Application for Investment Assistance

Print Form
Form ED-900A (Rev. 04/06)
OMB Control No. 0610-0094
Expires 04/30/2009

ECONOMIC DEVELOPMENT ADMINISTRATION

APPLICATION
FOR INVESTMENT ASSISTANCE
The Application for Investment Assistance (application) is used to request financial assistance for
programs administered by the Economic Development Administration (EDA) under the Public
Works and Economic Development Act of 1965, as amended (42 U.S.C. 3121 et seq.). This
application contains general requirements and instructions which apply to all EDA programs.
Additional requirements and instructions applicable to specific EDA programs are included in
separate program-specific supplements to this application.

PWEDA Section 201
(CFDA No. 11.300)
Public Works and Economic
Development Program
PWEDA Section 203
(CFDA No. 11.302)
Planning Program
PWEDA Section 207
(CFDA No. 11.303) National,
Local and University Center
Technical Assistance Program
PWEDA Section 207
(CFDA No. 11.312)
Research and Evaluation Program
PWEDA Section 209 (CFDA No.
11.307) Economic Adjustment
Assistance Program

Part I: Application Instructions
Part II: General Requirements
Checklist of Appllicable Exhibits

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Application for Investment Assistance (Form ED-900A)
OMB Control No. 0610-0094
Expires 04/30/2009
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any
person be subject to a penalty for failure to comply with, a collection of information subject to the
requirements of the Paperwork Reduction Act, unless the collection of information displays a
currently valid OMB Control Number. The information requested in the Application for Investment
Assistance is required to obtain or retain benefits from EDA pursuant to the Public Works and
Economic Development Act of 1965, as amended (42 U.S.C. 3121 et seq.).
The reasons for collecting this information are to enable applicants to apply for financial assistance,
and to assist EDA in determining applicants' eligibility and compliance with legal and programmatic
requirements. The information submitted on the application and in accompanying documents is
subject to public disclosure under the Freedom of Information Act, as amended (5 U.S.C. 552),
unless exempt from disclosure as trade secrets or privileged or confidential commercial or financial
information under 5 U.S.C. 552(b)(4).
The public reporting burden for this collection of information is estimated to average 38 hours per
response, including time for reviewing instructions, gathering data, and completing the application.
Comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing paperwork burden may be sent to: Economic Development
Administration, U.S. Department of Commerce, 1401 Constitution Avenue, N.W., Washington, D.C.
20230, and to the Office of Information and Regulatory Affairs, Office of Management and Budget,
Washington, D.C. 20503.

Page 2

I. APPLICATION INSTRUCTIONS
A. GENERAL INFORMATION
The Economic Development Administration (EDA) publishes Federal Funding Opportunity (FFO)
announcements at least annually in the Federal Register. The FFOs include important information on
program requirements, selection and evaluation criteria, and application procedures for all EDA
programs. Current FFO announcements, EDA's regulations, and other information are available at
EDA's Internet website at www.eda.gov.
B. PRE-APPLICATION REQUIREMENTS
To apply for EDA investment assistance, eligible applicants may be required to first submit an
investment proposal on EDA's Pre-application for Investment Assistance (Form ED-900P). Proposals
must include a narrative description of the region in which the project will be located, the project's
scope of work, the proponent's capability, the economic development problem(s), project impact,
project beneficiaries, budget and proposed sources of project funding, among other items as specified
in the applicable FFO announcement or EDA's regulations.
C. APPLICATION REQUIREMENTS
When EDA selects a proposal for further funding consideration, the applicant will receive a letter inviting
the submission of an Application for Investment Assistance (Form ED-900A) (application). The
application includes general requirements that apply to all applicants, and a separate supplement with
program requirements that apply to the specific program activity proposed for EDA investment.
Applicants must complete the general requirements and the program supplement, as specified in the
invitation letter, and submit both with required exhibits and assurances, as applicable.
Applicants are required to submit one (1) original (including all forms with original signatures) and two
(2) copies of the completed application to EDA. Identify exhibits by placing the exhibit number in the
upper right-hand corner of the first page of each exhibit. Please provide single-sided exhibits only (not
front and back). Instructions for completion of the questions and exhibits are incorporated into the text
of the application. Pre-printed forms, such as lobbying and name check forms, are provided as part of
this application package and may be reproduced by the applicant if multiple copies are needed. Preprinted forms are identified with an asterisk (*).
For some EDA programs, this application may require specific documentation for engineering,
environmental, financial or legal reviews, which may involve coordination with various local, State and
federal agencies, and with private sector organizations. Incomplete or incorrect documentation may
delay the processing of the application.

