Broadband Initatives Application Package and Reporting Burdens

Applicant Information
1-A. Name, Address, and Federal ID for Applicant
i. Legal Name:	ii. Employer/Taxpayer Identification Number (EIN/TIN):
Street 1: Street 2: City: County: State: Province: Country: Zip/Postal Code
1-B. Name and Contact Information of Person to be Contacted on Matters Involving this Application:
Prefix: First Name: Middle Name: Last Name: Suffix: Title:	Telephone Number: ___________ Fax Number: ___________ Email: ___________ Other (Specify ___________
1-C. Other Required Identification Numbers
i. Organizational DUNS:	ii. CRR :
iii. Funding Opportunity Number:	iv. Catalog of Federal Domestic Assistance Number: CFDA Title:
1-D Eligible Entities
Please classify your organization. (Note: If there are multiple organizations involved in the project, designate the lead applicant that would enter into a Loan or Grant agreement with the Agency and assume operational and financial responsibility should an award be made). Local, State, or Other Government Entity State or State Agency Political subdivision of a State, including Local or County Government District of Columbia Territory or Possession of the United States Indian Tribe Not for Profit Entity Non-Profit Corporation Non-Profit Foundation Non-Profit Institution Non-Profit Association For Profit Entity For-Profit Corporation Socially and economically disadvantaged small business concern (SDB) as defined by section 8(a) of the Small Business Act, 15 U.S.C.§637 Other Cooperative or Mutual Native Hawaiian organization Please identify any others: ________________
1-E. RUS Borrower Status
Please check the appropriate box: The applicant is, or has been, an RUS Title II Borrower. The applicant is not an RUS Title II Borrower.
1-F. Applicant Federal Debt Delinquency Explanation
Is the Applicant Delinquent On Any Federal Debt? Yes No (If “Yes”, provide explanation.) ____________________________________________________________

Project Description

Provide three or four sentences that most concisely describe the proposed project.

Your answer will be published on recovery.gov and broadbandusa.gov to showcase the types of proposals received.

[Limit 400 characters]

Multiple Submissions for BIP or BTOP:

Identify in the table below any other applications that you have submitted for BIP or BTOP

Project Type
BIP Infrastructure
BTOP Infrastructure
BTOP Public Computer Center
BTOP Sustainable Broadband Adoption

Rural Area Determination: Check the appropriate box based on the service area proposed to be funded by the applicant. The applicant's answer should be corroborated by the service area data in [Question 13]

At least 75 %of the proposed service area to be funded falls within rural areas that are unserved or underserved. If you answer “yes,” proceed to Question 5. If you answer “no” proceed to Question 6.

Applications for Rural Areas: Please choose the funding program(s) to which you are submitting this application.

a) If you answered Yes to Question 4, please choose the BIP broadband infrastructure category to which you are applying:

BIP– Last Mile Remote Area
BIP– Last Mile Non-Remote Area
BIP– Middle Mile Project

b) Would you like this Application for Rural Areas to also be considered for BTOP funding?

Yes
No (Implies Single Filing with BIP)

(Note: If YES, the applicant must complete all BTOP requirements as well. This requires the applicant to complete two separate budget and financial forms. Per the NOFA, NTIA may make awards with respect to such an application it deems to be meritorious after RUS has reviewed the application and determined to not provide funding.)

c) If Yes, please choose the BTOP Infrastructure category for which you are applying.

Last Mile
Middle Mile

Applications for All Other Areas: Per the NOFA, all applications to fund broadband infrastructure projects in areas that are less than 75% rural must be submitted to NTIA for consideration under BTOP.

Please choose the BTOP broadband infrastructure category to which you are applying:

Last Mile
Middle Mile

Eligibility Factors

Application Submission: Failure to comply with all eligibility factors set forth below will result in immediate rejection of your application.

Factors for BIP and BTOP

a) Fully Completed Application: Applicant has submitted a completed application and provided all supporting documentation required for the application.

b) Timely Completion: The Project will be substantially complete within two years of the award date, and the project will be fully complete within three years of the award date.

c) Technical Feasibility: For projects seeking more than $1 million funding, the Applicant has submitted a certification, from a Professional Engineer, that attests that: a) the system will deliver the stated performance; and b) the proposed project will be substantially complete within two years, and fully complete within three years.

d) Broadband Speed: The Applicant provides two-way data transmission with advertised speeds of at least 768 kbps downstream and 200 kbps upstream.

e) Nondiscrimination and Interconnection: Applicant understands and agrees to comply with the nondiscrimination and interconnection obligations outlined in the NOFA.

f) Last Mile Coverage Obligation: If applying for a last mile Broadband Infrastructure project, applicant understands and agrees to comply with the last mile coverage obligations as outlined in the NOFA.

Additional Factors for BIP

g) Eligible Service Area for BIP: At least 75 % of the proposed funded service area qualifies as unserved and underserved rural areas in accordance with the NOFA.

h) Fully Funded: Applicant understands and agrees that the project will be fully funded in accordance with the requirements of the NOFA.

i) Financial Feasibility and Sustainability: Applicant understands and agrees that only projects that RUS determines to be financially feasible and/or economically sustainable will be eligible under this NOFA

Additional Factors for BTOP

j) Conformity with Statutory Purposes: The project advances at least one of the statutory purposes for BTOP.

k) Cost Sharing/Matching: Applicant is providing matching funds of at least 20 %towards to the total eligible project costs or is requesting a waiver of the matching requirement

Yes
Requesting Waiver

l) Demonstration the Project Could not be Implemented But For Federal Grant Assistance: Applicant has provided documentation that the project would not have been implemented during the grant period without federal grant assistance.

m) Reasonableness of Project Budget: Applicant has provided a budget that is appropriate to the proposed technical solution and only includes eligible costs.

