the
program under which assistance is requested, as found in the program announcement, if applicable. 12. (Required) Enter the Funding Opportunity Number and title of
the opportunity under which assistance is requested, as found in the program announcement. 13. Enter the Competition Identification Number and title of the
competition under which assistance is requested, if applicable.
14-16. The information requested in these blocks is placed on the appropriate Site Worksheet. You may enter a
descriptive title in block 15. Most applications propose projects that operate at fixed sites such as schools or
medical clinics. Other projects operate at non-fixed sites. Examples of the latter include visiting nurse
associations and ambulance-based systems. To be eligible, projects must be exclusively one or the other.
Depending on the type of project, applicants will complete either the Fixed Site Worksheet or the Non-Fixed
Site Worksheet. Remember that an application cannot be evaluated or scored (which makes it ineligible) if it
contains both a fixed and non-fixed site component. See A., “Standard Form 424 and Attachments,” and D-1,
“Telecommunications System Plan,” in Section IV of the Application Guide for extended discussion of how to
categorize sites in your application and for determining which worksheet you should complete. 14. List the areas or
entities using the categories (e.g., cities, counties, states, etc.) specified in agency instructions. Use the continuation sheet to enter additional areas, if needed. 15.
(Required) Enter a brief descriptive title of the project. If appropriate, attach a map showing project location (e.g., construction or real property projects). For
preapplications, attach a summary description of the project. 16. (Required) 16a. Enter the applicant’s Congressional District, and 16b. Enter all District(s) affected by
the program or project. Enter in the format: 2 characters State Abbreviation – 3 characters District Number, e.g., CA-005 for California 5th district, CA- 012 for
California 12th district, NC-103 for North Carolina’s 103rd district. • If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD-all
for all congressional districts in Maryland. • If nationwide, i.e. all districts within all states are affected, enter US-all. • If the program/project is outside the US, enter 00000.

17. (Required) Enter the proposed start date and end date of the project.
18. (Estimated Funding): Data shown in this box is summary information only. Showing a match in Box 18-b
does not constitute documentation of matching funds in form and substance satisfactory to the Agency for
evaluating matching funds. You must document your matching funds under Tab E-3 – Leveraging. (Required) Enter
the 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.

a. Federal: Show the amount requested from the Agency as a grant. This number is line E, DLT GRANT
REQUEST, in the Budget Summary block at the bottom of the Overall Budget Worksheet (See Toolkit).
b. Applicant: Show the total proposed matching contributions regardless of source. This number is the sum of
lines B & C, Less Proposed Cash Match and Less Proposed In-Kind Match, in the Budget Summary block
at the bottom of the Overall Budget Worksheet. This is a summary number and does not constitute
documentation of your match, which must be provided under Tab E-3.
c, d, & f: Leave Blank.
e. Other: Show amounts in the project budget, but not in the grant request or proposed matching funds. This
number is line D, Less Other Funds, in the Budget Summary block of the Overall Budget Worksheet.
g. Total: Show the total budget. This number is line A, Overall DLT Project Budget, in the Budget Summary
block of the Overall Budget Worksheet.
19. The DLT Program is subject to Executive Order 12372, Intergovernmental Review of Federal Programs.
The Order requires that grant applicants consult with State and local officials if that state has a State Local Point
of Contact (SPOC). If your state has a SPOC, you must submit a copy of your application to them at the same
time you submit your application to us. Check this website to determine if your state has a SPOC and for
contact information:
www.whitehouse.gov/omb/grants/spoc.html

T-5

The following states had a SPOC at the time this Guide was prepared. Double-check the website above when
you prepare your application to make certain that your state has not established a SPOC in the meantime. 19.
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. Select the appropriate box. If “a.” is selected, enter the date the application was submitted to the State.

Arkansas
District of Columbia
Illinois
Maine
Mississippi
New Hampshire
Rhode Island
Utah
American Samoa
Puerto Rico

California
Florida
Iowa
Maryland
Missouri
New York
South Carolina
West Virginia
Guam
Virgin Islands

Delaware
Georgia
Kentucky
Michigan
Nevada
North Dakota
Texas
Wisconsin
North Mariana Islands

20. (Required) Select the appropriate box. We cannot make a grant if you are delinquent on Federal debt.
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. If yes, include an explanation on a
continuation sheet.
21. The SF-424 must be signed by an authorized representative of the applicant’s organization, the organization
that will manage the project if a grant is awarded. An authorized representative is one capable of obligating the
organization. You must include evidence that the signer is authorized to obligate the organization - no
exceptions. Remember that even for large organizations in the public eye, we have no administratively practical
way of confirming the name, title, or authority of the various people who have the legal ability to obligate your
organization. Place the evidence behind the SF-424 and Site Worksheet under Tab A. Applications submitted
without evidence that the person who signed the SF-424 is so authorized will be returned as ineligible. Also,
matching funds must be documented under Tab E-3 – Leveraging. A signature on the SF 424 does not
constitute documentation in form and substance satisfactory to the Agency. (Required) To be signed and dated by the authorized
representative of the applicant organization. Enter the name (First and last name required) title (Required), telephone number (Required), fax number, and email
address (Required) of the person authorized to sign for the applicant. A copy of the governing body’s authorization for you to sign this application as the 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.)