D. PROCESSING & APPROVAL
Applicants for EDA investment assistance should consult the Economic Development
Representative (EDR) serving the project region or the EDA regional office identified in the invitation
letter. One (1) original and two (2) copies of the completed application should be submitted to the EDR

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who will determine if it is complete, help resolve any problems noted and forward it to the appropriate
EDA regional office.
An applicant will be notified by the appropriate EDA regional office when its application received, and
whether it is acceptable for processing. An applicant may be requested to provide additional clarifying
information during EDA's review of the application. Should a problem arise during the review which
would seriously delay a final funding decision, an applicant may be requested to withdraw the
application pending the resolution of the problem and to resubmit at a later time. Problems that cannot
be resolved may lead to disapproval of the application. If the application is approved by EDA, a
financial assistance award package will be sent to the applicant. Upon acceptance of an investment,
EDA funds will be made available for disbursement in accordance with the terms and conditions of the
financial assistance award. A public announcement of the award may be made by EDA.
E. EDA Regional Offices

Atlanta Regional Office
401 W. Peachtree Street, N.W., Suite 1820
Atlanta, Georgia 30308
Telephone: (404) 730-3002
Fax: (404) 730-3025

Austin Regional Office
504 Lavaca Street, Suite 1100
Austin, Texas 78701-4037
Telephone: (512) 381-8144
Fax: (512) 381-8177

Serves: Alabama, Florida, Georgia,
Kentucky, Mississippi, North Carolina,
South Carolina, and Tennessee.

Serves: Arkansas, Louisiana, New Mexico,
Oklahoma, and Texas.

Chicago Regional Office
111 North Canal, Suite 855
Chicago, Illinois 60606
Telephone: (312) 353-7706
Fax: (312) 353-8575

Denver Regional Office
1244 Speer Boulevard, Suite 670
Denver, Colorado 80204
Telephone: (303) 844-4715
Fax: (303) 844-3968

Serves: Illinois, Indiana, Michigan, Minnesota,
Ohio, and Wisconsin.

Serves: Colorado, Iowa, Kansas, Missouri,
Montana, Nebraska, North Dakota, South
Dakota, Utah, and Wyoming.

Philadelphia Regional Office
Curtis Center, Suite 140 South
601 Walnut Street
Philadelphia, Pennsylvania 19106-3323
Telephone: (215) 597-4603
Fax: (215) 597-1063

Seattle Regional Office
Jackson Federal Building, Room 1890
915 Second Avenue
Seattle, Washington 98174-1001
Telephone: (206) 220-7660
Fax: (206) 220-7669

Serves: Connecticut, Delaware, District of
Columbia, Maine, Maryland,
Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania, Puerto
Rico, Rhode Island, Vermont, Virginia,
U.S. Virgin Islands, and West Virginia.

Serves: Alaska, American Samoa, Arizona,
California, Commonwealth of the
Northern Mariana Islands, Federated
States of Micronesia, Guam, Hawaii,
Idaho, Nevada, Oregon, Republic of
Palau, Republic of the Marshall Islands,
and Washington.

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II. GENERAL REQUIREMENTS
A. Updated Project Narrative
Provide a narrative description and documentation of any changes to the project region, scope of
work, economic development need(s), project purpose, project impact, or organization's status, since
submission of the pre-application. Attach as Exhibit II.A.
B. Potential Issues
Are there any issues, such as litigation (pending or potential), environmental concerns, financing
requirements, public opposition, condemnation or eminent domain proceedings, or any other matters
which could affect compliance with EDA or other federal requirements related to the construction,
financing, ownership or operation of the project, including the timely start and completion of the project?
If so, attach an explanation as Exhibit II.B.
C. Submit executed *Certifications Regarding Lobbying (Form CD-511)
All applicants for federal financial assistance must certify that federal funds have not been used and will
not be used for lobbying in connection with this request for federal financial assistance (Form CD-511).
If non-federal funds have been used or are planned to be used for lobbying in connection with this
request for federal financial assistance, a *"Disclosure of Lobbying Activities" (Form SF-LLL) must also
be completed.
Applicant's *"Certifications Regarding Lobbying" (Form CD-511) is attached as Exhibit II.C.1.

