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Rural Utilities Service
United States Department of Agriculture
RURAL UTILITIES SERVICE
Telecommunications Program
Distance Learning and Telemedicine
Grant Program
Application Guide
Fiscal Year 2016

Committed to the future of rural communities

DISTANCE LEARNING & TELEMEDICINE PROGRAM
GRANT APPLICATION GUIDE
FISCAL YEAR 2016

RURAL UTILITIES SERVICE
RURAL DEVELOPMENT
UNITED STATES DEPARTMENT OF AGRICULTURE

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 48 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
Persons with disabilities who require alternative means for communications of program
information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center on
(202) 720-1127 (TDD).
USDA is an equal opportunity employer.

2016 Distance Learning and Telemedicine Grant Application Guide

Table of Contents
1. General Information.................................................................................................................... 1
a. Changes for 2016 .................................................................................................................. 4
b. Applicant Eligibility ............................................................................................................. 4
c. Eligible Grant Purposes ........................................................................................................ 5
d. Ineligible Grant Purposes ..................................................................................................... 6
e. Additional Eligibility Criteria ............................................................................................... 7
f. Grant Limits .......................................................................................................................... 7
g. Grant Review Process ........................................................................................................... 7
2. Completing the Grant Application.............................................................................................. 9
a. Tab A: Standard Form 424 with Attachments ................................................................... 10
b. Tab B: Executive Summary ............................................................................................... 10
c. Tab C: Scoring Criteria Documentation ............................................................................ 11
i.
C-1: Rurality .......................................................................................................... 11
ii.
C-2: Economic Need.............................................................................................. 13
iii.
C-3: Leveraging ..................................................................................................... 16
iv.
C-4: Additional NSLP ........................................................................................... 19
v.
C-5: Need for Services and Benefits ..................................................................... 19
vi.
C-6: Innovativeness of the Project ......................................................................... 22
vii.
C-7: Cost Effectiveness of the Project ................................................................... 23
viii. C-8: Special Consideration .................................................................................... 23
d. Tab D: Scope of Work ....................................................................................................... 24
e. Tab E: Financial Information and Sustainability ............................................................... 26
f. Tab F: Statement of Experience ........................................................................................ 27
g. Tab G: Telecommunications System Plan ......................................................................... 27
h. Tab H: Compliance with Federal Statutes ......................................................................... 29
i. Tab I: Environmental Impact and Historic Preservation ................................................... 29
j. Tab J: Evidence of Legal Existence and Legal Authority to Contract with the Federal
Government ........................................................................................................................ 29
k. Tab K: Consultation with USDA State Director and State Strategic Plan Conformity..... 30
l. Tab L: Supplemental Information ..................................................................................... 30
3. Appendix A: Forms ................................................................................................................. 31
4. Appendix B: Finding Information on the Census Website...................................................... 66

Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

Rural Utilities Service Telecommunications Program
Distance Learning and Telemedicine Grant Program
Distance Learning is a telecommunications link to an end user through the use of equipment to provide
educational programs, instruction, or information originating in one area to students and teachers who
are located in rural areas and to connect teachers and students located in one rural area with teachers
and students in a different rural area. Telemedicine is a telecommunications link to an end user from
medical professionals at separate sites in order to exchange health care information for the purpose of
providing improved health care services primarily to residents of rural areas.
The Distance Learning and Telemedicine (DLT) Grant Program is specifically designed to assist rural
communities in acquiring distance learning and telemedical technologies so that local teachers, and
medical service providers who serve rural residents can link to other teachers, medical professionals,
and other needed expertise located at distances too far to access otherwise. Since 1994, the DLT
Grant Program has helped to establish hundreds of distance learning and telemedicine systems
improving quality of life for thousands of residents in rural communities all across the United States.

BEFORE YOU GET STARTED
You must read:
♦ 7 CFR 1703, Subparts D through G;
And
♦ Notice of Solicitation of Applications (NOSA) published in the Federal Register on
January 12, 2016
The regulation MUST be used in conjunction with this Application Guide. Should any
differences result in the interpretation of this Application Guide and the regulation, the
regulation takes precedence over information contained in this Application Guide.
For additional information concerning this grant program, please contact:
Loan Origination and Approval Division, Telecommunications Program
(202) 720-0800 or Email: dltinfo@wdc.usda.gov.
Additional information and forms are available on our website at:
http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants

When and Where to Submit Application:
GRANT applications must be postmarked by:

March 14, 2016
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Applications must be submitted in EITHER of the following two ways:
1) Electronically via www.grants.gov

OR
2) Postmarked, shipped, or hand-delivered 3 paper copies of a completed application, one
with original signatures, accompanied by an electronic version in the form of a CD-ROM
or USB Flash Drive. The paper applications and the CD-ROM/USB Flash Drive must
be submitted to:
Deputy Assistant Administrator
Loan Origination and Approval Division
Rural Utilities Service
STOP 1597, Room 2844
1400 Independence Ave., SW
Washington, D.C. 20250-1597
Due to the possible disruptions in mail delivery service, applicants are strongly encouraged to submit
applications via express mail or hand delivery to our office.
Applicants that submit their applications after the deadline noted above will be notified that
their applications will not be considered for funding and their applications will be returned.
Applications Delivered by Mail:
Paper applications must show proof of mailing or shipping consisting of one of the following:
1. A legibly dated U.S. Postal Service (USPS) postmark;
2. A legible mail receipt with the date of mailing stamped by the USPS; or
3. A dated shipping label from a commercial carrier showing the commercial carrier received the
package on or before the application submittal deadline. Self-generated shipping labels where the
actual pickup by the carrier occurs after the application submittal deadline are not acceptable.
If an application is sent through the USPS, neither of the following will be accepted as proof of
mailing:
1. A private metered postmark; or
2. A mail receipt that is not dated by the USPS.
Applicants should note that the USPS does not uniformly provide a dated postmark. Before relying on
this method, an applicant should check with its local post office.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Applications Delivered by Hand:
Applications delivered by hand will be accepted daily between 8:00 a.m. and 4:30 p.m. (Eastern Time),
except Saturdays, Sundays, and Federal holidays. Individuals delivering applications must provide
proper identification to enter the building.
Applications Submitted Electronically:
Electronic applications will only be accepted when submitted through the Grants.gov website.
Applications will not be accepted via facsimile machine transmission or electronic mail.
Before submitting an application on-line, the Rural Utilities Service (RUS) strongly encourages you to
obtain all necessary sign-ups, credentials and authorizations well in advance of the deadline.
Grants.gov requires some one-time credentialing and online authentication procedures. These
procedures may take several business days to complete. Several requirements on Grants.gov call for
an annual update; applicants should also ensure that their credentials and authorizations are up-to-date.
The Grants.gov website, like all web facilities, has finite capacity. If several federal grant programs
have the same application deadline date, periods of site overloading can be experienced. Please plan
accordingly.
Please follow the instructions at Grants.gov. If you experience a technical problem retrieving or
submitting an electronic application, contact the Grants.gov customer support resources (click the
"Customer Support" tab on any page of Grants.gov to get started). RUS staffers do not control the
technical aspects of Grants.gov and won't be able to help you if you experience a problem. However,
we are available to answer questions about the Program and the contents of an application.
Additional Registration Requirements for all Applicants:
Dun and Bradstreet Data Universal Numbering System Registration – As required by the Office
of Management and Budget (OMB), all applicants for grants must supply a Dun and Bradstreet Data
Universal Numbering System (DUNS) number when applying. The Standard Form 424 (SF–424)
contains a blank to enter your DUNS number. The DUNS number can be obtained free of charge by
calling Dun & Bradstreet. Please see
http://www.whitehouse.gov/sites/default/files/omb/grants/duns_num_guide.pdf for more information
on how to obtain a DUNS number or how to verify your organization’s number.
System for Award Management Registration – Applicants, whether applying electronically or by
paper, also must register in the System for Award Management (SAM) PRIOR to submitting an
application. Applicants may register for the SAM at https://www.sam.gov/. Applicants should keep in
mind that it can take up to ten (10) business days to register with SAM. Applicants should plan
accordingly and begin the process well in advance of the application deadline.
The SAM registration must remain active with current information at all times while RUS is
considering an application or while a Federal Grant Award or loan is active. To maintain the
registration in the SAM database the applicant must review and update the information in the SAM
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
database annually from date of initial registration or from the date of the last update. The applicant
must ensure that the information in the database is current, accurate, and complete.
Changes for 2016:
1. In-Kind Match from Vendors – In the review of the Fiscal Year 2014 and 2015 applications,
RUS determined that vendor donated matches did not have value without a corresponding
purchase of additional equipment from the vendor. For example, in many of the applications,
software licenses were donated in support of grant applications. Without a corresponding
purchase of the same vendor’s equipment, this donation would have no value towards the
project. This is considered a vendor discount which has never been eligible under the program.
Therefore, in-kind match from vendors is no longer eligible. This is consistent with past
practices prior to FY 2014.
2. Special Consideration Points – RUS expanded the definition of end-user sites eligible for
Special Consideration Points. End-user sites located in “Strike Force” or “Promise Zone” areas
are now eligible for the Special Consideration. Please see Section C-8 for further guidance.

3. Evidence of Legal Existence and Legal Authority – RUS will now accept an active registration
in the System for Award Management (SAM) as evidence of legal existence and legal authority
to contract with the Federal Government. The registration must be in the name of the applicant
with the applicant’s DUNS number, not in the name of a parent, subsidiary or other affiliated
entity.

Eligibility Requirements
Applicant Eligibility
To be eligible for a grant, your organization must:
1. Be legally organized as an incorporated organization or partnership; an Indian tribe or tribal
organization, as defined in 25 U.S.C. 450b (e); a state or local unit of government; a
consortium; or other legal entity, including a private corporation organized on a for-profit or
not-for-profit basis. Each applicant must provide written evidence of its legal capacity to
contract with the Rural Utilities Service to obtain the grant and comply with all applicable
requirements.
Consortium: A consortium is a combination or group of entities formed to undertake the
purposes for which the distance learning and telemedicine financial assistance is provided.
•

If the applicant is an existing established consortium with the legal ability to
contract with the Federal Government, that organization can apply in the name of
the formal consortium.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
•

If the applicant is an informal consortium which by itself lacks the legal capacity to
contract, each individual entity must contract with RUS in its own behalf. This
informal consortium must have a legally organized host organization which will
apply on behalf of the consortium.

2. Either operate a rural community facility, or deliver distance learning or telemedicine services
to entities that operate a rural community facility or to residents of rural areas at rates
calculated to ensure that the benefit of the financial assistance is passed through to such entities
or to residents of rural areas.
Equipment vendors, system integrators, and other businesses whose purpose in the proposal is to sell
equipment or technological services to support applicants cannot themselves be applicants or affiliates
of the applicant.
Note: Electric or telecommunications borrowers financed through the Rural Utilities Service are not
eligible for grants.