Public reporting burden for this collection of information is estimated to average 60 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.

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Survey on Ensuring Equal Opportunity for Applicants
Reproduction of OMB No. 1890-0014 EXP 02/28/09

Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faith-based,
have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal
funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey.
Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way
in making funding decisions and will not be included in the Federal grants database. While your help in this data collection process is
greatly appreciated, completion of this survey is voluntary.
Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an
envelope labeled "Applicant Survey." Seal the envelope and include it along with your application package. If you are applying
electronically, please submit this survey along with your application.

Applicant’s (Organization) Name:
Applicant’s DUNS Number:
Federal Program: Distance Learning & Telemedicine Grant Program
1. Has the applicant ever received a grant or contract from
the Federal government?
Yes

No

2. Is the applicant a faith-based organization?
Yes

No

6. How many full-time equivalent employees does the
applicant have? (Check only one box.) For example, two part-time
employees who each work half-time equal one full-time equivalent
employee. If the applicant is a local affiliate of a national
organization, the responses to questions 2 and 3 should reflect the
staff and budget size of the local affiliate.

3 or fewer
4-5
6-14

(Self-Identify)

3. Is the applicant a secular organization?
Yes

No

(Self-Identify)

4. Does the applicant have 501(c)(3) status? (501(c)(3) status
is a legal designation provided on application to the Internal
Revenue Service by eligible organizations. Some grant programs
may require non-profit applicants to have 501(c)(3) status. Others
do not.
Yes

less than $150,000
$150,000 - $299,999
$300,000 - $499,999
$500,000 - $999,999
$1,000,000 - $4,999,999
$5,000,000 or more

No

No

15-50
51-100
over 100

7. What is the size of the applicant’s annual budget? (Check
only one box.) Annual Budget means the amount of money your
organization spends each year on all such activities.

5. Is the applicant a local affiliate of a national organization?
Yes

CFDA Number 10.855

(Self-Explanatory)

Paperwork Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a valid OMB control number. The valid OMB control number for this information collection is 1890-0014. The time required to
complete this information collection is estimated to average five (5) minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy estimate(s) or suggestions for improving this form, please write to the Agency Contact listed in this grant
application.
Reproduction of OMB No. 1890-0014 Exp. 02/28/09

T-7

T-8

2009 DLT Project

Overall Budget Worksheet
(See D-1 and D-2 in Section IV of the Application Guide)
Line
Item
No.1

Site
Name2

Unit
Cost

Description

No.

Extended
Cost

DLT %
of Use3

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

Overall Project Budget – Page 1 Subtotal →

A.
B.
C.
D.
E.

Budget Summary
4
(Sum of page 1 and continuation sheets subtotals) Overall DLT Project Budget
5
(as documented under Tab E-3) Less Proposed Cash Match
5
(from In-Kind Match Worksheet) Less Proposed In-Kind Match
(from Other Funds Worksheet) Less Other Funds
DLT Grant Request (A – B – C – D = E)

1. Use the line-item number established on the Overall Budget Worksheet(s) on the other budget worksheets. If line-item 16 on the
Overall Sheet is ineligible, show it as item 16 on the Other Funds Worksheet. Don’t start a new numbering system on each sheet.
2. For non-fixed site applications, show the operational service center out of which the financed equipment will operate.
3. This number refers to the % of use that meets the DLT Grant definition of distance learning or telemedicine, the portion that is
eligible for either grant or match funding. Ineligible items or items for which no funding is requested are shown as zero percent,
regardless of their use in the project.
4. Line A is the sum of all DLT project extended costs as shown on this page and any continuation sheets. It includes the grant request
and all proposed matches, as well as ineligible funds that have been included in the budget.
5. Matching funds (lines B & C) must be properly documented under Tab E-3 of your application as described in detail in the
Application Guide. Any portion that is not will not be credited as an eligible match.

Place this Worksheet under Tab D-2 of your Application
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Overall Budget Worksheet (Continuation)
Line
Item
No.1

Site
Name2

Unit
Cost

Description

No.

Extended
Cost

Overall DLT Project Budget – Page ___ Subtotal →
1., 2., & 3. See footnotes on 1st page of Overall Budget Worksheet

Place this sheet with other budget sheets under Tab D-2
T-10

DLT %
of Use3

2009 DLT Project

In-Kind Match Worksheet
(See D-1, D-2, & E-3 in Section IV of the Application Guide)
Proposed Matching Funds are generally cash. If any of the line-items shown on the Overall Budget Worksheet
are specified in the match documentation, they are in-kind. Show them below in the same manner (line-item #,
site name, description) as on the Overall Budget Worksheet. If only a portion is attributable to the DLT project,
show that portion here and the balance that is not eligible on the Other Funds Worksheet. In the right column,
clearly identify the source. Remember to document proposed matching funds under Tab E-3, otherwise they
will not be credited as an eligible match.
Line
Item
No.

