Public Television Digital Transition Grant Program

Rural Public Television
Digital Transition Grant
Program

FY 2010

Toolkit
Rural Utilities Service
Rural Development
United States Department of Agriculture

Public Television Station Digital Transition Grant Toolkit - FY 2010

The grant application should be assembled and tabbed in the following order.
Numbered attachments have been provided in this toolkit for your use. Remember
that additional blank forms are available at the Agency Web site
(http://www.usda.gov/rus/telecom). Please use only the applicable attachments in
this toolkit.

Item
No.

Description

Toolkit
Number

1
2
3
4
5
6
7
8
9
10
11
12

1
2

19
20
21

Completed Application for Federal Assistance, Std. Form 424
Summary Worksheet
Evidence of Eligibility
Executive Summary
Project Cost Spreadsheet
Broadcast Coverage Maps
Complete Narrative Description
Applicant’s estimated Rurality Scoring
Applicant’s estimated Economic Need Scoring
Critical Need Information
Federal Communications Commission Authorization
E.O. 11246, Equal Employment Opportunity, as amended by E.O.
11375 and as supplemented by regulations contained in 41 CFR
part 60
Certificate Regarding Architectural Barriers
Certificate Regarding Flood Hazard Area Precautions
Uniform Relocation Assistance and Real Property Acquisition
Policies Act of 1970 Certification
Certification Regarding Drug-Free Workplace Requirements
E.O.s 12549 and 12689, Debarment and Suspension; (See 7 CFR
3017.510)
Byrd Anti-Lobbying Amendment (31 U.S.C. 1352). If the applicant
is engaged in lobbying activities, the applicant must submit a
completed disclosure form, “Disclosure of Lobbying Activities”
(See 7 CFR Part 3018)
Federal Obligations Certification on Delinquent Debt
Environmental Impact and Historic Preservation
Buy American Certification

22

Supplemental Information (If Any)

13
14
15
16
17
18

3
4
5
6
7
8
9

10
11
12

Public Television Station Digital Transition Grant Toolkit - FY2010

APPLICATION FOR
FEDERAL ASSISTANCE

Version 7/03

1. TYPE OF SUBMISSION:
Application

2. DATE SUBMITTED

Applicant Identifier

3. DATE RECEIVED BY STATE

State Application Identifier

4. DATE RECEIVED BY FEDERAL AGENCY

Federal Identifier

Pre-application

✔ Construction

Construction

Non-Construction
5. APPLICANT INFORMATION
Legal Name:

Non-Construction
Organizational Unit:
Department:

Organizational DUNS:

Division:

Address:
Street:

Name and telephone number of person to be contacted on matters
involving this application (give area code)
Prefix:
First Name:

City:

Middle Name

County:

Last Name

State:

Zip Code

Suffix:

Country:

Email:

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

Phone Number (give area code)

-

Fax Number (give area code)

7. TYPE OF APPLICANT: (See back of form for Application Types)

8. TYPE OF APPLICATION:

✔ New
Continuation
If Revision, enter appropriate letter(s) in box(es)
(See back of form for description of letters.)

Revision
Other (specify)

Other (specify)

9. NAME OF FEDERAL AGENCY:

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:

Rural Utilities Service

1 0
TITLE (Name of Program):

-8

6 1

12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):

13. PROPOSED PROJECT
Start Date:

14. CONGRESSIONAL DISTRICTS OF:
a. Applicant
b. Project

Ending Date:

15. ESTIMATED FUNDING:
00

a. Federal

$

.

b. Applicant

$

.

c. State

$

.

00

00

d. Local

$

.

00

e. Other

$

.

00

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
THIS PREAPPLICATION/APPLICATION WAS MADE
a. Yes.
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON
DATE:
b. No.

00

f. Program Income

$

.

g. TOTAL

$

.

PROGRAM IS NOT COVERED BY E. O. 12372

OR PROGRAM HAS NOT BEEN SELECTED BY STATE
FOR REVIEW
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

00

Yes If “Yes” attach an explanation.