Direction for Written Responses: Page limits are designated for certain written responses. Per instructions in the Application Guidelines, please use 12 point font with one-inch margins.

C. Executive Summary

Executive Summary of Project for BIP and BTOP: Please provide an Executive Summary of the proposed Project. The Executive Summary should be a brief description of the Project, and address the following topics. [Three Page Limit]

Opportunity the proposed system seeks to address
A general description of the proposed funded service areas (location, number of communities, etc.)
Number of households and businesses passed
Number of community anchor institutions, public safety entities, and critical community organizations passed and/or involved with project (e.g., health care, education, libraries, etc.)
Proposed services and applications for the proposed funded service areas and users
Approach to addressing the non-discrimination and interconnection obligations
Type of broadband system that will be deployed (network type and technology standard)
Qualifications of the applicant that demonstrate the ability to implement and operate a broadband infrastructure, and/or be a sustainable broadband services provider
Overall infrastructure cost of the broadband system
Overall expected subscriber projections for the project
Number of jobs estimated to be created or saved as a result of this project

Description of BTOP Project Purpose (BTOP Applicants Only Next Three Questions)

BTOP Statutory Purpose: Please indicate which statutory purposes – as designated for the Broadband Technology Opportunities Program from the Recovery Act – you are addressing with this proposal. (Check all that apply. One is required.)

Provide access to broadband service to consumers residing in “unserved” areas of the United States
Provide improved access to broadband service to consumers residing in “underserved” areas of the United States
Provide broadband education, awareness, training, access, equipment, and support to –
- Schools, libraries, medical and healthcare providers, community colleges and other institutions of higher education, and other community support organizations by or through these organizations
- Organizations and agencies that provide outreach, access, equipment, and support services to facilitate greater use of broadband service by low-income, unemployed, aged, and otherwise vulnerable populations
- Job-creating strategic facilities located within a State-designated economic zone, Economic Development District designated by the Department of Commerce, Renewal Community or Empowerment Zone designated by the Department of Housing and Urban Development, or Enterprise Community designated by the Department of Agriculture
Improve access to, and use of, broadband service by public safety agencies
Stimulate the demand for broadband, economic growth, and job creation

Description of BTOP Project Purpose: Describe the purpose of the project and how it supports the statutory objectives of the BTOP program (as set forth above). Please include information to support your assumptions relative to the following. [Two Page Limit]

Project addresses compelling problem or presents an opportunity consistent with the BTOP statutory goals
Project offers an effective solution to that problem or addresses the opportunity
Proposed solution demonstrates broad significance and includes developments that can be replicated to improve future projects
Whether the proposed funded service area is in an unserved or underserved area
The extent to which the project addresses more than one statutory purpose.

BTOP Enhanced Services for Health Care Delivery, Education, and Children: Describe the depth and breadth of the project’s ability to enhance broadband service for health care delivery, education and children as contemplated by the Recovery Act. Demonstrate how this project goes beyond providing broadband access to include a more robust health care, educational or related broadband service delivery. [One Page Limit]

D. Proposed Funded Service Area

Proposed Funded Service Area Maps: Please attach service area maps for each proposed service area to be funded, identifying the service area as: a) unserved; b) underserved; or c) for BIP, at least 75% rural. If a proposed funded service area is designated as at least 75 % rural, identify the unserved and underserved rural areas at the census designated community level. For a middle mile project the maps must indicate the service areas that will benefit from the project. As per the NOFA, at least one interconnection point for a middle mile project must terminate in a proposed funded service area that qualifies as unserved or underserved for a last mile project.

Identify the Map ID # for each Proposed Funded Service Area

Service Area	Map ID #

Proposed Funded Service Area (Last Mile Project): For each proposed funded service area identified in Question 12 above, please provide the following information:

Service Area Name
List of the contiguous census blocks
Total population using the last decennial Census
Total number of Households
Total number of Businesses
Total number of Critical Community Facilities, Community Anchor Institutions and Public Safety Entities
Individual census designated communities or “other areas”

Status of census designated community or “other area” as rural. Clarify the individual census designated communities in the proposed funded service area as being rural as defined in the NOFA or non rural, and specify the number of square miles in each census community. For areas that are not designated as part of a census community, identify these areas as an "other area" for the county and state in which they are located and specify whether such area is rural, as defined in the NOFA, or non-rural and the number of square miles in such area.

For BIP only. Status of the census designated community or "other area" as unserved, underserved, or Served

(A) Unserved. At least 90 % of households in the census designated community or "other area" lack access to facilities-based, terrestrial broadband service, either fixed or mobile, at the minimum broadband transmission speed; or

(B) Underserved (Indicate all that apply. One is required)

(1) No more than 50% of the households in the census designated community or "other area" have access to facilities-based, terrestrial broadband service at greater than the minimum broadband transmission speed;

(2) No fixed or mobile broadband service provider advertises broadband transmission speeds of at least 3 mbps downstream in the census designated community or "other area;" or

(3) The rate of broadband subscribership for the census designated community or "other area" is 40 % of households or less; or

(C) For BIP only, Served. (Please note that no more than 25% of the proposed funded service area may not meet the unserved or underserved definition at the census designated community level or does not meet the rural definition.)

For BTOP only. Status of the proposed funded service area as unserved or underserved

(A) Unserved. At least 90 % of households in the proposed funded service area lack access to facilities-based, terrestrial broadband service, either fixed or mobile, at the minimum broadband transmission speed; or

(B) Underserved (Indicate all that apply. One is required.)