Applicant's *"Disclosure of Lobbying Activities" (Form SF-LLL), if any, is attached as
Exhibit II.C.2.
D. Provide evidence of compliance with Executive Order 12372, State Single Point of Contact
(SPOC)
This request for EDA investment assistance meets the SPOC process established by the State, as
indicated below. See 13 C.F.R. § 302.9(b).

State Application Identification Number:

Date Assigned:

SPOC clearance/comments is/are attached as Exhibit II.D.
The State does not have a project review process.
Review period has expired and no comments were received.
E. Non-Federal Share of Project Costs
Generally, the amount of an EDA investment may not exceed 50% of the total cost of the project.
Projects may receive an additional amount that shall not exceed thirty (30) percent, based on the
relative needs of the region in which the project will be located, as determined by EDA. See 13 C.F.R.
§ 301.4(b).
Page 5

If a non-federal share is required for your project, complete the following:
1. Identify the source and nature of the non-federal share of project costs as shown in the project
budget and attach as Exhibit II.E.1.
2. Are in-kind contributions included as part of the non-federal share of the project funding?
Yes. If yes, explain the nature and the basis on which they are valued. Attach as Exhibit II.E.2.
No.
3. Provide evidence that funds required for the non-federal share of project costs are committed to the
project, will be made available as needed for the project, and are not or will not
be conditioned or encumbered in any way that would preclude its use consistent with the
requirements of EDA investment assistance. See 13 C.F.R § 301.5. Attach as Exhibit II.E.3.
4. Identify and explain the nature of any other sources of federal financial assistance received or
requested for this project. Attach as Exhibit II.E.4.
F. Civil Rights
Applicant will comply with all applicable civil rights requirements. See 13 C.F.R. § 302.20.
Yes
No
G. Other Parties
"Other Parties" (as defined in 13 C.F.R. § 302.20(b)) benefiting from the project, i.e., entities that will be
creating and/or saving fifteen (15) or more permanent jobs as a result of the EDA investment assistance,
will comply with all applicable civil rights requirements.
Yes
No
No "Other Parties" identified.
H. Justification for Sole Source Procurement
Where procurement activities under the EDA award will not be conducted by competitive bid,
provide a justification. See 15 C.F.R. § 14.40 or 15 C.F.R. § 24.36, as applicable. Attach as
Exhibit II.H.
Contracts will be awarded by competitive bid.

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I. Governmental Reviews
When the applicant is not a State, Indian tribe or other general purpose governmental authority, the
applicant must afford the appropriate general purpose local governmental authority a minimum of
fifteen (15) days in which to review and comment on (i) a proposed construction project under EDA's
Public Works and Economic Development program; or (ii) a proposed construction project or revolving
loan fund (RLF) grant under EDA's Economic Adjustment Assistance program. The applicant shall
furnish copies of any comments received (or a statement of efforts made to obtain comments if no
comments are received) with an explanation of any actions taken to address such comments. See 13
C.F.R. § 302.9(a).
Local governmental comments and/or statement attached as Exhibit II.I.1.
Not applicable.
Is the applicant a special-purpose unit of local government (such as a Port Authority, Water and
Sewer District, etc.)?
Yes. Describe the type of organization and attach as Exhibit II.I.2. a current statement from
the controlling local government as to why the special purpose unit is better qualified
to administer the proposed project.
No.
J. Non-governmental Applicants
1. Provide a *"Name Check" (Form CD-346) form completed by each officer, executive director and
chief financial officer, as Exhibit II.J.1. This form is required from applicants that are private or public
non-profit organizations, for-profit entities, or individuals. This form is not required from State or local
governments, designated Economic Development Districts, other Planning Organizations or Statecontrolled universities.
2. All applicants must provide a Certificate of Good Standing or its legal equivalent from the State in
which the organization is incorporated.
New applicants must also provide their Articles of Incorporation and By-Laws. Current recipients must
also provide their Articles of Incorporation or By-Laws if either has been amended; or a statement
certifying that there has been no change in the organization's Articles of Incorporation or By-Laws.
Attach as Exhibit II.J.2.
3. Public or private non-profit organizations must generally act in cooperation with officials of
a political subdivision of a State.
A resolution passed by (or a letter signed by) an authorized representative of a general purpose
political subdivision of a State, acknowledging that the applicant is acting in cooperation with
officials of the political subdivision, as applicable, is attached as Exhibit II.J.3. EDA may waive
this cooperation requirement for certain projects of significant regional or national scope under
13 C.F.R. parts 306 or 307 and 13 C.F.R. § 301.2(b).