No

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT. THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE
ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. Authorized Representative
Prefix
First Name
Middle Name
Last Name

Suffix

b. Title

c. Telephone Number (give area code)

d. Signature of Authorized Representative

e. Date Signed

Previous Edition Usable
Authorized for Local Reproduction

Standard Form 424 (Rev.9-2003)
Prescribed by OMB Circular A-102

Attachment 1

Public Television Station Digital Transition Grant Toolkit - FY2010

INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE
ADDRESS PROVIDED BY THE SPONSORING AGENCY.
This is a standard form used by applicants as a required face sheet for pre-applications and applications submitted for Federal
assistance. It will be used by Federal agencies to obtain applicant certification that States which have established a review and comment
procedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given an
opportunity to review the applicant’s submission.
Item:
1.

Entry:
Select Type of Submission.

Item:
11.

2.

Date application submitted to Federal agency (or State if applicable)
and applicant’s control number (if applicable).

12.

3.

State use only (if applicable).

13

Enter the proposed start date and end date of the project.

4.

Enter Date Received by Federal Agency
Federal identifier number: If this application is a continuation or
revision to an existing award, enter the present Federal Identifier
number. If for a new project, leave blank.
Enter legal name of applicant, name of primary organizational unit
(including division, if applicable), which will undertake the
assistance activity, enter the organization’s DUNS number
(received from Dun and Bradstreet), enter the complete address of
the applicant (including country), and name, telephone number, email and fax of the person to contact on matters related to this
application.

14.

List the applicant’s Congressional District and any District(s)
affected by the program or project

15

Amount requested or to be contributed during the first
funding/budget period by each contributor. Value of in kind
contributions should be included on appropriate lines as
applicable. If the action will result in a dollar change to an
existing award, indicate only the amount of the change. For
decreases, enclose the amounts in parentheses. If both basic
and supplemental amounts are included, show breakdown on
an attached sheet. For multiple program funding, use totals
and show breakdown using same categories as item 15.
Applicants should contact the State Single Point of Contact
(SPOC) for Federal Executive Order 12372 to determine
whether the application is subject to the State
intergovernmental review process.
This question applies to the applicant organization, not the
person who signs as the authorized representative. Categories
of debt include delinquent audit disallowances, loans and
taxes.

5.

6.

Enter Employer Identification Number (EIN) as assigned by the
Internal Revenue Service.

16.

7.

Select the appropriate letter in
the space provided.
I.
State Controlled
A. State
Institution of Higher
B. County
Learning
C. Municipal
J. Private University
D. Township
K. Indian Tribe
E. Interstate
L. Individual
F. Intermunicipal
M. Profit Organization
G. Special District
N. Other (Specify)
H. Independent School
O. Not for Profit
District
Organization
Select the type from the following list:
•
"New" means a new assistance award.
•
“Continuation” means an extension for an additional
funding/budget period for a project with a projected completion
date.
•
“Revision” means any change in the Federal Government’s
financial obligation or contingent liability from an existing
obligation. If a revision enter the appropriate letter:
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
Name of Federal agency from which assistance is being requested
with this application.

17.

8.

9.

10.

18

Entry:
Enter a brief descriptive title of the project. If more than one
program is involved, you should append an explanation on a
separate sheet. If appropriate (e.g., construction or real
property projects), attach a map showing project location. For
preapplications, use a separate sheet to provide a summary
description of this project.
List only the largest political entities affected (e.g., State,
counties, cities).

To be signed by the authorized representative of the applicant.
A copy of the governing body’s authorization for you to sign
this application as official representative must be on file in the
applicant’s office. (Certain Federal agencies may require that
this authorization be submitted as part of the application.)

Use the Catalog of Federal Domestic Assistance number and title of
the program under which assistance is requested.