Eligible Grant Purposes:
There are three categories of eligible purposes:
1. Acquiring, by lease or purchase eligible equipment. If leased, the cost of the lease during
the three year life of the grant is eligible.
The following are examples of eligible equipment. This list is not exhaustive. Neither does it
convey blanket eligibility. A computer is not automatically eligible. It must be used for an
eligible purpose. Remember also that the purpose of the DLT Grant program is to deliver
education or medicine between remote sites via telecommunications, not simply to furnish
educational or medical technology.
•
•
•
•
•
•
•

Computer hardware and software
Audio and video equipment
Computer network components
Telecommunications terminal equipment
Data terminal equipment
Interactive audio/video equipment
Inside wiring

In general, equipment not electronically interconnected to the grant and match funded
equipment is not eligible. The application must demonstrate both that the predominant purpose
(50% or more of use) of every line-item in the grant and match budget meets the DLT Grant
definition of distance learning and/or telemedicine, and further, that none of the use is for
ineligible purposes.
NOTE: All equipment purchased for this Project must be new or non-depreciated.
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
2. Acquiring instructional programming that is a capital asset (including the purchase or lease
of instructional programming already on the market). Renewals of instructional programming
are not eligible. Also, expenses (such as those for tuition, fees for coursework on a per course
basis, or fees for cultural events or virtual field trips) are not capital assets and therefore, are
not eligible.
3. Providing technical assistance and instruction for using eligible equipment, including any
related software; developing instructional programming that is a capital asset and providing
engineering or environmental studies relating to the establishment or expansion of the phase of
the project to be financed with the grant. The costs for this category cannot exceed 10% of
the grant amount requested or 10% of the eligible matching funds calculated separately.
Ineligible Grant Purposes:
The following purposes are considered ineligible grant purposes (see 7 CFR 1703.123):
1. To cover the costs of acquiring, installing or constructing telecommunications transmission
facilities.
2. To pay for medical equipment not having telemedicine as its essential function;
3. To pay salaries, wages, or employee benefits to medical or educational personnel;
4. To pay for the salaries or administrative expenses of the applicant or the project;
5. To purchase equipment that will be owned by the local exchange carrier or another
telecommunications service provider unless that service provider is the applicant.
6. To duplicate facilities providing distance learning or telemedicine services in place or to
reimburse the applicant or others for costs incurred prior to RUS' receipt of the completed
application;
7. To pay costs of preparing the application package for financial assistance under this program;
8. For projects whose sole objective is to provide links between teachers and students or between
medical professionals who are located at the same facility;
9. For site development and the destruction or alteration of buildings;
10. For the purchase of land, buildings, or building construction;
11. For projects located in areas covered by the Coastal Barrier Resources Act (16 U.S.C. 3501 et
seq.);
12. For any purpose that the Administrator has not specifically approved;
13. Except for leases provided for in §1703.121, to pay the cost of recurring or operating
expenses for the project including but not limited to internet connection fees and
maintenance contracts or
14. For any other purposes not specifically contained in §1703.121.
Additionally, except as otherwise provided in §1703.112, grants shall not be used to finance a project,
in part, when the success of the project is dependent upon the receipt of additional financial assistance
under this subpart or is dependent upon the receipt of other financial assistance that is not assured.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Additonal Eligiblity Criteria:
1. Minimum Rurality Score: In order to be eligible to receive a grant, an application must receive
a minimum of 20 points as an average score for all end user sties included in the project. See
instructions beginning on Page 11 for computing the Rurality Score.
2. Matching Contribution: The grant applicant’s minimum matching contribution must equal 15
percent of the grant amount requested and be used for eligible grant purposes. See instructions
beginning on Page 16 for more information on the Matching Contribution.

Other Considerations:
Rural Areas: The intent of the DLT program is to benefit rural areas (populations of 20,000 or less).
We recognize that some projects could include end users in more urbanized areas, however; the
Agency will evaluate projects based on their benefit to rural areas.
Online Education Services: Because this program is intended to fund end-user equipment at
specifically identified sites, applications which propose to provide only web-based services which are
universally available are considered ineligible. This type of project does not have a defined service
area and the beneficiaries can be located anywhere, including urban areas.

Grant Limits
Grant limits are set forth in 7 CFR 1703 and the Notice of Solicitation of Applications dated January
12, 2016. The minimum Grant amount which can be requested is $50,000. The maximum Grant
amount which can be requested is $500,000.

Grant Review Process
1. Grant Receipt: Completed applications must be postmarked, hand-delivered, or submitted
through www.grants.gov by March 14, 2016 in order to be considered for funding.
2. Completeness Review: RUS will review each application for completeness in accordance with
§ 1703.125. Within 15 working days of application receipt, RUS will notify the applicant of
the results of this review, citing any information that is incomplete. The applicant will have 15
working days from this notification to submit the required information.
The completeness review and letter will only cover items which are not material to the
eligibility and scoring of the application. Items which may be requested include missing
certifications or unsigned certifications. Applicants will not have the opportunity to submit
additional documentation in support of the scoring criteria or for eligibility purposes, nor to
adjust their budget or match.
The letter will be sent via email or fax to the person listed as the Contact Person in Block 8(f)
of the Form SF-424. If no Contact Person is listed in this block, the letter will be sent via fax
or email to the Authorized Representative in Block 21.
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

3. Scoring: All complete applications will be scored in accordance with the criteria set forth in
§1703.126. All applicants will be notified in writing of the score each application receives
along with a tentative minimum required score to receive financial assistance.
4. Appeals: If the score received by the applicant could result in the denial of its application, or if
the score, while sufficient to qualify for financial assistance, may be surpassed by a score
awarded to a competing application after appeal, the applicant may appeal its numerical
scoring. The appeal must be based on inaccurate scoring of the application by RUS and no new
information or data that was not included in the original application will be considered.
The appeal must be made, in writing, within 10 days after the applicant is notified of the
scoring results. RUS will review the original scoring to determine whether to sustain, reverse,
or modify the original scoring determination. Final determinations will be made after
consideration of all appeals. A copy of RUS’ decision will be furnished promptly to the
applicant.
5. Selection Process: Applications will be selected for approval based on scores assigned,
availability of funds, and the provisions of § 1703.127.
Regardless of the number of points an application receives, the Administrator may take any of
the following actions:
a) Limit the number of applications selected for projects located in any one State during a
fiscal year. (This authority allows the Administrator to limit awards to any one state. It
does not allow the Administrator to make awards in other states regardless of score.)
b) Limit the number of selected applications for a particular project.
c) Select an application receiving fewer points than another application if there are
insufficient funds during a particular funding period to select the higher scoring
application. If the Administrator makes this kind of selection and it affects your
application, we will provide you an opportunity to reduce the amount of your grant
request to the amount of funds available.
6. Legal Documents: All grantees will be required to execute a standard DLT Grant Agreement.
A standard form of this agreement can be found on our website under the Forms and Resources
tab at: http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

Completing the Grant Application
This section addresses all of the information that must be submitted in order for an application to be
deemed complete and considered for funding. Please make sure that all the necessary information is
included in the appropriate section. All the required forms and certifications are included in Appendix
A to this Guide
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

Standard Form 424 w/Attachments
An Executive Summary of the Project
Scoring Criteria Documentation
Scope of Work
Financial Information and Sustainability
Statement of Experience
Telecommunications System Plan
Compliance with other Federal Statutes
Environmental Impact and Historic Preservation
Evidence of Legal Authority and Existence
Consultation with USDA State Director and State Strategic Plan Conformity
Supplemental Information

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

A. Standard Form 424 w/Attachments
There are two attachments to the SF-424. One is a Site Worksheet (required) and the other is a Survey
on Ensuring Equal Opportunity for Applicants (optional). Some of the information requested on the
Site Worksheets such as population, school districts and congressional districts can be obtained at the
US Census web site. Further guidance on navigating the US Census website is available in Appendix
B.
The application must be signed by an authorized representative of the organization who has the
authority to commit the organization’s resources to carry out the project for the term of the grant. If the
authorized representative is not a corporate officer, evidence must be included that demonstrates that
the signer has authority to obligate the organization.

B. Executive Summary
The Executive Summary gives reviewers their first overall view of the project area, the problems that
residents face, and how the proposed project will address those problems. This is your opportunity to
discuss the core aspects of the project. It should contain a concise description of the project including:
1. A description of why the project is needed;
2. An explanation of how the applicant will address the need cited, why the applicant requires the
financial assistance, the types of education or medical services to be offered by the projects,
and the benefits to rural resident;
3. A description of the applicant, documenting eligibility;
4. An explanation of the total project cost including a breakdown of the grant required and the
source of matching contribution and other financial assistance for the remainder of the project;
5. A statement specifying whether the project is either a distance learning or telemedicine facility
as defined in § 1703.102. If the project provides both distance learning and telemedicine
services, the applicant must identify the predominant use of the system;
6. A general overview of the telecommunications system to be developed, including the types of
equipment, technologies, and facilities used; and
7. A description of the participating hubs and end user sites and the number of rural residents that
will be served by the project at each end user site.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

C. Scoring Criteria Documentation
The DLT Grant Program is a competitive program. Applications are scored in objective and
subjective categories. The table below lists each DLT category, and the maximum points available.
Objective Criteria
Rural Area (Rurality)

Economic Need (NSLP)

Matching Funds (Leveraging)

This criterion measures rural benefit. The score threshold for
the application to be considered in the competition at all is 20
points. This category based on Census data (up to 45 Points).
This criterion measures the general economic need of the area
through the use of statistics from the National School Lunch
Program (NSLP) (up to 35 Points).
The DLT program requires a minimum match of 15%. Higher
matches receive more points. There are special matching
provisions for American Samoa, Guam, Virgin Islands, and the
Northern Mariana Islands (up to 35 Points).

Subjective Criteria
Additional NSLP

Need for Services and Project
Benefits (Needs & Benefits)
Innovativeness
Cost Effectiveness

Special Consideration

An applicant with NSLP eligibility below 50% may request
additional points, and could receive additional points if they can
document that the NSLP percentage is not an accurate indicator
of the economic need of the area. (up to 10 Points)
This criterion compares the specific need for the technology in
the proposed service territory, and how the proposed project
will address those needs and benefit the residents of the area
affected. (up to 45 Points)
This criterion assesses how the objectives of the proposed
project are met in new and creative ways. (up to 15 Points)
This criterion evaluates the efficiency with which the proposed
project and its technology deliver educational and/or medical
benefits to beneficiaries. (up to 35 Points)
RUS will offer special consideration to applications that contain
at least one end-user site within a trust area or a tribal
jurisdictional area; Strike Force Area; or Promise Zone. Such
applications will be awarded 15 points.