(1) No more than 50 % of the households in the proposed funded service area have access to facilities-based, terrestrial broadband service at greater than the minimum broadband transmission speed;

(2) No fixed or mobile broadband service provider advertises broadband transmission speeds of at least 3 mbps downstream in the proposed funded service area; or

(3) The rate of broadband subscribership for the proposed funded service area is 40 % of households or less

Proposed Funded Service Area (Middle Mile Project): For the proposed middle mile project, please provide the following information:

Middle mile span name:
List of contiguous census blocks for proposed middle mile project
List of associated last mile service areas indicating the following:

Total population using the last decennial Census
Total number of Households
Total number of Businesses
Identify Critical Community Facilities, Community Anchor Institutions and/or Public Safety Entities expected to be direct customers
Individual census designated communities or “other areas”

Status of census designated community or “other area” as rural. Clarify the individual census designated communities in the associated last mile service area as being rural as defined in the NOFA or non rural, and specify the number of square miles in each census community. For areas that are not designated as part of a census community, identify these areas as an "other area" for the county and state in which they are located and specify whether such area is rural, as defined in the NOFA, or non-rural and the number of square miles in such area.

For BIP only. Status of the census designated community or "other area" as unserved, underserved, or served

(B) Underserved (indicate all that apply. One is required)

(1) No more than 50 % of the households in the census designated community or "other area" have access to facilities-based, terrestrial broadband service at greater than the minimum broadband transmission speed;

(2) No fixed or mobile broadband service provider advertises broadband transmission speeds of at least 3 mbps downstream in the census designated community or "other area;" or

(3) The rate of broadband subscribership for the census designated community or "other area" is 40 % of households or less; or

(C) For BIP only, Served. (Please note that no more than 25% of the proposed funded service area may not meet the unserved or underserved definition, or does not meet the rural definition)

For BTOP, Status of each of the proposed last mile service areas as unserved or underserved

Unserved

At least 90 % of households in the proposed funded service area lack access to facilities-based, terrestrial broadband service, either fixed or mobile, at the minimum broadband transmission speed; or

Underserved (Indicate all that apply. One is required)

No more than 50 % of the households in the proposed funded service area have access to facilities-based, terrestrial broadband service at greater than the minimum broadband transmission speed;
No fixed or mobile broadband service provider advertises broadband transmission speeds of at least 3 mbps downstream in the proposed funded service area; or
The rate of broadband subscribership for the proposed funded service area is 40 % of households or less

Non-Funded Service Area (BIP Only): If applicable, for all areas of an applicant's service area that will not be funded by BIP or BTOP, please provide the following information in the aggregate for such areas:

Total population using the last decennial Census
Total number of Households
Total number of Businesses
Total subscriber numbers

Coverage Waiver: There is a presumption that applicant will provide service to the entire territory of each census block included in the proposed funded service area, unless the applicant provides a reasoned explanation as to why providing coverage for the entire census block is infeasible. Applicants may be permitted to serve less than the entire census block under certain conditions. For example, an applicant might request to be relieved of this requirement if the census block exceeds 100 square miles or more or is larger than the applicant’s authorized operating territory, e.g., it splits a rural incumbent local exchange carrier’s (ILEC’s) study area or exceeds the boundaries of a wireless carrier’s licensed territory.

State whether the applicant is seeking a waiver for providing less than 100% coverage of a census block.

Yes (provide supporting documentation)
No

Methodology for Area Status: Describe the methodology, source of data, and analytical approaches used to determine whether the proposed funded service areas are classified as “unserved,” “underserved,” or for BIP, at least 75% rural. [Limit One page]

Middle Mile Benefits: Identify the last mile service areas for which your middle mile project will provide service. List the service providers with whom the proposed network proposes to interconnect with as well as the critical community facilities, community anchor institutions and public safety entities that the network will target as direct customers. Please provide the projected end users that will be served by these proposed connections and the basis for these end-user projections. If applicable, describe the level of need or vulnerability and how such connections will enhance services to the community beyond providing broadband service.

E. Proposed Service Offerings

Broadband Service Offerings for Last Mile Project: Please download and upload Attachment A describing the proposed broadband service features for download/upload speeds, latency, and price (if applicable). *For price, state the price that a subscriber would have to pay absent special promotions and discounts.

Service Offerings for Middle Mile Project: Please download and upload Attachment B describing the service offerings including speed, price, and other facts that demonstrate the value of your service. In addition, please provide a description of how you will make it available to the broadest group of users (e.g. libraries, hospitals, educational institutions, public safety, etc) and if there are any restrictions on use. (Two Pages Limit).

Competitive Service Providers

Existing Broadband Service Providers and Services Offered: Please complete and upload a table based on the formats provided in Attachment C. For last mile projects, describe the service offerings currently being advertised in the proposed funded service area. For middle mile projects, describe the middle mile service offerings currently being advertised in the last mile service areas of the proposed middle mile project.

Non-Discrimination, Interconnection

Description of Network Openness: Please explain how the proposed project will be consistent with the NOFA’s non-discrimination and network interconnection obligations. In addition, describe the interconnection, non-discrimination, and network management practices that would be adopted if you are awarded BIP or BTOP funds. [One Page Limit]

Non-Discrimination and Interconnection (BTOP applicants only for next three questions)

Non-Discrimination Obligations (applicable to Last Mile and Middle Mile Applicants): Please check the following boxes as applicable. Regarding non-discrimination, you will:

Adhere to the minimum non-discrimination requirements as set forth in the NOFA.
Display the nondiscrimination practices in a prominent location on the service provider’s web page, and provide notice to customers of changes to these policies.

Interconnection Obligations (applicable to Last Mile Applicants): Please check the following boxes as applicable. Regarding interconnection, you will:

Adhere to the minimum interconnection requirements as set forth in the NOFA.
Display the interconnection policies in a prominent location on the service provider’s web page, and provide notice to customers of changes to these policies.
Commit to offering wholesale access to the project facilities at reasonable rates and terms.
Commit to binding private arbitration of disputes concerning interconnection obligations.

