Broadband Grant Program

2006-Broadband Grant - commcconnect-app-guide

Broadband Grant Program

OMB: 0572-0127

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Rural Development
United States Department of Agriculture

RURAL DEVELOPMENT
UTILITIES PROGRAMS
Community Connect
Broadband Program
Grant Application Guide
Fiscal Year 2006

Committed to the future of rural communities

Contents:
Introduction and General Information
Applying for a Grant
Completing the Grant Application
Putting It All Together
Federal Forms and Attachments

Page No.
2
8
11
22
24

Community Connect Broadband Grant Program, FY 2006

Rural Development Utilities Programs
Community-Oriented Connectivity Broadband Grant
Program
The Community-Oriented Connectivity Broadband Grant
Program is designed to provide financial assistance to furnish
broadband service in rural, economically-challenged
communities where such service does not currently exist. Grant
funds may be utilized to deploy broadband transmission service
to critical community facilities, rural residents, and rural
businesses and to construct, acquire, or expand, equip, and
operate a community center that provides free access to
broadband services to community residents for at least two
years. Grants will be awarded, on a competitive basis, to entities
serving communities of up to 20,000 inhabitants to ensure rural
consumers enjoy the same quality and range of
telecommunications service as are available in urban and
suburban communities.

Community Connect Broadband Grant Program, FY 2006

General Information

!! BEFORE YOU GET STARTED !!
You must read:
♦ 7 CFR 1739, Subpart A, published in the Federal Register on July 28,

2004.
And
♦ Notice of Funds Availability (NOFA) published in the Federal Register

on May 15, 2006.
The regulation MUST be utilized 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.

When and Where to Submit Your Application:
GRANT applications must be postmarked by:
May 15, 2006
An original and two copies of a completed application must be posted, shipped,
or hand-delivered by the deadline date. Applications must be submitted to:
Director, Broadband Division
Rural Development Utilities Programs
STOP 1599, Room 2844
1400 Independence Ave., SW
Washington, D.C. 20250-1550
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.
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Community Connect Broadband Grant Program, FY 2006

Applications Delivered by Mail:
Applications must show proof of 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, invoice, or receipt from a commercial carrier.
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.
Applications Delivered by Hand:
Applications delivered by hand will be accepted daily between 8:00 a.m. and 4:30
p.m. (Eastern Standard Time), except Saturdays, Sundays and Federal holidays.
Individuals delivering applications must provide proper identification to enter the
building.
Late applicants will be notified that their applications will not be considered
for funding and their applications will be returned.
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.
www.grants.gov
If you want to submit an application on-line, Rural Development Utilities
Programs strongly encourages you to obtain all the necessary sign-ups, credentials
and authorizations well in advance of the deadline. You will need a Central
Contractor Registry (CCR) registration before you can submit electronically. In
addition, Grants.gov requires some one-time credentialing and online
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Community Connect Broadband Grant Program, FY 2006

authentication procedures. These procedures may take several business days to
complete. Please ensure that your credentials and authorizations are up-to-date if
you went through the process within the last year. Some or all of Grants.gov's
requirements require an annual update.
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). Rural Development Utilities Programs 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.
With an electronic application you do not need to submit two copies as required
from mailed applications. However, we may request original signatures on paper
later.

New for 2006:
Rural Development Utilities Programs clarifies that the definition of
“critical community facilities” includes the mandatory community
center, and that the operating expenses associated with the
community center for the first two (2) years of operations are
eligible for financial assistance.
“Reasonable operating expenses” for critical community facilities
that are eligible for financial assistance shall not exceed $200,000
over the two year period.
Other pertinent information:
The minimum grant request amount is: $50,000

Community Connect Broadband Grant Program, FY 2006

Definition of communities:
• Census Designated Places (CDPs) are considered to be unincorporated
cities, towns, villages, or boroughs and they are eligible communities.
• Rural Development Utilities Programs will accept communities added to the
Census through the Count Question Resolution Process. Communities made
eligible through the Count Question Resolution Process may lack
corresponding Per Capita Income (PCI) data, so for scoring purposes,
applicants claiming eligibility through the Count Question Resolution
Process should propose a substitute PCI which is available for a
geographical area which includes and most nearly replicates the applicant's
proposed service area, subject to Rural Development Utilities Programs
acceptance.
• 7 CFR 1739.10 (a) provides that an Indian tribe is an eligible applicant. We
hold this to mean that every Indian tribe is eligible. Some Indian
reservations do not include discrete communities. Where this is the case, the
application may be for the entire reservation and the census reference to the
reservation will be the community for application purposes. Where a
reservation does contain discrete communities, an application must cover
one and only one community.
Organization of the application:
The volume of applications makes it impractical for reviewers to search through
the entire application to find required information. We ask that all information
relevant to a category be included under that category's tab. If that
information is relevant to another category, it should be repeated under that
category.

Key Definitions:
Please refer to 7 CFR 1739, published July 28, 2004, in the Federal Register for all
defined terms.
Basic Broadband Transmission Service: The broadband service level provided
by the applicant at the lowest rate or service package level for residential or
business customers, as appropriate, providing such service meets the definition of
broadband transmission service.
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Community Connect Broadband Grant Program, FY 2006

Broadband Transmission Service: Providing an information rate equivalent to at
least 200 kilobits/second in the consumer’s connection to the network, both from
the provider to the consumer (downstream) and from the consumer to the provider
(upstream).
Community: Any incorporated or unincorporated city, town, village, or borough
recognized in the U.S. Census in a Rural Area. This includes Census Designated
Places (CDPs), which will now be recognized as an unincorporated city, town,
village or borough.
Community Center: A public building or section of a public building, with at least
ten (10) Computer Access Points, that is used for the purposes of providing free
access to and/or instruction in the use of broadband Internet service, and is of the
appropriate size to accommodate this purpose. The community center must be
open and accessible to area residents before, during, and after normal working
hours and on Saturday or Sunday. Examples of facilities that may be used for the
described purposes include school, library, or city hall.
Computer Access Point: A new computer terminal with access to basic broadband
transmission service.
Critical Community Facility: A community center, public school, public library,
public medical clinic, public hospital, community college, public university, or law
enforcement, fire and ambulance stations.
Project: The applicant’s proposed Basic Broadband Transmission Service
financed by the grant and Matching Contribution for the proposed Service Area.
Rural Area: Any area not included within the boundaries of any incorporated or
unincorporated city, town, village, or borough having a population of more than
20,000 inhabitants within the United States.
Service Area: A single Community and, may include the unincorporated areas or
locally recognized communities, not recognized in the U.S. Census, located outside
and contiguous to the Community's boundaries.
For additional information concerning this grant program, please contact:
Kenneth Kuchno, Director, Broadband Division, Telecommunications Program, (202) 6904673 or Email: [email protected]. Information about Rural Development
Utilities Programs and this application/guide can be retrieved via the internet at:

http://www.usda.gov/rus/telecom
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Community Connect Broadband Grant Program, FY 2006

Applying for a Grant
Grant Processing
Completed applications must be postmarked no later than May 15, 2006, or be received by
Grants.gov by that date to be considered for funding. Grant applications will be scored in
accordance with the provisions 7 CFR 1739.

