CPF Grant Application

TAB 0: Landing Page/Program Information

[ “Start Submission” button]

Are you applying for funding from the Coronavirus Capital Projects Fund (CPF) program?

[“CPF application?”: picklist: “Yes”, “No”]

[If Yes, shows the following]

Applicant Type

[“Applicant Type” Picklist: State Government, Territory or Freely Associated State, Tribal Government]

Once you click the Create button, a draft CPF application form will appear under the tab “Submissions & Compliance Forms” on the SLT homepage. Navigate to that tab and then click the link “Provide Information” to complete the application. [Create button]

[(if “Applicant Type” = “State Government” OR “Territory or Freely Associated State”, then visible)]

TAB 1a: User Instructions for States and Territories

The Capital Projects Fund application consists of five sections that are listed in the tabs on the left side of the screen.

[Additional text may be inserted here from relevant sections of the Guidance Document]

Section 1 provides instructions and background information; this section also asks each Applicant to identify their Applicant Type.

Sections 2 and 3 collect administrative data regarding applicant name, contact information, and banking information.

Section 4 provides the opportunity to indicate the amount of funding the Applicant would like to receive.

Section 5 provides the opportunity to upload documentation necessary for application completion, certification, and/or funding receipt.

After completing a section, you must click the NEXT button at the bottom right corner of the screen to save your responses and advance to the next section.

At any time, you may click the SAVE button on the bottom left corner of the screen to save an application in progress. Once an in-progress application is saved, you may return to it later to complete it or change it before the application deadline. Once you have saved the appropriate information and attachments in the application, you may submit it using the SUBMIT button on Section 5. All applications must be completed and submitted by the [December 22, 2021], and must be accompanied by a signed certification.

To submit this application, please provide the information requested in each section, upload the required documentation, and click the SUBMIT button. You will receive an email confirming your submission within X HOURS of submission. If you do not receive an email upon submission, please contact [email protected].

OMB Control Number 1505-0274
PAPERWORK REDUCTION ACT NOTICE
The information collected in this application will be used by the U.S. Government to process requests for financial support. 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 control number assigned by OMB. The estimated burden associated with this collection of information is 60 minutes per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency, and Records, U.S. Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address.

[(if “Applicant Type” = Tribal Government”, then visible)]
TAB 1b: User Instructions for Tribal Governments

The Capital Projects Fund application consists of five sections that are listed in the tabs on the left side of the screen.

[Additional text may be inserted here from relevant sections of the Guidance Document]

Sections 1 provides instructions and background information; this section also asks each Applicant to identify their Applicant Type.

Sections 2 and 3 collect administrative data regarding applicant name, contact information, and banking information.

Section 4 provides the opportunity to indicate the amount of funding the Applicant would like to receive, and the proposed uses for CPF funds.

Section 5 provides the opportunity to upload documentation necessary for application completion, certification, and funding receipt. At the conclusion of the application, you will sign a Grant Agreement.

After completing a section, you must click the NEXT button at the bottom right corner of the screen to save your responses and advance to the next section.

At any time, you may click the SAVE button on the bottom left corner of the screen to save an application in progress. Once an in-progress application is saved, you may return to it later to complete it or change it before the application deadline. Once you have saved the appropriate information and attachments in the application, you may submit it using the SUBMIT button on Section 5. All applications must be completed and submitted by [December 22, 2021], and must be accompanied by a signed certification.

To submit this application, please provide the information requested in each section, upload the required documentation, and click the SUBMIT button. You will receive an email confirming your submission within X HOURS of submission. If you do not receive an email upon submission, please contact [email protected].

OMB Control Number 1505-0274
PAPERWORK REDUCTION ACT NOTICE
The information collected in this application will be used by the U.S. Government to process requests for financial support. 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 control number assigned by OMB. The estimated burden associated with this collection of information is 120 minutes per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency, and Records, U.S. Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address.

TAB 2: Applicant Info

Subtab1 “Applicant Category”

Please provide the following information about the applying entity and related personnel.