Interconnection Obligations (applicable to Middle Mile Applicants): Please check the following boxes as applicable. Regarding interconnection, you will:

Adhere to the minimum interconnection requirements as set forth in the NOFA.
Display the interconnection policies in a prominent location on the service provider’s web page, and provide notice to customers of changes to these policies.
Commit to offering wholesale access to network components and services such as wavelength or fibers at reasonable rates and terms.
Commit to binding private arbitration of disputes concerning interconnection obligations.

Cost Effectiveness and Affordability

Cost per Household (BTOP only): For last mile projects, taking into account the total cost of the proposed project, estimate the cost per household (provide supporting data for the proposed pricing).

27. Affordability: Explain why the pricing for your broadband service offerings are affordable in comparison to the pricing of existing broadband services in proposed funded service area. If there are no existing broadband services in the proposed funded service area, please explain why the proposed pricing is appropriate for the area (provide supporting data for the proposal).

F. Technology Strategy

28. Technology Type: Please identify the network technology(ies) that will be used to deliver service to the final link to customer premises. Check all that apply.

Wireline

xDSL
Coaxial cable
Fiber-optic cable
Broadband over Power Line
Hybrid system – Please specify __________________
Other Wireline – Please specify __________

Wireless

Terrestrial Fixed Wireless
Terrestrial Mobile Wireless
Satellite

Other________________________ __________

29. System Design: Provide a description of the system design used to deliver the broadband service. Please address and provide sufficient detail for a reviewer to evaluate the soundness of the design. [Three Page Limit]

The key network components that enable connectivity from the end-user to the Internet backbone – showing what will be funded versus what already exists
For wireless access, state the frequency, how much spectrum is available, technology used, morphology of the area, topology of the area, power levels at the user devices, whether or not mobile
Specific advantages for using this particular technology strategy, taking into account service offering capacity, speed, reliability, and cost effectiveness
Paths to upgrade the system and add additional capabilities in the future

30. Network Diagram: Provide a network diagram for your Project. An example is provided in the Guidelines for last-mile projects. The diagram must show:

All the network elements and the capacity, facilities, and mileage between each element
The types of facilities used in connecting all the network elements (fiber, copper, microwave, etc.)
The points-of-connection with the backbone service providers, if applicable
The proposed Aggregation Node facilities that will provide the egress point(s) from the broadband backbone to the networks of the selected service provider(s) and the selected Internet Service Provider(s) and any other value-added services that may be provided in the new infrastructure
Wireless Systems: Please state the antennae height, cell site radius and approximate coverage area for each access point
For middle mile projects, the points of interconnection in the proposed funded service area, including the extent to which these interconnection points are in unserved or underserved service areas

31. Certification by Professional Engineer: For Projects requesting more than $1 million in funding, the network diagram and system design must be certified by a Professional Engineer registered in the state(s) where the service will be provided. The certification must indicate that the proposed broadband system will work as described in the System Design and Network Diagram sections, and can deliver the proposed services outlined in the Proposed Service Offerings Section. Moreover, the certification must indicate that Applicant can meet the proposed build-out timeframe and will substantially complete the project within two years, and complete it within three years. Download and upload Attachment D.

32. Buy American Requirement: Are you seeking a waiver of the Buy America provision?

Yes. If yes, please provide a legal justification.

33. Choice of Service Provider: Does the project’s infrastructure and the company’s business plan allow more than one provider to serve end users in the proposed funded service area?

G. Project Milestones and Completion Factors

Timeline & Milestones

34. Infrastructure Build-out Timeline: Using the formats provided in Attachment E please complete and upload the project plan and the build-out timeline showing the following on a quarterly basis for each year of the project (based on the date of award funding.

Milestones: Milestones for key network build-out stages, could include: a) network design; b) securing of all relevant licenses and agreements; c) site preparation; d) equipment procurement; e) inside plant deployment; f) outside plant deployment; g) equipment deployment; h) network testing; and i) network complete and operational
Covered Households, Businesses and Community Anchor Institutions/Public Safety Entities: The number and percentage of households, businesses, community anchor institutions, public safety entities and/or critical community facilities in the proposed coverage footprint that will have access to the network
Challenges: Describe the key challenges, if any, to a timely completion of the project, including any applicable mitigation plans.

35. Licenses, Regulatory Approvals and Agreements: Please list all of the licenses and regulatory approvals required to implement and operate the proposed project, and indicate the status of each. Please address the following if relevant: Tower Leases, Equipment Leases, Building Leases, Land Leases, FCC Authorizations, State Authorizations, Video Franchise Agreements, Leasing of Local Loops, etc.

36. Construction and Vendor Contracts: Identify the extent to which you intend to rely on contractors and/or vendors to deploy the network facilities. Please provide any evidence that contractors and/or vendors are ready to enter into agreements with the applicant, should the application be approved. Signed contracts or other signed agreements would carry the most weight with respect to evidence, but are not necessary.

Qualification of Management Team and Organizational Readiness

37. Management Team Resumes: Provide resumes of the senior management team and project team members significant to the project’s success. Please identify their years of experience and relevant expertise with projects of similar size, scope and complexity. Please identify specific prior (or current) projects, dates, and outcomes that showcase the management team’s track record as relevant to executing this project. [Each resume can be up to one page; limit overall summary of track record to one page.]

38. Organizational Readiness: Describe key factors to indicate how your organization will be prepared to implement, manage and operate a broadband services network. Describe the organizational governance and management. Address how your organization will ensure that the necessary sales, operational, and billing support systems are in place to provide the proposed services (e.g., network management, provisioning, billing and customer care, etc.)

Other

39. Organizational Chart: Please include an organizational chart that details the structure of your organization including any parent, subsidiary, affiliates, or partnership organizations.