SF-424 (Rev. 7-97) Back

Attachment 1

Survey on Ensuring Equal Opportunity for Applicants
Reproduction of OMB No. 1890-0014 EXP 02/28/09

Purpose: The Federal government is committed to ensuring that all qualified applicants, small or large, non-religious or faith-based,
have an equal opportunity to compete for Federal funding. In order for us to better understand the population of applicants for Federal
funds, we are asking nonprofit private organizations (not including private universities) to fill out this survey.
Upon receipt, the survey will be separated from the application. Information provided on the survey will not be considered in any way
in making funding decisions and will not be included in the Federal grants database. While your help in this data collection process is
greatly appreciated, completion of this survey is voluntary.
Instructions for Submitting the Survey: If you are applying using a hard copy application, please place the completed survey in an
envelope labeled "Applicant Survey." Seal the envelope and include it along with your application package. If you are applying
electronically, please submit this survey along with your application.

Applicant’s (Organization) Name:
Applicant’s DUNS Number:
Federal Program: Public TV Digital Transition Grant Program
1. Has the applicant ever received a grant or contract from
the Federal government?
Yes

No

2. Is the applicant a faith-based organization?
Yes

No

(Self-Identify)

3. Is the applicant a secular organization?
Yes

No

(Self-Identify)

4. Does the applicant have 501(c)(3) status? (501(c)(3) status
is a legal designation provided on application to the Internal
Revenue Service by eligible organizations. Some grant programs
may require non-profit applicants to have 501(c)(3) status. Others
do not.

Yes

No

No

6. How many full-time equivalent employees does the
applicant have? (Check only one box.) For example, two parttime employees who each work half-time equal one full-time
equivalent employee. If the applicant is a local affiliate of a national
organization, the responses to questions 2 and 3 should reflect the
staff and budget size of the local affiliate.

3 or fewer

15-50

4-5

51-100

6-14

over 100

7. What is the size of the applicant’s annual budget? (Check
only one box.) Annual Budget means the amount of money your
organization spends each year on all such activities.

less than $150,000
$150,000 - $299,999

5. Is the applicant a local affiliate of a national organization?
Yes

CFDA Number 10.861

$300,000 - $499,999

(Self-Explanatory)

$500,000 - $999,999
$1,000,000 - $4,999,999
$5,000,000 or more

Paperwork Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a valid OMB control number. The valid OMB control number for this information collection is 1890-0014. The time required to
complete this information collection is estimated to average five (5) minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy estimate(s) or suggestions for improving this form, please write to the Agency Contact listed in this grant
application.
Reproduction of OMB No. 1890-0014 Exp. 02/28/09

Public Television Station Digital Transition Grant Toolkit - FY 2010

Summary Worksheet
Please print or type

Legal Name
Organization Name
Contact Person & Title
Phone & Fax
Email
Address

Grant Requested
Other Funding
Total Project Cost

Attachment 2

Public Television Station Digital Transition Grant Toolkit - FY 2010

Equal Opportunity and Nondiscrimination Certification
All grants made under the Public Television Station Digital Transition Grant Program are subject
to the nondiscrimination provisions of Title VI of the Civil Rights Act of 1964, as amended, (7
CFR Part 15); Section 504 of the Rehabilitation Act of 1973, as amended, (29 U.S.C. 901 et seq;
7 CFR Part 15b); and Age Discrimination of 1975, as amended (42 U.S.C. 6101 et seq.; 45 CFR
Part 90); and as amended by Executive Order 11375 Amending Executive Order 11246, Relating
to Equal Employment Opportunity (3 CFR, 1966, 1970 Comp., p. 684).
All recipients of financial assistance from RUS, the prospective primary participant commits to
carry out RUS’ 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 Public Television Station Digital
Transition Grant Program.
The __________________________________________________ (Grantee) hereby certifies
that, as a prospective recipient under the said Public Television Station Digital Transition Grant
Program, it will comply with the above reference laws and executive orders.