The authorized representative is the individual who will sign the necessary certifications, submit the Application, and sign the Grant Agreement on behalf of the Applicant. Please select one of the following two options:

• The authorized representative is an employee or member of the applicant entity and is duly authorized by virtue of their position (e.g., Tribal leader, governor) within the entity to submit an application on the applicant’s behalf and legally bind the applicant

• The authorized representative is not duly authorized to submit an application by virtue of their position, but is acting on the applicant’s behalf to legally bind the applicant through delegated authority granted to the authorized representative by the applicant entity

(Helptext: All Applicants must clearly delegate authority to the appropriate entity and individual to serve as the authorized representative. )

[If (“Applicant is Delegated? = TRUE )]

You will be asked to provide more information about the authorized representative on the next page.

The Application must include a designation letter signed by the chief executive or individual legally authorized to act on behalf of the decision-making body of the Applicant (e.g., duly authorized Tribal official, governor) that identifies and delegates authority, as appropriate, to the authorized representative. Please provide the designation letter signed by the chief executive or individual legally authorized to act on behalf of the decision-making body of your organization at the end of this application form in the Certifications section. If you do not yet have a signed designation letter, you will be able to submit the application, but you will not receive payments until Treasury has received the necessary designation letter.

Only one application shall be accepted for each eligible entity. If a Tribal consortium, organization, or anyone other than the eligible Tribal government’s duly authorized Tribal official is completing this application, a signed designation letter is required. Please consult the Application Guidance ([hyperlink: Treasury Website]) for additional information.

If the designation letter is not received by June 1, 2022, the Applicant’s grant award will be forfeited.

([(if “Applicant Type” = “Tribal Government”, then visible)]
Are you a Tribal consortium, Tribal organization, or similar entity applying on behalf of one or more Tribal governments? [“Tribal Consortium?” Picklist: Yes, No]

[(if “Applicant Type” = “Tribal Government”, then visible)]

Are you a Tribal government applying on behalf of one or more additional Tribal governments in addition to your own? (Helptext: A separate application must be submitted for each eligible Tribal government)
[“Tribal government on behalf?” Picklist: Yes, No]

Subtab2 “Primary Contact Information”

Please provide primary contact information below. The primary contact person will be contacted with relevant application information; only this individual will receive program updates and application information. You also have the option to add three additional email addresses to receive program notifications.

Primary Point of Contact First Name

Primary Point of Contact Last Name

Primary Point of Contact Title

Primary Point of Contact Phone

Primary Point of Contact Email

Optional: If you have additional POCs who should receive program emails, please add up to three emails below:

Additional POC Email

Additional POC Email

Additional POC Email

Subtab3 “Applicant Info”

The Applicant is the entity that is eligible for CPF grant funds. In this section you should provide the business address and related information pertaining to the state, territory, freely associated state, or Tribal government currently applying and authorizing the application.

[if “Tribal Consortium?” = Yes]

Provide the name of the first eligible Tribal government that you are applying on behalf of (You will be able to add additional eligible Tribal governments below)?

[if “Tribal Consortium?” = No]

Applicant Name

(Helptext: if you cannot find your entity name, please contact [email protected].)

Applicant’s Employer ID Number (9 Digits)

Applicant’s DUNS Number (9 Digits)

Applicant Street Address

Applicant City

Applicant State/Territory

(if “Applicant Type” = Territory or Freely Associated State, then optional)

Applicant Postal Code (5 Digits)

(if “Applicant Type” = Territory or Freely Associated State, Tribal Government, then optional)

Applicant Post Code (+4 Digits)

Entity’s Authorized Individual

The authorized individual will certify that the application information is accurate and will also be required to sign the Grant Agreement.

First Name of Authorized Representative for the Government Entity

Last Name of Authorized Representative for the Government Entity

Authorized Representative Title

Authorized Representative Organization

Authorized Representative Phone

Authorized Representative Email

Authorized Individual Street Address

Authorized Individual City

Authorized Individual State/Territory

(if “Applicant Type” = Territory or Freely Associated State, then optional)

Authorized Individual Postal Code (5 Digits)

(if “Applicant Type” = Territory or Freely Associated State, then optional)

Authorized Individual Post Code (+4 Digits)

[If “Tribal government on behalf?” = Yes OR “Tribal Consortium?” = Yes]

BUTTON:[Add Eligible Entity to Application]

Allows applicants to add multiple applicants

Lists of records below

Subtab(N) “Additional Eligible Entities”

This section allows the applicant to list additional tribal entities that are linked to this application and eligible for CPF grant funds.

Applicant Name

(Helptext: if you cannot find your entity name, please contact [email protected].)

Applicant’s Employer ID Number (9 Digits)

Applicant’s DUNS Number (9 Digits)

Applicant Street Address

Applicant City

Applicant State/Territory

Applicant Postal Code (5 Digits)

Applicant Post Code (+4 Digits)

TAB 3: Banking Info

Please provide the following information about the financial institution to which you want your Capital Projects Fund financial assistance to be paid electronically. Payments can be made via Automated Clearing House (ACH) or FEDWIRE (Wire Transfer); if an alternative method is required, please contact the CPF team at [email protected].

[Additional text may be inserted here regarding timing of payments]

Routing Transit Number (ACH) (required)

Confirm Routing Transit Number (ACH) (required)

[Error message if value doesn’t match “Routing Number (ACH)”]

Routing Transit Number (Wire) (optional)

Confirm Routing Transit Number (Wire)

(optional)

[Error message if value doesn’t match “Routing Number (Wire)”]

Select Account Type

[picklist: Checking, Savings]

Account Number

Confirm Account Number

Error message if value doesn’t match “Account Number”

Financial Institution Name

Financial Institution Address

Financial Institution Phone Number

TAB 4a: Award Information – States, Territories, and Freely Associated States [(If “Applicant Type” = State Government or, Territory or Freely Associated State Territory or Freely Associated State, then visible)]

You may select to receive up to the full amount allocated to you by the statutory formula, which is displayed below. Your claim is the awardable amount that you will receive if you meet the CPF requirements. You may reduce your claim at any time during the period of performance, but you may not increase your award above what you initially request on this form. Generally, your CPF claim should be equal to the CPF allocation; unclaimed funds will be forfeited. Please indicate the awardable amount you wish to receive.

CPF Allocation: [Display Dollar Amount]

(Helptext: This is the amount that CPF has allocated to your entity. This is the maximum amount that you may receive as your Awardable Amount.)

Do you wish to receive the full CPF allocation of:
[“Receive Full Allocation”: picklist: Yes, No]

[(If “Receive Full Allocation” = No, then show)]

CPF Funds – Maximum Awardable Amount: [Dollar Value Displayed]

(Helptext: Of the amount listed above, how much would you like to apply for from the Capital Projects Fund program? The amount you indicate below will be known as your CPF Claim, or the Awardable Amount. You may reduce this claim at any time during the period of performance, but you may not increase it.)

[“Awardable Amount”: currency, 2 decimals]

Available Administrative Funds: [Dollar Value Displayed]

(Helptext: Available Administrative Funds are calculated as the greater of five percent of your CPF Award or $25,000; if you indicate that you wish to claim the full amount, then Available Administrative Funds will be the greater of five percent of your CPF Allocation or $25,000.)

Immediate Administrative Funds

(Helptext: Administrative Funds are available immediately to assist with planning and preparation of CPF grant activities. You may request up to your full Available Administrative Funds (the greater of five percent of your CFP award or $25,000) to be distributed immediately upon execution of the Grant Agreement. Immediate Funds will be distributed by Treasury upon review and acceptance of the Application. Any unrequested amounts will be available to payment to you at a later date. Please see the Application Guidance document for additional information. )

[“Immediate Funds”: currency, 2 decimals]

[(if “Applicant Type” = Tribal Government, then visible)]

TAB 4b: Award Information – Tribal Governments

You may select to receive up to the full amount allocated to you by the statutory formula, which is displayed below. Your claim is the awardable amount that you will receive if you meet the CPF requirements. You may reduce your claim at any time during the period of performance, but you may not increase your award above what you initially request on this form. Generally, your CPF claim should be equal to the CPF allocation; unclaimed funds will be forfeited. Please indicate the awardable amount you wish to receive.

CPF Allocation; [Display Dollar Value]

(Helptext: This is the amount that CPF has allocated to your entity. This is the maximum amount that you may receive as your Awardable Amount.)

Do you wish to receive the full CPF allocation of:
[“Receive Full Allocation”: picklist: Yes, No]

[(If “Receive Full Allocation” = No, then show)]

CPF Funds – Maximum Awardable Amount: [Dollar Value Displayed]

(Helptext: Of the amount listed above, how much would you like to apply for in the Capital Projects Fund program? The amount you indicate below will be known as your CPF Claim, or the Awardable Amount. You may reduce this claim at any time during the period of performance, but you may not increase it.)

[“Awardable Amount”: currency, 2 decimals]

Eligible Uses

CPF Funds may only be used for eligible uses set forth in Treasury’s Guidance document. CPF Funds may only be used for more than one eligible use. Please check the box next to each of the following eligible uses for which CPF Funds will be used. For each eligible use, we ask that you provide a short response explaining how the funds will be used in alignment with the Guidance. **Applications involving other than presumptively eligible uses will be subject to a case-by-case review, which may add time to the Application review process and may delay payment.

Determining Eligible Use

Have you determined how you are going to use CPF grant funds?
[“Determined CPF Funds Use”: picklist: Yes, No-I require additional time]

[IF “Determined CPF Funds Use”:=No, show below]

If you need additional time, please save this application and return when you can provide the details of how the CPF grants funds will be used. You will not be able to complete the application until you can provide your plans on how you intend to use CPF grant funds.

Presumptively Eligible Uses:

• Purchasing devices to be owned by the Applicant and utilized by or distributed to households, businesses, or other organizations to facilitate internet access.

[“Funds: Purchase Devices”: = Yes, show below]

• Please describe the device purchase and distribution plans, if known. Limit responses to 1-3 sentences.

• Will the devices be used to connect to broadband internet?

• Has affordability been identified as a barrier to access to the internet?

• Will this address critical need(s) within the community?

• Will funds be used solely to purchase devices deemed eligible by the Guidance (e.g., laptops, tablets, and desktop personal computers)?

• [If “No” answer to any of the above subquestions, reveal this field] If you answered “No” to any of the above, please explain below in 1-2 sentences.

• Purchasing digital connectivity technologies (e.g., public Wi-Fi) to be owned by the Applicant.

[“Funds: Purchase Connectivity”: = Yes, show below]

• Please describe the equipment purchase and distribution plans, if known. Limit responses to 1-3 sentences.

• Will the equipment be used to provide broadband internet?

• Has affordability been identified as a barrier to access to the internet?

• Will this address critical need(s) within the community?

• Will funds be used solely to purchase equipment deemed eligible in the Guidance (e.g., equipment and devices necessary for public Wi-Fi infrastructure development)?

• [If “No” answer to any of the above subquestions, reveal this field] If you answered “No” to any of the above, please explain below in 1-2 sentences.

• Installation or enhancement of broadband infrastructure meeting minimum service standards.

[“Funds: Install Infrastructure”: = Yes, show below]

• Please describe the use of these funds. Limit responses to 1-3 sentences.

• Will this project reliably deliver speeds of 100/100 or higher?

• [If “Infrastructure: speeds 100/100” = “No”] If not, will this project reliably deliver speeds of 100/20?

• [If “Infrastructure: speeds 100/100” = “No”] If not, describe the conditions that make the above speed standards impracticable to implement. Limit responses to 1-3 sentences.

• Supplementing another federal government broadband support program.

[“Funds: Other Gov Program”: = Yes, show below]

• Please select which other federal government broadband support programs these funds will be supporting. [Picklist: Coronavirus State and Local Fiscal Recovery Funds; NTIA Tribal Broadband Connectivity Program; USDA Reconnect Fund; Other]

• Provide grant identifier (i.e., award number, etc.).

• Provide contact information for the aforementioned grant(s).

• Please describe what is being funded by the existing federal grant(s). Limit responses to 1-3 sentences.

• [If “No” answer to any of the above subquestions, reveal this field] If you answered “No” to any of the above, please explain below in 1-2 sentences.

• Projects to construct or improve buildings that are designed to jointly and directly enable work, education, and health monitoring.

[“Funds: Buildings”: = Yes, show below]

• Please describe the use of these funds. Limit responses to 1-3 sentences.

• How will the program directly enable work? Limit responses to 1-3 sentences.

• How will the program directly enable education? Limit responses to 1-3 sentences

• How will the program directly enable health monitoring? Limit responses to 1-3 sentences

Non-Presumptively Eligible Uses:

If this option is selected, Treasury will review the proposed eligible use on a case-by-case basis and may request additional information – case-by-case reviews may add time to the Application review process. Please refer to Treasury’s Guidance for information on eligible uses.

[“Funds: Other Uses”: = Yes, show below]

• Please describe the proposed use of CPF Funds.

Tribal Partnerships

Are you using CPF funds on a project in partnership with another Tribal government or Tribal consortium?

[IF “Partnering with another Tribe” = Yes, show below]

If yes, please provide the name(s) of the other tribal entities

TAB 5: Certification and Submission

[PLACEHOLDER for introductory text]

(text visible if “Applicant is Delegated?” = TRUE)

Designation Letter

(Helptext: Please use the upload feature below to submit the designation letter signed by the chief executive or individual legally authorized to act on behalf of the decision-making body of your organization (e.g., duly authorized Tribal representative, organizational leader, governor) that identifies and delegates authority, as appropriate, to an authorized representative.)

If you do not yet have a signed designation letter and you are not otherwise legally authorized to submit the application, then you may still submit the application, but you will not receive payments until Treasury has received the necessary designation letter.

If the designation letter is not received by June 1, 2022, the Applicant’s grant award will be forfeited.

Please upload one or more delegation letters from the following tribes: [List Displayed]

[File Upload]

Is the identified authorized individual planning to sign/certify a digital or physical document?

[“Type of Certification”: picklist: Digital, Physical]

[ONLY ONE OF THE FOLLOWING 4 CERTIFICATION SECTIONS WILL BE DISPLAYED, BASED ON APPLICANT TYPE AND SIGNATURE TYPE (DIGITAL/PHYSICAL) PREFERENCE ]

(if “Type of Certification” = Digital, then visible)
Application Certification– State/Territory - Digital
The authorized representative (entered in Tab 2), with authority to legally bind the applicant, must certify your application using a DocuSign electronic signature.

Authorized Individual Email: [Display E-mail Address]

By electronically signing the certification for the application, the undersigned, acting on behalf of the applicant, certify and agree under penalty of perjury that

1. all the information provided in this application is true, complete, and correct

2. the entity has and will retain documentation and records to support the information provided in this application; and

3. the entity has and will make such supporting documents and records available upon request.

After you click the SIGN TO CERTIFY APPLICATION button below, an email will be sent to your authorized representative with a certification statement and a DocuSign link for an electronic signature.

[SIGN TO CERTIFY APPLICATION]
[button]

WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil penalties (18 U.S.C. §§ 287, 1001; 31 U.S.C. §§ 3729, 3802). Treasury may refer any allegations of fraud, waste, or abuse in connection with CPF to the Treasury Inspector General.

[(if “Type of Certification” = Physical, then visible)]
Application Certification – State/Territory - Physical

Since the authorized individual is planning to sign a physical copy, someone must be identified to receive the digital documents needing signature. Once received, the digital documents can be printed out and signed by the authorized representative. Please enter the email address where you would like to receive the digital documents needing signature below:

Send DocuSign Documents here: [Display E-mail Address]

Once the user receives the DocuSign emails, DocuSign offers the option to download the draft document and then upload a signed document. For guidance on this process, please refer to DocuSign’s guidance here: [link to pdf]

By physically signing the certification for the application, I the undersigned, acting on behalf of the entity, certify and agree under penalty of perjury that:

1. all the information provided in this application is true, complete, and correct

2. the entity has and will retain documentation and records to support the information provided in this application; and

3. the entity has and will make such supporting documents and records available upon request.

After you click the SIGN TO CERTIFY APPLICATION button below, an email will be sent to the address entered in the field above (Send DocuSign Documents here). That user must provide the document to the authorized representative for signature and must then upload the signed file back into the DocuSign website. Your authorized representative will physically sign a certification statement.

[SIGN TO CERTIFY APPLICATION and SIGN AGREEMENT]
[button]

WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil penalties (18 U.S.C. §§ 287, 1001; 31 U.S.C. §§ 3729, 3802). Treasury may refer any allegations of fraud, waste, or abuse in connection with CPF to the Treasury Inspector General.

[(if “Type of Certification” = Digital, then visible)]

Application Certification – Tribal - Digital

An authorized representative with authority to legally bind the applicant (entered in Tab 4), must certify your application using a DocuSign electronic signature.

Authorized Individual Email: [Display E-Mail Address]

By electronically signing the certification for the application, the undersigned, acting on behalf of the entity, certify and agree under penalty of perjury that:

1. all the information provided in this application is true, complete, and correct

2. the entity has and will retain documentation and records to support the information provided in this application; and

3. the entity has and will make such supporting documents and records available upon request.

After you click the SIGN TO CERTIFY APPLICATION and SIGN AGREEMENT button below, two emails will be sent to the authorized representative. Your authorized representative will then digitally sign both a certification statement and a Grant Agreement.

[SIGN TO CERTIFY APPLICATION and SIGN AGREEMENT] [button]

WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil penalties (18 U.S.C. §§ 287, 1001; 31 U.S.C. §§ 3729, 3802). Treasury may refer any allegations of fraud, waste, or abuse in connection with CPF to the Treasury Inspector General.

[(if “Type of Certification” = Physical, then visible)]
Application Certification – Tribal - Physical

Since the authorized individual is planning to sign a physical copy, someone must be identified to receive the digital documents needing signature. Once received, the digital documents can be printed out and signed by the authorized representative. Please enter the email address where you would like to receive the digital documents needing signature below:

Send DocuSign Documents here: [Display E-mail Address]

Once the user receives the DocuSign emails, DocuSign offers the option to download the draft document and then upload a signed document. For guidance on this process, please refer to DocuSign’s guidance here: [link to pdf]

By physically signing the certification for the application, I the undersigned, acting on behalf of the entity, certify and agree under penalty of perjury that:

1. all the information provided in this application is true, complete, and correct

2. the entity has and will retain documentation and records to support the information provided in this application; and

3. the entity has and will make such supporting documents and records available upon request.

[(if “Applicant Type” = Tribal, then visible)] After you click the SIGN TO CERTIFY APPLICATION and SIGN AGREEMENT button below, twoemails will be sent to the address entered in the field above (Send DocuSign Documents here). That user must provide those documents to the authorized representative for signatures and must then upload the signed files back into the DocuSign website. Your authorized representative will physically sign a certification statement and a Grant Agreement.

[SIGN TO CERTIFY APPLICATION and SIGN AGREEMENT]
[button]

WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil penalties (18 U.S.C. §§ 287, 1001; 31 U.S.C. §§ 3729, 3802). Treasury may refer any allegations of fraud, waste, or abuse in connection with CPF to the Treasury Inspector General.

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