Applicant Eligibility
To be eligible for a grant, the applicant must:

♦

Be legally organized as an incorporated organization, an Indian tribe or tribal
organization, as defined in 25 U.S.C. 450b(b) and (c), a state or local unit of government,
or other legal entity, including cooperatives or private corporations or limited liability
companies organized on a for profit or not-for profit basis.
Have the legal capacity and authority to own and operate the broadband facilities as
proposed in its application, to enter into contracts and to otherwise comply with
applicable federal statutes and regulations.

Note: The applicant may not be an individual or partnership.

Project Eligibility
To be eligible for a grant, the Project must:

♦

Serve a Rural Area throughout which Broadband Transmission Service does not
currently exist, to be verified by Rural Development Utilities Programs prior to the award
of the grant.

♦

Serve one and only one Community recognized in the latest U.S. Census. Additional
communities located in the contiguous areas outside the Community’s boundaries that are
not recognized (due to size) in the U.S. Census, can be included in the applicant’s
proposed Service Area, but must be supported by documentation, acceptable to Rural
Development Utilities Programs, as to their existence (and these additional non-Census
communities must meet the qualification of not having any broadband available);
Note: Remember, CDPs are considered valid communities and would count in
the "serve one and only one" rule.

♦

Deploy Basic Broadband Transmission Service, free of all charges for at least 2 years, to
all Critical Community Facilities located within the proposed Service Area;

♦

Offer Basic Broadband Transmission Service to residential and business customers
within the proposed Service Area; and
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Community Connect Broadband Grant Program, FY 2006

♦

Provide a Community Center with at least ten (10) Computer Access Points within the
proposed Service Area, and make Broadband Transmission Service available therein, free
of all charges to users for at least 2 years.

!! COMMUNITY CENTER !!
The community center must have at least 10 Computer Access Points

Rurality Requirement
The proposed project must provide broadband transmission service to a rural area that does not
currently have such service anywhere in the proposed service area. A “Rurality Calculation
Table” is provided for this computation (See attachment 2), and should be based upon 2000
Census Data.

Eligible Grant Purposes
Grants funds may be used to finance:
1. The construction, acquisition, or lease of facilities, including spectrum, to deploy
broadband transmission services to all critical community facilities and to offer such
service to all residential and business customers located within the proposed service
area;
2. The improvement, expansion, construction, or acquisition of a community center that
furnishes free access to broadband Internet service, provided that the community
center is open and accessible to area residents before, during, and after normal
working hours and on Saturday or Sunday. Grant funds provided for the community
center are limited to the greater of $100,000 or 5% of the grant amount requested.
The costs of the computer access points, their installation, connection to the
broadband transmission system are not included in this limitation;
3. End-user equipment needed to carry out the project;
4. Operating expenses incurred in providing broadband transmission service to critical
community facilities for the first 2 years of operations and to provide training and
instruction shall not exceed $200,000. Salary and administrative expenses will be
subject to review, and may be limited, by Rural Development Utilities Programs, for
reasonableness in relation to the scope of the project; and
5. The purchase of land, buildings, or building construction needed to carry out the
project.

Community Connect Broadband Grant Program, FY 2006
Grant Funds may not be used to finance the duplication of any existing broadband services
provided by other entities; and
Facilities financed may not be used, in any way, to provide local exchange
telecommunications service to any person or entity where it currently exists.

Matching Funds Requirement
The applicant’s minimum matching contribution must be for eligible purposes and equal 15% of
the grant amount requested. Eligible purposes include:

♦

Cash for eligible grant purposes; and

♦

In-kind contributions of eligible grant purposes.

In-kind contributions include:
•

New or non-depreciated assets with established monetary values. Manufacturers’
or service providers’ discounts are not matching contributions.

•

The value of rental income for donated space in a community center, calculated for
the entire term of the donation;

•

Salaries and expenses up to $200,000 incurred by
the community center in operating the community
center, for the first two years of operations.

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 matching
contribution.

!! Note !!
Rental values must be supported by
rental agreements documenting the
cost of space of a similar size in a
similar location.
Rental values and salaries and
expenses incurred by the community
center are subject to review by Rural
Development Utilities Programs for
reasonableness

The source and amount of matching funds must be identified in the application. If matching
funds are to be provided by a third party, documentation of the third party’s commitment must be
included in the application.
Any financial assistance from Federal sources will not be considered as matching contributions
unless there is a Federal statutory exception authorizing the Federal financial assistance to be
considered as a matching contribution.

Community Connect Broadband Grant Program, FY 2006

Completing the Grant Application
This section addresses all of the information that must be submitted for an application to be
complete and considered for financing:
G.
H.
I.
J.
K.

A. A Completed Application for Federal
Assistance (Standard Form 424)
B. An Executive Summary of the Project
C. Scoring Criteria Documentation
D. System Design
E. Scope of Work
F. Community-Oriented Connectivity Plan

Financial Information and Sustainability
A Statement of Experience
Evidence of Legal Authority and Existence
Funding Commitments from Other Sources
Compliance with Other Federal Statutes
and Regulations

Tips:

•

Please double check your application to ensure it includes all requested items

•

Place all of the information supporting a scoring criterion together in the
section of the application that responds to that criterion

•

Reviewers are unlikely to have first-hand knowledge regarding your specific
locale or circumstances; always provide source documentation to
substantiate your assertions

A Completed Standard Form 424, “Application for Federal Assistance”

Use the Standard Form 424, Application for Federal Assistance (SF 424), to apply for
Community Connect Broadband grants. You can find a copy of the form in the Federal Forms
and Attachments section. It is important that you complete every relevant entry. Please use the
following notes in conjunction with the SF-424 instruction page.
Block 1: Select “Application”
Block 2: Select “New”
Block 3: For Rural Development Utilities Programs use - leave blank
Block 4: For Rural Development Utilities Programs use - leave blank
Block 5: (a) and (b): For Rural Development Utilities Programs use - leave blank
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Community Connect Broadband Grant Program, FY 2006
Block 6: Not Applicable
Block 7: Not Applicable
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 fax number for rapid correspondence. If you do not have a fax number, we
will need a reliable e-mail address. Otherwise, correspondence will be sent by mail. You must
provide full, accurate contact information for someone with the authority to answer any
questions Rural Development Utilities Programs 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. Obtaining a
DUNS number costs nothing but requires a telephone call to Dun and Bradstreet (1-866-7055711). Please see this website for more information:
http://www.whitehouse.gov/omb/grants/duns_num_guide.pdf