Site
Name

In-Kind
Cost

Description

Source

C. Total Proposed In-Kind Match →
(Insert this number in line C of the Budget Summary
on the Overall Budget Worksheet)

Make copies of this sheet if needed and label them “continuation.” Place this sheet with
other budget sheets under Tab D-2
T-11

2009 DLT Project

Other Funds Worksheet
(See D-1 & D-2 in Section IV of the Application Guide)
Some line-items included in a DLT Project Budget are not eligible as either grant or match. The funds for these
must come from other sources and are designated “Other Funds.” Some line-items are only partially eligible as
grant or match. The balance of these must also come from other sources. Show all other funds below in the
same manner (line item #, site name, and description) as on the Overall Budget Worksheet. Show the ineligible
line-item cost (or portion thereof) in the “other fund cost” column adjacent to the source of that funding.
Line
Item
No.

Site
Name

Other Fund
Cost

Description

Source

D. Total Proposed Other Funds →
(Insert this number in line D of the Budget Summary
on the Overall Budget Worksheet)

Make copies of this sheet if needed and label them “continuation.” Place this sheet with other
budget sheets under Tab D-2
T-12

2009 Site Worksheet - Fixed Sites (Attachment to SF 424)

Column 1.

Column 2.
Column 3.
Column 4.
Column 5.

(See A, D-1 and D-2 in Section IV of the Application Guide)
For each Hub, combined Hub/End-User, and End-User site, show its complete official name (and abbreviation should you choose to use
one). Each site name (or abbreviation) must be used consistently throughout the balance of your application. Below the site name, show
the complete street address. The address must be one that can be positively identified as described in the Application Guide. If the only
address available for a site is a PO Box, Star Route, Rural Route, or other address not locatable on a map, give that address supplemented
by the precise latitude and longitude (DD/MM/SS or DD.DDDD).
For each site, show how you designate the site. i.e., as a Hub, a Hub/End-User, or End-User.
Show the County in which the site is located
Show the School District in which the site is located.
Show the Congressional District in which the site is located (example: MI 57th Dist., John Smith.)
1. Complete Site Name (Abbreviation, if any)
Complete Street Address
(DD/MM/SS or DD.DDDD if needed, see instructions)

2.
Site
Designation

3.
County

4.
School
District

5.
Congressional
District

1

2

3

4
5
.
You are not restricted to 5 sites. A continuation sheet follows this page. If you have many sites, use as many continuation sheets as you need.

Place this sheet behind SF-424 under Tab A of your Application
T-13

Site Worksheet - Fixed Sites (Continuation)
1. Complete Site Name (Abbreviation, if any)
Complete Street Address
(DD/MM/SS or DD.DDDD if needed, see instructions)

2.
Site
Designation

3.
County

Place this sheet behind SF-424 under Tab A of your Application
T-14

4.
School
District

5.
Congressional
District

2009 Rurality Worksheet – Fixed Sites
(For more complete guidance in completing this sheet, see E-1 in Section IV of the Application Guide)
Category
Exceptionally Rural – Any area of the US NOT included within the boundary of a
Census Urbanized Area or Urban Cluster having a population in excess of 5,000. This
includes Urban Clusters between 2500 and 5000 as well as Census Rural Areas.

Population

Points

5000 or
fewer

45

Rural – Any area of the US included within the boundary of a Census Urban Cluster
having a population over 5,000 and not in excess of 10,000.

5001 10,000

30

Mid-Rural - Any area of the United States included within the boundary of a Census
Urban Cluster over 10,000 and not in excess of 20,000.

10,001 20,000

15

20,001 or
more

0

Urban Area - Any area of the United States included within the boundary of any
Urbanized Area or Urban Cluster in excess of 20,000.

Enter each site (hub, hub/end-user, or end-user) in the table below. Place pure hubs at the beginning of the list
separated by a space and do not include them in your estimated Rurality score. To document the numbers,
attach Census maps and data sheets for each site as described in the Application Guide. For each site in an
Urbanize Area (UZA) or Urban Cluster (UC), enter points from the table above based on the population of the
UZA or UC. For each site located in a Census Rural area, show the population as “<2500 points” enter 45
points. Note – The population for sites in Census Rural areas should be shown as “<2500” because there is no
specific population associated with such an area. Any end-user site without verifiable census documentation
will be evaluated as urban (zero points). Remember that your sites must be consistent throughout the
application including on the Rurality and NSLP Worksheets, the Site Worksheet, the Executive Summary, the
Telecommunications System Plan, and the Budget. If the end-user sites are not consistent, your application
is unscorable and will be returned as ineligible.
Site Name (Location)

Site Type

(Same numbering and order as Site & NSLP Worksheets)

(Hub, etc.)