40. Legal Opinion: Please complete and upload the legal opinion (Attachment F) that addresses the applicant’s ability to enter into the award documents and that describes all pending litigation matters, and additionally for loan and loan/grant combinations, that addresses the applicant’s ability to pledge security as required by the award documents.

41. Government and other Key Partnerships: If applicable, please identify your strategy for partnering with unaffiliated organizations in the project area (from the public, non-profit, and private sectors), particularly community anchor institutions and public safety entities, that will play an integral role in the Project’s planning and ongoing operations. Identify each organization, the type and degree of its role and/or contribution, and projected impact. Please provide documentation of support from each of the organizations identified. ([1/2 Page Limit ½ Page for summary, no limit on supporting documentation

42. Recovery Act and Other Governmental Collaboration. Describe how your project will leverage Recovery Act or other state or federal development programs such as Department of Energy, Department of Transportation and Department of Housing and Urban Development Recovery Act programs. Please identify the programs themselves and the dollar value of those programs. In addition, specify how collaboration can lead to greater project efficiencies. [One Page Limit]

Community Involvement (BTOP Applicants Only)

43. Partnering with Disadvantaged Small Businesses: If applicable, indicate whether you have established agreements in principle to contract with socially and economically disadvantaged small businesses (SDB), as defined by section 8(a) of the Small Business Act, 15 U.S.C. §637. If you have established a partnering relationship with an SDB, please specify the arrangements of that partnership. [1/2 Page Limit]

H. Project Budget

	Budget
		Loan Request	Grant Request	Equity	Debt	Bonds	Other Funding	Total
Network & Access Equipment (switching, routing, transport, access)
Outside Plant (cables, conduits, ducts, poles, towers, repeaters, etc.)
Buildings and Land – (new construction, improvements, renovations, lease)
Customer Premise Equipment (modems, set-top boxes, inside wiring, etc.)
Billing and Operational Support Systems (IT systems, software, etc.)
Operating Equipment (vehicles, office equipment, other)
Professional Services (engineering design, project management, consulting, etc.)
Testing (network elements, IT system elements, user devices, test generators, lab furnishings, servers/computers, etc.)
Site Preparation
Other
Total Broadband System

44. General Overall Budget: Please fill out the following table.

45. Detailed Budget: Please download and upload Attachment G, a detailed budget of the proposed project.

46. Reasonableness: Concisely and convincingly explain why the unit price and total number of units required for this project are reasonable to deliver your proposed services in the designated proposed funded service areas. Provide any relevant data and summaries of your analysis (e.g., industry benchmarks around units required per household or institutions served, etc.) [One Page Limit]

Sustainability

47. Historical Financial Statements: Please provide the following financial statements for the last two (2) years: a) Income Statement; b) Balance Sheet; and c) Statement of Cash Flows (CPA audits if available); start-up firms should provide the most recent financial statements

48. Broadband Subscriber Estimates: Please download and upload Attachment H, regarding subscriber projections, including households, businesses, community anchor institutions, public safety entities, and/or critical community facilities for each of your service offerings, along with a brief description of the methodology used to forecast this on a separate sheet. For last mile subscribers, provide your estimated take rate (the percentage of total customers passed who will subscriber to your service), along with a brief description of the methodology used to forecast this.

49. Other Services (BIP Only): Please download and upload Attachments I and J, regarding other services that you plan to sell or provide in addition to broadband Internet access services. (e.g., Voice, Video, etc.)

50. Pro Forma 5-Year Financial Forecast and Assumptions: Please submit the following pro-forma financial statements (on an annual basis) for a five (5) year forecast period as applicable: Balance Sheet, Income Statement, and Statement of Cash Flows. Please use the Attachments K, L, and M to document the components of the financials.

In addition, please upload a table(s) that list all assumptions used to produce the financials and a brief explanation of why each assumption is reasonable for your business case.

51. Commitment of Capital Funding Support: Please identify all sources of funding committed to the project (other than the funding sought through the BIP or BTOP award) including the funds from federal and non-federal sources. Please include the following:

Name of Party
Funding Amount [and % of project cost]
Type of Funding (e.g., grant match, equity, debt, internal, other)
Use of Funding (infrastructure, working capital, operating losses, other)
Key Financing Terms and Conditions

BTOP Requirements

52. Matching Funds: Please specify the percentage of matching funds you will contribute to the project, as well as the total amount of the contribution, as well as the specific amounts that are in cash or in-kind, and/or a combination thereof. If you have requested a waiver of the matching requirement, provide a letter attachment clearly defining your financial need. An applicant applying for a waiver should submit complete financial documentation, including its assets, liabilities, operating expenses and revenues, and any other documents that would demonstrate financial need, such as a denial of funding from a public or private lending institution.

__________%
Total Contribution $____________
Cash $__________
In-kind $_________

53. Demonstration of Financial Need: Please explain the reasons regarding why the project would not have been implemented “but for” federal grant assistance. Provide any key data points and analysis to substantiate this case. The NOFA provides examples of documentation that can be used to make this case.

54. Unjust Enrichment: Please state whether this project is receiving or if you have applied for any Federal support for non-recurring costs in the area for which you are seeking an award. If so, please state how much and from which federal program.

55. Disclosure of Federal and/or State Funding Sources: Disclose the source and amount of other federal or state funding including, but not limited to all Universal Service Funds, the applicant has received or has requested for activities or projects to which the application relates.