Block 9: Refer to Instructions; Select Appropriate Letter (A-X)
Block 10: The Name of the Federal Agency is Rural Utilities Service
Block 11: The Catalog of Federal Assistance Number is 10.863
Block 12: Funding Opportunity Number is RDUP-06-01-CC
The Title is “Community Connect Grant Program”
Block 13: Not Applicable
Block 14: Please provide the name of the community (city, town, village, borough, or CDP),
county, and state.
Block 15: Brief descriptive title of project
Block 16: Please provide the Congressional District of the community you are in, and if
different provide the Congressional District for the community you are proposing to service in
your project.
Block 17: Self Explanatory
Block 18: (Estimated Funding)
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a. Federal

Community Connect Broadband Grant Program, FY 2006
Show the amount requested from Rural Development Utilities Programs as grant

b. Applicant

Show the total matching contributions, regardless of source

c, d, e, & f.

Leave Blank

Show Total Eligible Community Connect Grant + Matching Purposes (this
g. TOTAL
should be the sum of a. and b. above - and it should also equal the Total Eligible Grant and
Matching Purposes shown in your budget under the Scope of Work Section E.)
Block 19: Please select “C” “Program is not covered by E.O. 12372”. Per regulation 7 CFR
1739-Supplementary 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 a grant is awarded. If
the signer is not a corporate officer, you must include evidence that the signer is authorized to
obligate the organization.
Please note: Additional instructions can be found with the SF-424.

An Executive Summary of the Project

The Executive Summary of the project is one of the most important parts of the application. It
gives reviewers their first overall view of the area to be served, what problems the residents face,
and how the proposed project will help alleviate those problems, increase quality of life, and
provide enhanced opportunities for rural residents. This is your opportunity to discuss the core
aspects of the project:
♦ The goals of the project;
♦ The community to be served;
♦ The community organizations participating as project partners; and
♦ The technologies to be used.
The Executive Summary gives the applicant the opportunity to discuss the project subjectively
and to point out its unique characteristics. Be clear and provide convincing links between project
and benefits.
The Executive Summary must provide a general project overview covering the following
six categories:
1.

A description of why the project is needed;

A description of the applicant;

An explanation of the total project cost;

Community Connect Broadband Grant Program, FY 2006
A general overview of the telecommunications system to be developed, including
the types of equipment, technologies, and facilities used;

Documentation describing the procedures used to determine the unavailability of
existing broadband service; and

A description of the participating community organizations (such as schools,
health care providers, police and fire departments, etc.).

Number each paragraph as shown above. Remember, this summary is the first overall
picture of your request for assistance and what problems you are attempting to solve.

Scoring Criteria Documentation

There are three scoring categories that must be addressed by applicant in order to be considered
for funding. They are:
1.

The rurality of the community served by the project (up to 40 points) as
determined by the population of the community, as determined by the U.S.
Bureau
of
the
Census,
U.S.
Department
of
Commerce,
at
http://factfinder.census.gov (up to 40 points);
The economic need of the project’s service area(s) as determined by per capita
personal income of the community, as determined by the U.S. Bureau of the
Census, U.S. Department of Commerce, at http://factfinder.census.gov (up to 30
points);
The benefits derived from the proposed service area (up to 30 points).

The first two categories are objective criteria. The objective criteria are straightforward
indicators that measure the rurality and economic need of the service area.
1.

Rurality of the Project Service Area:

A rurality table is provided in this application guide to assist you with this process (Attachment
2). An applicant must base this calculation on 2000 U.S. Census data. Instructions for
determining the correct census data:
1. Go to http://factfinder.census.gov
2. Locate the heading "Fast Access to Information" and the search box titled "Get a fact sheet
for your community". Enter your community and select your state from the state list, then
click on "go"
3. At the top of your community fact sheet, check to confirm that your community is: city,
town, village, borough, or CDP
4. The total population for your community is listed at the top in the first row of data of the fact
sheet

Community Connect Broadband Grant Program, FY 2006

The following table outlines the definitions used in evaluating rurality:

Level
1
2
3
4
5
6
7
8

Community Having a Population:
Over
Not in Excess of
499
499
1,000
1,000
2,000
2,000
3,000
3,000
4,000
4,000
5,000
5,000
10,000
10,000
20,000

Points
40
35
30
25
20
15
10
5

Points are awarded based on the population of the community located within the service area:
For example, a project proposes to serve the town of Belle Haven, Virginia. In accordance
with U.S. Bureau of the Census statistics, the town of Belle Haven, Virginia has a
population of 480. A population of 480 is a Level 1 community eligible to receive 40 points,
as follows:

Service Area Community
Belle Haven town, Virginia

Population

Level

Points

480

Instructions for Native American Indian Reservations: If your eligible community is an Indian
Reservation (per explanation on page 6 of this application guide), follow these instructions for
determining the correct population:
1. Go to http://factfinder.census.gov
2. Scroll down the web page to find the "Special Interest" heading on the right and click on
"American Indian and Alaska Native"
3. Under the "Census 2000" heading, click on "Fast access to popular data"
4. Select the state where the reservation is located and type an asterisk "*" in the reservation
box
5. Select your reservation from the list
6. The total population for your reservation is listed at the top in the first row of data of the fact
sheet
7. Use the rurality evaluation table above to determine the correct points for your reservation's
population
2.