__________________________
(Date)

____________________________________________
(Authorized Representative’s Signature)
____________________________________________
(Name Typed or Printed)
____________________________________________
(Title)

Attachment 3

Public Television Station Digital Transition Grant Toolkit - FY 2010

Certificate Regarding Architectural Barriers
All facilities financed with RUS grants 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 CFR subpart 10119.6).
As a prospective primary participant recipient of financial assistance from RUS, this
organization commits to carry out RUS’ 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.
The _______________________________________ (Grantee) hereby certifies, that, as a
prospective recipient under the Public Television Station Digital Transition Grant Program, it is
in compliance, or will be in compliance upon completion of the project, with the above
referenced law.

________________________
(Date)

___________________________________
(Authorized Representative’s Signature)
___________________________________
(Name Typed or Printed)
___________________________________
(Title)

Attachment 4

Public Television Station Digital Transition Grant Toolkit - FY 2010

Certificate Regarding Flood Hazard Area Precautions
If the project is located in an area subject to flooding, flood insurance must be provided to the
extent available and required under the National Flood Insurance Act of 1968, as amended by the
Flood Disaster Protection Act of 1973, as amended (42 U.S.C. 4001 through 4128). If applicable,
the insurance must cover, in addition to the buildings, any machinery, equipment, fixtures, and
furnishings contained in the buildings. RUS will comply with Executive Order 11988,
Floodplain Management (3 CFR, 1977 Comp., p. 117), and 7 CFR 1794.41, of this chapter in
considering the application for the project.
Please check the appropriate line below:
___ a) The project is not located in a 100 year flood plain; therefore, no Flood Insurance is
required.
___ b) The project is located in a 100 year flood plain and the required insurance is or will be
provided by:
________________________________
________________________________
________________________________
The _______________________________________ (Grantee) hereby certifies, that, as a
prospective recipient under the Public Television Station Digital Transition Grant Program, it is
in compliance, or will be in compliance during construction and/or installation of equipment and
upon completion of the project, with the above referenced law.
________________________
(Date)

__________________________________
(Authorized Representative’s Signature)
__________________________________
(Name Typed or Printed)
__________________________________
(Title)

Attachment 5

Public Television Station Digital Transition Grant Toolkit - FY 2010

Uniform Relocation Assistance and Real Property Acquisition Policies
Act of 1970 Certification
The _________________________________________________________ (Grantee) assures
that it will comply with the Uniform Relocation Assistance and Real Property Acquisition
Policies Act of 1970, as amended (Uniform Act), 42 U.S.C. 4601-4655, and with implementing
Federal regulations in 49 CFR Part 24 and 7 CFR Part 21.
Specifically, the ________________________________________________ (Grantee) 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)

Attachment 6

Public Television Station Digital Transition Grant Toolkit - FY 2010

Certification Regarding Drug-Free Workplace Requirements
Alternative I – For Grantees Other than Individuals
This certification is required by the regulations implementing Sections 5151-5160 of the DrugFree Workplace Act of 1988 (P.L. 100-690, Title V, Subtitle D; 41 U.S.C. 701 et seq.), 7 CFR
Part 3017, Subpart F, Section 3017.600, Purpose. The January 31, 1989, regulations were
amended and published as Part II of the May 25, 1990, Federal Register (pages 21681-21691).
Copies of the regulations may be obtained by contacting the Department of Agriculture agency
offering the grant.
ALTERNATIVE I
A. The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the grantee’s
workplace and specifying the actions that will be taken against employees for violation of
such prohibition;
(b) Establishing an ongoing drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The grantee’s policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in
the workplace;
(c) 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 paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of
employment under the grant, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug
statute occurring in the workplace no later than 5 calendar days after such conviction;
(e) Notifying the Agency in writing, within 10 calendar days after receiving notice under
subparagraph (d) (2) from an employee or otherwise receiving actual notice of such
conviction. Employers of convicted employees must provide notice, including position title,
to every grant officer on whose grant activity the convicted employee was working, unless
the Federal agency has designated a central point for the receipt of such notices. Notice shall
include the identification number(s) of each affected grant;
Page 1 of 2
Attachment 7