C-1. Rurality – Up to 45 Points
The Rurality score is based on the population size of each community where an end user site is located.
For non-fixed site projects and projects which contain non-fixed components, the Rurality score will
be based on the population of the Hub site. Applicants can use Census population data either from the
Census FactFinder Website or from Rand McNally Atlas (Atlas) that cites the 2010 Census as its
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
source for population statistics. Population figures used in the 2016 DLT Grant competition must use
the 2010 Census as the source, whether it is from the Atlas, or from the FactFinder Website.
Please use the Rurality Worksheet in Appendix A to calculate your Rurality Score. The Worksheet is
also available as an Excel worksheet at: http://www.rd.usda.gov/programs-services/distance-learningtelemedicine-grants
Include the population statistics and rurality calculations for all sites, including those you have
designated as (pure) hubs. Use the following definitions for assistance in designating the type of site:
Hub Sites: A hub site is a facility that is part of a network or telecommunications system that
provides educational or medical services to end user sites. A pure hub receives no end user
benefits. The site is usually a connection management point or is exclusively an educational or
medical source of distance learning or telemedicine.
End-User Site: An end-user site is a facility that is part of a network or telecommunications
system that is utilized by end users. In order for a site to be included as an end-user site for
scoring purposes, the applicant must demonstrate that equipment purchased from the proceeds
of the grant will be installed or placed at the site.
A Hub/End-User site performs both functions: a hub which also accommodates end-users.
The following classifications define the various population levels determining the Rurality score.
EXCEPTIONALLY RURAL AREA – 5,000 and under: 45 Points. Any area of the USA not
included within the boundaries of any incorporated or unincorporated city, village, or borough
having a population in excess of 5,000 inhabitants.
RURAL AREA – 5,001-10,000: 30 Points. Any area of the USA included within the
boundaries of any incorporated or unincorporated city, village, or borough having a population
over 5,000 and not in excess of 10,000 inhabitants.
MID-RURAL AREA – 10,001-20,000: 15 Points. Any area of the USA included within the
boundaries of any incorporated or unincorporated city, village, or borough having a population
over 10,000 and not in excess of 20,000 inhabitants.
URBAN AREA - Over 20,000: 0 Points . Any area of the USA included within the
boundaries of any incorporated or unincorporated city, village, or borough having a population
in excess of 20,000 inhabitants.
Use the Rurality Worksheet to enter: 1) the name you have given to the site; 2) the town, city, or place
within a state where the site is located; 3) the population (2010 Census) of the town; and 4) the
Rurality score (as derived from the Population-to-Score table).
Although pure hubs are not included in the calculation, except in the case of Non-fixed end-users
applications and hybrid applications, the Agency will need this data to recalculate the score if there
appears to be end user beneficiaries at the site. Place the sites in the same order and use the same
numbering as on the Site Worksheet (and which will be used on the NSLP Worksheet).
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

If any end user sites are not within the boundaries of a town or a place that cannot be identified by
2010 Census or found in the listing of cities, towns, and places in the Rand McNally, please provide
documentation verifying the existence and population of the site.
Adding up Individual Scores for an Overall Rurality Score
After you have entered all your sites and the corresponding population on the Rurality Worksheet
calculate your estimated score by taking the average of the scores you designated as end users or
hub/end-users. Do not include pure Hubs in the calculation. Exception: Non-fixed End-User
applications only use Hub sites in the calculation and Hybrid Projects use Hub sites for the Non-fixed
portion of the service area.
Rounding
Scores should be shown with their decimals rounded out to 2 decimal places (i.e., 30.49999 rounds to
30.50).

C-2. Economic Need – Up to 35 Points
Economic Need is measured by the National School Lunch Program (NSLP) or the Community
Eligibility Provision (CEP). All applicants are required to provide the applicable percentage of
students eligible to participate in the NSLP/CEP for each area to be served by the end user site. The
appropriate State or local organization administering the program must certify the percentages as being
correct. Some official NSLP/CEP data is posted on state websites. If so, you may provide printouts
from these sites as documentation. Data from unofficial websites is not acceptable.
Please use the Economic Need Worksheet in Appendix A to calculate your score. The Worksheet is
also available as an Excel worksheet at: http://www.rd.usda.gov/programs-services/distance-learningtelemedicine-grants
The Economic Need score is based on NSLP/CEP data for the sites where the end-users are
located. Exception: Non-fixed End-User applications only use Hub sites in the calculation and Hybrid
Projects use Hub sites for the Non-fixed portion of the service area.

Tips: If you are in a small district, where K-12 is in one school, or on one campus where the lunch
facility is shared so that separate NSLP/CEP data is not available for the individual high, middle, or
elementary school, make this clear in the supporting documentation you supply behind the Economic
Need Worksheet. If you provide printouts of NSLP/CEP data for many schools other than the sites in
the application, please highlight the data relevant to your application and submit applicable pages only.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Determining the EconomicNeed Score
The Economic Need score is based on the average of the relevant NSLP/CEP eligibility percentage for
all hub/end-user and end/user sites. Use the following guidelines in preparing the Economic Need
Worksheet.
Does the applicant use specific school or district-wide statistics?
1. If the hub/end-user or end-user site is a public school or non-profit private school of
Kindergarten through Grade 12 (K-12), use the eligibility percentage for that specific school. Do
not provide district-wide data or data from another school.
2. If the hub/end-user or end-user site is any other entity (college, private for-profit school, library,
hospital, clinic, etc.) use the NSLP/CEP eligibility score for the public school district in which the site
is located.
Required Documentation
Support each site’s NSLP/CEP percentage with printouts from the official NSLP/CEP Web pages for
your state or area’s educational Website. Most official NSLP/CEP data is posted on state and/or local
governmental websites. Include in your NSLP/CEP section each site’s NSLP/CEP percentage by
providing printouts from these government official sites. HIGHLIGHT THE SCHOOL OR SCHOOL
DISTRICT NSLP/CEP LINE-ITEM RECORD ON YOUR PRINTOUTS so that RUS can expedite the review
process for NSLP/CEP. Make certain that the official Website address from which those printouts are
obtained is provided either on the printout or is specified to it so that we can verify the information.
Provide the Web address with the printout, and ensure that the web link provided is operational. If an
official Website does not exist for this information, please contact the Superintendent’s office of the
school district you are seeking and request the NSLP/CEP data. Also request a signed letter which
validates that the NSLP/CEP information provided is the most current official NSLP/CEP data.
Printouts without evidence of source and data from unofficial sites, such as commercial websites that
report information about schools are not acceptable.
Place all NSLP/CEP certifications and any other documentation behind the Economic Need Worksheet
under Tab C-2 of your application.

Documentation Errors to Avoid:
• No documentation.
• A statement from the certifying official that the data is correct and the most recent available,
but with no evidence in the letter of what the data is.
• An unsigned letter from the certifying official.
• A letter from the certifying official without a clearly printed name and title.
• No reference to an official Website for the state NSLP/CEP data with clearly marked Web
address (in lieu of submitting letter from certifying official).

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
How is the score calculated?
1. The “Average NSLP/CEP” entered on the Economic Need Worksheet is the average of the relevant
eligibility percentages for all the hub/end-user and end-user sites. When calculating the average, use
the eligibility percentages exactly as received from the source of the data. In other words, if the
administrator of the lunch program provides data to two decimal places, enter that data for each site on
the Economic Need Worksheet to two places.
2. Do not round: After calculating the average, enter it in the “Average NSLP/CEP” block on the
Economic Need Worksheet.
3. Use the scoring table below (it also appears on the Economic Need Worksheet) to enter the score in
the “Applicant’s Estimated Economic Need Score” block.
Scoring Table
NSLP/CEP Percentage:
Points
NSLP/CEP < 25%
0
25% ≤ NSLP/CEP < 50%
15
50% ≤ NSLP/CEP < 75%
25
75% ≤ NSLP/CEP
35

Example of Economic Need Calculation
Central Community College (Central) will link itself, a community library, and two rural schools to the
Deepwoods Nature Center for the purpose of receiving instructor led environmental courses via
videoconferencing. The Deepwoods Nature center is the source of the distance learning content and
will not receive any content from the other sites. As such, it is a pure (educational) hub and the
NSLP/CEP data will not be used in the calculation. However, the applicant must provide the data
anyway for the hub site (if the Agency were to determine that the site is also an end-user, it can
recalculate the score). Central will be the electronic hub of the network, and will receive distance
learning content from the Nature Center. As such, that site is categorized as a hub/end-user. The
average of the four relevant percentages is 36.125%. The applicant refers to the scoring table and will
enter 15 points in the “Applicant’s Estimated Economic Need Score” block.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

C-3. Leveraging (Matching Funds) - Up to 35 Points
The Leveraging score is based on the matching fund contribution from non-Federal sources of the
applicant and other participants. This criterion is intended to measure the level of commitment in the
local community for the project. As such, the applicant is encouraged to seek financial contributions
locally as well as their own financial resources. A DLT project that is widely supported within a rural
community is more likely to be strong and successful.
Use the Leveraging form provided in Appendix A. Additionally, documentation submitted in support
of the application should reflect any additional financial support for the project from non-Federal
sources above the applicant’s minimum matching contribution of 15 percent as required by §1703.122.
The applicant must provide evidence, from authorized representatives of the sources, of a commitment
that the funds are available and will be used for the project.
Points are awarded as follows:
Percentage of Eligible Match Compared to Grant Request
15% < Match % ≤ 30%

Points
0

30% < Match % ≤ 50%

15

50% < Match % ≤ 75%

25

75% < Match % ≤ 100%

30

Match > 100%

35

Remember to use your proposed DLT Grant Request amount and your matching amount(s) for
the Leverage calculation. Do not use the Overall DLT Project amount in your Leverage
calculation.
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