I. Self Scoring – BIP only

56. Self Scoring Sheet: Please complete the self-scoring chart for the applicant's proposal.

Criteria	Method	Points	Self Score

PROJECT PURPOSE
Proportion of Rural Residents Served in Unserved Areas	1 point for every 10,000 unserved households	1 - 5
Rural Area Targeting	1 point for every 5% increase in the rural service area up the minimum 75% rural area requirement	5
Remote Area targeting	1 point for every 50 miles a service area is located from a non-rural area	5
Title II Borrower	If you are or were a Title II borrower	5
Recovery Act and other governmental collaboration	1 point will be awarded for each governmental or Recovery program the applicant is partnering with	5
PROJECT BENEFITS
Performance of the offered services	If a last mile wireline project delivers 20M to household – if a last mile wireless projects delivers 2M to end-user – if a middle mile projects delivers 100M to end points	10
Affordable of services offered	Points awarded based on the proposed rate structure and the logistics of the proposed funded service area	1 - 5
Choice of service provider	If the proposed infrastructure is available to be used by multiple service providers	5
Critical Community Facilities	If discounted rate packages at least 25% lower than advertise rates are available to critical facilities	5
PROJECT VIABILITY
Applicant’s organizational capability	Points will be awarded on the strengths and accomplishments of key management	1 - 12
Community Support	If a letter of support has been received from a designated representative of the community for every community in the proposed service territory	2
Ability to promptly start project	If the applicant can demonstrate that all licenses and regulatory approvals have been received, contractors and vendors are ready to enter into contracts, and equity has been deposited into applicant accounts	10
Socially and economically disadvantaged small businesses (SDB), as defined by section 8(a) of the Small Business Act, 15 U.S.C. §637.	If the applicant is a Section 8(a) entity	1
PROJECT BUDGET AND SUSTAINABLITY
Reasonableness of the budget	Points will be awarded based the adequacy of the proposed budget	1 - 5
Leverage of outside resources (outside funding/financing requested)	(i) 10 points if this ratio is greater than 100% (ii) 7 points if this ratio is between 100% and 75% (iii) 5 points if this ratio is between 75% and 50% (iv) 3 points if this ratio is between 50% and 25% (v) 1 points if this ratio is lower than 25%	10
Extent of grant funding (Grant funds/loan funds)	(i) 0 points if this ratio equals 100% (ii) 1 points if this ratio is between 100% and 75% (iii) 3 points if this ratio is between 75% and 50% (iv) 5 points if this ratio is lower than 50% (v) 10 points if no grant funds are requested	10
Total Points		100

J. Certification Requirements for BTOP

U .S. Department of Commerce

Broadband Technology Opportunities Program

(i) I certify that I am authorized to submit this grant application on behalf of the eligible entity(ies) listed on this application, that I have examined this application, that all of the information and responses in this application, including certifications, and forms submitted, all of which are part of this grant application, are material representations of fact and true and correct to the best of my knowledge, that the entity(ies) that is requesting grant funding pursuant to this application and any subgrantees and subcontractors will comply with the terms, conditions, purposes, and federal requirements of the grant program; that no kickbacks were paid to anyone; and that a false, fictitious, or fraudulent statements or claims on this application are grounds for denial or termination of a grant award, and/or possible punishment by a fine or imprisonment as provided in 18 U.S.C. §1001 and civil violations of the False Claims Act.

(ii) I certify that the entity(ies) I represent have and will comply with all applicable federal, state, and local laws, rules, regulations, ordinances, codes, orders and programmatic rules and requirements relating to the project. I acknowledge that failure to do so may result in rejection or deobligation of the grant or loan award. I acknowledge that failure to comply with all federal and program rules could result in civil or criminal prosecution by the appropriate law enforcement authorities.

(iii) I certify that the entity(ies) I represent has and will comply with all applicable administrative and federal statutory, regulatory, and policy requirements set forth in the DOC Pre-Award Notification, published in the Federal Register on February 11, 2008 (73 FR 7696), as amended; DOC Financial Assistance Standard Terms and Conditions (Mar. 8, 2009); DOC American Recovery and Reinvestment Act Award Terms (April 9, 2009); and any Special Award Terms and Conditions that are included by the Grants Officer in the award."

__________________________ ____________________________________________

(Date) (Authorized Representative’s Signature)

____________________________________________

Name:

____________________________________________

Title:

U .S. Department of Commerce

Broadband Technology Opportunities Program

SF-424D Assurances—Construction Programs (Schedule N)

U .S. Department of Commerce

Broadband Technology Opportunities Program

CD-511, Certification Regarding Lobbying (Attachment O)

U .S. Department of Commerce

Broadband Technology Opportunities Program

SF-LLL, Disclosure of Lobbying Activities (Attachment P)

U .S. Department of Commerce

Broadband Technology Opportunities Program

CD-512, Certification Regarding Lobbying—Lower-Tier Covered Transactions (Attachment Q) This certification will not be required until the time of the grant award, because it applies to subcontractors, etc.

Certifications (requested from BIP)

Equal Opportunity and Nondiscrimination Certification

U .S. Department of Agriculture

Broadband Initiatives Program

All loans and grants made under the Broadband Initiatives Program are subject to the nondiscrimination provisions of Title VI of the Civil Rights Act of 1964, as amended, (7 C.F.R. Part 15); Section 504 of the Rehabilitation Act of 1973, as amended, (29 U.S.C. 901 et seq; 7 C.F.R. Part 15b); and the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101 et seq.; 45 C.F.R. Part 90), and Executive Order 11375, Amending Executive Order 11246, Relating to Equal Employment Opportunity (3 C.F.R. 1966, 1970).

All recipients of financial assistance from Rural Development, the prospective primary participant commits to carry out Rural Development’s 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 Broadband Initiatives Program.

We __________________________________________________ (the Applicant) hereby certify that, as a prospective recipient under the said Broadband Initiatives Program, we will comply with the above referenced laws and executive orders.

__________________________ ____________________________________________

(Date) (Authorized Representative’s Signature)

____________________________________________

Name:

____________________________________________

Title:

Certification Regarding Architectural Barriers

U .S. Department of Agriculture

Broadband Initiatives Program

All facilities financed with Rural Development loans 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 C.F.R. subpart 101-19.6).

