Form 17423-17423a Joint Application and Applicant Disclosure Forms

TVA RESTRICTED INFORMATION

JOINT APPLICATION FORM

OMB No. 3316-0060
Exp. Date 06/30/2022

Department of the Army/TVA

The Department of the Army (DA) permit program is authorized by Section 10 of the Rivers and Harbors Act of 1899 and Section 404 of the Clean Water
Act (P.L. 95-217). These laws require permits authorizing structures and work in or affecting navigable waters of the United States and the discharge of
dredged or fill material into waters of the United States. Section 26a of the Tennessee Valley Authority Act, as amended, prohibits the construction,
operation, or maintenance of any structure affecting navigation, flood control, or public lands or reservations across, along, or in the Tennessee River or any
of its tributaries until plans for such construction, operation, and maintenance have been submitted to and approved by the Tennessee Valley Authority (TVA).

Name and Mailing Address of Applicant:

Name, Mailing Address, and Title of Authorized Agent:

Email Address:

Email Address:

Telephone Number:

Home
Office
Mobile

Telephone Number:

Facility/Activity Location (include all known information):
Address:
Subdivision, Lot No., and/or Tax Parcel No.:
Stream Name and Mile:
Application submitted to

DA

Home
Office
Mobile

Reservoir

Longitude/Latitude:

TVA

Date activity is proposed to commence:

Date activity is proposed to be completed:

Describe in detail the proposed activity, its purpose and intended use (private, public, commercial, or other). Describe structures to be
erected including those placed on fills, piles, or floating platforms. Also, describe the type, composition, and quantity of materials to be
discharged or placed in the water; the means of conveyance; and the source of discharge or fill material. Please attach additional sheets if
needed.

Application is hereby made for approval of the activities described herein. I certify that I am familiar with the information contained in this
application, and that to the best of my knowledge and belief such information is true, complete, and accurate. I further certify that
I possess the authority to undertake the proposed activities. I understand that TVA and the U.S. Army Corps of Engineers may contact an
Authorized Agent listed above and such Agent may act on my behalf on all aspects of this application. I agree that, if TVA approves this
application, I will comply with the terms and conditions and any special conditions that TVA may impose. Please note the U.S.
Army Corps of Engineers may impose additional conditions or restrictions.
Date

Name of Applicant (Printed)

Signature of Applicant

18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and
willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations
or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than
$10,000 or imprisoned not more than five years, or both. The appropriate DA fee will be assessed when a permit is issued.

Names, addresses, and telephone numbers of adjoining property owners, lessees, etc., whose properties also join the waterway:

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TVA RESTRICTED INFORMATION
List of previous DA/TVA permits/approvals

DA

TVA

Permit Number

Permit Number

Previous Property Owner (if known)
(If “Yes” attach explanation)
Is any portion of the activity for which authorization is sought now complete?
Yes
No
Month and year the activity was completed:
. Indicate the existing work on the drawings.
List all approvals or certifications required by other federal, interstate, state, or local agencies for any structures, construction, discharges,
deposits, or other activities described in this application.
Issuing Agency

Type Approval

Identification No.

Date of Application

Date of Approval

Has any agency denied approval for the activity described herein or for any activity directly related to the activity described herein?
(If “Yes” attach explanation)
Yes
No
Project plans or drawings, on paper suitable for reproduction no larger than 11 x 17 inches or in electronic format (dxf, docx, or pdf) must
accompany the application. Submit the application to the appropriate TVA and U.S. Army Corps of Engineers offices. An application that
is not complete will be returned for additional information.

U.S.A.C.E. Offices
U.S. Army Corps of Engineers
Eastern Regulatory Field Office
501 Adesa Parkway., Suite 250
Lenoir City, Tennessee 37771
(865) 986-7296
U.S. Army Corps of Engineers
Regulatory Branch
3701 Bell Road
Nashville, Tennessee 37214
(615) 369-7500
U.S. Army Corps of Engineers
Norfolk District
P.O. Box 338
Abingdon, Virginia 24212
(276) 623-5259

TVA Offices

U.S. Army Corps of Engineers
Savannah District
The Plaza, Suite 130
1590 Adamson Parkway
Morrow, Georgia 30260-1763
(678) 422-2729
U.S. Army Corps of Engineers
Western Regulatory Field Office
2424 Danville Road, SW, Suite N
Decatur, Alabama 35603
(256) 350-5620
U.S. Army Corps of Engineers
Asheville Regulatory Field Office
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
(828) 271-4856

Tennessee Valley Authority
Chattanooga Regional Office
4601 N. Access Road, Bldg. B
Chattanooga, Tennessee 37415-3825
1-800-882-5263

Tennessee Valley Authority
Murphy Regional Office
4195 West US Highway 64, Suite 10
Murphy, North Carolina 28906
1-800-882-5263

Tennessee Valley Authority
Gray Regional Office
106 Tri-Cities Business Park Drive
Gray, Tennessee 37615
1-800-882-5263

Tennessee Valley Authority
Muscle Shoals Regional Office
Post Office Box 1010, MPB 1H
Muscle Shoals, Alabama 35662-1010
1-800-882-5263

Tennessee Valley Authority
Guntersville Regional Office
3941 Brashers Chapel Road
Guntersville, Alabama 35976
1-800-882-5263

Tennessee Valley Authority
Paris Regional Office
2835-A East Wood Street
Paris, Tennessee 38242-5948
1-800-882-5263

Tennessee Valley Authority
Knoxville Regional Office
400 West Summit Hill Drive, WT 11D-K
Knoxville, Tennessee 37902
1-800-882-5263

Tennessee Valley Authority
Floating Cabin Program Manager
400 West Summit Hill Drive, WT 11D-K
Knoxville, Tennessee 37902
1-800-882-5263