Census
Designation

Census
Rurality
Population Points

1
2
3
4
5
Applicant’s Estimated Rurality Score
(Sum of Rurality Points ÷ # of End-User Sites)

Rurality Score
(For Agency Use)

You are not restricted to 5 sites. A continuation sheet follows this page. If you have many sites, use as many continuation
sheets as you need. Be sure to indicate your estimated Rurality score for all end-user sites on this sheet.

Place this sheet and Census documentation under Tab E-1 of your Application
T-15

Rurality Worksheet – Fixed Sites (Continuation)
Site Name (Location)
(Same numbering and order as Site & NSLP Worksheets.
Number consecutively from previous sheet )

Site Type
(Hub, etc.)

Census
Designation

Census
Rurality
Population Points

Place Rurality Worksheets and Census Documentation under Tab E-1 of your Application
T-16

2009 NSLP Worksheet – Fixed Sites

(For more complete guidance in completing this sheet, see E-2 in Section IV of the Application Guide)
Is site
Eligible
for
NSLP?

Decision Table
Type of End-User
A Public School (K-12)

Yes

A Private School (K-12)

No

A College or Other Educ. Org.

No

All Others - Hospital, Public
Library, Clinic, etc.

N/A

Use NSLP % for
Specific School

Use NSLP % for
School District
where site
located

Scoring Table

Yes
No
No
No

No
Yes
Yes
Yes

NSLP < 25%

Zero

25%≤NSLP<50%

15

50%≤NSLP<75%

25

NSLP ≥ 75%

35

NSLP
Eligibility %

Point
s

Enter each site in the table below placing them in the same order as on the Site Worksheet and Rurality Worksheet.
Identify the site by type. Provide data for hubs. Place pure hubs at the beginning of the list separated by a space and
do not include them in your estimated NSLP score. The Decision Table above shows whether to enter specific
school or district information for each site. Remember that your sites must be consistent throughout the application.
If the end-user sites are not consistent, your application is unscorable and will be returned as ineligible.
Any site without verifiable documentation attached behind this Worksheet will be evaluated at zero percent
eligibility. The Agency will not research undocumented data. Applicants must provide documentation for each
site’s percentage with a written certification from the organization that administers the NSLP in your area that the
data are accurate and the most recent available. Some official NSLP data is posted on state websites. If so, you may
provide printouts from these sites. Data from unofficial websites is not acceptable. Please highlight the relevant
data on the attached documentation.
Site Name
(Same numbering and order as Site & Rurality Worksheets)

Site Type
(Hub, etc.)

Total
Students

% Eligible
(See Attached)

1
2
3
4
5
Average NSLP
(Sum of NSLP Percentages ÷ # of Sites & then rounded to an Integer)

Applicant’s Estimated NSLP Score

NSLP Score

(Enter Points from Scoring Table)

(for Agency Use)

You are not restricted to 5 sites. A continuation sheet follows this page. If you have more sites, use as many continuation sheets as
you need. Be sure to indicate your estimated NSLP score for all end-user sites on this sheet.

Place this sheet and certified NSLP documentation under Tab E-2 of your Application
T-17

NSLP Worksheet - Fixed Sites (Continuation)
Site Name
(Same numbering and order as Site & Rurality Worksheets)

Site Type
(Hub, etc.)

Total
Students

% Eligible
(See Attached)

Place NSLP Worksheets and supporting documentation under Tab E-2 of your Application
T-18

2009 Site Worksheet - Non-Fixed Sites (Attachment to SF 424)

Use the Non-Fixed Worksheets only if your application is for a non-fixed site project - ambulance, visiting nurse, etc.)
(For more complete guidance in completing this worksheet, refer to D-1 and D-2 in Section IV of the Application Guide)

Column 1 - Identify the operational service center site(s) and the service territory over which the service operates. For each service center site, show its precise
address and provide a brief description of the nature of the facility. The address must be one that can be positively identified as described in the Application Guide. If
the only address available for a site is a PO Box, Star Route, Rural Route, or other address not locatable on a map, give that address supplemented by the precise
latitude and longitude (DD/MM/SS or DD.DDDD). For example, an ambulance service would show the address of and describe its emergency vehicle operations
center. A visiting nurse project would show the central hospital or VNA offices from which it operates the service.
For the service territory, attach a detail map (as described in the Application Guide) showing the location of the service center and the defined boundary within which
the service is offered from that center. (If the service territory is not defined, we cannot score the application, which makes it ineligible for funding.) Enter a narrative
description of the service territory using as many blocks as appropriate showing the information relevant to the described territory in columns 3, 4, & 5. If the service
operates multiple, autonomous, and operationally independent territories, show each physical service center and its associated service territory separately.
Columns 2-4 - Show the relevant County, School District, and Congressional District Data associated with the sites and territory listed.