As a prospective primary participant recipient of financial assistance from Rural Development, this organization commits to carry out Rural Development’s 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.

We, _______________________________________ (the Applicant) hereby certify that, as a prospective recipient under the Rural Broadband Access Loan and Loan Guarantee Program, we are in compliance, or will be in compliance upon completion of the Project, with the above referenced law.

__________________________ ____________________________________________

(Date) (Authorized Representative’s Signature)

____________________________________________

Name:

____________________________________________

Title:

Uniform Relocation Assistance and Real Property Acquisition

Policies Act of 1970 Certification

U .S. Department of Agriculture

Broadband Initiatives Program

We, __________________________________ (the Applicant) assure the U.S. government that we will comply with the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, as amended, 42 U.S.C. §4601 et seq., and with implementing federal regulations in 49 C.F.R. Part 24 and 7 C.F.R. Part 21.

Specifically, we 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)

____________________________________________

Name:

____________________________________________

Title:

Certification Regarding Debarment, Suspension, and Other Responsibility Matters –

Primary Covered Transactions

U .S. Department of Agriculture

Broadband Initiatives Program

This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 7 C.F.R. § 3017.510, Participants’ Responsibilities.

(1) We, _____________________________ (the Applicant) (hereinafter the “Company”) hereby certify to the best of our knowledge and belief that neither the Company, nor any of its principals:

(a) are presently debarred, suspended, proposed for Debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) have 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 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 within a 3-year period preceding this Application had one or more public transactions (Federal, State, or local) terminated for cause or default.

(2) If we are unable to certify to any of the statements in this certification, we shall attach an explanation hereto.

__________________________ ____________________________________________

(Date) (Authorized Representative’s Signature)

____________________________________________

Name:

____________________________________________

Title:

Certification Regarding Lobbying for Contracts, Grants, Loans, and Cooperative Agreements

U .S. Department of Agriculture

Broadband Initiatives Program

We, _________________________________ (the Applicant) the undersigned certify, to the best of our knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on our behalf, 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, we shall complete and submit Standard Form-LLL, Disclosure Form to Report Lobbying, in accordance with its instructions. See http://www.whitehouse.gov/omb/grants/sflllin.pdf for Disclosure Instructions.

(3) We 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 31 U.S.C. § 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

________________________ ___________________________________

(Date) (Authorized Representative’s Signature)

___________________________________

Name:

___________________________________

Title:

Network Design and Implementation Plan Certification (to be complete for projects requesting more than $1 million in federal assistance)

U .S. Department of Agriculture and U.S. Department of Commerce

BIP and BTOP Program

We the undersigned, certify that the proposed broadband system will work as described in the System Design and Network Diagram sections, and can deliver the proposed services outlined in the Service Offerings Section. Moreover, the system, as designed, can meet the proposed build-out timeframe based on the resources designated in Project Viability Section, and will be substantially complete in two years, and complete within three years.

________________________ ___________________________________

(Date) (Authorized Representative’s Signature)

___________________________________

Name:

___________________________________

Title:

________________________ ___________________________________

(Date) (Certifying Engineer's Signature)

___________________________________

Name:

___________________________________

Title:

L. Schedules

Schedule: A-1 Congressional Districts

Congressional District

(Fill)

1. State the Congressional District of the Applicant’s headquarters.

State the Congressional District for each area covered by the Project.

Step Two for BIP and BTOP Infrastructure Applications

For purposes of the Step Two process, applicants will be asked to submit additional information to further substantiate the representations made in their applications. The following will be required in Step Two for BIP and BTOP Broadband Infrastructure Applications:

1. Outstanding Obligations: The applicant must provide a list of all outstanding and contingent obligations, including copies of existing notes, loan and security agreements, and guarantees;

2. Working Capital: The applicant must provide a detailed description of working capital requirements and the source of these funds;

3. Detailed Network Design: A detailed description of the proposed technology that will be used to provide service at the proposed broadband speed. This description must clearly demonstrate that all households in the proposed funded service area will be offered service at the proposed broadband speed;

4. Detailed Build-Out Schedule: The application must provide a detailed construction build-out schedule that includes a description of the necessary work force, a timeline demonstrating project completion within the required timeframe, a depreciation schedule for the proposed facilities, the appropriate environmental review documentation prepared in accordance with 7 CFR Part 1794 and other applicable environmental requirements, and other information listed as required within the online application;

5. Environmental Questionnaire: the applicant must complete download and upload the environmental questionnaire;

6. Underlying Documentation: applicants will need to be prepared to provide any of the underlying documentation that is referenced in the application, as appropriate; and

7. Service Metric: For BIP applicants only, the applicant must provide a description of measurable service metrics and target service level objectives (SLOs) (e.g., the speed with which new service will be established, service availability, and response time for reports of system failure at a residence) that will be provided to the customer, and a description of the approach and methodology for monitoring ongoing service delivery and service quality for the services being employed.

Environmental Questionnaire

Any project-related activity that may adversely affect the environment must not be undertaken prior to the completion of Rural Utilities Service/National Telecommunication and Information Administration environmental review process. Doing so may jeopardize consideration of your application. All of the following questions must be completed or the application will be considered incomplete. Note: The applicant may submit a copy of any environmental review 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.

Project Description:- Describe all project-related construction activities, including, but not limited to building construction related to installing pre-fabricated buildings; internal modifications, or equipment additions to buildings or other structures (e.g., relocating interior walls or adding computer facilities); the construction and installation of buried cable; or installation of telecommunications transmission facilities including construction of new monopole towers, satellite dishes. Complete descriptions must be provided for each site affected by project-related construction activities.