Public Television Station Digital Transition Grant Toolkit - FY 2010

(f) Taking one of the following actions, within 30 calendar days of receiving notice under
subparagraph (d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or
(2) 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; and
(g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e), and (f).
B. The grantee may 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 Zip Code

____ Check if there are workplaces on file that are not identified here.
______________________________________________________________________________
Organization Name
______________________________________________________________________________
Authorized Representative’s Signature & Date
______________________________________________________________________________
Name Typed or Printed

Page 2 of 2
Attachment 7

Public Television Station Digital Transition Grant Toolkit - FY 2010

Certification Regarding Debarment, Suspension, and Other
Responsibility Matters – Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 7 CFR Part 3017, Section 3017.510, Participants’ Responsibilities.
The regulations were published as Part IV of the January 30, 1989, Federal Register (pages
4722-4733). Copies of the regulations may be obtained by contacting the Department of
Agriculture agency offering the proposed transaction.
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it
and its principals:
(a) are not presently debarred, suspended, proposed for Debarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal department or agency;
(b) have not 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 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
(d) have not within a 3-year period preceding this application/proposal 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 this
certification, such prospective participant shall attach an explanation to this proposal.
______________________________________________________________________________
Organization Name
______________________________________________________________________________
Authorized Representative’s Signature Date
______________________________________________________________________________
Name Typed or Printed

Attachment 8

Public Television Station Digital Transition Grant Toolkit - FY 2010

Certification Regarding Lobbying for Contracts, Grants,
Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee
of any agency, a Member of Congress, 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, the
undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report
Lobbying,” in accordance with its instructions. (Copies of this form may be obtained from
RUS.)
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all subrecipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for
making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any
person who fails to file the required certification shall be subject to a civil penalty of not less
than $10,000 and not more than $100,000 for each such failure.
______________________________________________________________________________
Organization Name
______________________________________________________________________________
Authorized Representative’s Signature Date
______________________________________________________________________________
Name Typed or Printed

Attachment 9

Public Television Station Digital Transition Grant Toolkit - FY 2010

Federal Obligations Certification on Delinquent Debt
IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

YES

NO

Note: Example of debts include, but are not limited to, delinquent taxes, guaranteed or direct
government loans (more than 31 days past due) and other administrative debts.
If Yes, provide explanatory information.
APPLICANT CERTIFICATION
FEDERAL COLLECTION POLICIES FOR COMMERCIAL DEBT
The Federal Government is authorized by law to take any or all of the following actions in the
event that a borrower’s loan payments become delinquent or the borrower defaults on its loan:
(1) Report the borrower’s delinquent account to a credit bureau; (2) Assess additional interest
and penalty charges for the period of time that payment is not made; (3) Assess charges to cover
additional administrative costs incurred by the Government to service the borrower’s account;
(4) Offset amounts owed to the borrower under other Federal programs; (5) Refer the borrower’s
debt to the Internal Revenue Service for offset against any amount owed to the borrower as an
income tax refund; (6) Refer the borrower’s account to a private collection agency to collect the
amount due; and (7) Refer the borrower’s account to the Department of Justice for litigation in
the courts.
All of these actions can and will be used to recover any debts owed when it is determined to be
in the interest of the Government to do so.
Certification
I have read and understand the actions the Federal Government can take in the event that
I fail to meet my scheduled payments in accordance with the terms and conditions of my
agreements.
Signed: ____________________________________________________
Title:

____________________________________________________

Company:____________________________________________________
Date:

____________________________________________________

Attachment 10

Public Television Station Digital Transition Grant Toolkit - FY 2010

Public Television Station Digital Transition Grant Program
Environmental Questionnaire/Certification
Environmental Project Summary:

(Describe all construction in the project, no matter the source of funding. Provide details of how
the project will impact the environment (wetlands, farmlands, floodplain, cultural environment,
endangered species, environmental quality, and historic preservation). If additional space is
needed, continue on white bond paper and insert between the first and second pages.)
If the construction proposed in this application, as described above, will NOT impact the
environment or historic preservation, you may sign the certification indicating no adverse impact
and skip filling out the questionnaire.