Economic Need of the Project Service Area (up to 30 points):

Community Connect Broadband Grant Program, FY 2006
An “Economic Need Calculation Worksheet” is provided in this application guide to assist you
in this calculation (Attachment 3). This criterion measures the economic need of the service area
based upon the per capita income (PCI) of the Community as determined by the U.S. Bureau of
the Census, U.S. Department of Commerce. An applicant must base this calculation on 2000
U.S. Census data. Instructions for determining the correct census data:
1. Go to http://factfinder.census.gov
2. Locate the heading "Fast Access to Information" and the search box titled "Get a fact sheet
for your community". Enter your community and select your state from the state list, then
click on "go"
3. Scroll down to "Economic Characteristics" and look for "Per capita income (dollars)"
4. Use that figure to calculate the community's PCI as a percentage of the National Average
using Attachment 3 of this guide
Points are awarded for service provided in a Community where the PCI is less than 75 percent of
the national average per capita personal income (NAPCI) and according to the following scale:
PCI is:
Percent of NACPI Percent of NAPCI
Less than:
Greater than or
equal to:
75
75
70
70
65
65
60
60
55
55
50
50

Points
Awarded
0
5
10
15
20
25
30

Instructions for Native American Indian Reservations: If the eligible community is an Indian
Reservation (per explanation on page 6), follow these instructions for determining the correct per
capita income
1. Go to http://factfinder.census.gov
2. Scroll down the web page to find the "Special Interest" heading on the right and click on
"American Indian and Alaska Native"
3. Under the "Census 2000" heading, click on "Fast access to popular data"
4. Select the state where the reservation is located and type an asterisk "*" in the box
5. Select your reservation from the list
6. Scroll down to page with the heading "Profile of Selected Economic Characteristics" (usually
page 3 of the fact sheet) and locate the per capita income (dollars) - usually on the lower right
of the table. Use that figure to calculate the community's PCI as a percentage of the national
average using Attachment 3 of this guide
7. Determine correct points for your reservation based on the table above

Benefits derived from the proposed service (up to 30 points):

The “benefits derived from the proposed service area” is a subjective scoring category for which
applicants may receive up to 30 points. This criterion will be scored based on the documentation
16

Community Connect Broadband Grant Program, FY 2006
in support of the need for services, benefits derived from the services proposed by the project,
and local community involvement in planning and implementing of the project.
Rural Development Utilities Programs will consider:
1.

2.
3.

The extent of the applicant’s documentation explaining the economic,
educational, health care, and public safety issues and challenges facing the
community and the applicant’s proposed plan to address these challenges on a
community-oriented basis.
The extent of the project’s planning, development, and support by local residents,
institutions, and community facilities.
This includes evidence of
community-oriented 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.

The extent to which the community center will be used for educational or
instructional purposes.

Web-based community resources enabled or provided by the applicant, such as
community bulletin boards, directories, public web-hosting, notices, etc.

In addressing this scoring criterion, applicants must describe the unique circumstances involving
their proposed project and how they propose to utilize Federal financing provided from this
program in conjunction with any other resources to meet their community’s needs. When
addressing this criterion, applicants should specifically discuss all aspects of the application that
contribute to the scoring criterion.
Applicants should attempt to quantify benefits in terms of outcomes from the project; that is,
ways in which peoples’ lives, or the community, will be improved. Try to provide estimates of
the number of people affected by the benefits arising from the project.
Use as many pages as is necessary to address the subjective criterion.

System Design

The system design must contain the following information:
1.

A narrative discussing the proposed community center and all costs of the project,
all existing and proposed facilities that are a part of the project, the services to be
provided by the project, and the proposed service area;

Engineering design studies providing an economical and practical engineering
design of the project, including a detailed description of the facilities to be
funded, technical specifications, data rates, and costs; and

A map of the proposed service area reflecting the proposed location of the
community center and critical community facilities.
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Community Connect Broadband Grant Program, FY 2006

A Scope of Work

The scope of work must include, at a minimum:

The specific activities and services to be performed under the project;

Who will carry out the activities and services;

The time-frames for accomplishing the project objectives and activities; and

A budget for all capital and operating expenditures reflecting the line item costs
for eligible purposes for the grant funds, the matching contributions, and other
sources of funds necessary to complete the project.

Community-Oriented Connectivity Plan

The provision of broadband service is vital to the economic development, education, health, and
safety of rural Americans. To further this objective, Rural Development Utilities Programs will
provide financial assistance to eligible entities that propose, on a “community-oriented
connectivity” basis, to provide broadband service that fosters economic growth and delivers
enhanced educational, health care, and public safety services. The “community-oriented
connectivity” concept integrates the deployment of broadband infrastructure with the practical,
everyday uses and applications of the facilities.
Specifically, Rural Development Utilities Programs will provide financial assistance to eligible
entities that are proposing to deploy broadband transmission service in a rural community where
such service does not currently exist; who will connect the critical community facilities including
the local schools, libraries, hospitals, police, fire and rescue services; and who will operate a
community center that provides free and open access to residents. A state-of-the-art community
center will not only provide improved access but will aid rural residents in developing on-line
businesses and will allow them to reap the benefits of Internet-based advanced placement
courses, and continuing adult education. Priority will be given to rural areas that have the
greatest need for broadband services. The applicant must provide a community-oriented
connectivity plan consisting of the following:
1.

A listing of all critical community facilities located in the service area, including
public schools, public libraries, public medical clinics, public hospitals,
community colleges, public universities, and law enforcement, fire and ambulance
stations. The applicant must provide documentation of consultation with these
groups, including commitments to participate in the proposed project;

A description of the services available to local residents through the use of the
community center;

A listing of the proposed telecommunications terminal equipment,
telecommunications transmission facilities, data terminal equipment, interactive
18

Community Connect Broadband Grant Program, FY 2006
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 deployment
and use of broadband services, that the applicant intends to build or fund using
Rural Development Utilities Programs grant funds and matching contributions;
and

A description of the consultations with the appropriate telecommunications
carriers (including inter-exchange carriers, cable television operators, enhanced
service providers, providers of satellite services and telecommunication
equipment manufacturers and distributors) and the anticipated role of such
providers in the proposed telecommunications system.

Financial Information and Sustainability

The applicant must provide a narrative description demonstrating sustainability 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. The following financial
information is required:
1.

Certified financial statements, if available; otherwise, the most current income statement
and balance sheet for existing operations; and

5 years of pro-forma financial information for the project, or for the applicant taking into
consideration the conclusion of the project, including income statements, balance sheets,
cash flow statements. Applicants must include sufficient pro-forma financial data to
demonstrate the financial capability of the project participants to continue a sustainable
project for a minimum of 5 years after completion of the project.

This documentation should include non-contingent sources of income or revenues that are
sufficient to pay all operating expenses including system maintenance, salaries, training, and any
other general operating expenses, and provide for replacement of depreciable items. Applicants
must also include depreciation rates, based upon current industry standards, for the equipment
being financed. All assumptions in support of the pro-forma must be clearly identified.

A Statement of Experience

An applicant must provide a written narrative describing its demonstrated capability and
experience, if any, in operating a telecommunications system, or any project similar to the
proposed project. The applicant must include the owner’s and principal employees’ relevant
work experience that would ensure the success of the project.

Community Connect Broadband Grant Program, FY 2006

Evidence of Legal Authority and Existence

The applicant must provide evidence of its legal existence and authority to enter into a grant
agreement with the Rural Development Utilities Programs and perform the activities proposed
under the grant application.
Satisfactory documentation of legal authority includes, but is not limited to: articles of
incorporation, bylaws, board resolutions, excerpts from state statutes, or an attorney’s opinion of
counsel.
Satisfactory documentation of legal existence includes, but is not limited to, certificates from the
Secretary of State, state statutes or laws establishing your organization. Letters from the IRS
awarding tax-exempt status are not considered adequate evidence.

