[Name of SSBIC Applicant] |
[Date of Submission] |
SSBIC APPLICATION PACKAGE NMVC PROGRAM OA GRANTS
Page
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OMB
No: 3245-0332 Exp.
Date: 10/31/2008
You must submit all parts of this Application Package as outlined below. These documents must be signed and acceptable to SBA before SBA will award a grant. Prior to filling out these documents, you will need to read and become familiar with The Office of Management and Budget (OMB) Circular A-110 (2 CFR § 215)
[http://www.whitehouse.gov/omb/circulars/a110/a110.html].
Standard Forms can be downloaded in PDF by clicking on the links provided below. If you don't have the free reader software, go to http://www.adobe.com/products/acrobat/readstep.html.
Documents you are required to complete and submit are the following:
1. SF424, Application for Federal Assistance [http://www.whitehouse.gov/omb/grants/sf424.pdf]
2. SF424A, Budget Information [http://www.whitehouse.gov/omb/grants/sf424a.pdf]
3. Appendix A, Supplement to SF 424A, Section F, Other Budget Information
4. SF424B, Assurances – Non-Construction Programs [http://www.whitehouse.gov/omb/grants/sf424b.pdf]
5. Appendix B, Supplement to SF 424B, SBA Assurances and Certifications
6. Statement of Applicant’s eligibility to apply for the grant, in accordance with 13 CFR 108.2002.
7. Statement of specific amounts of Regulatory Capital and Operational Assistance grant, as required in 13 CFR 108.2004(a).
8. Applicant’s plan for use of the grant, addressing the topics required in 13 CFR 108.2005.
Submit one electronic version of your Application Package in Word format on standard IBM readable 3½” diskettes or CD Rom. The electronic versions of these documents must be identical to the hard copies that you submit.
Submit two complete, original hard copy sets. Place each of the two original sets in a large 3-ring binder. Label the binders with the SSBIC’s name.
Submit one complete hard copy. It must be unbound and suitable for photocopying (i.e., no hole punches, staples, paper clips, tabs or binders).
You must accompany your application with a grant issuance fee of $5,000, in accordance with 13 CFR 108.2003.
Appendix A
Other Budget Information
INSTRUCTIONS FOR PERSONAL SERVICES AND FRINGE BENEFITS WORKSHEET
1. Personnel
Enter in Column 1 the annual (12 months) salary rate for each key position referred to in the narrative, which will be filled for all or any part of the year by an incumbent working on the project. This rate may not be more than that paid by the grantee to other employees in comparable positions or, if the grantee has no comparable positions, the rate may not be more than that paid for such services elsewhere in the community.
Enter in column 2 the number of months the position will be filled by an incumbent working on the project.
Enter in Column 3 the percent of time or effort the incumbent will devote to the project during the number of months shown in Column 2.
Enter in Column 4 the total amount required, as computed from the information shown in Columns 1 through 3.
Use the following formula:
Annual Salary
|
X
|
No. of Months 12 Months |
X |
Percent of Time |
= |
Total Amount Required |
Personal Services and Fringe Benefits Worksheet Examples |
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Personnel (Name/Position) |
(1) |
(2) |
(3) |
(4) |
||||||
Annual Salary Rate |
Number of Months |
Percent of Time |
Total Amount Required |
|||||||
Jane Doe - Fulltime Employee of Institution working 60% time on project. |
$24K |
12 |
60% |
$14.4K |
||||||
Calculation |
$24K |
X |
12 12 |
X |
60% |
= |
$14.4K |
|||
John Doe - Summer Employee (3 months to be paid $1K per month) working 25% time on project. |
$12K |
3 |
25% |
$750 |
||||||
Calculation |
$12K |
X |
3 12 |
X |
25% |
= |
$750 |
|||
2. Fringe Benefits
Enter in the parenthesis the fringe benefit rate applicable to employees of the institutions. In Column 4, enter the amount determined by applying the rate to the total of the salaries in Column 4 to which the rate applies.
3. Option for Salary Detail Submission
Institutions may require that the salary rates and amounts requested for individuals not be made available to SBA reviewing consultants. To do so, an additional copy of this page must also be submitted, complete in all respects, except that Columns 1 and 4 may be left blank.
Supplement to SF 424A, Section F
Personal Services and Fringe Benefits Worksheet |
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Personnel (Name/Position) |
(1) |
(2) |
(3) |
(4) |
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Annual Salary Rate |
Number of Months |
Percent of Time |
Total Amount Required |
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Total |
$ |
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Fringe Benefits Rate |
(Rate) |
Total Fringe Benefits |
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_____________________________ _____________________ ____________
(Signature) (Title) (Date)
Supplement to SF 424A, Section F
Detailed Budget for Project and Budget Period
Direct Cost |
Totals |
Personal Services (Refer to Personal Services and Fringe Benefits Worksheet) |
$ |
Fringe Benefits (Refer to Personal Services and Fringe Benefits Worksheet) |
$ |
Consultants (Refer contractual agreements to Contractual Category) |
$ |
Travel
|
$ |
Equipment
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$ |
Supplies
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$ |
Contractual
|
$ |
Other
|
$ |
Total Direct Cost
|
$ |
Indirect Cost |
-0- |
Profit/Fees |
-0- |
Total Allowable Budget |
$ |
NOTE: All costs approved on this budget must meet the tests of necessity, reasonableness, allowability, and allocability in accordance with applicable cost principles applicable to this award. All costs charged to this project are subject to audit. Recipients are responsible to insure proper management and financial accountability of federal funds to preclude future costs disallowances.