1. Sites and Service Territory (attach Detail Map)

2.
County

For Service Center Sites, complete Street Address with Brief Description
(DD/MM/SS or DD.DDDD, if needed, see Application Guide)
For Service Territory, a narrative Description that is related to Detail Map

3.
School District

1

2

3

4
5
.
You are not restricted to these lines. A continuation sheet follows this page. Use as many as you need.

Place this sheet behind SF-424 under Tab A of your Application
T-19

4.
Congressional. District

Site Worksheet - Non-Fixed Sites (Continuation)
1. Sites and Service Territory (attach Detail Map)

2.
County

For Service Center Sites, complete Street Address with Brief Description
(DD/MM/SS or DD.DDDD, if needed, see Application Guide)
For Service Territory, a narrative Description that is related to Detail Map

3.
School District

Place this sheet behind SF-424 under Tab A of your Application
T-20

4.
Congressional. District

2009 Rurality Worksheet – Non-Fixed Sites
Use the Non-Fixed Worksheets only if your application is for a non-fixed site project - ambulance, VNA, etc.
(For more complete guidance in completing this sheet, refer to E-1 in Section IV of the Application Guide)
Category
Population Points
Exceptionally Rural – Any area of the US NOT included within the boundary of a
5000 or
Census Urbanized Area or Urban Cluster having a population in excess of 5,000. This
45
fewer
includes Urban Clusters between 2500 and 5000 as well as Census Rural Areas.
Rural – Any area of the US included within the boundary of a Census Urban Cluster
having a population over 5,000 and not in excess of 10,000.

5001 10,000

30

Mid-Rural - Any area of the United States included within the boundary of a Census
Urban Cluster over 10,000 and not in excess of 20,000.

10,001 20,000

15

20,001 or
more

0

Urban Area - Any area of the United States included within the boundary of any
Urbanized Area or Urban Cluster in excess of 20,000.

Any non-fixed site application that does not include a defined service territory documented by Census data
can not be scored and will be returned as ineligible. Place each Census Urbanized Area (UZA) and Census
Urban Cluster (UC) in which you provide service on an individual row in column 1 and attach Census data
printouts showing the population of each UZA or UC in column 3. From the table above, enter points in column five
based on the population of the UZA or UC. Enter the entire population of the UZA or UC in column 4 unless you
have demonstrated in your application that your defined service territory excludes part of the UZA or UC. (See the
Application Guide for additional guidance.) If you have so demonstrated, enter the portion you serve in Column 4.
Enter the Census Rural (below 2500) population(s) separately as appropriate and provide census data sheets to
support the number(s). For Census Rural population(s), enter 45 points in column 5. Enter the product of columns 4
and 5 in column 6. Divide the sum of column 6 by the sum of column 4 to obtain your estimated score.
3.
2.
4. Population in
5.
1. Service Territory Population Centers
6. Product
Census
Census
Service
Rurality
(List each Urbanized Area & Urban Cluster on a separate
(4 X 5 = 6)
line. Show Census Rural Area(s) separately.
Designation Population Territory
Points

1
2
3
4
5
Sum Rows 1-5 of columns 4 & 6 ►
(include any additional rows from continuation sheets)

Applicant’s Estimated Rurality Score
(Sum of Column 6 ÷ Sum of Column 4)

Rurality Score
(For Agency Use)

A continuation sheet follows this page. Use as many as you need.

Place this sheet and Census documentation under Tab E-1 of your Application
T-21

Rurality Worksheet – Non-Fixed Sites (Continuation)
1. Service Territory Population Centers
(List each urbanized area & urban cluster on a separate
line. Show the entire Census Rural Area on one line.

3.
2.
4. Population
5.
Census
Census
in Service Rurality
Designation Population Territory
Points

6. Product
(4 X 5 = 6)

Place Rurality Worksheets and Census documentation under Tab E-1 of your Application
T-22

2009 NSLP Worksheet – Non-Fixed Sites
Use the Non-Fixed Worksheets only if your application is for a non-fixed site project - ambulance, VNA, etc.
(For more complete guidance in completing this sheet, refer to E-2 in Section IV of the Application Guide)

Scoring Table
NSLP Eligibility %

Points

NSLP < 25%

Zero

25%≤NSLP<50%

15

50%≤NSLP<75%

25

NSLP ≥ 75%

35

In column 1, enter the name of each School District into which the service offered by the applicant extends,
whether that area coincides with the entire School District in whole or in part. Enter the number of students in that
district and the percentage that are eligible for the National School Lunch Program in columns 2 and 3.
Any site without verifiable documentation attached behind this Worksheet will be evaluated at zero percent
eligibility. The Agency will not research undocumented data. Applicants must provide documentation of each
school district’s percentage with a written certification from the organization that administers the NSLP in your
area that the data are accurate and the most recent available. Some official NSLP data is posted on state websites.
If so, you may provide printouts from these websites. Data from unofficial websites is not acceptable. Please
highlight the relevant data on the attached documentation.
School District Name

Total Students

% Eligible
(See Attached)

1
2
3
4
5
Average NSLP
(Sum of NSLP Percentages ÷ # of School Districts rounded to an Integer)

Applicant’s Estimated NSLP Score

NSLP Score

(Enter Points from Scoring Table)

(for Agency Use)

A continuation sheet follows this page. Use as many as you need. Be sure to include continuation sheet data in the average.

Place this sheet and supporting documentation under Tab E-2 of your Application
T-23

NSLP Worksheet – Non-Fixed Sites (Continuation)
School District Name

Total Students

% Eligible
(See Attached)

Place NSLP Worksheets and supporting documentation under Tab E-2 of your Application
T-24

2009 Leveraging Worksheet

(Matching Funds – For more complete guidance, see E-3 in Section IV of the Application Guide)

• The applicant must demonstrate an eligible match of at least 15% of the grant request.
• To be credited, the proposed match must be for eligible purposes. If the Agency cannot fund an item if it
were in the grant request, we cannot accept it as match.
• As an applicant, you submit a proposed match and estimated score. The eligibility of the match and
actual score is determined by the Agency.
• You must document your matching funds as described in the Application Guide. Place letters of financial
commitment and other match documentation along with this form under TAB E-3 of your application
package. Each donor’s match as listed below must be supported by a matching letter. If you have more
than ten donors, use another copy of this sheet and label it “continuation.”
Matches not properly documented
behind this Sheet under Tab E-3
will not be credited. Depending on
the consequent reduction of your
match, this could lower your score
or make your project ineligible
(i.e., if resultant match is < 15%)

Eligible Match ÷ Eligible Grant Request (%)

Points

15% < Match % ≤ 30%

0

30% < Match % ≤ 50%

15

50% < Match % ≤ 75%

25

75% < Match % ≤ 100%

30

Match > 100%

35

Donor
(place documentation letter from each donor behind this sheet)

Proposed Match

i.

$

ii.

$

iii.

$

iv.

$

v.

$

vi.

$

vii.

$

viii.

$

ix.

$

x.

$
1. Total proposed matching contributions (sum of i thru x):

$

2. Total DLT Grant requested:

$

3. Match as Percent of Grant Request (Line1 ÷ Line 2 • 100%):

%

Applicant’s Estimated Leveraging Score

Leveraging Score

(Enter Points from Scoring Table)

(For Agency Use)

Place this sheet and supporting documentation under Tab E-3 of your Application
T-25

2009 EZ/EC Worksheet

(USDA EZ/EC and Champion Community Worksheet)
(See Section E-4 of the Application Guide)
If any of your sites are located in a USDA Rural Empowerment Zone, USDA Enterprise Community or USDA Champion
Community, your application may be eligible for points in this category. Check the official websites shown below for
USDA designated areas. These lists are reprinted on other websites and sometimes the other sites are not up-to-date. We
do not accept information not shown on the official website. If you believe the official website to be in error, use the
“feedback” link on that site to contact the webmaster responsible for maintaining the site.
www.ezec.gov/ezec/mainmap.html
www.ezec.gov/Communit/champions.html
Ten points can be earned if at least 1 end-user site is within an EZ/EC. (Additional sites located in that or another EZ/EC
do not earn additional points.) Five points can be earned if at least 1 end-user site is in a Champion Community. (Again,
additional sites located in that or another Champion community do not earn additional points.) The maximum score an
applicant can earn in this category is fifteen points for having at least one site in an EZ/EC and another site in a Champion
Community. Remember that the two categories are mutually exclusive. There are no areas that are both an EZ/EC and a
Champion Community so one site can not earn all fifteen points.
List end-user sites that are in either an EZ/EC or Champion Community in the appropriate table below. Any end-user site
shown on this Worksheet must be consistent with the sites shown on the Rurality and NSLP Worksheets. To document
the EZ/EC or Champion Community status of the sites, place printouts from the USDA websites shown above behind
this Worksheet under Tab E-4. As discussed above, we do not accept documentation except from the official sites
shown above. If not properly documented behind this Worksheet under Tab E-4, no points will be awarded in this
category. USDA EZ/EC designations use Census tracts. The Census tract information for each EZ or EC is available at
the Web page listed above. You must supply the Census tract information if you wish to claim either EZ or EC status.
End-User Site Name

EZ/EC Name

Census Tract

1
2
3
End-User Site Name

Champion Community Name

1
2
3

Applicant’s Estimated EZEC Score

EZEC Score

(Enter Points from Scoring Table)

(For Agency Use)

Place this sheet and supporting documentation under Tab E-4 of your Application
T-26

2009 Additional NSLP Worksheet

(See more complete information about additional NSLP, see F-1 in Section IV of the Application Guide)
The NSLP eligibility percentage on our NSLP Worksheet (Tab E-2) is: __________