Funding Commitments from Other Sources

If the project requires additional funding from other sources in addition to the Rural
Development Utilities Programs grant, the applicant must provide evidence that funding
agreements have been obtained to ensure completion of the project. These agreements shall be
sufficient to ensure:
1.

Payment of all proposed expenditures for the project;

All required matching contributions;

Any additional matching funding; and

Any other funds necessary to complete the project.

A letter from the organization providing the matching funds or in-kind contributions is an
example of the evidence required. In the case of in-kind contributions of equipment, the letter
should include a description of the items, value and date purchased. For donations of space for
the community center, the letter should include the dimensions of the space and a calculation of
the value of the foregone rental income, and a commitment to provide the space for a minimum
of two (2) years. For donations of space, evidence of the value of the donation is required. For
donations of operating and administrative expenses of the community center, the letter should
include detailed calculations of the individual expense line items used to determine the value.

Compliance with Other Federal Statutes and Regulations

The applicant is required to submit evidence that it is in compliance with other Federal statutes
and regulations as follows:
♦ E.O. 11246, Equal Employment Opportunity, as amended by E.O. 11375 and as
supplemented by regulations contained in 41 CFR part 60, Attachment 4;
♦ Architectural barriers, Attachment 5;
♦ Flood hazard are precautions, Attachment 6;
♦ Assistance and Real Property Acquisition Policies Act of 1970, Attachment 7;
20

♦
♦
♦

Community Connect Broadband Grant Program, FY 2006
Drug-Free Workplace Act of 1998 (41 U.S.C. 701), Attachment 8;
E.O.s 12549 and 12689, Debarment and Suspension; (See 7 CFR 3017.510),
Attachment 9;
Byrd Anti-Lobbying Amendment (31 U.S.C. 1352), Attachment 10;
¾ If the applicant is engaged in lobbying activities, the applicant must submit a
completed disclosure form, “Disclosure of Lobbying Activities” (See 7 CFR
Part 3018)”; and
Non Duplication of Services Certificate, Attachment 11;

♦
♦ Federal Obligations Certification on Delinquent Debt, Attachment 12; and

♦ Environmental Impact Report, in accordance with 7 CFR 1794, Attachment 13 (see
further information below).
Environmental Impact and Historic Preservation:
Details of the project’s impact on the environment and historic preservation must be provided.
The application must contain a separate section entitled “Environmental Impact of the Project.”
An “Environmental Questionnaire/Certification” may be used by applicants to assist in complying
with the requirements of this section. Attachment 13.
For a proposed project that only involves internal modifications or equipment additions to
buildings or other structures, the environmental information normally required includes a
description of the internal modifications or equipment additions, the size of the site in hectares,
and the general nature of the proposed use of the facilities once the project is completed,
including any hazardous materials to be used, created or discharged, any substantial amount of
air emissions, wastewater discharge, or solid waste that will be generated.

Community Connect Broadband Grant Program, FY 2006

Putting It All Together
The GRANT application should be assembled and tabbed in the following order listed below.
Material not located under the proper tab will not be considered by reviewers. If material is
relevant under more than one tab, it should be repeated under each relevant tab. Any
supplemental information that the applicant wants to submit should be included under the
relevant tab. Numbered attachments are provided at the end of this guide for your use. Use only
the applicable attachments listed below.
A. An Application for Federal Assistance: Completed Standard Form 424, Attachment 1
B. An Executive Summary of the Project
C. Scoring Criteria Documentation
1. Rurality Calculation Table, Attachment 2
2. Economic Need Calculation Worksheet, Attachment 3
3. The Benefits Derived from Services
D. System Design
E. Scope of Work
F. Community-Oriented Connectivity Plan
G. Financial Information and Sustainability
1. Certified Financial Statements, if available
2. Pro-Forma Financial Statements
H. Statement of Experience
I. Evidence of Legal Existence & Legal Authority to Contract with the Government
J. Evidence of Funding Commitments from all sources, if applicable.
K. Compliance with Other Federal Statutes and Regulations
1. Equal Opportunity and Nondiscrimination Certification, Attachment 4
2. Certificate Regarding Architectural Barriers, Attachment 5
3. Certificate Regarding Flood Hazard Area Precautions, Attachment 6
4. Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
Certification, Attachment 7
5. Certification Regarding Drug-Free Workplace Requirements, Alternative I – For
Grantees Other than Individuals, Attachment 8
6. Certification Regarding Debarment and Suspension, and Other Responsibility
Matters – Primary Covered Transactions, Attachment 9
7. Certification Regarding Lobbying for Contracts, Grants, Loans, and Cooperative
Agreements, Attachment 10
¾ If the applicant is engaged in lobbying activities, the applicant must submit
a completed disclosure form, “Disclosure of Lobbying Activities” (See 7
CFR Part 3018)”;
8. Non Duplication of Services Certificate, Attachment 11;
9. Federal Obligations Certification on Delinquent Debt, Attachment 12; and
10. Environmental Questionnaire/Certification, Attachment 13
Sample certificates and forms are included for your use
22

Rural Development Utilities Programs
Community Connect
Broadband Grant Program
Federal Forms and Attachments
Fiscal Year 2006
Contents :
Attachment
1
2
3
4
5
6
7
8
9
10
11
12
13

Page No.

Application for Federal Assistance
Rurality Calculation Table
Economic Need Calculation Worksheet
Equal Opportunity and Nondiscrimination Certification
Certificate Regarding Architectural Barriers
Certificate Regarding Flood Hazard Area Precautions
Uniform Relocation Assistance and Real Property
Acquisition Policies Act of 1970 Certification
Certification Regarding Drug-Free Workplace
Requirements
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters – Primary Covered Transactions
Certification Regarding Lobbying for Contracts,
Grants, Loans, and Cooperative Agreements
Non Duplication of Services Certificate
Federal Obligations Certification on Delinquent Debt
Community-Oriented Connectivity Environmental
Questionnaire/Certification

24
30
31
32
33
34
35
36
38
39
40
41
42

OMB Number: 4040-0004
Expiration Date: 07/31/2006

Version 02

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:

Completed by Grants.gov upon submission.