Special Matching Provisions for American Samoa, Guam, the Virgin Islands, and the Northern
Mariana Islands. Under Federal law, applications from these areas are exempt from matching
requirements up to $200,000. The maximum DLT Grant in FY 2016 is $500,000 and the required
minimum match is 15%, or $75,000. This means that for the FY 2016 DLT Grant Program, these
areas are not required to provide a minimum match. However, if no matching funds are provided, an
applicant from these special Matching Provision Areas cannot score any points in the Leverage
category. To score points in this category, applicants from these areas would need to provide the same
match levels as other applicants, i.e., a 30% match would yield 15 points.
Eligible purposes for in-kind matching funds are identical to eligible purposes for a DLT grant.
For a line-item to be eligible in full for match funding, the application must demonstrate:
1. The match is used for eligible purposes;
2. That none of the use is to benefit sites not shown in the scoring; and
3. That the predominant purpose (over 50% of use) of that line-item is for purposes which meet the
DLT grant definition of distance learning or telemedicine.
If any part of a line-item is for ineligible purposes, the line-item cannot be budgeted for match. To be
eligible, items proposed as match must be integral to the project in exactly the same way as items
the applicant proposes to obtain with the grant. The technology purchased with DLT grant monies or
credited as in-kind match items are intended to build distance learning and/or telemedicine systems
that would not otherwise be financially possible if not for the grant.
Federal funds are not eligible as matching funds. E-rate funds are federal funds cannot be
applied as matching funds to a DLT project.
Special Matching Provisions for projects located in eligible counties under Counties in
Appalachia. If counties in your proposed project are any of the counties eligible under this provision
you may use ARC funds toward your matching contribution. Please see www.arc.gov for a list of
eligible counties under the Counties in Appalachia heading. Applying ARC funds as a match requires
coordination with ARC State Program Managers and States in the Region. See the ARC Members,
Partners and Staff link also at www.arc.gov for ARC State Program Managers contact information.
DLT applicants considering an ARC match are strongly encouraged to contact their ARC State
Program Manager(s) early in the process to explore the feasibility of an ARC grant.
Use of non-Federal Grants as Matching Funds To document the match, include a copy of the
announcement letter from the grantor. The letter from the grantor must be explicit about the purpose
of the grant and not have limitations or exclusions. If you intend to apply another grant as matching
funds toward the DLT Grant application, include a letter from the grant recipient stating that the
money in that grant is available and can be applied to the purposes of the DLT Grant.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Types of Matching Funds
A. Cash
B. In-Kind Match
An in-kind match must be integral to and necessary for the DLT project, not simply a technology
purchase made in the same timeframe. Unlike cash, in-kind matches are tied directly to the eligibility
of the proposed in-kind item. Should we determine that the item is not eligible or not integral and
necessary for the project, the item would be removed from the grant and match budget and the
proposed match would not be credited.
In-kind items must be non-depreciated or new assets with established monetary values.
Costs incurred by the applicant, or others on behalf of the applicant, for facilities or equipment
installed, or other services rendered prior to submission of a completed application, shall not be
considered as an eligible in-kind matching contribution.
Funding Commitments
The applicant must provide, in form and substance satisfactory to RUS, that funding agreements have
been obtained to ensure completion of the project. These agreements, which must be placed in this
section of the Application, shall be sufficient to ensure:
(1) Payment of all proposed expenditures for the project;
(2) All required matching contribution in 1703.120;
(3) any additional matching funding provided in accordance with §1703.126(b)(4); and
(4) Any other funds necessary to complete the project.

Match Documentation Specifics - The applicant must document the project’s proposed matching
funds in form and substance satisfactory to the Agency. The documentation must be placed under Tab
C-3 of your application. Each proposed match entry on the Leveraging Worksheet must be supported
by a signed letter from the entity proposing the match, including when the entity is the applicant.
1. Be signed by a person capable of obligating the donor organization. Include the printed name
and title of the person signing the letter. The letter must clearly indicate the name of the donor
organization and state that the funds are committed to the proposed DLT project as described in the
Budget and elsewhere in the application. If the name and title do not appear on the donor
organization’s letterhead, attach evidence of the signer’s authority to obligate the funds.
2. If the match is cash, state the dollar amount. Letters without a stated cash amount cannot be
credited as a cash match.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
3. If the proposed match is in-kind, state the actual dollar amount and give a complete description of
the donation identified by the line-item number in the budget and the expected date of purchase.
Letters that do not identify the line-items in the budget cannot be credited as an in-kind match. Keep
in mind that items acquired before the application deadline are not eligible for grant or match. Also,
demonstrate how the established monetary value of the item was determined.
Proposed matches must be consistent on the SF-424, the Budget, and the Leveraging Worksheet.
Proposed matches not documented under Tab C-3 with a letter as described above will not be credited
in the Leveraging score.

C-4. Additional NSLP – Up to 10 Points
The DLT program uses the National School Lunch Program (NSLP as described above under Section
C-2) as the primary measure of general economic need for an area served by a proposed project. The
Additional NSLP category is intended to provide an opportunity for an applicant that has scored
below average to make their case that the NSLP score underestimates the relative economic need
of their project area.
An applicant with NSLP eligibility below 50% may request Additional NSLP points. If that applicant
can demonstrate that the area it would serve, or a subset of the public it would serve, is not accurately
captured by the NSLP percentage. Based on the strength of the evidence provided by the
applicant, the Agency may award up to ten points in this category.
To gain points in this category, the applicant must specifically request them in Section C-4 of the
Application using the form, Additional NSLP Worksheet located in Appendix A.
C-5. Need for Services and Project Benefits – Up to 45 Points
This criterion measures the extent to which the proposed project meets the need for distance learning
or telemedicine services in rural areas, benefits derived from the services proposed by the project, and
local community involvement in planning, implementing, and financial assistance of the project.
RUS will consider the extent of the applicant's documentation explaining the economic, education, or
health care challenges facing the community; the applicant's proposed plan to address these challenges;
how the grant can help; and why the applicant cannot complete the project without a grant. RUS will
also consider the extent to which the applicant provides evidence that economic, education, or health
care challenges could not be addressed without employing advanced technology. RUS will also
consider any support by recognized experts in the related educational or health care field, any
documentation substantiating the educational or health care underserved nature of the applicant's
proposed service area, and any justification for specific educational or medical services which are
needed and will provide direct benefits to rural residents.
Some examples of benefits to be provided by the project include, but are not limited to:
1.
2.
3.

Improved educational opportunities for a specified number of students;
Travel time and money saved by telemedicine diagnoses;
Number of doctors retained in rural areas;
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
4.
5.
6.
7.
8.
9.

Number of additional students electing to attend higher education institutions;
Lives saved due to prompt medical diagnoses and treatment;
New education courses offered, including college level courses;
Expanded use of educational facilities such as night training;
Number of patients receiving telemedicine diagnoses;
Provision of training, information resources, library assets, adult education, lifetime
learning, community use of technology, jobs, connection to region, nation, and world.

Other matters that will be considered by RUS under this criterion include:
1. That rural residents, and other beneficiaries, desire the educational or medical services to be
provided by the project. A strong indication of need is the willingness of local end users or
institutions, to the extent possible, to contribute to the capital costs of establishing the project.
This could include letters of financial commitment toward the project from local institutions.
2. The extent of the project's planning, development, and support by local residents and
institutions. This may include evidence of community involvement, as exemplified in
community meetings, public forums, and surveys. In addition, applicants should provide
evidence of local residents' participation in the project planning and development.
Additionally, a complete project may require items that are ineligible as grant or match, such as
a building addition or a vehicle for mobile telemedicine. Although not eligible for in-kind
matching credit, any kind of financial support and contributions from the local community
(other than the applicant) does show evidence of the commitment of the community to the
project.
3. The extent to which the application addresses the problems of population out-migration and
how the project seeks to slow, halt, or prevent population loss.
4. The extent to which the application is consistent with the State strategic plan prepared by the
Rural Development State Director of the United States Department of Agriculture. (Section K)

Need for Services
Clearly state the economic, geographic, educational, or health care challenges facing the project’s
respective communities, and provide any documentation that demonstrates the challenges. Use
verifiable data and statistics to substantiate and quantify these challenges. Demonstrate how the
proposed project will help resolve these challenges and why the applicant cannot afford the project
without a grant.
Document support for the project provided by professionals in the educational or health care fields.
The more specific their professional opinion is regarding your situation and the proposed project as a
solution, the more compelling it is. Substantiate the underserved educational or health care nature of
the project’s proposed service area; and justify, explain, and document the specific educational or
medical services that will provide direct benefits to rural residents.
Demonstrate demand by rural residents and other beneficiaries for the educational or medical services
that the project would provide. Show that the project is designed to meet local community needs.
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Willingness of local end-users or community-based organizations to contribute to the costs of
completing, operating, or maintaining the project is a strong indication of community support.
Documentation of support includes letters of financial and non-financial commitment towards the
project from local organizations.
Benefits Derived from Services
In addition to documenting the need for services, describe how the project would assist the community
in solving these challenges. Document the specific benefits of your project and quantify them in
terms of expected outcomes. Tie the benefits of your project DIRECTLY to the stated needs you
intend to address. Provide measurable targets or goals such as estimates of the number of people that
will benefit from the project.
Examples
For a distance learning project that serves secondary schools, provide the number of schools and
students that will benefit. You should also document all other benefits provided by the project with
quantifiable goals when possible such as:
•
•
•
•

four-year foreign language availability up from 300 to 1,200 students;
organic chemistry offered for first time to entire district;
expanded educational facility use, such as evening vocational training;
a reduction in the rate of high school dropouts from 17% to 12%.

For a telemedicine project that serves a group of hospitals, provide the number of health care
facilities and the potential number of patients to benefit. You should also document all other
benefits provided by the project such as:
•
•
•
•

time and monetary savings to the community from telemedicine diagnoses;
400 patients receiving at-home monitoring;
4 doctors retained in your community or medical staff trained;
lives saved due to prompt medical diagnosis.

Document any ancillary benefits or multiple uses that would create added value in the rural
communities which the project will serve. Examples include training, information resources, library
assets, adult education, lifetime learning, and job creation. If applicable, you can address particular
community problems such as out-migration and the extent to which the project would reduce or
prevent population loss.
Local community involvement in planning, implementing, and financial assistance of the project
Address the participation by local residents and organizations in planning and developing the project.
Include evidence of this participation in your application. Examples of evidence of community
involvement include community meetings, public forums and surveys.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Discuss Other Projects involving DLT Awards
DLT Grants cannot be awarded to projects that duplicate facilities. If any of the sites or service
territory in the project as described in the application are part of another application in FY 2016 or
were part of a project funded in the previous two DLT competitions (2014 & 2015), explain any
relationship between or among these projects as you discuss the specific need and benefit that will be
provided by the proposed project. In particular, discuss how match and grant funding for this project,
if approved, would complement previous efforts. (Provide a more thorough discussion of project
overlaps in the Telecommunications System Plan, as described above. In the absence of an
explanation, overlaps in projects are assumed to be duplication and as a consequence, the project could
be rejected as ineligible or scored comparatively low in Needs and Benefits.)
In addition, applicants with previous awards should discuss the implementation of the previous award
with respect to the use of funds. This is particularly true if funds from the former award have not yet
been drawn down in its entirety.

