Rural Library Application Form

Rural Library Broadband Grant Program

Application Submission to the Rural Utilities Service (RUS)

1. General Application Information

1. Applicant Information
1-A. Name, Address, and Contact Information of Applicant
Legal Business Name of Applicant:
Full Name of Primary Point of Contact:
Title:
Street 1:
Street 2:
City:
County:
State:
Province:
Country:
Zip/Postal Code:
Email Address:
Telephone Number:
Fax Number:
1-B. Required Identification Numbers of Applicant
Employer/Taxpayer Identification Number (EIN/TIN):
Organizational (DUNS):
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. Name and Contact Information of Environmental Point of Contact
Full Name:
Title:
Email Address:
Telephone:
1-E. Type of Organization
Please classify your organization. (Note: If there are multiple organizations involved in the project, provide information below about the lead Applicant). 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 Native Hawaiian organization Please identify any others: ______________________
1-F. Type of Eligible Entity
Please classify your entity type. Awardees under the First Round NOFA or Secnd Round NOFA Applicants under the Second Round NOFA Provide the EasyGrants ID assigned to your applicable application(s) _______________
1-G. Applicant Federal Debt Delinquency Explanation
Is the Applicant Delinquent On Any Federal Debt? Yes No (If yes, provide an explanation.) _____________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
1-H. Buy American Requirement
Is the Applicant seeking a waiver of the Buy America provision? Yes No (If yes, provide a legal justification) ___________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________
1-I. Congressional District
List the State and Congressional District of the Applicant’s headquarters (e.g. CA-4): ___________________________ (Ensure that you have provided the state and congressional district where the applicant is physically headquartered, not where the applicant is incorporated, unless they are the same.)
2. Co-Applicant Name and Contact Information
Please list any Co-Applicants if applicable. If listing more than one Co-Applicant, please include additional Co-Applicant information as an attachment. (Attachment A)
Organization:
Point of Contact Name:
Project Role:
Email Address:
Telephone:
3. Project Description
Project Title:
Project Description: Provide three or 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. Quality of Service Being Provided
Provide a description of the quality of service provided to the rural library or libraries served by the project. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________
5. Project Benefits
Provide a description of the benefits of your project to the community or communities to be served. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________
6. Project Budget
What is the total amount of RUS funding being requested for the project? $_______________ (Ensure that this amount matches the information contained in Attachment E, the Detailed Project Budget)
Attachments
The remaining items, #7 - #13, are items/questions that the Applicant will complete and attach in the same order outlined within the Application Guide. Additional attachment requirements will be explained further within the Application Guide. Use the checklist below to ensure you have provided all required attachments. 7. Attachment B – Executive Summary 8. Attachment C – Listing of Rural Libraries 9. Attachment D – Certification Regarding Availability of Broadband Service and Community Facilities Funding 10. Attachment E – Detailed Project Budget 11. Attachment F – Project Build-Out Timeline and Milestones 12. Attachment G – Environmental Questionnaire 13. Certifications Attachment H – Equal Opportunity and Nondiscrimination Certification Attachment I – Certification Regarding Architectural Barriers Attachment J – Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 Certification Attachment K – Certification Regarding Debarment, Suspension, and Other Responsibility Matters- Primary Covered Transactions Attachment L – Certification Regarding Lobbying for Contracts, Grants, Loans, and Coop. Agreements
Applicant Certification
The Applicant must certify 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 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, an/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.); and The Applicant certified 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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