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:
* 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:

Attachment 1

OMB Number: 4040-0004
Expiration Date: 07/31/2006

Version 02

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:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

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

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.
Add Attachments

Delete Attachments

View Attachments

Option not available here

OMB Number: 4040-0004
Expiration Date: 07/31/2006

Version 02

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.
Add Attachment

Delete Attachment View Attachment

Option not available here

17. Proposed Project:
* b. End Date:

* a. Start Date:

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

$0.00

* 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.)
Yes

Explanation

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to
comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims
may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)
** I AGREE
** The list of 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:

Completed by Grants.gov upon submission.

Authorized for Local Reproduction

* Date Signed:

Completed by Grants.gov upon submission.

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

OMB Number: 4040-0004
Expiration Date: 07/31/2006

Version 02

Application for Federal Assistance SF-424
* Applicant Federal Debt Delinquency Explanation
The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debt. Maximum number of
characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.

INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED
BY THE SPONSORING AGENCY.

This is a standard form (including the continuation sheet) required for use as a cover sheet for submission of preapplications and applications and
related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the Federal
agency (agency). Required items are identified with an asterisk on the form and are specified in the instructions below. In addition to the instructions
provided below, applicants must consult agency instructions to determine specific requirements.
Item
1.

Entry:
Type of Submission: (Required): Select one type of submission in
accordance with agency instructions.
•
Preapplication
•
Application
•
Changed/Corrected Application – If requested by the agency, check
if this submission is to change or correct a previously submitted
application. Unless requested by the agency, applicants may not
use this to submit changes after the closing date.

Item
10.

Entry:
Name Of Federal Agency: (Required) Enter the name of the
Federal agency from which assistance is being requested with
this application.

11.

Catalog Of Federal Domestic Assistance Number/Title:
Enter the Catalog of Federal Domestic Assistance number and
title of the program under which assistance is requested, as
found in the program announcement, if applicable.

Type of Application: (Required) Select one type of application in
accordance with agency instructions.
•
New – An application that is being submitted to an agency for the
first time.
•
Continuation - An extension for an additional funding/budget period
for a project with a projected completion date. This can include
renewals.
•
Revision - Any change in the Federal Government’s financial
obligation or contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be
selected. If "Other" is selected, please specify in text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)
Date Received: Leave this field blank. This date will be assigned by the
Federal agency.

12.

Funding Opportunity Number/Title: (Required) Enter the
Funding Opportunity Number and title of the opportunity under
which assistance is requested, as found in the program
announcement.
Competition Identification Number/Title: Enter the
Competition Identification Number and title of the competition
under which assistance is requested, if applicable.

Applicant Identifier: Enter the entity identifier assigned by the Federal
agency, if any, or applicant’s control number, if applicable.

Federal Entity Identifier: Enter the number assigned to your
organization by the Federal Agency, if any.
Federal Award Identifier: For new applications leave blank. For a
continuation or revision to an existing award, enter the previously
assigned Federal award identifier number. If a changed/corrected
application, enter the Federal Identifier in accordance with agency
instructions.
Date Received by State: Leave this field blank. This date will be
assigned by the State, if applicable.
State Application Identifier: Leave this field blank. This identifier will
be assigned by the State, if applicable.

5b.

6.
7.
8.

13.

14.

15.

16.

Congressional Districts Of: (Required) 16a. Enter the
applicant’s Congressional District, and 16b. Enter all District(s)
affected by the program or project. Enter in the format: 2
characters State Abbreviation – 3 characters District Number,
th
th
e.g., CA-005 for California 5 district, CA-012 for California 12
rd
district, NC-103 for North Carolina’s 103 district.
•
If all congressional districts in a state are affected, enter
“all” for the district number, e.g., MD-all for all
congressional districts in Maryland.
•
If nationwide, i.e. all districts within all states are affected,
enter US-all.
•
If the program/project is outside the US, enter 00-000.

17.

Proposed Project Start and End Dates: (Required) Enter the
proposed start date and end date of the project.

18.

Estimated Funding: (Required) Enter the amount requested
or to be contributed during the first funding/budget period by
each contributor. Value of in-kind contributions should be
included on appropriate lines, as applicable. If the action will
result in a dollar change to an existing award, indicate only the
amount of the change. For decreases, enclose the amounts in
parentheses.

19.

Is Application Subject to Review by State Under Executive
Order 12372 Process? Applicants should contact the State
Single Point of Contact (SPOC) for Federal Executive Order
12372 to determine whether the application is subject to the

Applicant Information: Enter the following in accordance with agency
instructions:
a. Legal Name: (Required): Enter the legal name of applicant that will
undertake the assistance activity. This is the name that the organization
has registered with the Central Contractor Registry. Information on
registering with CCR may be obtained by visiting the Grants.gov website.
b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the
Employer or Taxpayer Identification Number (EIN or TIN) as assigned by
the Internal Revenue Service. If your organization is not in the US, enter
44-4444444.
c. Organizational DUNS: (Required) Enter the organization’s DUNS or
DUNS+4 number received from Dun and Bradstreet. Information on
obtaining a DUNS number may be obtained by visiting the Grants.gov
website.
d. Address: Enter the complete address as follows: Street address (Line
1 required), City (Required), County, State (Required, if country is US),
Province, Country (Required), Zip/Postal Code (Required, if country is
US).
e. Organizational Unit: Enter the name of the primary organizational
unit (and department or division, if applicable) that will undertake the

Areas Affected By Project: List the areas or entities using
the categories (e.g., cities, counties, states, etc.) specified in
agency instructions. Use the continuation sheet to enter
additional areas, if needed.
Descriptive Title of Applicant’s Project: (Required) Enter a
brief descriptive title of the project. If appropriate, attach a
map showing project location (e.g., construction or real
property projects). For preapplications, attach a summary
description of the project.

assistance activity, if applicable.
f. Name and contact information of person to be contacted on
matters involving this application: Enter the name (First and last name
required), organizational affiliation (if affiliated with an organization other
than the applicant organization), telephone number (Required), fax
number, and email address (Required) of the person to contact on
matters related to this application.

Type of Applicant: (Required)
Select up to three applicant type(s) in accordance with agency
instructions.
A. State Government
M. Nonprofit with 501C3 IRS
B. County Government
Status (Other than Institution
C. City or Township Government
of Higher Education)
D. Special District Government
N. Nonprofit without 501C3 IRS
E. Regional Organization
Status (Other than Institution
F. U.S. Territory or Possession
of Higher Education)
G. Independent School District
O. Private Institution of Higher
H. Public/State Controlled
Education
Institution of Higher Education P. Individual
I.
Indian/Native American Tribal
Q. For-Profit Organization
Government (Federally
(Other than Small Business)
Recognized)
R. Small Business
J. Indian/Native American Tribal
S. Hispanic-serving Institution
Government (Other than
T. Historically Black Colleges
Federally Recognized)
and Universities (HBCUs)
K. Indian/Native American
U. Tribally Controlled Colleges
Tribally Designated
and Universities (TCCUs)
Organization
V. Alaska Native and Native
L. Public/Indian Housing
Hawaiian Serving Institutions
Authority
W. Non-domestic (non-US)
Entity
X. Other (specify)

State intergovernmental review process. Select the
appropriate box. If “a.” is selected, enter the date the
application was submitted to the State
20.