Privacy Act Statement
This information is being requested in accordance with Section 26a of the TVA Act as cited on the front page of this form. Disclosure of the information requested is voluntary; however, failure to provide any required information or documents may result in a delay in processing your application or in your being denied a Section 26a permit. An application that is
not complete wil be returned for additional information. TVA uses this information to assess the impact of the proposed project on TVA programs and the environment and to determine if the project can be approved. Information in the application is made a matter of public record through issuance of a public notice if warranted. Routine uses of this information
include providing to federal, state, or local agencies, and to consultants, contractors, etc., for use in program evaluations, studies, or other matters involving support services to the program; to respond to a congressional inquiry concerning the application or Section 26a program; and for oversight or similar purposes, corrective action, litigation or law enforcement.
The information requested in this form becomes part of the Section 26a Permit Application Records Privacy Act System of Records (TVA-36). Authority for maintenance of this system of records is provided by the Tennessee Valley Authority Act of 1933, 16 U.S.C. 831-831ee.
The information solicited on this form may be made available as a "routine use." A complete list of the routine uses can be found in the system of records notice associated with this form, "Section 26a Permit Application Records, TVA-36." TVA's system of records notices can be found on the TVA website at https://www.tva.com/information/about-the-tva-privacyprogram.
Burden Estimate Statement

Public reporting burden for this collection of information is estimated to average 2 hours 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. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Agency Clearance Officer, Tennessee
Valley Authority, 1101 Market Street, Chattanooga, Tennessee 37402; and to the Office of Management and Budget, Paperwork Reduction Project (33160060), Washington, D.C. 20503.

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TVA RESTRICTED INFORMATION
Section 26a Permit and Land Use Application
Applicant Disclosure Form

OMB No. 3316-0060
Exp. Date 06/30/2022

By signing the Joint Application Form (Department of Army/TVA) or TVA’s Land Use Application and again below, you agree to disclose
any business, political, or financial interest that may present an actual or potential conflict of interest with TVA. If a new significant
business, political, or financial interest is obtained during the period of the time that the application is under review, you agree to file an
additional disclosure.
Disclose if any of the following apply to you (check all that apply

 ).

I am:

An elected government official or a candidate to an elected government office (whether federal, state, or local).
A senior management level employee of an entity that regulates TVA or its activities.
A senior management level employee of a power customer of TVA.
A current TVA employee or Director.
A former TVA officer or former TVA Director and it is less than one year after my last date of service with TVA.
A current member of a TVA council created pursuant to the Federal Advisory Committee Act (FACA), such as the Regional Resource
Stewardship Council (RRSC) or Regional Energy Resource Council (RERC), or I am a former council member and it is less than one
year after my last date of service on the council.
The spouse or dependent child of any of the above. List which one of the above applies.
__________________________________________________________________________
A representative of a corporation or other non-governmental entity submitting an application and one of the above applies to me. Print
entity or corporation name, and identify which of the above applies to you.

A representative of a corporation or other non-governmental entity submitting an application and I have significant financial interest in
the corporation or non-governmental entity. Print entity or corporation name.

None of the above
Please sign and return this form with your application package. Your application cannot be processed without receipt of this signed form.
By signing this form, you consent to this Applicant Disclosure Form being made available to the public in response to an appropriate request, including,
without limitation, a request made under the Freedom of Information Act. All applications and communications that occur as part of the application
process may be made public to the extent permitted by applicable law, including the Freedom of Information Act and the Privacy Act, and could be
reviewed formally by the Office of Inspector General (OIG). All written correspondence regarding your request may be forwarded to the TVA Designated
Agency Ethics Official (DAEO) and the OIG, and all oral communication between TVA and the applicant regarding this request may be documented and
maintained by TVA.

Name of Applicant (Printed)

Signature of Applicant

Date

18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and
willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or
representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statement or entry, shall be
fined not more than $10,000 or imprisoned not more than five years, or both.
Privacy Act Statement
This information is being requested in accordance with Sections 4(k), 15d, 26a, and/or 31 of the TVA Act; 40 U.S.C. § 1314; 30 U.S.C. § 185; 16 U.S.C. § 667b; and/or 40 U.S.C. § 483. Disclosure of the information requested is voluntary; however, failure to provide any required
information or documents may result in a delay in processing your application or in your application being denied. An application that is not complete will be returned for additional information. TVA uses this information to assess the impact of the proposed project on TVA programs
and the environment and to determine if the project can be approved. Information in the application is made a matter of public record through issuance of a public notice if warranted. Routine uses of this information include providing to federal, state, or local agencies, and to
consultants, contractors, etc., for use in program evaluations, studies, or other matters involving support services to the program; to respond to a congressional inquiry concerning the application or the applicable program; and for oversight or similar purposes, corrective action,
litigation, or law enforcement.
The information requested in this form becomes part of the Section 26a Permit Application Records Privacy Act System of Records (TVA-36). Authority for maintenance of this system of records is provided by the Tennessee Valley Authority Act of 1933, 16 U.S.C. 831-831ee.
The information solicited on this form may be made available as a "routine use." A complete list of the routine uses can be found in the system of records notice associated with this form, "Section 26a Permit Application Records, TVA-36." TVA's system of records notices can be
found on the TVA website at https://www.tva.com/information/about-the-tva-privacy-program.
Burden Estimate Statement
Public reporting burden for this collection of information is estimated to average 5 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. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Agency Clearance
Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, Tennessee 37402; and to the Office of Management and Budget, Paperwork
Reduction Project (3316-0060), Washington, D.C. 20503.

TVA 17423A [01-24-2022]

TVA RESTRICTED INFORMATION