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CHECKLIST OF APPLICATION EXHIBITS
This checklist identifies all of the exhibits in the application. The exhibit number refers to the specific
section of the application. Those with an asterisk (*) are preprinted forms. Check all of the exhibits
submitted with the application.
Form SF-424, Application for Federal Assistance
*Form SF-424
Part II - General Requirements
II.A.

Updated Project Narrative

II.B.

Statement of Potential Issues

II.C.1.

*Certifications Regarding Lobbying (Form CD-511)

II.C.2.

*Disclosure of Lobbying Activities (Form SF-LLL)

II.D.

State Single Point of Contact (SPOC) Clearance/Comments

II.E.1.

Source and Nature of Non-Federal Share of Project Costs

II.E.2.

In-Kind Contributions

II.E.3.

Availability of Non-Federal Share of Project Costs

II.E.4.
II.H.

Other Federal Financial Assistance
Justification for Sole Source Procurement

II.I.1.
II.I.2.

Local Government Comments
Special Purpose Unit of Local Government

II.J.1.
II.J.2.

*Name Check Forms (Form CD-346)
Articles of Incorporation and Bylaws

II.J.3.

Resolution (or Letter) of Cooperation from Political Subdivision

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FORM CD-511
(REV 1-05)

U.S. DEPARTMENT OF COMMERCE

CERTIFICATION REGARDING LOBBYING

Applicants should also review the instructions for certification included in the regulations before completing this form. Signature on
this form provides for compliance with certification requirements under 15 CFR Part 28, "New Restrictions on Lobbying." The
certifications shall be treated as a material representation of fact upon which reliance will be placed when the Department of
Commerce determines to award the covered transaction, grant, or cooperative agreement.
LOBBYING

Statement for Loan Guarantees and Loan Insurance

As required by Section 1352, Title 31 of the U.S. Code, and
implemented at 15 CFR Part 28, for persons entering into a grant,
cooperative agreement or contract over $100,000 or a loan or
loan guarantee over $150,000 as defined at 15 CFR Part 28,
Sections 28.105 and 28.110, the applicant certifies that to the
best of his or her knowledge and belief, that:

The undersigned states, 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 in conncection with the awarding of any
Federal contract, the making of any Federal grant, the making of
any Federal loan, the entering into of any cooperative agreement,
and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative
agreement.
(2) If any funds other than Federal appropriated funds have been
paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of
a member of Congress in connection with this Federal contract,
grant, loan, or cooperative agreement, the undersigned shall
complete and submit Standard Form-LLL, ''Disclosure Form to
Report Lobbying.'' in accordance with its instructions.

In any 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 commitment providing for
the United States to insure or guarantee a loan, the
undersigned shall complete and submit Standard Form-LLL,
''Disclosure Form to Report Lobbying,'' in accordance with its
instructions.
Submission of this statement 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
statement shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure
occurring on or before October 23, 1996, and of not less than
$11,000 and not more than $110,000 for each such failure
occurring after October 23, 1996.

(3) The undersigned shall require that the language of this
certification be included in the award documents for all
subawards at all tiers (including subcontracts, subgrants, and
contracts under grants, loans, and cooperative agreements) and
that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which
reliance was placed when this transaction was made or entered
into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by section 1352, title 31,
U.S. Code. Any person who fails to file the required certification
shall be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure occurring on or
before October 23, 1996, and of not less than $11,000 and not
more than $110,000 for each such failure occurring after
October 23, 1996.