All categories must be supported by narrative justification.
The Applicant hereby assures and certifies that he/she will comply with the regulations, policies, guidelines, and requirements including 13 C.F.R. Part 143; OMB CircularsA‑87 (2 CFR §225), A‑89, A‑102, A‑110 (2 CFR §215), A‑122 (2 CFR §230) (or any regulations which are later promulgated to supplement or replace it), and A‑130, as appropriate and as they relate to the application, acceptance and use of Federal funds for this federally assisted project. Also the applicant assures and certifies with respect to the grant/cooperative agreement that:
It possesses legal authority to apply for the grant; that a resolution, motion or similar action has been duly adopted or passed as an official act of the applicant's governing body, authorizing the filing of the application, including all understandings and assurances contained therein, and directing and authorizing the person identified as the official representative of the application and to provide such additional information as may be required.
2. It will comply with Title V1 of the Civil Rights Act of 1964 (P.L. 88‑352) and in accordance with Title V1 of that Act no person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the applicant receives Federal assistance and will immediately take any measures necessary to effectuate this agreement.
3. It will comply with Title V1 of the Civil Rights Act of 1964 (42 USC 2000d) prohibiting employment discrimination where (1) the primary purpose of a grant is to provide employment or (2) discriminatory employment practices will result in unequal treatment of persons who are or should be benefiting from the grant‑aided activity.
4. It will comply with requirements of the provision of the Uniform Relocation Assistance and Real Property Acquisition Act of 1970 (P.L. 91‑646) which provides for fair and equitable treatment of persons displaced as a result of Federal and federally assisted programs.
5. If it is a State or local governmental entity, that those of its employees whose principal employment is in connection with an activity which is financed in whole or in part by loans or grants made by the United States or a Federal agency will comply with the relevant provisions of the Hatch Act. See U.S.C. Sections 1501‑1503.
6. It will comply with the minimum wage and maximum hours provisions of the Federal Fair
Labor Standard Act, as they apply to hospital and educational institution employees of State and local governments.
7. It will establish safeguards to prohibit employees from using their positions for a purpose that is or gives the appearance of being motivated by a desire for a private gain for themselves, or others, particularly those with whom they have family, business, or other ties.
8. It will give the grantor agency or the Comptroller General through any authorized representative the access to and the right to examine all records, books, papers, or documents related to the grant.
9. It will comply with all requirements imposed by the Federal grantor agency concerning special requirements of law, program requirements, and other administrative requirements approved in accordance with Office of Management and Budget Circulars A‑102, A‑110 (2 CFR §215), and A‑122 (2 CFR §230) (and any regulations which are later promulgated to supplement or replace it), 13 C.F.R. Part 143 as appropriate.
10. This application does not propose any activities that would involve human beings who might be considered subjects, human material, or personal data from primary or secondary sources.
11. This is to hereby certify that this project does not have an effect on the environment such as on the following areas: natural resources, pollution, populations, and any adverse effect through the delivery of services.
12. This is to hereby acknowledge that the U.S. Small Business Administration has a royalty‑free, nonexclusive and irrevocable license to reproduce, publish, or otherwise use, and to authorize others to use any copyrighted materials and reports which shall have been developed under this grant. The recipient also, hereby agrees to notify and provide three copies of any copyrighted materials developed under this grant to the Small Business Administration.
13. This hereby certifies that applicant possesses adequate grant management capabilities as required by OMB circulars and SBA Federal Assistance Administration Regulations and Guidelines in all of the following areas: fiscal administration, facilities management, management information, personnel, planning and budget, procurement and property management.
This hereby certifies that applicant meets the standards for fund control and accountability as prescribed in 13 C.F.R. part 143 or OMB Circulars A‑102, , A‑110 (2 CFR §215), and A‑122 (2 CFR §230) (or any regulations which are later promulgated to supplement or replace it) as appropriate in accordance with the legal status of the applicant's organizational status and has established or can demonstrate the willingness and ability to establish procedures that will minimize the time elapsing between the transfer of funds from the Treasury and their disbursement by the grantee if advance payment procedures are used.
15. It will ensure that the facilities under its ownership, lease or supervision which shall be utilized in the accomplishment of the project are not listed on the Environmental Protection Agency's (EPA) list of Violating facilities and that it will notify the Federal grantor agency of the receipt of any communication from the Director of the EPA Office of Federal Activities indicating that a facility to be used in the project is under consideration from listing by the EPA.
16. It will comply with the flood insurance purchase requirements of Section 102(a) of the Flood Disaster Insurance Act of 1973, Public Law 93‑234, 87 Stat. 975, approved December 31, 1976. Section 102(a) requires, on and after March 2, 1975, the purchase of flood insurance in communities where such insurance is available as a condition for the receipt of any Federal financial assistance for construction or acquisition purposes for use in any area that has been identified by the Secretary of the Department of Housing and Urban Development as an area having flood hazard.