If this percentage is under 50%, and you believe your NSLP eligibility percentage does not accurately reflect
the economic conditions in your area compared to other areas with similar eligibility percentages, you have the
option to request additional points here. (If the eligibility on your NSLP Worksheet is 50% or higher, but you
suspect that the percentage could drop below 50% after Agency review of your application, you may also
request these points. Such a request will be acted upon only if your final NSLP eligibility is below 50% as
determined by the Agency.) Points awarded by the Agency in this category, if any, are based on the supporting
information provided. Attach your supporting documentation behind this worksheet under Tab F-1.
Requests for Additional NSLP will not be considered if not accompanied by supporting documentation
(i.e., no Additional NSLP points will be awarded).

I hereby request additional NSLP Points and have attached documentation
behind this Worksheet to support my request.

________________________________________________
Signature of Authorized Representative
(Same person who signed the SF - 424, Application for Federal Assistance)

_____________________________________________
Date

Additional NSLP Points
(for Agency Use)

Place this sheet and supporting documentation under Tab F-1 of your Application
T-27

Equal Opportunity and Nondiscrimination Certification
All grants made under 7 CFR 1703 are subject to the nondiscrimination provisions of Title VI of the Civil
Rights Act of 1964, as amended, (7 CFR 15); Section 504 of the Rehabilitation Act of 1973, as amended, (29
U.S.C. 901 et seq.; 7 CFR 15b); and the Age Discrimination of 1975, as amended (42 U.S.C. 6101 et seq.; 45
CFR 90), and as amended by Executive Order 11375 Amending Executive Order 11246, Relating to Equal
Employment Opportunity (3 CFR, 1966, 1970 Comp., p. 684).
As a prospective primary participant recipient of financial assistance from RUS, this organization commits to
carry out RUS’ established policy to comply with the requirements of the above laws and executive orders to
the effect that no person in the United States shall, “on the basis of race, color, national origin, handicap, or age,
be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under
the RUS Distance Learning and Telemedicine Loan and Grant Programs.”
The __________________________________________________ (Grantee)
hereby certifies that, as a prospective recipient under the said Distance Learning and Telemedicine Loan and
Grant Program, it will comply with the above referenced laws, regulations and Executive Orders.
____________________________
Date

__________________________________________
Signature
__________________________________________
Type or Print Name
__________________________________________
Title

Place this Certification under Tab H of your Application
C-1

Certificate Regarding Architectural Barriers
All facilities financed with RUS grants that are open to the public, or in which physically handicapped persons
may be employed or reside, must be designed, constructed, and/or altered to be readily accessible to and usable
by handicapped persons. Standards for these facilities must comply with the Architectural Barriers Act of 1968,
as amended (42 U.S.C. 4151 et seq.), and with the Uniform Federal Accessibility Standards (UFAS), (Appendix
A to 41 CFR subpart 101-19.6).
As a prospective primary participant recipient of financial assistance from RUS, this organization commits to
carry out RUS’ established policy to comply with the requirements of the above referenced law to the effect that
all facilities must be readily accessible to and usable by handicapped persons.
The _______________________________________ (Grantee) hereby certifies, that, as a prospective recipient
under the Distance Learning and Telemedicine Grant and Loan Program, it is in compliance, or will be in
compliance upon completion of the project, with the above referenced law.
____________________________
Date

__________________________________________
Signature
__________________________________________
Type or Print Name
__________________________________________
Title

Place this Certification under Tab H of your Application
C-2

Certificate Regarding Flood Hazard Area Precautions
In accordance with 7 CFR 1788, if the project is in an area subject to flooding, flood insurance must be
provided to the extent available and required under the National Flood Insurance Act of 1968, as amended by
the Flood Disaster Protection Act of 1973, as amended (42 U.S.C. 4001-4128). If applicable, the insurance must
cover, in addition to the buildings, any machinery, equipment, fixtures, and furnishings contained in the
buildings. RUS will comply with Executive Order 11988, Floodplain Management (3 CFR, 1977 Comp., p.
117), and 7 CFR 1794.41, of this chapter in considering the application for the project.
Please check the appropriate line below:
___ a) The project is not located in a 100-year flood plain; therefore, no Flood Insurance is required.
___ b) The project is located in a 100-year flood plain and the required insurance is or will be provided by:
____________________________________
____________________________________
____________________________________
The _______________________________________ (Grantee) hereby certifies, that, as a prospective recipient
under the Distance Learning and Telemedicine Loan and Grant Program, it is in compliance, or will be in
compliance during construction and/or installation of equipment and upon completion of the project, with the
above referenced law.
____________________________
Date

__________________________________________
Signature
__________________________________________
Type or Print Name
__________________________________________
Title

