Technical Assistance Application Form

OMB Number: 0572-xxxx

Expiration Date: 12/31/2010

Technical Assistance Grant Program Application

Submission to the Rural Utilities Service (RUS)

1. Applicant Information

1-A. Name, Address, and Contact Information of Applicant

Full Name of Primary Point of Contact:

Title:

Legal Business Name:

Street 1:

Street 2:

City:

County:

State:

Zip Code:

Email Address:

Telephone Number:

Fax Number:

1-B. Required Identification Numbers of Applicant

Employer/Taxpayer Identification Number (EIN/TIN):

DUNS Number:

CCR (CAGE) Number:

Catalog of Federal Domestic Assistance Number:

1-C. Name and Contact Information of Additional Project Contact

Full Name:

Organization:

Project Role:

Email Address:

Telephone:

1-D. Type of Organization

Please classify your organization. (Note: If there are multiple organizations involved in the project, designate the lead applicant that would enter into a 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 or Limited Liability Company

Other

• Cooperative or Mutual organization

• Native Hawaiian organization

• Please identify any others: ______________________________________

1-E. Type of Eligible Entity

Please classify your entity type:

• Awardee under the First Round NOFA

• Applicant under the Second Round NOFA

• Indian Tribe

1-F. Applicant Federal Debt Delinquency Explanation

Is the Applicant Delinquent On Any Federal Debt? (If “Yes”, attach an explanation to this form.)

Yes No

1-G. Congressional District

List the Congressional District of the Applicant’s headquarters (e.g., CA – 04): _____________

(List the state and congressional district where the applicant is physically headquartered not where the applicant is incorporated.)

2. Co-Applicant Name and Contact Information (Optional)

Please list any additional co-applicants if applicable. If listing more than one co-applicant, please include additional co-applicant information using Attachment A.

Full Name:

Organization:

Project Role:

Email Address:

Telephone:

3. Project Description

Project Title:

Project Description – Provide three to four sentences that most concisely describe the proposed project. The description of the project will be made public consistent with the requirements of the Recovery Act.

How many jobs will be created or saved from this project? _______________

4. Project Budget

What is the total amount of RUS funding being requested for the project? $_______________

(This amount must match the information contained in Attachment B – Detailed Project Budget)

5. Grant Proposal

Along with this application form, the Applicant must submit its Technical Assistance Grant Proposal, which must not exceed twenty (20) consecutively numbered, 8.5x11-inch pages of single-spaced, standard 12-point type with 1-inch margins, addressing all of the following information:

1. An overview of the plan to address the following USDA key strategy: Use of broadband and other critical infrastructure as a strategy to facilitate local entrepreneurship and expansion of market opportunities for small businesses;
   
   

2. The description of the identified Region or USDA Region in need of assistance;
   
   

3. An explanation of the economic integration and cohesion that will be created in the Region or USDA Region with the Award. Proposals with detailed plans for a market study, engineered broadband network, or pro forma financial analysis will be favored. The qualifications of consultants to provide such work should also be addressed;
   
   

4. Evidence of resources which will be used to implement the regional economic and community development strategies, such as letters of endorsement from State and local governments, educational institutions, and the private and nonprofit sectors;
   
   

5. The identity of communities within the Region or USDA Region that would be eligible under RUS’ Infrastructure Telecommunications, Rural Broadband Access, Community-Oriented Connectivity Broadband, and/or Distance Learning and Telemedicine grant and loan programs, and basic data regarding population, numbers of households, numbers and types of businesses, local revenue and employment should be provided;
   
   

6. The amount of the grant request, supported by a detailed budget estimate to create the plan.
   
   

7. A list the objectives of the plan and why the objectives are important. This section should also include any background or introductory information that would help explain the objectives.
   
   

8. An outline of the research design, methods, analytical tools, and techniques that the applicant intends to use in meeting the objectives stated above. Methods must be clearly stated so that the agency can evaluate the appropriateness of the applicant’s approach and tools to be used. A statement such as: “we will evaluate the data using the usual statistical methods” is not specific enough for evaluation.
   
   

9. Describe the expected results, benefits, and outcomes the applicant expects to achieve if awarded the grant and the potential benefits of the results to the communities and region served in the plan. A clear, concise description will help the agency understand the merits of the proposal; and
   
   

10. Discuss other information relevant to the potential success of the project. This should include facilities, personnel expertise/experience, project schedules, proposed management, interactions with other institutions, etc. Applications for multi-investigator projects must identify project management and the functions of each investigator in each team and describe plans to communicate and share data.

Attachments Checklist

The remaining items, #6-#8, are items/questions that the Applicant will complete and attach in the same order outlined within the Application Guide. Attachment A is only required if three or more co-applicants are submitting a single application.

Please complete the following attachments checklist:

Only if applicable: Attachment A – Additional Co-Applicant Information

6. Attachment B – Detailed Project Budget

7. Attachment C – Project Timeline and Milestones

8. Certifications:

Attachment D – Equal Opportunity and Nondiscrimination Certification

Attachment E – Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions

Attachment F – Certification Regarding Lobbying for Contracts, Grants, Loans, and Cooperative Agreements

Application Checklist

Please complete the following checklist to ensure the submission of a complete application:

Have you completely answered Questions 1, 3, and 4 of this form?

If your application has co-applicants, have you completed Question 2 of this form?

Have you completed Question 5 (Grant Proposal), and does it conform to the page limits, margins, font size, and line spacing specified in the RFP?

Have you completed all attachments as required in the prior checklist?

Applicant Certification
The undersigned certifies that he or she is authorized to submit the application on behalf of the eligible entity(ies) listed on the application; that the Applicant has examined the application, that all of the information in the application, including certifications and forms submitted, all of which are part of the application, are material representations of fact and true and correct to the best of his or her knowledge; that the entity(ies) that is requesting funding pursuant to the application and any subawardees will comply with the terms, conditions, purposes, and federal requirements of the program; that no kickbacks were paid to anyone; and that a false, fictitious, or fraudulent statement or claim on this application is grounds for denial or termination of an 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 (31 U.S.C. § 3729 et seq.). The undersigned also certifies that the entity(ies) he or she represents 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. The Applicant acknowledges that failure to do so may result in rejection or deobligation of the award. The Applicant acknowledges that failure to comply with all federal and program rules could result in civil or criminal prosecution by the appropriate law enforcement authorities.
SIGNATURE OF AUTHORIZED OFFICIAL	TITLE	DATE

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