Map: Include a map for each site affected by construction (recommend U.S. Geological Survey 7.5-minute quadrangle maps at a map scale of 1:24,000; larger scale maps may be provided for site-specific proposals). USGS maps may be obtained and purchased at the following website: http://www.usgs.gov/pubprod/maps.html. If appropriate, photographs or aerial photographs of site-specific proposals may be provided.

Property Changes: Describe and indicate the amount of property to be cleared, excavated, fenced, or otherwise disturbed by the project and describe the current land use and zoning for each project site affected by construction including whether the project is proposed to be located on public land owned or managed by the federal government.

Buildings: Describe buildings or other structures (i.e., transmission facilities), including dimensions, to be constructed or modified. For linear projects, state whether the project is to be located on or within previously disturbed public rights-of-way.

Wetlands: Describe and indicate whether wetlands are present on or near the project site(s) affected by construction (maps of wetlands may be obtained from the U.S. Fish and Wildlife Service’s National Wetland Inventory website: http://www.fws.gov/wetlands/ or from soil maps obtained from the USDA, Natural Resource Conservation Service’s website: http://websoilsurvey.nrcs.usda.gov/app/HomePage.htm).

Critical Habitats: Describe and indicate whether any project site(s) include or are near critical habitats or will affect any threatened, endangered or candidate species. Applicants must provide species lists and appropriate specie accounts obtained from the U.S. Fish and Wildlife Service’s website: http://ecos.fws.gov/tess_public/ for each county affected by construction of the project.

Floodplains: Describe whether or not any facility(ies) or site(s) are located within a 100 or 500-year floodplain. Information related to floodplains and National Flood Insurance Maps may be obtained from the Federal Emergency Management Agency’s (FEMA) website http://www.msc.fema.gov/webapp/wcs/stores/servlet/CategoryDisplay?catalogId=10001&storeId=10001&categoryId=12001&langId=-1&userType=G&type=1. If any project-related construction activities are within floodplains, a copy of the FEMA, “FIRMette” with construction activities depicted on the map must be included. For obtaining FIRMettes review the tutorial provided by FEMA.

Protected Lands: Describe any cultural resources, including historic properties, i.e., properties listed in or eligible for listing in the National Register of Historic Places, which are located in or within a one-mile radius of the project area and how they may be impacted by the project. Information related to historic properties can be obtained from the State Historic Preservation Office (SHPO) in your respective State – see the website of the National Conference of SHPO: http://www.ncshpo.org/find/index.htm or from the Tribal Historic Preservation Officer (THPO) when tribal lands are involved. Applicants must gather information about the nature and location of these properties from the SHPO. SHPOs should be asked the following questions:
1. Is the proposed project located on, within or adjacent to any properties listed in or eligible for listing in the National Register of Historic Places? Is the proposed project located on, within or adjacent to a National Historic Landmark? If the answer is yes, describe and indicate the geographic relationship between the project and property with maps.
2. Will the proposed project impact, use or alter a building or structure that was constructed more than 50 years ago? If so, describe the building/structure with a statement of its condition, including photographs, and document its age.
3. Is any portion of the project located on tribal lands, meaning lands within the exterior boundaries of any Indian reservation and all dependent Indian communities?
4. Applicants must provide SHOP/THPO responses/information to these questions including any correspondence with the SHPO/THPO, as applicable.

Coastal Areas: Determine whether or not the project is within the boundaries of a coastal zone management area (CZMA). For boundary related and contact information related to CZMA, see National Oceanic and Atmospheric Administration, Office of Ocean and Coastal Resource Management’s website: http://coastalmanagement.noaa.gov/consistency/welcome.html

Brownfields: Determine whether the project is located within a brownfield site. Per 42 U.S.C. 9601, the term "brownfield site" means real property, the expansion, redevelopment, or reuse of which may be complicated by the presence or potential presence of a hazardous substance, pollutant, or contaminant. Maps and locations of sites, facilities and properties that have been contaminated by hazardous materials and are being, or have been, cleaned up under EPA's Superfund, RCRA and/or brownfields cleanup programs can be found at the following website: http://iaspub.epa.gov/Cleanups/

Note: The applicant may submit a copy of any environmental review 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.

Printed Legal Name of Applicant:

Signature: 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.

Paperwork Reduction Act

The U.S. Department of Agriculture’s Rural Utilities Service (RUS) and NTIA have partnered on the broadband Recovery Act programs. The programs share a common infrastructure application. This infrastructure application contains collection of information requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provision of 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 PRA unless that collection of information displays a currently valid OMB control number.

OMB Control No. for Broadband Initiatives Program (BIP) application: 0572-0142

Expiration Date: 1/31/2010

OMB Control No. for BTOP application: 0660-0031

Expiration Date: 1/31/2010

RUS's estimated response time for step one of the applications is 360.0 hours, and RUS's estimated response time for step two of the application is 35.0 hours. For infrastructure projects, NTIA's estimated response time for step one of the application is 225.0 hours, and NTIA's estimated response time for step two of the application is 170.0 hours. The response time includes 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 estimate or any other aspects of this collection of information, including suggestions for reducing the length of this questionnaire, to

Michele Brooks, Rural Utilities Service

USDA, Rural Development, Stop 1530

1400 Independence Ave, SW

Washington, DC 20250-1530

(202) 690-1078

Gwellnar Banks

U.S. Department of Commerce

1401 Constitution Ave., NW

Washington, DC 20230

(202) 482-3781

Katherine Scott

Communications Policy Analyst, NTIA

U.S. Department of Commerce

Room 4880

(202) 482-2205

Page 39 of 39

File Type	application/msword
File Title	Table of Contents
Author	taxali
File Modified	2009-07-10
File Created	2009-07-10

Broadband Initatives Application Package and Reporting Burdens

Broadband Initiatives Program

Rev Infra App