The phrase "Federal financial assistance" includes any form of loan, grant, guaranty, insurance payment, rebate, subsidy, disaster assistance loan or grant, or any other form of direct or indirect Federal assistance.
17. It will assist the Federal grantor agency in its compliance with Section 106 of the National Historic Preservation Act of 1966 as amended (16 U.S. C. 4 70), Executive Order 11593, and the Archeological and Historic Preservation Act of 1966 (16 U.S. C. 469a‑1 et seq.) by (a) consulting with the State Historic Preservation Officer on the conduct of investigations, as necessary, to identify properties listed in or eligible for inclusion in the National Register of Historic places that are subject to adverse effects (see 36 CFR Part 800.8) by the activity, and notify the Federal grantor agency of the existence of any such properties, and by (b) complying with all requirements established by the Federal grantor agency to avoid or mitigate adverse effects upon such properties.
18. It will comply with the requirements which provide that no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to the discrimination under any activity receiving Federal financial assistance.
19. It will comply with P.L. 93‑112 and P.L. 93‑516 which provide that no otherwise qualified handicapped individual in the United States shall, solely by reason of his handicap, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any activity receiving Federal financial assistance.
20. It will comply with P.L. 94‑135 which provides that no person in the United States shall, on the basis of age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any activity receiving Federal financial assistance.
21. Certification regarding debarment, suspension, and other responsibility matters: primary covered transactions:
Certification Regarding Debarment, Suspension and Other
INSTRUCTIONS FOR CERTIFICATION
a. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below.
b. The inability of a person to provide the certification required below will not necessarily result in the denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.
c. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowing rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.
The prospective primary participant shall provide immediate written notice to the department or agency to whom this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
The terms "covered transactions," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations (2 CFR Part 180).
The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction.
The prospective primary participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion‑Lower Tier Covered Transaction, " provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List.
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings
Except for transactions authorized under paragraph “f.” of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.
Certification
Regarding Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
are not presently debarred, suspended, proposed or for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;
have not within a three‑year period preceding this application 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;
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
have not within a three‑year period preceding this application 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 his certification, such prospective primary participant shall attach an explanation to this proposal.
22. Certification regarding debarment, suspension, ineligibility and
voluntary exclusion: lower tier covered transactions.
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
INSTRUCTIONS FOR CERTIFICATION
By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below.
The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension andlor debarment.
The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and voluntarily excluded," as used in this clause, have the meanings set out in the definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations (2 CFR Part 180)
The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.
The prospective lower tier participant further agrees by submitting this proposal that it will include the clause title "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion‑Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List.
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed which is normally possessed by a prudent person in the ordinary course of business dealings.
Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions
The prospective lower tier participant certifies, by submission of this proposal, that either it nor its principals are presently debarred, suspended, proposed of debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.
Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
23. Certification Regarding Compliance with Section 5153 of the Drug‑Free Workplace Act of 1988, Public Law 100‑690, Title V, Subtitle D
By signing and submitting this proposal, the participant is providing the certification set out below.
a. The participant hereby certifies that it will provide a drug‑free workplace by.
publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the applicant's workplace and specifying the actions that will be taken against employee for violations of such prohibition;
establishing a drug‑free awareness program to inform employees about:
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 program; and
the penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
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 subparagraph (A);
notifying the employee in the statement required by subparagraph (A), that as a condition of employment in such grant, the employee will.
abide by the terms of the statement; and
notify the employer of any criminal drug use statute conviction for a violation occurring in the workplace no later than 5 days after such conviction;
notifying the granting agency within 10 days after receiving notice of a conviction under subparagraph (D)(ii from an employee or otherwise receiving actual notice of such conviction;
taking one of the following actions, within 30 days of receiving notice under subparagraph (D)(ii), with respect to any employee who is so convicted:
taking appropriate personnel action against such an employee, up to and including termination; or
requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;
(7) making a good faith effort to continue to maintain a drug‑free workplace through implementation of subparagraphs (A), (B), (C), (E), (F), and (G).
The grantee shall 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 and Zip Code)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
The participant hereby certify that, as a condition of this grant, he/she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of controlled substance in conducting any activity with such grant.
Certification regarding lobbying for contracts, grants, loans, and cooperative agreements:
Certification
Regarding Lobbying for
Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his/her knowledge and belief, that.
(a) 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 an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
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. (Standard Form LLL-A is "Continuation Sheet" of Standard Form LLL).
The undersigned shall require that the language of this certification be included in the award documents for all subaward of 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 3 1, 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.
The participant also certifies that the information in these assurances and certifications in support of this proposal is correct to the best of his/her knowledge and belief and the filing of this application has been duly authorized.
______________________________________________________________________
Legal Name of Participant
______________________________________________________________________
______________________________________________________________________
Address
______________________________________________________________________
Print Name and Title of Authorized Representative
______________________________________________________________________
Signature of Authorized Representative Date signed
| File Type | application/msword |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |