Public Television Digital Transition Grant Program

RURAL UTILITIES SERVICE
Telecommunications Program

Rural Public Television
Digital Transition
Grant Program

FY 2014 Toolkit

Committed to the future of rural communities

Public Television Station Digital Transition Grant Toolkit – FY 2014

The grant application should be assembled and tabbed in the order outlined
below. Numbered attachments have been provided in the toolkit for your use.
Please use only the applicable attachments listed below.

Item # Description

Toolkit #

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

1
2

3

19
20
21

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
Representation Regarding Felony or Tax Delinquency

22

Supplemental Information (If Any)

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

13
14
15
16
17
18

4
5
6
7
8
9

10
11
12

OMB Number: 4040-0004
Expiration Date: 03/31/2012

Application for Federal Assistance SF-424
* 1. Type of Submission:

* 2. Type of Application:

Preapplication

New

Application

Continuation

Changed/Corrected Application

Revision

* 3. Date Received:

* If Revision, select appropriate letter(s):

* Other (Specify):

4. Applicant Identifier:

5a. Federal Entity Identifier:

* 5b. Federal Award Identifier:

State Use Only:
6. Date Received by State:

7. State Application Identifier:

8. APPLICANT INFORMATION:
* a. Legal Name:
* c. Organizational DUNS:

* b. Employer/Taxpayer Identification Number (EIN/TIN):

d. Address:
* Street1:
Street2:
* City:
County/Parish:

* State:
Province:

* Country:

USA: UNITED STATES

* Zip / Postal Code:
e. Organizational Unit:
Department Name:

Division Name:

f. Name and contact information of person to be contacted on matters involving this application:
Prefix:

* First Name:

Middle Name:

* Last Name:
Suffix:
Title:

Organizational Affiliation:

* Telephone Number:

Fax Number:

* Email:

Attachment 1

Application for Federal Assistance SF-424
9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

Add Attachment

Delete Attachment

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Add Attachments

Delete Attachments

View Attachments

Attachment 1

View Attachment

Application for Federal Assistance SF-424
16. Congressional Districts Of:
* a. Applicant

* b. Program/Project

Attach an additional list of Program/Project Congressional Districts if needed.

Add Attachment

Delete Attachment

View Attachment

17. Proposed Project:
* a. Start Date:

* b. End Date:

18. Estimated Funding ($):
* a. Federal
* b. Applicant
* c. State
* d. Local
* e. Other
* f. Program Income
* g. TOTAL

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

a. This application was made available to the State under the Executive Order 12372 Process for review on

.

b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E.O. 12372.
* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

Yes

No

If "Yes", provide explanation and attach
Add Attachment

Delete Attachment

View Attachment

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to
comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may
subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** I AGREE
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency

specific instructions.
Authorized Representative:
Prefix:

* First Name:

Middle Name:
* Last Name:
Suffix:

* Title:
* Telephone Number:

Fax Number:

* Email:
* Signature of Authorized Representative:

* Date Signed:

Attachment 1

INSTRUCTIONS FOR THE SF-424
This is a standard form required for use as a cover sheet for submission of pre-applications and applications and related information under discretionary
programs. Some of the items are required and some are optional at the discretion of the applicant or the federal agency (agency). Required fields on the
form are identified with an asterisk (*) and are also specified as “Required” in the instructions below. In addition to these instructions, applicants must
consult agency instructions to determine other specific requirements.
Item
1.

2.

Entry:
Type of Submission: (Required) Select one type of submission
in accordance with agency instructions.
• Pre-application
• Application
• Changed/Corrected Application – Check if this submission is to
change or correct a previously submitted application. Unless
requested by the agency, applicants may not use this form to
submit changes after the closing date.
Type of Application: (Required) Select one type of application in
accordance with agency instructions.
• New – An application that is being submitted to an agency for
the first time.
• Continuation - An extension for an additional funding/budget
period for a project with a projected completion date. This can
include renewals.
• Revision - Any change in the federal government’s financial
obligation or contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be
selected. If "Other" is selected, please specify in text box
provided.

3.

4.

5a.
5b.

6.
7.
8.

A. Increase Award
D. Decrease Duration
B. Decrease Award
E. Other (specify)
C. Increase Duration
Date Received: Leave this field blank. This date will be assigned
by the Federal agency.

Applicant Identifier: Enter the entity identifier assigned buy the
Federal agency, if any, or the applicant’s control number if
applicable.
Federal Entity Identifier: Enter the number assigned to your
organization by the federal agency, if any.
Federal Award Identifier: For new applications leave blank. For a
continuation or revision to an existing award, enter the previously
assigned federal award identifier number. If a changed/corrected
application, enter the federal identifier in accordance with agency
instructions.
Date Received by State: Leave this field blank. This date will be
assigned by the state, if applicable.
State Application Identifier: Leave this field blank. This identifier
will be assigned by the state, if applicable.
Applicant Information: Enter the following in accordance with
agency instructions:
a. Legal Name: (Required) Enter the legal name of applicant that
will undertake the assistance activity. This is the organization that
has registered with the Central Contractor Registry (CCR).
Information on registering with CCR may be obtained by visiting
www.Grants.gov.
b. Employer/Taxpayer Number (EIN/TIN): (Required) Enter the
employer or taxpayer identification number (EIN or TIN) as
assigned by the Internal Revenue Service. If your organization is
not in the US, enter 44-4444444.

Item:
10.

Entry:
Name Of Federal Agency: (Required) Enter the name of the
federal agency from which assistance is being requested with this
application.

11.

Catalog Of Federal Domestic Assistance Number/Title:
Enter the Catalog of Federal Domestic Assistance number and
title of the program under which assistance is requested, as found
in the program announcement, if applicable.
Funding Opportunity Number/Title: (Required) Enter the
Funding Opportunity Number and title of the opportunity under
which assistance is requested, as found in the program
announcement.

12.

13.

Competition Identification Number/Title: Enter the competition
identification number and title of the competition under which
assistance is requested, if applicable.

14.

Areas Affected By Project: This data element is intended for use
only by programs for which the area(s) affected are likely to be
different than the place(s) of performance reported on the SF-424
Project/Performance Site Location(s) Form. Add attachment to
enter additional areas, if needed.

15.

Descriptive Title of Applicant’s Project: (Required) Enter a
brief descriptive title of the project. If appropriate, attach a map
showing project location (e.g., construction or real property
projects). For pre-applications, attach a summary description of
the project.

16.

Congressional Districts Of: 15a. (Required) Enter the
applicant’s congressional district. 15b. Enter all district(s) affected
by the program or project. Enter in the format: 2 characters state
abbreviation – 3 characters district number, e.g., CA-005 for
California 5th district, CA-012 for California 12 district, NC-103 for
North Carolina’s 103 district. If all congressional districts in a state
are affected, enter “all” for the district number, e.g., MD-all for all
congressional districts in Maryland. If nationwide, i.e. all districts
within all states are affected, enter US-all. If the program/project
is outside the US, enter 00-000. This optional data element is
intended for use only by programs for which the area(s) affected
are likely to be different than place(s) of performance reported on
the SF-424 Project/Performance Site Location(s) Form. Attach an
additional list of program/project congressional districts, if needed.
Proposed Project Start and End Dates: (Required) Enter the
proposed start date and end date of the project.

17.

18.

c. Organizational DUNS: (Required) Enter the organization’s
DUNS or DUNS+4 number received from Dun and Bradstreet.
Information on obtaining a DUNS number may be obtained by
visiting www.Grants.gov.

19.

d. Address: Enter address: Street 1 (Required); city (Required);
County/Parish, State (Required if country is US), Province,
Country (Required), 9-digit zip/postal code (Required if country
US).

20.

13

Estimated Funding: (Required) Enter the 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.
Is Application Subject to Review by State Under Executive
Order 12372 Process? (Required) 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. Select the appropriate box. If
“a.” is selected, enter the date the application was submitted to
the State.
Is the Applicant Delinquent on any Federal Debt?
(Required) Select the appropriate box. This question applies to
the applicant organization, not the person who signs as the
authorized representative. Categories of federal debt include; but,
may not be limited to: delinquent audit disallowances, loans and
taxes. If yes, include an explanation in an attachment.

ATTACHMENT 1

e. Organizational Unit: Enter the name of the primary
organizational unit, department or division that will undertake the
assistance activity.

9.

f. Name and contact information of person to be contacted on
matters involving this application: Enter the first and last name
(Required); prefix, middle name, suffix, title. Enter organizational
affiliation if affiliated with an organization other than that in 7.a.
Telephone number and email (Required); fax number.
Type of Applicant: (Required) Select up to three applicant type(s)
in accordance with agency instructions.
M. Nonprofit
A. State Government
N. Private Institution of
B. County Government
C. City or Township
Higher Education
Government
O. Individual
D. Special District
P. For-Profit Organization
Government
(Other than Small
Business)
E. Regional Organization
Q. Small Business
F. U.S. Territory or
R. Hispanic-serving
Possession
Institution
G. Independent School
S. Historically Black
District
Colleges and
H. Public/State Controlled
Universities (HBCUs)
Institution of Higher
T. Tribally Controlled
Education
Colleges and
I.
Indian/Native American
Universities (TCCUs)
Tribal Government
U. Alaska Native and
(Federally Recognized)
Native Hawaiian
J. Indian/Native American
Serving Institutions
Tribal Government
V. Non-US Entity
(Other than Federally
W. Other (specify)
Recognized)
K. Indian/Native American
Tribally Designated
Organization
L. Public/Indian Housing
Authority

21.

Authorized Representative: To be signed and dated by the
authorized representative of the applicant organization. Enter the
first and last name (Required); prefix, middle name, suffix. Enter
title, telephone number, email (Required); and fax number. A
copy of the governing body’s authorization for you to sign this
application as the 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.)

Attachment 1

Survey on Ensuring Equal Opportunity for Applicants
OMB No. 1894-0010 EXP 01/31/2016

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 four (4) 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 comments concerning the
accuracy estimate or suggestions for improving this form, please write to the Agency Contact listed in this grant application.