21.

Is the Applicant Delinquent on any Federal Debt?
(Required) Select the appropriate box. This question applies to
the applicant organization, not the person who signs as the
authorized representative. Categories of debt include
delinquent audit disallowances, loans and taxes.
If yes, include an explanation on the continuation sheet.
Authorized Representative: (Required) To be signed and
dated by the authorized representative of the applicant
organization. Enter the name (First and last name required)
title (Required), telephone number (Required), fax number,
and email address (Required) of the person authorized to sign
for the applicant.
A copy of the governing body’s authorization for you to sign
this application as the official representative must be on file in
the applicant’s office. (Certain Federal agencies may require
that this authorization be submitted as part of the application.)

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Rurality Calculation Table
Please list the proposed Community to be served with the proceeds of the Community Connect
Broadband Grant, its population based upon 2000 Census data, and its rurality level.

Service Area Community

Population

Level*

Points

* Denote Level based on the following table:

Level
1
2
3
4
5
6
7
8

Community Having a Population:
Over
Not in Excess of
499
499
1,000
1,000
2,000
2,000
3,000
3,000
4,000
4,000
5,000
5,000
10,000
10,000
20,000

Points
40
35
30
25
20
15
10
5

(This is not an official Government form. It has been prepared to assist and expedite the
application process and is only intended for use in the Community-Oriented Connectivity
Broadband Grant Program.)

Attachment 2
30

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Economic Need Calculation Worksheet
Applicants are awarded points for providing service in a Community where the per capita
personal income (PCI) is less than 75% of the national average per capita income (NAPCI) of
21,587. Enter the Community name and it’s PCI in dollars (found at
http://factfinder.census.gov) and calculate the percentage of the NAPCI in the table below.

(a)
Community PCI in
Dollars

Service Area
Community

(a) ÷ (b)

(b)
NAPCI in Dollars

$_______________

$21,587

PCI as % of NAPCI
_____________%

Using the scale below, award the appropriate number of points in the box below
for the community on PCI as a percent of NAPCI:
0 pts.
5 pts.
10 pts.
15 pts.
20 pts.
25 pts.
30 pts.

if
If
if
if
if
if
if

≥
≥
≥
≥
≥
≥
<

75%
70%
65%
60%
55%
50%
50%.

but
but
but
but
but

POINTS:

< 75%
< 70%;
< 65%;
< 60%;
< 55%;

_________________

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Equal Opportunity and Nondiscrimination Certification
All grants made under the Community-Oriented Connectivity Broadband Grant Program
are subject to the nondiscrimination provisions of Title VI of the Civil Rights Act of 1964, as
amended, (7 CFR Part 15); Section 504 of the Rehabilitation Act of 1973, as amended, (29
U.S.C. 901 et seq; 7 CFR Part 15b); and Age Discrimination of 1975, as amended (42 U.S.C.
6101 et seq.; 45 CFR Part 90); and as amended by Executive Order 11375 Amending Executive
Order 11246, Relating to Equal Employment Opportunity (3 CFR, 1966, 1970 Comp., p. 684).
All recipients of financial assistance from Rural Development Utilities Programs, the
prospective primary participant commits to carry out Rural Development Utilities Programs
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 Community-Oriented Connectivity Broadband Grant
Program.
The __________________________________________________ (Grantee)
hereby certifies that, as a prospective recipient under the said Community-Oriented Connectivity
Broadband Grant Program, it will comply with the above reference laws and executive orders.

__________________________
(Date

____________________________________________
(Authorized Representative’s Signature)

____________________________________________
(Name Typed or Printed)

____________________________________________
(Title)

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Certificate Regarding Architectural Barriers
All facilities financed with Rural Development Utilities Programs 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 Rural Development
Utilities Programs, this organization commits to carry out Rural Development Utilities Programs
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 Community-Oriented Connectivity Broadband Grant Program, it
is in compliance, or will be in compliance upon completion of the project, with the above
referenced law.

________________________
(Date)

___________________________________
(Authorized Representative’s Signature)

___________________________________
(Name Typed or Printed)

___________________________________
(Title)

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Certificate Regarding Flood Hazard Area Precautions
If the project is located 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 through 4128). If applicable, the insurance must
cover, in addition to the buildings, any machinery, equipment, fixtures, and furnishings contained in the
buildings. Rural Development Utilities Programs 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 Community-Oriented Connectivity Broadband 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)

__________________________________
(Authorized Representative’s Signature)

__________________________________
(Name Typed or Printed)

__________________________________
(Title)

(This is not an official Government form. It has been prepared to assist and expedite the application
process and is only intended for use in the Community-Oriented Connectivity Broadband Grant
Program.)

Attachment 6
34

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

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, as amended (Uniform Act), 42 U.S.C. 4601-4655, and with implementing
Federal regulations in 49 CFR Part 24 and 7 CFR Part 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

______________________________________________________
(Authorized Representative’s Signature)

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Certification Regarding Drug-Free Workplace Requirements
Alternative I – For Grantees Other than Individuals
This certification is required by the regulations implementing Sections 5151-5160 of the Drug-Free
Workplace Act of 1988 (P.L. 100-690, Title V, Subtitle D; 41 U.S.C. 701 et seq.), 7 CFR Part 3017,
Subpart F, Section 3017.600, Purpose. The January 31, 1989, regulations were amended and published as
Part II of the May 25, 1990, Federal Register (pages 21681-21691). Copies of the regulations may be
obtained by contacting the Department of Agriculture agency offering the grant.
ALTERNATIVE I
A. The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the grantee’s workplace and
specifying the actions that will be taken against employees for violation of such prohibition;
(b) Establishing an ongoing drug-free awareness program to inform employees about:
(1)
(2)
(3)
(4)

The dangers of drug abuse in the workplace;
The grantee’s policy of maintaining a drug-free workplace;
Any available drug counseling, rehabilitation, and employee assistance programs; and
The penalties that may be imposed upon employees for drug abuse violations occurring in
the workplace;

(c) Making it a requirement that each employee to be engaged in the performance of the grant be
given a copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of
employment under the grant, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug
statute occurring in the workplace no later than 5 calendar days after such conviction;
(e) Notifying the Agency in writing, within 10 calendar days after receiving notice under
subparagraph (d) (2) from an employee or otherwise receiving actual notice of such
conviction. Employers of convicted employees must provide notice, including position title, to
every grant officer on whose grant activity the convicted employee was working, unless the
Federal agency has designated a central point for the receipt of such notices. Notice shall include
the identification number(s) of each affected grant;