C-6. Innovativeness of the Project – Up to 15 Points
This criterion will be used to evaluate the innovativeness of application based on documentation that
shows how the project utilizes advanced telecommunications in a unique way to: improve how
educational or medical services are delivered in a community; address the needs of the community; or
introduce new methods, ideas or procedures to those services as a result of the technology.
Innovativeness should be addressed in the context of how the project will deliver distance learning or
telemedicine services more effectively or at a lower cost. The following issues may be addressed to
show how the project differs from a typical distance learning and telemedicine network as follows:
1.
2.
3.
4.

The extent to which the project differs from a technical standpoint;
The extent to which the project differs from an educational or medical programmatic
standpoint;
The extent to which the project reflects a unique adaptation of technology based on the special
needs or circumstances of the proposed area to be served by the project; and
The potential of the project to influence or lead changes in how telecommunications services
can be delivered in other areas.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
C-7. Cost Effectiveness of the Project – Up to 35 Points
This criterion will be used to evaluate the cost effectiveness of the application based on the extent that
cost-efficiency is considered in delivering the services in the project. The following issues should be
addressed under this criterion:
1. The extent to which the applicant has considered various technological options for delivering
the services. The applicant must provide sufficient documentation reflecting accepted analytical
and financial methodologies to substantiate its choice of technology as the most cost-effective
option. A spreadsheet showing initial cost and annual costs of all considered alternative
technologies and implementations can offer strong support for a good score in this category.
Explain the assumptions and sources for cost information used in the comparison.
RUS will consider the applicant's documentation and analysis comparing various systems and
technologies.
2. Whether buying or leasing specific equipment is more cost effective.
3. The extent to which the project will utilize other existing networks at the regional, statewide,
national or international levels. To the extent possible, educational and health care networks
should be designed to utilize the widest practicable number of other networks that expand the
capabilities of the project, thereby affording rural residents opportunities that may not be
available at the local level. The ability to connect to the Internet alone cannot be used as the
sole basis to fulfill this criteria.
4. The extent to which the facilities being constructed with the grant provided to entities other
than the applicant, will be utilized to extend or enhance the benefits of the project.
5. The extent to which the project utilizes existing telecommunications transmission facilities that
could provide the transmission path for the needed services. For projects that do not utilize
existing transmission facilities, RUS will consider documentation explaining the necessity of
this option. RUS will also consider any agreements between the applicant and other entities for
sharing transmission facilities to lower the fixed costs of such facilities.

C-8. Special Consideration – 15 Points
RUS will offer special consideration to applications that contain at least one end-user site within a trust
area or a tribal jurisdictional area, a “Strike Force” area or a “Promise Zone”. Such applications will be
awarded 15 points. The application will need to include a map showing the end-user site(s) located in
the Special Consideration area, as well as the geographical coordinate(s), and physical street
address(es) of the end-user site(s).
For those applications that propose end-user sites in a trust area or a tribal jurisdictional area, the
applicant will also need to submit evidence indicating that the area where the end-user site is located is
a trust area or a tribal jurisdictional area. The following resources may be used to provide evidence to
support whether a particular end-user site is located in trust area or tribal jurisdictional area:
•

Official maps of Federal Indian Reservations based on information compiled by the U. S.
Department of the Interior, Bureau of Indian Affairs and made available to the public;
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
•
•
•
•

•
•

Title Status Reports issued by the U. S. Department of the Interior, Bureau of Indian Affairs
showing that title to such land is held in trust or is subject to restrictions imposed by the United
States;
Trust Asset and Accounting Management System data, maintained by the Department of the
Interior, Bureau of Indian Affairs;
Official maps of the Department of Hawaiian Homelands of the State of Hawaii identifying
land that has been given the status of Hawaiian home lands under the provisions of section 204
of the Hawaiian Homes Commission Act, 1920;
Official records of the U.S. Department of the Interior, the State of Alaska, or such other
documentation of ownership as the RUS may determine to be satisfactory, showing that title is
owned by a Regional Corporation or a Village Corporation as such terms are defined in the
Alaska Native Claims Settlement Act (43 U.S.C. 1601 et seq);
Evidence that the land is located on Guam, American Samoa or the Commonwealth of the
Northern Mariana Islands, and is eligible for use in the Veteran’s Administration direct loan
program for veterans purchasing or constructing homes on communally owned land; and
Any other evidence submitted by the applicant that is satisfactory to RUS to establish that area
where the end-user site is located is a trust area or a tribal jurisdictional area within the
meaning of 38 U.S.C. 3765(1).
For more information on Strike Force Areas, go to:
http://www.usda.gov/wps/portal/usda/usdahome?navid=STRIKE_FORCE
For more information on Promise Zones, go to:
http://www.rd.usda.gov/about-rd/initiatives/promise-zones

D. Scope of Work
Provide a narrative (with charts, if needed) explaining the Scope of Work. Make a clear and
convincing presentation of how you will achieve the goals of your project. The scope of work
completes the picture for the reviewer. It discusses how your organization proposes to proceed with
the project. An application that does not include a scope of work cannot be evaluated and could
be returned as ineligible.
The scope of work must include, at a minimum, the following:
1.
2.
3.
4.

The specific activities to be performed under the project;
Who will carry out the activities;
The timeframes for accomplishing the project objectives and activities; and
A budget for all capital expenditures reflecting the line item costs for approved purposes
for both the grant funds and the matching funds for the project. Separately, the budget must
specify any line item costs that are nonapproved purposes for grants as contained in
§1703.123.

Additional Guidance for the Budget: The budget is a required document for RUS to evaluate an
application. The Budget worksheet with instructions is available in Appendix A. An excel
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
spreadsheet for completing the budget is also available on our website at:
http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants
•

Your Budget should show each cost as a line-item. The items listed and described in your
Telecommunications System Plan (Section G) should track line-by-line with the entries in your
budget.

•

Do not combine items into lump sums that cannot be evaluated individually by the Agency.
The individual parts have to be evaluated for cost comparison and program eligibility.

•

If, in your project, you have to pay a user fee or a license fee that is required to use grant or
match purchased equipment, it must be presented as such in the application.

•

Provide detail such as the brand and model number, i.e., “VideoKing TX-90, $5,600,” as
opposed to “One Video System, $75,000 each site;” Installation,” $50,000; or “Wiring,
$100,000.”

Examples:
The following are some abbreviated examples to use as guidance in completing the budget worksheet.
They are not all inclusive of the equipment needed for a complete DLT project.
•

Weaver County Memorial Hospital is installing remote diagnostic systems in 2 small rural
urgent care centers throughout the county to provide telemedicine services. This will involve
the purchase of a diagnostic system for each site plus computers. The hospital board agreed to
contribute $25,000 to the project.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
•

Gretchen County Community College is proposing a distance learning project with three high
schools to provide advanced placement courses. Each school has agreed to provide the needed
laptops computers at their respective site.

E. Financial Information and Sustainability
The applicant must provide a narrative description demonstrating the feasibility of the project,
including having sufficient resources and expertise necessary to undertake and complete the project
and, how the project will be sustained following completion of the project.
The application needs to show that funding is available for the three-year period that it takes to put
together the project (required for eligibility), and to ensure the project’s continuance as a viable
community resource.
Provide a narrative description that addresses your project’s feasibility. The narrative should include a
description of the project’s leadership, its technical expertise, and how leadership and technical
expertise is distributed throughout all of the sites or the service territory. Describe how the flow of
funds and institutional financial support (local government, businesses, school system, university or
foundation) will sustain the project and maintain a continuity of service.
Your narrative should include all assumptions and the following information:
•

A description of the project’s revenues and expenses in the project budget;

•

Evidence of cost sharing arrangements among hub and end-user sites, if applicable;

•

Identification of any other items that may affect feasibility or sustainability of the project.
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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

F. Statement of Experience
Provide a written narrative describing your organization’s demonstrated capability and experience in
operating an educational or health care endeavor and any project similar to the proposed project.
Experience in a similar project is desirable but not required. If your organization does not have
experience with projects similar to the proposed project, you should explain how you plan to overcome
this.

G. Telecommunications System Plan
A telecommunications system plan consisting of the following:
(1) The capabilities of the telecommunications terminal equipment, including a description of
the specific equipment which will be used to deliver the proposed service. The applicant
must document discussions with various technical sources which could include consultants,
engineers, product vendors, or internal technical experts, provide detailed cost estimates for
operating and maintaining the end user equipment and provide evidence that alternative
equipment and technologies were evaluated.
(2) A listing of the proposed telecommunications terminal equipment, telecommunications
transmission facilities, data terminal equipment, interactive video equipment, computer
hardware and software systems, and components that process data for transmission via
telecommunications, computer network components, communication satellite ground
station equipment, or any other elements of the telecommunications system designed to
further the purposes of this subpart, that the applicant intends to build or fund using RUS
financial assistance.
(3) A description of the consultations with the appropriate telecommunications carriers
(including other interexchange carriers, cable television operators, enhanced service
providers, providers of satellite services and telecommunications equipment manufacturers
and distributors) and the anticipated role of such providers in the proposed
telecommunications system.

A successful DLT grant application includes a well-planned TSP, starting with a diagram or map of the
proposed system overlaid with a geographic map of the service area. Also included in the TSP are
other diagrams (if necessary), technical descriptions, and a narrative accounting of each item in the
budget.
The TSP shows the sites (hubs, hub/end-users, or end/users) that will participate in the project and
where the equipment will be located. It shows how the equipment is interconnected and how the
distance learning or telemedicine benefits flow from the hub sites to the rural end user sites.

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Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
Telecommunications System Plan Map/Diagram
Attach a map or a drawing which is a spatial representation of the service area encompassing the
project, displaying an overlay of your proposed distance learning or telemedicine system, including
hub sites and end users. This map can be displayed as a series of maps containing an overview,
followed by close-up maps of individual sites.
Each site, hub and end user, must be represented on the map. This representation need not be to scale,
but it must be representational of your project, not generic. These generic network diagrams, usually
depicting some kind of campus architecture are by themselves insufficient. However, applicants can
provide a network diagrams (without geographic references) if they can also provide geographic maps
that reference the diagram. Nevertheless, an application that does not contain a map that shows each
site could be difficult to evaluate thereby losing competitive value when compared to applications that
present visual clarity of their project.
 Some items requested for DLT funding will have more general uses than other equipment,
which may have 100% distance learning or tele-medical purposes. For each item, specify the
percentage of use that can be attributed to purposes that meet the DLT grant definition of
distance learning and/or telemedicine, explain how you’ve determined those percentages and
addressing the capabilities of the proposed equipment/software. The percentage of use is only
to be used for analysis as part of line item explanations. Do not breakout items in the actual
budget by percentage of use.
 Document your discussions with various technical sources, such as consultants, engineers,
product vendors or internal technical experts.
 Address whether or not any part of the project will duplicate any adequate, established
telemedicine or distance learning services already in operation. In particular, discuss how match
and grant funding for this project, if approved, would complement previous efforts. Describe the
status of previous projects and, in particular, the extent to which the funds have been drawn for
eligible grant purposes. Please note that you will need to complete a Non-duplication of
Services Certificate, which is part of the certification section. The form is located in the Toolkit.
 Identify any previous grants that the applicant has received from our Agency in the previous
three grant cycles (2012, 2013 & 2014) and how they would affect the project proposed in the
current application.
 This applies not only to prior grants received by the current applicant, but to grant funding that
may have gone to any of the end-users in the current proposal via a grant received by another
entity.
 Discuss how match and grant funding for this project, if approved, would complement previous
efforts. Specify the progress/status of any previous awards and the extent of grant and match
funds expended toward completing those projects.
 Discuss whether or not any of the sites in the current project are included as participants in
another application for a Fiscal Year 2016 DLT Grant.
28

Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
 In the absence of any explanation, overlaps in projects are assumed to be duplication and, as a
consequence, scores could be negatively affected in the criterion of Needs and Benefits.

H. Compliance with other Federal Statutes
Appendix A contains certification forms to demonstrate compliance with other Federal statutes and
regulations. There are ten required certifications and we have numbered them H-1 through H-10 so
that you can see at a glance if they are all in your application. Applications submitted without a nonduplication certification will be assumed that the project is duplicative in the services offered and will
be returned as ineligible.
Important Note: If you are applying as a consortium which does not have the legal authority to apply
(See Eligibility Requirements on Page 4 of the Application Guide with respect to Legal Eligibility),
each entity that comprises the consortium must provide a set of these certifications.
H-1 Equal Opportunity and Nondiscrimination
H-2 Architectural barriers
H-3 Flood hazard area precautions
H-4 Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
H-5 Drug-free workplace
H-6 Debarment and suspension rules
H-7 Lobbying for contracts, grants, etc.
H-8 Non-duplication of services
H-9 Federal Debt Certification
H-10 Assurance Regarding Felony Conviction or Tax Delinquent Status for Corporate
Applicants

I. Environmental Impact and Historic Preservation
The applicant must provide details of the project's impact on the environment and historic preservation.
Grants made under this part are subject to part 1794 of this chapter which contains RUS' policies and
procedures for implementing a variety of Federal statutes, regulations, and executive orders generally
pertaining to the protection of the quality of the human environment that are listed in 7 CFR 1794.1.
The application shall contain a separate section entitled “Environmental Impact of the Project.” The
applicant may use the “Environmental Questionnaire,” in Appendix A, to assist in complying with the
requirements of this section.

J. Evidence of Legal Existence and Legal Authority to Contract with the Federal
Government
Evidence of Legal Existence and Legal Authority to Contract with the Federal Government is
demonstrated by an active registration in the System for Award Management (SAM). Please complete
Schedule J in Appendix A. Provide the Cage Code and certify the applicant’s current and active
registration in SAM.
29

Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide
The Entity Name and DUNS Number must be for the applicant. It cannot be for a parent, subsidiary or
other affiliated company.
Additional Guidance for Consortia:
•

If the applicant is an existing established consortium with the legal ability to contract with
the Federal Government, the consortium must provide the above documentation;

•

If the applicant is an informal consortium which by itself lacks the legal capacity to
contract, the applicant must have a legally organized host organization which is part of the
consortium. That host must submit the required documentation.
Under this approach, if the entity receives an award and does not take steps to establish
itself as a legal entity, there are two approaches which could be taken:


Each organization within the consortium, which must each have legal existence
and the legal authority to contract with the government, will be a party to the
grant agreement and will be required to sign the document and individually
supply an opinion of counsel; or



The host organization will be legally responsible for the execution of the grant
documents. This organization would be solely responsible for ownership and
control of all assets acquired with the grant funds regardless of where they are
installed.

K. Consultation with USDA State Director and State Strategic Plan Conformity
The applicant must provide evidence that your organization has consulted with the USDA State
Director for Rural Development about the availability of other sources of funding available at the State
or local level. Include this evidence as part of your application.
You must also provide evidence from the State Director for Rural Development that your application
conforms with the State strategic plan as prepared under section 381D of the Consolidated Farm and
Rural Development Act (7 U.S.C. 1921 et seq.). Not all states have a strategic plan, so you should
indicate if such a plan does not exist.
Note: Applicants should contact the USDA State Director as early as possible in the application
process. You can find a listing of the State Rural Development Offices at:
www.rurdev.usda.gov/recd_map.html

L. Supplemental Information
The applicant can use this section to provide any additional information it considers relevant to the
project and likely to be helpful in determining the extent to which the project will further the purposes
of the Distance Learning and Telemedicine Grant Program.
30

Fiscal Year 2016 Distance Learning and Telemedicine Grant Application Guide

Appendix A – Forms
1.
2.
3.
4.
5.
6.
7.
8.
9.

Standard Form 424 .................................................................................................................. 32
Survey Ensuring Equal Opportunity for Applicants ................................................................ 36
Site Worksheet ......................................................................................................................... 38
Rurality Worksheet .................................................................................................................. 40
Economic Need Worksheet ..................................................................................................... 42
Leveraging Worksheet ............................................................................................................. 44
Additional NSLP Worksheet ................................................................................................... 46
Budget Worksheet ................................................................................................................... 48
Certifications
A. Equal Opportunity and Nondiscrimination Certification .................................................. 50
B. Certificate Regarding Architectural Barriers ..................................................................... 51
C. Certificate Regarding Flood Hazard Area Precautions ..................................................... 52
D. Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
Certification ....................................................................................................................... 53
E. Certification Regarding Drug-Free Workplace Requirements for Grantees Other than
Individuals ......................................................................................................................... 54
F. Certification Regarding Debarment, Suspension, and Other Responsibility Matters –
Primary Covered Transactions .......................................................................................... 58
G. Certification Regarding Lobbying for Contracts, Grants, Loans, and Cooperative
Agreements ........................................................................................................................ 60
H. Non-Duplication of Services Certificate ........................................................................... 61
I. Federal Obligations Certification on Delinquent Debt ...................................................... 62
J. Form AD3030 - Representations Regarding Felony Conviction and Tax Delinquent Status
for Corporate Applicants ................................................................................................... 63
10. System for Award Management Registration Information Form ............................................ 64
11. Environmental Impact Certification ........................................................................................ 65

31

OMB Number: 4040-0004
Expiration Date: 8/31/2016

Application for Federal Assistance SF-424
* 1. Type of Submission:

* 2. Type of Application:

Preapplication

New

Application

Continuation

Changed/Corrected Application

Revision

* 3. Date Received:

* If Revision, select appropriate letter(s):

* Other (Specify):

4. Applicant Identifier:

5a. Federal Entity Identifier:

5b. Federal Award Identifier:

State Use Only:
6. Date Received by State:

7. State Application Identifier:

8. APPLICANT INFORMATION:
* a. Legal Name:
* b. Employer/Taxpayer Identification Number (EIN/TIN):

* c. Organizational DUNS:

d. Address:
* Street1:
Street2:
* City:
County/Parish:
* State:
Province:
* Country:

USA: UNITED STATES

* Zip / Postal Code:

e. Organizational Unit:
Department Name:

Division Name:

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

* First Name:

Middle Name:
* Last Name:
Suffix:
Title:
Organizational Affiliation:

* Telephone Number:

Fax Number:

* Email:

32

Application for Federal Assistance SF-424
* 9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

Rural Utilities Service
11. Catalog of Federal Domestic Assistance Number:

10.855
CFDA Title:

Distance Learning and Telemedicine Loans and Grants
* 12. Funding Opportunity Number:

RUS-16-01-DLT
* Title:

Distance Learning and Telemedicine Grant Program

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

Use Site Worksheet

Add Attachment

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Add Attachments

Delete Attachments

View Attachments

33

Delete Attachment

View Attachment

Application for Federal Assistance SF-424
16. Congressional Districts Of:
* a. Applicant

* b. Program/Project

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

Use Site Worksheet

Add Attachment

Delete Attachment

View Attachment

17. Proposed Project:
* a. Start Date:

* b. End Date:

18. Estimated Funding ($):
* a. Federal
* b. Applicant
* c. State
* d. Local
* e. Other
* f. Program Income
* g. TOTAL

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?
.

a. This application was made available to the State under the Executive Order 12372 Process for review on
b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E.O. 12372.
* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

Yes

No

If "Yes", provide explanation and attach
Add Attachment

Delete Attachment

View Attachment

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 certifications and 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:

* Email:
* Signature of Authorized Representative:

* Date Signed:

34

Additional Instructions for SF-424 Form
Block 8: There are multiple entries in this block. We will use the contact information provided in this
box for all contact and correspondence. Please complete this in full and attach a sheet if you want to
provide additional contacts. It is crucial that we have accurate information, including a reliable e-mail
address for rapid correspondence. Otherwise, correspondence will be sent by mail. You must provide
full, accurate contact information for someone with the authority to answer any questions that RUS
staff may have about your application.
If you wish to supply a contact from outside your organization, attach a letter immediately behind the
SF-424 listing these items: person's name, organization, contact information (phone, fax, e-mail,
mailing address), relationship to your organization. Make sure the letter contains language granting
authority to the person to answer our questions or provide additional information on your behalf, and
any time limit you wish to apply to that person's authority. This letter must be signed by the signatory
on the SF-424.
As required by the Office of Management and Budget, all applicants for grants must supply a Dun
and Bradstreet Data Universal Numbering System (DUNS) number. See instructions on Page 3 of
this guide for assistance in obtaining a DUNS number
Block 10: The Name of the Federal Agency is Rural Utilities Service.
Block 11: The Catalog of Federal Assistance Number is 10.855.
Block 12: Funding Opportunity Number is RUS-16-01-DLT. The Title is “Distance Learning and
Telemedicine Grant Program”.
Block 14: Please use the Site Worksheet to provide this information
Block 15: Brief descriptive title of project.
Block 16: Please use the Site Worksheet to provide this information
Block 19: Please select “C” “Program is not covered by E.O. 12372”. Per regulation 7 CFR 1739Supplementary Information, this program is not subject to the requirements of Executive Order 12372.
Block 20: You must supply an explanation of the delinquency if you check “yes”.
Block 21: Please be sure to check “I agree”. The application must be signed by an authorized
representative of the organization that will own and operate the project if the grant is awarded. If the
authorized representative is not a corporate officer, evidence must be included that demonstrates that
the authorized representative has authority to obligate the organization.

35

Survey Ensuring Equal Opportunity for Applicants
Purpose: The Federal Government is committed to ensuring that all qualified applicants, small or large, nonreligious 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 and Telemedicine Grant Program
CFDA Number: 10.855

1. Has the applicant ever received a grant or contract
from the Federal government?
Yes

6. How many full-time equivalent employees does the
applicant have? (Check only one box).

No

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

No

3. Is the applicant a secular organization?
Yes

3 or Fewer

15-50

4-5

51-100

6-14

over 100

7. What is the size of the applicant’s annual budget?
(Check only one box.)

No

Less Than $150,000
4.

Does the applicant have 501(c)(3) status?
$150,000 - $299,999
Yes

No

$300,000 - $499,999
$500,000 - $999,999

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

$1,000,000 - $4,999,999

No

$5,000,000 or more

36

SURVEY INSTRUCTIONS ON ENSURING EQUAL OPPORTUNITY FOR APPLICANTS
PROVIDE THE APPLICANT’S (ORGANIZATION) NAME AND DUNS NUMBER AND THE GRANT NAME AND CFDA NUMBER.

1. Self-explanatory.
2. Self-identify.
3. Self-identify.
4. 501(c)(3) status is a legal designation provided on application to the Internal Revenue Service
by eligible organizations. Some grant programs may require nonprofit applicants to have
501(c)(3) status. Other grant programs do not.
5. Self-explanatory.
6. 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 survey
questions 2 and 3 should reflect the staff and budget size of the local affiliate.
7. Annual budget means the amount of money your organization spends each year on all of its
activities.
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 of the time estimate(s) or suggestions for
improving this form, please write to: The Agency Contact listed in this grant application package.

37

Site Worksheet
Site
Number

Site Name

Site
Designation
(Hub;
Hub/EndUser/End-user)

Street Address

Town

38

County

State

School
District

Congressional
District

Instructions for Completing Site Worksheet
1. If using the Excel worksheets provided on our website at:
http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants
please insert additional rows as needed to accommodate your Sites. If using a printed form,
please use additional copies as needed to list all of your Sites.
2. Site Number – Number each Site consecutively regardless of its designation. This number
should be used consistently to identify each site in the Site Worksheet, Rurality Worksheet and
NSLP Worksheet.
3. Site Name – Input the official name of the site. Use this name consistently in the Site
Worksheet, Rurality Worksheet and NSLP Worksheet.
4. Site Designation – Designated each Site as Hub, Hub/End-User, or End-User according to the
guidance on Page 12 of this guide.
5. Street Address, Town, County, State – Input the Street Address, Town or Place Name,
County and State in which the Site is located.
6. School District – Input the School District in which the Site is located.
7. Congressional District – Input the Congressional District in which the Site is located. This
information can be found on the House of Representatives website: www. House.gov.

39

Rurality Worksheet
Site
Number

Site Name

Site Designation
(Hub; Hub/End-User/End-user)

Applicant’s Estimated Rurality Score
(Sum of Rurality Points ÷ # of End-User Sites)

40

Town

Census
Population

Rurality Score
(For Agency use)

Rurality
Score

Instructions for Completing Rurality Worksheet
1. If using the Excel worksheets provided on our website at:
http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants
please insert additional rows as needed to accommodate your Sites. If you added rows you
will need to copy the cell references as well in order to carry the input information from the
Site Worksheet. If using a printed form, please use additional copies as needed to list all of
your Sites.
2. Site Number – Number each Site consecutively regardless of its designation. This number
should be used consistently to identify each site in the Site Worksheet, Rurality Worksheet
and NSLP Worksheet.
3. Site Name – Input the official name of the site. Use this name consistently in the Site
Worksheet, Rurality Worksheet and NSLP Worksheet.
4. Site Designation – Designated each Site as Hub, Hub/End-User, or End-User according to
the guidance on Page 12 of this guide.
5. Town or Place – Input the Town or Place Name, in which the Site is located.
6. Population – Input the population from the 2010 Census, guidance provided in Appendix
B. If town is not located in the Census, you must provide documentation verifying the
existence and population of the site
7. Rurality Score – Input the Rurality Score for each End-User or Hub/End-User site
according to the following table:

Category
Exceptionally Rural – Any area of the US NOT included within the boundaries of
any incorporated or unincorporated city, village, or borough having a population in
excess of 5,000 inhabitants.
Rural – Any area of the USA included within the boundaries of any incorporated or
unincorporated city, village, or borough having a population over 5,000 and not in
excess of 10,000 inhabitants.
Mid-Rural - Any area of the USA included within the boundaries of any incorporated
or unincorporated city, village, or borough having a population over 10,000 and not in
excess of 20,000 inhabitants.
Urban Area - Any area of the USA included within the boundaries of any
incorporated or unincorporated city, village, or borough having a population in excess
of 20,000 inhabitants.

41

Population

Points

5,000 or fewer

45

5001 - 10,000

30

10,001 - 20,000

15

20,001 or
more

0

Economic Need Worksheet
Site
Number

Site Name

Site Designation
(Hub; Hub/End-User/End-user)

School
District

Total
Students

Average NSLP/CEP (sum of % Eligible ÷ # of Sites

Applicant’s Estimated Economic Need Score
(Enter Points from Scoring Table)

42

Economic Need
Score
(for Agency Use)

%
Eligible

Instructions for Completing Economic Need Worksheet
1. If using the Excel worksheets provided on our website at:
http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants
please insert additional rows as needed to accommodate your Sites. If you added rows you
will need to copy the cell references as well in order to carry the input information from the
Site Worksheet. If using a printed form, please use additional copies as needed to list all of
your Sites.
2. Site Number – Number each Site consecutively regardless of its designation. This number
should be used consistently to identify each site in the Site Worksheet, Rurality Worksheet
and Economic Need Worksheet.
3. Site Name – Input the official name of the site. Use this name consistently in the Site
Worksheet, Rurality Worksheet and Economic Need Worksheet.
4. Site Designation – Designated each Site as Hub, Hub/End-User, or End-User according to
the guidance on Page 12 of this guide.
5. School District – Input the School District in which the Site is located.
6. Total Students – Input the either the Total Students for the facility or Total Students for the
School District according to the following decision matrix:

Type of End-User

Is site
Eligible for
NSLP/CEP
?

Use Student
Population and
NSLP/CEP % for
Specific School

Use Student Population
and NSLP/CEP % for
School District

Public School (K-12)

Yes

Yes

No

Private Non Profit School (K-12)

Yes

Yes

No

A College or Other Educ. Org.

No

No

Yes

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

N/A

No

Yes

7. Percent Eligible – Input the percent of students eligible for the National School Lunch
Program/Community Eligibility Provision in either the facility or the School District
according to the decision matrix in Number 6 above.
8. Economic Need Score – Calculate the Average NSLP/CEP and input the Economic Need
Score according to the following table:
Scoring Table
Average NSLP/CEP Percentage:
NSLP/CEP < 25%
25% ≤ NSLP/CEP < 50%
50% ≤ NSLP/CEP < 75%
75% ≤ NSLP/CEP
43

Points
0
15
25
35

Leveraging Worksheet
Donor
(must provide Documentation Letter from each donor)

1. Total Proposed Matching Contribution (must equal Line B + Line C in the Budget Worksheet)
2. Total DLT Grant Request (must equal Line D in the Budget Worksheet)
Match Percent (Line 1 ÷ Line 2)

44

Proposed Match ($)

Instructions for Completing Leveraging Worksheet
1. If using the Excel worksheets provided on our website at:
http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants
please insert additional rows as needed to accommodate your Matching Contributions. If
using a printed form, please use additional copies as needed to list all of your Matching
Contributions.
2. List each matching contribution and the dollar value on separate line items.
3. Input the total value of the matching contributions in Line 1 at the bottom of the sheet.
4. Input the total grant request in Line 2 at the bottom of the sheet.
5. Calculate the percent match and input in Line 3.
6. Calculate your score based on the following table:
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

7. 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 C-3 of your application package. Each donor’s match must be supported by a
matching letter. Matches not properly documented 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%)

45

2016 Additional NSLP Worksheet
(For more information about additional NSLP, Section C-4 of the Application Guide)

The NSLP eligibility percentage on our NSLP Worksheet (Tab C-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)

46

47

Budget Worksheet

Line
Item #

Site Name

Unit
Cost

Description

# of
Units

Extended Cost
Grant or
Cash Match
In-Kind
Funds
Match

Totals
A
B
C

Overall DLT Project Budget (Sum of Total Grant/Cash Match and In-Kind Match Columns)
Less Proposed Cash Match (as documented in Tab ___)
Less Proposed In-Kind Match (From total of In-Kind Match Column)

D

DLT Grant Request (A-B-C)

48

Instructions for Completing Budget Worksheet
1. If using the Excel worksheets provided on our website at:
http://www.rd.usda.gov/programs-services/distance-learning-telemedicine-grants
please insert additional rows as needed to accommodate your Budget items. If using a
printed form, please use additional copies as needed.
2. Site Name – Insert Site Name, consistent with previous worksheets, where equipment will
be installed.
3. Description – Provide a detailed description, such as band and model number, for the
equipment to be purchased.
4. Unit Cost – Provide the cost for purchasing one unit of the equipment
5. # of Units – Provide the number of units to be purchased for the site
6. Extended Cost: Grant or Cash Match – Provide the total amount of grant and/or cash
match funds which will be used to purchase the line item.
7. Extended Cost: In-Kind Match – Provide the total value of the equipment which will be
provided as an in-kind match.
8. Place Totals of each column in the Totals boxes.
9. Line A is the total of the Grant/Cash Match column and the In-Kind Match column and
represents the total cost of the project
10. Line B is the total amount of Cash Match contributed to the project and supported by the
Leveraging Worksheet and documentation
11. Line C is the total amount of In-Kind Match contributed to the project and supported by the
Leveraging Worksheet and documentation.
12. Line D is Line A minus Line B and Line C. This should reconcile with the Grant Request
on the Form SF 424 Block 18 Line a. Federal.

49

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

50

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

51

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

52

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

53

This form is available electronically.

OMB No. 0505-0027
Expiration Date: 12/31/2018

United States Department of Agriculture

AD-1049

Certification Regarding Drug-Free Workplace Requirements (Grants)
Alternative I – For Grantees Other Than Individuals

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552(a), as amended). This certification is required by the
regulations implementing §§ 5151-5160 of the Drug-Free Workplace Act of 1998 (Pub. L.100-690, Title V, Subtitle D: 41 U.S.C. § 8101 et seq.), and
2 C.F.R. Parts 182 and 421. The regulations were amended and published on June 15, 2009, in 74 Fed. Reg. 28150-28154 and on December 8, 2011, in
76 Fed. Reg. 76610-76611. Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the grant.
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 0505-0027. The time required
to complete this information collection is estimated to average 0.25 minutes 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. The provisions of appropriate
criminal and civil fraud privacy, and other statutes may be applicable to the information provided.