Place this Certification under Tab H of your Application
C-3

Uniform Relocation Assistance and Real Property Acquisition
Policies Act of 1970 Certification
The _________________________________________________________ (Grantee) assures that it will
comply with the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (Uniform
Act) as amended, 42 U.S.C. 4601-4655, and with implementing Federal regulations in 49 CFR 24 and 7 CFR
21.
Specifically, the ________________________________________________ (Grantee) assures that:
Whenever Federal financial assistance is used to pay for any part of the cost of a program or project which
will result in the displacement of any person;
(a) Fair and reasonable relocation payments and assistance shall be provided to or for displaced
persons in accordance with sections 202, 203, and 204 of the Uniform Act,
(b) Relocation assistance programs offering the services described in section 205 of the Uniform Act
shall be provided to displaced persons, and
(c) Within a reasonable period of time prior to displacement, comparable replacement dwellings will
be available to displaced persons in accordance with section 205(c) (3) of the Uniform Act.
____________________________
Date

__________________________________________
Signature of President or Authorized Official of
Ultimate Recipient

Place this Certification under Tab H of your Application
C-4

Certification Regarding Drug-Free Workplace Requirements for Grantees Other
than Individuals
This certification is required by the regulations implementing Sections 5151-5160 of the Drug-Free Workplace
Act of 1988 (P.L. 100-690, Title V, Subtitle D; 41 U.S.C. 701 et seq.), 7 CFR 3017.600.
A. The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the grantee’s workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
(b) Establishing an ongoing drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The grantee’s policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
(c) Making it a requirement that each employee to be engaged in the performance of the grant be given a
copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment
under the grant, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute
occurring in the workplace no later than 5 calendar days after such conviction;
(e) Notifying the Agency in writing, within 10 calendar days after receiving notice under subparagraph (d)
(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted
employees must provide notice, including position title, to every grant officer on whose grant activity
the convicted employee was working, unless the Federal agency has designated a central point for the
receipt of such notices. Notice shall include the identification number(s) of each affected grant;
Page 1 of 2

C-5a

(f) Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph
(d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including termination,
consistent with the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or other
appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
B. The grantee may insert in the space provided below the site(s) for the performance of work done in
connection with the specific grant:

Place of Performance:
______________________________________________________________________________
Street Address
City
______________________________________________________________________________
County
State
Zip Code
____ Check if there are workplaces on file that are not identified here.
__________________________________________
Organization Name
__________________________________________
Name and Title of Authorized Representative
__________________________________________
Signature

_________________________
Date
Page 2 of 2

Place this Certification under Tab H of your Application
C-5b

Certification Regarding Debarment, Suspension, and Other Responsibility
Matters—Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, 7 CFR 3017.510.
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its 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 3-year period preceding this proposal been convicted of or had a civil judgment
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 governmental 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 3-year period preceding this application/proposal had one or more public transactions
(Federal, State, or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.
__________________________________________
Organization Name
__________________________________________
Name and Title of Authorized Representative
__________________________________________
Signature

_________________________
Date

Place this Certification under Tab H of your Application
C-6

Certification Regarding Lobbying for Contracts, 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 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 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 or 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-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
(Copies of this form may be obtained from RUS.)
(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 subcontracts, 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 31 U.S.C. 1352. 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.
__________________________________________
Organization Name
__________________________________________
Name and Title of Authorized Representative
__________________________________________
Signature

_________________________
Date

Place this Certification under Tab H of your Application
C-7

Non-Duplication of Services Certificate
As a prospective primary participant recipient of assistance from RUS, this organization commits to carry out
RUS’ established policy to comply with the requirements that no facilities using financial assistance will
duplicate adequate established telemedicine services and/or distance learning services.
The ______________________________________________ (Grantee) hereby certifies that as a prospective
recipient under the said Distance Learning and Telemedicine Loan and Grant Program, that it will not use RUS
grant funds to duplicate any adequate established services as referenced above.
(Note: Applicants and participants in DLT grant applications are sometimes applicants or participants in other
current year applications or are sometime applicants or participants in projects that received awards in prior
years. For guidance on disclosing such situation with respect to duplication of adequate established services,
please refer to “Include the Following in your TSP” under D-1, Telecommunications System Plan, in Section IV
of the Application Guide.)

____________________________
Date

__________________________________________
Signature
__________________________________________
Type or Print Name
__________________________________________
Title

Place this Certification under Tab H of your Application
C-8

Environmental Impact Certification
Environmental Project Summary:

(This description should encompass all construction in the project, no matter the source of funding. It should
provide details of how the project will affect the environment (wetlands, farmlands, floodplain, cultural
environment, endangered species, environmental quality, and historic preservation). If additional space is
needed, continue on white bond paper and attach to this certification.)

CERTIFICATION
I hereby certify that the construction proposed in this application will not adversely impact the
environment or historic preservation.
_____________________________________________
(Signature and Date)
_____________________________________________
(Print or Type Title)

Place this Certification under Tab H of your Application
C-9