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Attachment 8
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Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005
(f) Taking one of the following actions, within 30 calendar days of receiving notice under
subparagraph (d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended;
or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency; and
(g) Making a good faith effort to continue to maintain a drug-free workplace through implementation
of paragraphs (a), (b), (c), (d), (e), and (f).
B. The grantee may insert in the space provided below the site(s) for the performance of work done in
connection with the specific grant:

Place of Performance:

______________________________________________________________________________
Street Address
City

______________________________________________________________________________
County
State
Zip Code

____ Check if there are workplaces on file that are not identified here.
______________________________________________________________________________
Organization Name

______________________________________________________________________________
Authorized Representative’s Signature
Date

______________________________________________________________________________
Name Typed or Printed

Page 2 of 2
37

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Certification Regarding Debarment, Suspension, and Other
Responsibility Matters – Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, 7 CFR Part 3017, Section 3017.510, Participants’ Responsibilities. The regulations were
published as Part IV of the January 30, 1989, Federal Register (pages 4722-4733). Copies of the regulations
may be obtained by contacting the Department of Agriculture agency offering the proposed transaction.
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its
principals:
(a) are not presently debarred, suspended, proposed for Debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) have not within a 3-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a
public transaction; violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of
this certification; and
(d) have not within a 3-year period preceding this application/proposal had one or more public
transactions (Federal, State, or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.

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

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

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 Rural Development Utilities
Programs.)
(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 section 1352, title 31, U.S. Code. Any person who fails to file
the required certification shall be subject to a civil penalty of not less than $10,000 and not more than
$100,000 for each such failure.
______________________________________________________________________________
Organization Name
______________________________________________________________________________
Authorized Representative’s Signature
Date
______________________________________________________________________________
Name Typed or Printed

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Utilities Service

Non Duplication of Services Certificate
As a prospective primary participant recipient of assistance from Rural Development Utilities
Programs, this organization certifies that facilities financed under the Community-Oriented
Connectivity Broadband Grant Program will provide broadband service only in areas where it
does not currently exist.
The ______________________________________________ (Grantee/Borrower) hereby
certifies that as a prospective recipient under the said Community-Oriented Connectivity
Broadband Grant Program, that it will not use Rural Development Utilities Programs grant funds
to duplicate any established broadband services or facilities as referenced above.

________________________
(Date)

_______________________________
(Signature)
________________________________
(Name Typed or Printed)

________________________________
(Title)

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

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

YES

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:
Title:
Company:
Date:
(This is not an official Government form. It has been prepared to assist and expedite the
application process and is only intended for use in the Community-Oriented Connectivity
Broadband Grant Program.
Attachment 12
41

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

U.S. Department of Agriculture

Rural Development Utilities Programs

Community-Oriented Connectivity Broadband Grant Program
Environmental Questionnaire/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 impact 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 insert between the first and second pages.)
If the construction proposed in this application, as described above, will not impact the
environment or historic preservation, you may sign the certification indicating that no adverse
impact and skip filling out the questionnaire.

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)

Page 1 of 4
Attachment 13
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Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

QUESTIONNAIRE
Note: It is extremely important to respond to all questions completely to ensure expeditious
processing of the Community-Oriented Connectivity Broadband Grant Program application.
The information herein is required by Federal law.
Important: Any activity related to the project that may adversely affect the environment or limit
the choice of reasonable development alternatives shall not be undertaken prior to the
completion of Rural Utilities Service’s environmental review process.

Legal Name of Applicant
Signature (Type, sign, & date)
The applicant’s representative certifies to the best of his/her knowledge and belief that the
information contained herein is accurate. Any false information may result in disqualification
for consideration of financial assistance or the rescission of financial assistance.
I. Project Description - Detailing construction, including, but not limited to internal
modifications of existing structures, and/or installation of telecommunications
transmission facilities including satellite uplinks or downlinks, microwave transmission
towers, and cabling.
1. Describe the portion of the project, and site locations (including legal ownership of real
property), involving internal modifications, or equipment additions to buildings or other
structures (e.g., relocating interior walls or adding computer facilities) for each site.

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Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

2. Describe the portion of the project, and site locations (including legal ownership or real
property), involving construction of transmission facilities, including cabling, microwave
towers, satellite dishes, or disturbance of property of .99 acres or greater for each project site.

3. Describe the nature of the proposed use of the facilities and whether any hazardous materials,
air emissions, wastewater discharge, or solid waste will result.

4. State whether or not any project site(s) contain or are near properties listed or eligible for
listing in the National Register of Historic Places, and identify any historic properties. (The
applicant must supply evidence that the State Historic Preservation Officer (SHPO) has
cleared development regarding any historical properties).

5. Provide information whether or not any facility(ies) or site(s) are located in a 100-year
floodplain. A National Flood Insurance Map should be included reflecting the location of the
project site(s).

Page 3 of 4

Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005
II. For projects that involve construction of transmission facilities, including cabling,
microwave towers, satellite dishes, or physical disturbance of real property of .99 acres or
greater, the following information must be submitted.
1. A map (preferably a U.S. Geological Survey map) of the area for each site affected by
construction (include as an attachment).
2. A description of the amount of property to be cleared, excavated, fenced, or otherwise
disturbed by the project and a description of the current land use and zoning and any
vegetation for each project site affected by construction.

3. A description of buildings or other structures (i.e., transmission facilities), including
dimensions, to be constructed or modified.

4. A description of the presence of wetlands or existing agricultural operations and/or
threatened or endangered species or critical habitats on or near the project site(s) affected
by construction.

5. Describe any actions taken to mitigate any environmental impacts resulting from the
proposed project (use attachment if necessary).

Note: The applicant may submit a copy of any environmental review, study assessment, report
or other document that has been prepared in connection with obtaining permits, approvals, or
other financing for the proposed project from State, local or other Federal bodies. Such
material, to the extent relevant, may be used to meet the requirements herein.
(This is not an official Government form. It has been prepared to assist and expedite the
application process and is only intended for use in the Community-Oriented Connectivity
Broadband Grant Program.)

Page 4 of 4
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Community Connect Broadband Grant Program
Federal Forms and Attachments, FY 2005

The U.S. Department of Agriculture prohibits discrimination in its programs on the basis of race,
color, National origin, sex, religion, age disability, political beliefs, and marital or family status.
(Not all bases apply to all programs.) 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.

File Type	application/pdf
File Modified	2006-04-24
File Created	2006-03-14