Public Television Station Digital Transition Grant Toolkit - FY 2014

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 2014
OMB No. 0572-0134; EXP 07/31/2014

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)

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 05720134. The time required to complete this information collection is estimated to average one (1) minute 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 or suggestions for improving this certification, please
write to the Agency Contact listed in this grant application.

Attachment 3

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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)

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 05720134. The time required to complete this information collection is estimated to average one (1) minute 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 or suggestions for improving this certification, please
write to the Agency Contact listed in this grant application.

Attachment 4

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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)
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 05720134. The time required to complete this information collection is estimated to average one (1) minute 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 or suggestions for improving this certification, please
write to the Agency Contact listed in this grant application.

Attachment 5

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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
that:

(Grantee) assures

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)

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 05720134. The time required to complete this information collection is estimated to average one (1) minute 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 or suggestions for improving this certification, please
write to the Agency Contact listed in this grant application.

Attachment 6

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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;

Public Television Station Digital Transition Grant Toolkit - FY 2014

(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
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 0572-0134. The
time required to complete this information collection is estimated to average fifteen (15) minute 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 comments concerning the accuracy estimate or suggestions for improving this form, please write to the Agency contact listed in
this grant application.

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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
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 0572-0134. The time required to complete this
information collection is estimated to average fifteen (15) minute per response, including the time to review instructions, gather the data and complete
and review the information collection. If you have comments concerning the accuracy estimate or suggestions for improving this certification, please
write to the Agency contact listed in this grant application.

Attachment 8

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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
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 0572-0134. The time required to complete this
information collection is estimated to average fifteen (15) minute per response, including the time to review instructions, gather the data and complete
and review the information collection. If you have comments concerning the accuracy estimate or suggestions for improving this certification, please
write to the Agency contact listed in this grant application.

Attachment 9

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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:
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 05720134. The time required to complete this information collection is estimated to average one (1) minute 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 or suggestions for improving this form, please write to
the Agency contact listed in this grant application.

Attachment 10

Public Television Station Digital Transition Grant Toolkit - FY 2014
OMB No. 0572-0134; EXP 07/31/14

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.)

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)

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 18900014. The time required to complete this information collection is estimated to average thirty (30) minutes per response,
including the time to review instructions, search existing data resources, gather needed date, and complete and review the
information collection. If you have any comments concerning the accuracy estimate or suggestions for improving this
certification, please write to the Agency contact listed in this grant application.

Page 1 of 4
Attachment 11

Public Television Station Digital Transition Grant Toolki - FY 2014

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 2014

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).

Page 3 of 4
Attachment 11

Public Television Station Digital Transition Grant Toolkit - FY 2014

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.

Page 4 of 4
Attachment 11

This form is available electronically.

AD-3030

Form Approved – OMB No. 0505-0025
Expiration Date: 2/29/2016
U.S. DEPARTMENT OF AGRICULTURE

REPRESENTATIONS REGARDING FELONY CONVICTION
AND TAX DELINQUENT STATUS FOR CORPORATE APPLICANTS
Note: You only need to complete this form if you are a corporation. A corporation includes, but is not limited to, any entity

that has filed articles of incorporation in one of the 50 States, the District of Columbia, or the various territories of the
United States including American Samoa, Federated States of Micronesia, Guam, Midway Islands, Northern Mariana
Islands, Puerto Rico, Republic of Palau, Republic of the Marshall Islands, or the U.S. Virgin Islands. Corporations
include both for profit and non-profit entities.
The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552(a), as amended). The authority for requesting the following
information for USDA Agencies and staff offices is in §738 and 739 of the Agriculture, Rural Development, Food and Drug Administration, and Related
Agencies Appropriations Act, 2012, P.L. 112-55, as amended and/or subsequently enacted. The information will be used to confirm applicant status
concerning entity conviction of a felony criminal violation, and/or unpaid Federal tax liability status.
According to the Paperwork Reduction Act of 1985 an agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0505-0025. The time
required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

1. APPLICANT’S NAME

2. APPLICANT’S ADDRESS (Including Zip Code)

3. TAX ID NO.
(Last 4 digits)

4A. Has the Applicant been convicted of a felony criminal violation under Federal or State law in the 24 months preceding the
date of application?
YES
NO
4B. Has any officer or agent of Applicant been convicted of a felony criminal violation for actions taken on behalf of Applicant
under Federal or State law in the 24 months preceding the date of application?
YES
NO
4C. Does the Applicant have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative
remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with
the authority responsible for collecting the tax liability?
YES
NO

Providing the requested information is voluntary. However, failure to furnish the requested information will make the applicant
ineligible to enter into a contract, memorandum of understanding, grant, loan, loan guarantee, or cooperative agreement with
USDA.
PART B – SIGNATURE
5A. APPLICANT’S SIGNATURE (BY)

5B. TITLE/RELATIONSHIP OF THE INDIVIDUAL IF
SIGNING IN A REPRESENTATIVE CAPACITY

5C. DATE SIGNED
(MM-DD-YYYY)

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived
from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program
information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA,
Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at
(866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and
employer.
Rev: 11/12 Destroy all previous copies

Attachment 12