CERTIFICATION
I hereby certify that the construction proposed in this application will not adversely
impact the environment or historic preservation.

______________________________________________
(Signature and Date)
______________________________________________
(Print or Type Title)

Page 1 of 4
Attachment 11

Public Television Station Digital Transition Grant Toolki - FY 2010

QUESTIONNAIRE
Note: It is extremely important to respond to all questions completely to ensure expeditious
processing of the Public Television Station Digital Transition Grant Program application. The
information herein is required by Federal law.
Important: Any activity related to the project that may adversely affect the environment or
limit the choice of reasonable development alternatives shall not be undertaken prior to the
completion of Rural Utilities Service’s environmental review process.
Legal Name of Applicant
Signature (Type, sign, & 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.
I. Project Description - Detailing construction, including, but not limited to internal
modifications of existing structures, and/or installation of telecommunications
transmission facilities including satellite uplinks or downlinks, microwave transmission
towers, and cabling.
1. Describe the portion of the project, and site locations (including legal ownership of real
property), involving internal modifications, or equipment additions to buildings or other
structures (e.g., relocating interior walls or adding computer facilities) for each site.

Page 2 of 4
Attachment 11

Public Television Station Digital Transition Grant Toolkit - FY 2010

2.
Describe the portion of the project, and site locations (including legal ownership or real
property), involving construction of transmission facilities, including cabling, microwave towers,
satellite dishes, or disturbance of property of .99 acres or greater for each project site.

3. Describe the nature of the proposed use of the facilities and whether any hazardous materials,
air emissions, wastewater discharge, or solid waste will result.

4. State whether or not any project site(s) contain or are near properties listed or eligible for
listing in the National Register of Historic Places, and identify any historic properties. (The
applicant must supply evidence that the State Historic Preservation Officer (SHPO) has
cleared development regarding any historical properties).

5. Provide information whether or not any facility(ies) or site(s) are located in a 100-year
floodplain. A National Flood Insurance Map should be included reflecting the location of the
project site(s).

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Public Television Station Digital Transition Grant Toolkit - FY 2010

II. For projects that involve construction of transmission facilities, including cabling,
microwave towers, satellite dishes, or physical disturbance of real property of .99 acres or
greater, the following information must be submitted (7 CFR 1703.109(i)(3)).
1. A map (preferably a U.S. Geological Survey map) of the area for each site affected by
construction (include as an attachment).
2. A description of the amount of property to be cleared, excavated, fenced, or otherwise
disturbed by the project and a description of the current land use and zoning and any
vegetation for each project site affected by construction.

3. A description of buildings or other structures (i.e., transmission facilities), including
dimensions, to be constructed or modified.

4. A description of the presence of wetlands or existing agricultural operations and/or
threatened or endangered species or critical habitats on or near the project site(s) affected
by construction.

5. Describe any actions taken to mitigate any environmental impacts resulting from the
proposed project (use attachment if necessary).

Note: The applicant may submit a copy of any environmental review, study assessment, report or
other 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.

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Public Television Station Digital Transition Grant Toolkit - FY 2010

The Buy American Act (41 U.S.C. 10a - 10d) gives preference to those products that are
manufactured in the United States or an eligible country, and are substantially all from articles,
materials, and supplies mined, produced, or manufactured in the United States or eligible
country. The list of eligible countries can be found at:
www.usda.gov/rus/electric/listmat/eligible.htm

“Buy American” CERTIFICATION
I hereby certify that the equipment to be procured under the prospective grant will comply
with the Buy American Act.
__________________________________
(Signature and Date)
__________________________________
(Print or Type Title)

Attachment 12