(Read Instructions On Page Three Before Completing Certification)
A. The grantee certifies that it will or will continue to provide a drug-free workplace by:
1. Publishing a statement notifying employees that the 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;
2. Establishing an ongoing drug-free awareness program to inform employees about –
a. The dangers of drug abuse in the workplace;
b. The grantee’s policy of maintaining a drug-free workplace;
c. Any available drug counseling, rehabilitation, and employee assistance programs; and
d. The penalties that may be imposed upon employees for drug-abuse violations occurring in the workplace.
3. 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.1.).
4. Notifying the employee in the statement required by paragraph (A.1.) that, as a condition of employment under
grant, the employee will –
a. Abide by the terms of the statement; and
b. 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 five calendar days after such conviction;
5. Notifying the agency in writing, within ten calendar days after receiving notice under subparagraph (A.4.b.)
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;

54

6. Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph (A.4.b.),
with respect to any employee who is so convicted –
a. 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
b. 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;
7. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs
(A.1. through A.6.).
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

PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)

SIGNATURE(S)

DATE

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived
from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program
information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA,
Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at
(866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and
employer.

55

Form AD-1049 (REV 07/15)
Page 2 of 3

Instructions for Certification
(1) By signing and submitting this form, the grantee is providing the certification set out on pages one and two in accordance with these
instructions.
(2) The certification set out on pages one and two is a material representation of fact upon which reliance is placed when the agency
awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the
requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government,
may take action authorized under the Drug-Free Workplace Act.
(3) Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If known, they may be
identified in the grant application. If the grantee does not identify the workplaces at the time of application, or upon award, if there
is no application, the grantee must keep the identity of the workplace(s) on file in its office and make the information available for
Federal inspection. Failure to identify all known workplaces constitutes a violation of the grantee’s drug-free workplace
requirements.
(4) Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the
grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department
while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).
(5) If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the
change(s). If it previously identified the workplaces in question, see paragraph (3) above.
(6) Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply
to this certification. Grantees’ attention is called, in particular, to the following definitions from these rules:
•
•
•
•

“Controlled substance” means a controlled substance in Schedules I through V of the Controlled Substances Act, 21 U.S.C.
§ 812, and as further defined by 21 C.F.R. §§ 1308.11-1308.15.
“Conviction” means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial
body charged with the responsibility to determine violations of the Federal or State criminal drug statutes.
“Criminal drug statute” means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use,
or possession of any controlled substance.
“Employee” means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) all
“direct charge” employees (ii) all “indirect charge” employees unless their impact or involvement is insignificant to the
performance of the grant and, (iii) temporary personnel and consultants who are directly engaged in the performance of work
under the grant and who are on the grantee’s payroll. This definition does not include workers not on the payroll of the grantee
(e.g., volunteers, even if used to meet a matching requirement, consultants or independent contractors not on the grantee’s
payroll, or employees of subrecipients or subcontractors in covered workplaces).

56

Form AD-1049 (REV 07/15)
Page 3 of 3

57

This form is available electronically.

OMB No. 0505- 0027
Expiration Date: 12/31/2018

AD-1047
AD-1047

United States Department of Agriculture
Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552(a), as amended). This certification is required by the
regulations implementing Executive Order 12549, Debarment and Suspension, and 2 C.F.R. § 180.335, Participants' responsibilities. The regulations
were amended and published on August 31, 2005, in 70 Fed. Reg. 51865-51880. Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the proposed covered transaction.
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 0505-0027. The time required
to complete this information collection is estimated to average 0.25 minutes 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. The provisions of appropriate
criminal and civil fraud privacy, and other statutes may be applicable to the information provided.

(Read Instructions On Page Two Before Completing Certification)
A. The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
1. Are not presently debarred, suspended, or proposed for debarment, declared ineligible, or voluntarily excluded from
covered transactions by any Federal department or agency;
2. Have not within a three-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;
3. 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 (A.2.) of this certification; and
4. 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.
B. 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

PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)

SIGNATURE(S)

DATE

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived
from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program
information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA,
Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at
(866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and
employer.

58

Instructions for Certification
(1) By signing and submitting this form, the prospective primary participant is providing the certification set out on page 1 in accordance
with these instructions.
(2) The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered
transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out on this form.
The certification or explanation will be considered in connection with the department or agency's determination whether to enter into
this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
(3) The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency
determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an
erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate
this transaction for cause or default.
(4) The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is
submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.
(5) The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person,"
"primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in
the Definitions and Coverage sections of the rules implementing Executive Order 12549, at 2 C.F.R. Parts 180 and 417. You may
contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations.
(6) The prospective primary participant agrees by submitting this form that, should the proposed covered transaction be entered into, it
shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this
transaction.
(7) The prospective primary participant further agrees by submitting this form that it will include the clause titled "Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," provided by the
department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
(8) A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction
that is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification
is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each
participant may, but is not required to, check the System for Award Management (SAM) database.
(9) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith
the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of business dealings.
(10) Except for transactions authorized under paragraph (6) of these instructions, if a participant in a covered transaction knowingly enters
into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation
in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this
transaction for cause or default.

59

Form AD-1047 (REV 07/15)
Page 2 of 2

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

60

_________________________
Date

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

61

Federal Obligations Certification on Delinquent Debt
IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

YES

NO

Note: Example of debts include, but are not limited to, delinquent taxes, guaranteed or direct
government loans (more than 31 days past due) and other administrative debts.
If Yes, provide explanatory information.

APPLICANT CERTIFICATION
FEDERAL COLLECTION POLICIES FOR COMMERCIAL DEBT
The Federal Government is authorized by law to take any or all of the following actions in the event that a
borrower’s loan payments become delinquent or the borrower defaults on its loan: (1) Report the
borrower’s delinquent account to a credit bureau; (2) Assess additional interest and penalty charges for the
period of time that payment is not made; (3) Assess charges to cover additional administrative costs
incurred by the Government to service the borrower’s account; (4) Offset amounts owed to the borrower
under other Federal programs; (5) Refer the borrower’s debt to the Internal Revenue Service for offset
against any amount owed to the borrower as an income tax refund; (6) Refer the borrower’s account to a
private collection agency to collect the amount due; and (7) Refer the borrower’s account to the
Department of Justice for litigation in the courts.
All of these actions can and will be used to recover any debts owed when it is determined to be in the
interest of the Government to do so.
Certification
I have read and understand the actions the Federal Government can take in the event that I fail to
meet my scheduled payments in accordance with the terms and conditions of my agreements.

Signed:
Printed Name:
Title:
Company:
Date:

62

This form is available electronically.

AD-3030

Form Approved – OMB No. 0505-0025
Expiration Date: 2/29/2016
U.S. DEPARTMENT OF AGRICULTURE

REPRESENTATIONS REGARDING FELONY CONVICTION
AND TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS
Note: You only need to complete this form if you are a corporation. A corporation includes, but is not limited to, any entity

that has filed articles of incorporation in one of the 50 States, the District of Columbia, or the various territories of the
United States including American Samoa, Federated States of Micronesia, Guam, Midway Islands, Northern Mariana
Islands, Puerto Rico, Republic of Palau, Republic of the Marshall Islands, or the U.S. Virgin Islands. Corporations
include both for profit and non-profit entities.
The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552(a), as amended). The authority for requesting the following
information for USDA Agencies and staff offices is in §738 and 739 of the Agriculture, Rural Development, Food and Drug Administration, and Related
Agencies Appropriations Act, 2012, P.L. 112-55, as amended and/or subsequently enacted. The information will be used to confirm applicant status
concerning entity conviction of a felony criminal violation, and/or unpaid Federal tax liability status.
According to the Paperwork Reduction Act of 1985 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 0505-0025. The time
required to complete this information collection is estimated to average 15 minutes 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.

1. APPLICANT’S NAME

2. APPLICANT’S ADDRESS (Including Zip Code)

3. TAX ID NO.
(Last 4 digits)

4A. Has the Applicant been convicted of a felony criminal violation under Federal or State law in the 24 months preceding the
date of application?
YES
NO
4B. Has any officer or agent of App
licant been convicted of a felony criminal violation for actions taken on behalf of Applicant under Federal or State law in the 24
months preceding the date of application?
YES
NO
4C. Does the Applicant have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative
remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with
the authority responsible for collecting the tax liability?
YES
NO

Providing the requested information is voluntary. However, failure to furnish the requested information will make the applicant
ineligible to enter into a contract, memorandum of understanding, grant, loan, loan guarantee, or cooperative agreement with
USDA.
PART B – SIGNATURE
5A. APPLICANT’S SIGNATURE (BY)

5B. TITLE/RELATIONSHIP OF THE INDIVIDUAL IF
SIGNING IN A REPRESENTATIVE CAPACITY

63

5C. DATE SIGNED
(MM-DD-YYYY)

Schedule J
Proof of Legal Existence and Authority to Contract with the Federal
Government
System for Award Management Registration Information

System for Award Management (SAM) registration
CAGE Code:____________

_______________________________________________________________ (Applicant) hereby
certifies, that the SAM registration is active, with current information and complete.

________________________________________________________________________
Organization Name
______________________________________________________________________________
Authorized Representative’s Signature
Date
______________________________________________________________________________
Name Typed or Printed

64

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)

65

Appendix B: Finding Information on the Census Website
Finding the Population of a Town or Place Name Using the Census FactFinder
The following instructions are based on the Department of the Census FactFinder website.
1. Go to the FactFinder2 main page, http://factfinder.census.gov .
2. Select Advanced Search from the top menu. In the main part of the screen, you will see a
peach- colored window with 2 blank text boxes.
3. In the field “topic or table name”, type P1
4. In the “state, county or place”, field type your town name followed by a comma, and the state
abbreviation. Click
5. Select TOTAL POPULATION for the total population of the place that you have selected.
Example:
We have entered our example,
Tishomingo, Oklahoma.
FactFinder will respond with a
pop-up window listing places
that correspond to your typed
place/name, (often adding the
word “city” or “town” after the
name you typed-in).
From those options, choose the
one that is most correct.

In our example, Census has added the
word “city” to our request for the town
Tishomingo. This may not be the way
the town is usually referred to, but it is
how Census categorizes the town. So,
we select “Tishomingo city,
Oklahoma” from this pop-up window

66

In the “Geographies” table, next to the town we have selected, you will see that Tishomingo comes
under a Geographic Type Census calls place within a state. Click on the name of the town.

Select TOTAL POPULATION
for the total population of the
place that you have selected.

We see that the population for Tishomingo in the
2010 Census is 3,034.
Comparing this population of 3034 against the
Rurality Population-to-Score table, we determine
that the Tishomingo site is rated exceptionally
rural, with a score of 45.

67