As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the
above applicable certification.
NAME OF APPLICANT

AWARD NUMBER AND/OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
SIGNATURE

DATE

Page 9

DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
year _________ quarter _________
e. loan guarantee
date of last report ______________
f. loan insurance
4. Name and Address of Reporting Entity:
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:
Subawardee
Prime
Tier ______, if known:

Congressional District, if known:
6. Federal Department/Agency:

Congressional District, if known:
7. Federal Program Name/Description:

CFDA Number, if applicable: _____________
8. Federal Action Number, if known:

9. Award Amount, if known:
$

10. a. Name and Address of Lobbying Registrant
(if individual, last name, first name, MI):

b. Individuals Performing Services (including address if
different from No. 10a)
(last name, first name, MI):

11. Information requested through this form is authorized by title 31 U.S.C. section 1352.

Signature:

This disclosure of lobbying activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction was made or entered into.
This disclosure is required pursuant to 31 U.S.C. 1352. This information will be
available for public inspection. Any person who fails to file the required disclosure
shall be subject to a civil penalty of not less than $10,000 and not more than $100,000
for each such failure.

Print Name:
Title:
Telephone No.: _______________________

Date:

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

Federal Use Only:

Page 10

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make
payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with a covered Federal action. Complete all items that apply for both the initial filing and
material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate
classification of the reporting entity that designatesif it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the
first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known.
For example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number; Invitation for
Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the
Federal agency). Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle Initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are 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 OMB No. 0348-0046. Public reporting burden for this collection of information is
estimated to average 10 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 (0348-0046), Washington, DC 20503.

Page 11

OMB Approval No. 0605-0001 Expires 08-06
U.S. DEPARTMENT OF COMMERCE

FORM CD-346
(REV. 08-03)
DAO 207-10

DO NOT COMPLETE THIS SECTION
DATE OF REQUEST

APPLICANT FOR FUNDING ASSISTANCE

"
"

NAME CHECK
IDENTIFICATION CHECK

INSTRUCTIONS: Please type or print clearly. Information below will be used for investigation of named person's or firm's character and/or integrity. In answer to
question 11 below, the fact that you may have a conviction record or have cirminal charges pending against you will not necessarily disqualify you. An incorrect
answer may cause your application to be turned down. Please read Privacy Act Advisory Statement on reverse of form.
1. NAME OF APPLICANT (If no middle name use (NMN). Also list former names used).
LAST

FIRST

MIDDLE

5. NAME AND ADDRESS OF FIRM (Post Office Box is not sufficient)
MAIDEN

SPOUSE

6. PHONE NUMBER OF FIRM

2. DATE OF BIRTH

3. SOCIAL SECURITY NUMBER (Voluntary)

7. REGIONAL OFFICE

8. U.S. CITIZEN?

"

YES

"

NO (If no, give alien registration number)

4. PLACE OF BIRTH

9. EMPLOYMENT (Last 3 years)
FROM

TO

EMPLOYER NAME AND COMPLETE ADDRESS

TO

COMPLETE ADDRESS

10. RESIDENCE (Last 3 years)
FROM

11. HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE OR ARE CRIMINAL CHARGES PENDING AGAINST YOU? (You may omit minor traffic violations for
which you forfeited $50.00 or less).

"

YES

"

NO (If yes, please furnish details on the reverse side of this form).

12. RESULTS OF CHECK (Government Use Only)

With knowledge of 18 U.S.C. 1001 and 42 U.S.C. 3220 which provide for criminal penalties for the making of false statements, the undersigned hereby certifies that
the above information is correct.
SIGNATURE

DATE

Page 12

FORM CD-346
(REV. 08-03)
DAO 207-10

PRIVACY ACT ADVISORY STATEMENT

The Privacy Act of 1974 (P.L. 93-479) requires that you be given certain information in connection with: (a) " The request for information
solicited on Form CD-346; or (b) " The request for your Social Security Number. Accordingly, pursuant to the requirements of the Act,
please be advised:
PRINCIPAL
THE AUTHORITY FOR THE COLLECTION OF THIS DATA IS: 42 USC 3211(12); as well as the THE
responsibilities cited in the Inspector General Act of 1978, Sec. 4(a)(3)
Information

YOUR SOCIAL SECURITY NUMBER IS VOLUNTARY DATA, BUT PROVIDING YOUR SOCIAL
SECURITY NUMBER MAY REDUCE DELAYS IN THE REVIEW PROCESS.

PURPOSE(S)

FOR

WHICH

THE

DATA

WILL

BE

USED

IS:

is used to establish good character of principal
officers and employees of organizations, firms or recipients or
beneficiaries of grants, loans, or loan guarantee programs that
may receive grants, loans, or guarantees from the U.S.
Department of Commerce.

QUESTION 11 CONTINUATION:

PREFATORY STATEMENT OF GENERAL ROUTINE USES
The following routine uses apply to, and are incorporated by reference into, each system of records set forth below:
1. In the event that a system of records maintained by the department to
carry out its functions indicates a violation or potential violation of law or
contract, whether civil, criminal or regulatory in nature, and whether
arising by general statute or particular program statute or contract, or
rule, regulation, or order issued pursuant thereto, or the necessity to
protect an interest of the Department, the relevant records in the system
of records may be referred, as a routine use, to the appropriate agency,
whether federal, state, local or foreign, charged with the responsibility of
investigating or prosecuting such violation or charged with enforcing or
implementing the statute or contract, or rule, regulation or order issued
pursuant thereto, or protecting the interest of the Department.
2. A record from this system of records may be disclosed, as a routine
use, to a Federal, state or local agency maintaining civil, criminal or other
relevant enforcement information or other pertinent information, such as
current licenses if necessary to obtain information relevant to a Department
decision concerning the hiring or retention of an individual, the issuance of a
security clearance, the letting of a contract, or the issuance of a license, grant
or other benefit.
3. A record from this system may be disclosed, as a routine use, to a
Federal, state, or local, or international agency, in response to its request, in
connection with the assignment, hiring or retention of an individual, the
issuance of a security clearance, the reporting of an investigation of an
individual, the letting of a contract, or the issuance of a license, grant, or
other benefit by the requesting agency, to the extent that the information is
relevant and necessary to the requesting agency's decision on the matter.
4. A record from this system of records may be disclosed, as a routine
use in the course of presenting evidence to acourt, magistrate or
administrative tribunal, including disclosures to opposing counsel in the
course of settlement negotiations.
5. A record in this system of records may be disclosed, as a routine use,
to a Member of Congress submitting a request involving an individual when
the individual has requested assistance from the Member with resepct to the
subject matter of the record.
6. A record in this system of records which contains medical information
may be disclosed, as a routine use, to the medical advisor of any indi-

vidual submitting a request for access to the record under the Act and 15
CFR Part 4b if, in the sole judgement of the Department, disclosure could
have an adverse effect upon the individual, under the provision of 5 U.S.C.
552a(f) (3) and implementing regulations at 15 CFR 4b.6.
7. Deleted, Reserved.
8. A record in this system of records may be disclosed, as a routine use,
to the Office of Managmenet and Budget in connection with the review of
private relief legislation as set forth in OMB Circular No. A-19 at any state of
the legislative coordination and clearance process as set forth in that
Circular.
9. A record in this system may be disclosed, as a routine use, to the
Department of Justice in connection with determining whether disclosure
thereof is required by the Freedom of Information Act 5 U.S.C. 552.
10. A record from this system of records may be disclosed, as a routine
use, to a contractor of the Deapartment having need for the information in
the performance of the contract, but not operating a system of records
within the meaning of 5 U.S.C. 552a(m).
11. Deleted, Reserved.
12. A record in this system may be transferred, as a routine use, to the
Office of Personnel Management for personnel research purposes; as a data
source for management information; for the production of summary
descriptive statistics and analytical studies in support of the function for
which the records are collected and maintained; or for related man-power
studies.
13. A record in this system of records may be disclosed, as a routine use,
to the Archivist of the United States, National Archives & Records
Administration (NARA), or his designee, during an inspection of records
conducted by NARA as part of that agency's responsibility to recommend
improvements in records management practices and programs, under
authority of 44 U.S.C. 2904 and 2906. Such disclosure shall be made in
accordance with the NARA regulations governing inspection of records for
this purpose, and other relevant (i.e., NARA or Commerce) directive. Such
disclosure shall not be used to make determinations about individuals.

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection
of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.
The public reporting burden for this 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. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to: Office of Inspector General, Department of Commerce, 1401
Constitution Avenue, NW, Washington, DC 20230.

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