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Please add the appropriate title header to clarify that this document is the TBCP Project Information Form. Keep the OMB control number and expiration date at the top of the sheet.
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OMB Control No. 0660-0046
Expiration Date: TBD |
| Applicant Information |
| Field Name |
Response |
Instructions |
| Applicant Name |
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Provide the name of your Federally Recognized Tribe |
| Applicant Type (drop down) |
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Indicate whether you are a Federally Recognized Tribe, Tribal Organization, Tribal College/University |
| Consortium Applicant (Y/N) |
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Are you applying on behalf of a consortium of federally recognized tribes?
Please note that the application requests that the consortium application submission should contain authorized Tribal Resolutions attesting to participation in the Consortium project. |
| Applicant Tribe(s) |
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Please list the participating tribes separated by a comma (Final Form Draft may use data validation) |
| UEI |
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Enter the organization’s UEI received from SAM. The UEI is a unique 12 character organization identifier. Information on registering with System for Award Management (SAM.gov) may be obtained by visiting the Grants.gov website. |
| Authorized Organization Representative (AOR) Name |
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Name of the authorized representative of the applicant organization. Enter the first and last name (required); prefix, middle name, and suffix. A copy of the governing body's authorization recognizing the official representative must be on file in the applicant's office. (NTIA also requires that this authorization be submitted as part of the application.) |
| AOR Email |
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Email of the AOR for the applicant organization |
| AOR Title |
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Title of the AOR for the applicant organization |
| AOR Telephone |
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Telephone number of the AOR for the applicant organization (e.g. 123-555-4567) |
| Point Of Contact (POC) Name |
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Name of the point of contact for questions concerning this application. Enter the first and last name (required); prefix, middle name, and suffix. |
| POC Email |
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Email of the POC |
| POC Title (if applicable) |
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Title of the POC if applicable |
| POC Telephone |
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Telephone number of the POC (e.g. 123-555-4567) |
| Address |
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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 is US). If +4 does not exist for the address, enter “0000” |
| Basic Project Information |
| Project Title |
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Enter a brief descriptive title of the project. |
| Project Type (Drop down) |
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Please select the Project Type from among Infrastructure Deployment, Use & Adoption, and Planning. |
| Project Area Census Tracts |
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Identify the census tract number of the project. Please visit NTIA's webpage to review a full list of census tracts by state and county or refer to the Census Bureau's TIGER Web map to identifiy. For example, if the most central tract is Census Tract 93.30, please enter '93.30' into the cell. The last zero may be missing from your response (e.g., 93.30 may display as 93.3). If the project is located in more than one census tract, please identify the census tract in which the majority of the project is located.
See attached draft instructions |
| Proposed Budget (Total) |
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Provide the total amount of Federal funding being requested (field will be restricted to dollar format) |
| Proposed Use & Adoption Budget (UA) |
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Provide the total amount of Federal funding being requested for the Use & Adoption project proposed. |
| Proposed Broadband Infrastructure Deployment Budget (ID) |
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Provide the total amount of Federal funding being requested for the Broadband Infrastructure Deployment project proposed. |
| Proposed Broadband Infrastructure Deployment Planning Study Budget (Planning) |
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Provide the total amount of Federal funding being requested for the Planning Study project proposed. |
| ID Deployment Technology(s) |
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Please select the broadband technology(ies) proposed to complete the Infrastructure Deployment project.
(This will be a selection including but not limited to Fiber, Wireless, Satellite, etc.) |
| Service Area Information |
| Total # of NA/AN/NH Households |
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What is the total number of Native American, Alaskan Native, or Native Hawaiian households contained in the proposed service area of the project? |
| # of NA/AN/NH Households Unserved |
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What is the total number of Unserved Native American, Alaskan Native, or Native Hawaiian households contained in the proposed service area of the project?
(Please refer to the definition for Unserved in the TBCP2 NOFO) |
| # of NA/AN/NH Households Below 150% of the Poverty Line |
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What is the total number of Native American, Alaskan Native, or Native Hawaiian households contained in the proposed service area of the project that are below 150% of the Federal Poverty Rate?
(See TBCP2 NOFO, Section xxx for specific guidance) |
| Total # of NA/AN/NH Businesses |
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What is the total number of Native American, Alaskan Native, or Native Hawaiian Businesses contained in the proposed service area of the project? |
| # of NA/AN/NH Businesses Unserved |
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What is the total number of Native American, Alaskan Native, or Native Hawaiian Businesses that are Unserved within in the proposed service area of the project?
(Please refer to the definition for Unserved in the TBCP2 NOFO) |
| Total # of NA/AN/NH CAIs |
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What is the total number of Native American, Alaskan Native, or Nativie Hawaiian Community Anchor Institutions contained in the proposed service area of the project? |
| # of NA/AN/NH CAIs Unserved |
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What is the total number of Native American, Alaskan Native, or Nativie Hawaiian Community Anchor Institutions that are Unserved within in the proposed service area of the project?
(Please refer to the definition for Unserved in the TBCP2 NOFO) |
| Does any area within the proposed service area currently have an enforceable buildout commitment? |
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Please list the Broadband Service Providers with which the Tribal Government has an Enforceable Buildout Commitment within the proposed service area.
Please write "NA" if your project does not include a particular indicator. |
| Project Service Information |
| Total # of NA/AN/NH Households to be connected to qualifying service |
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What is the total number of Native American, Alaskan Native, or Native Hawaiian households contained in the proposed service area of the project that will be connected by completing the proposed project? |
| # of NA/AN/NH Households Unserved to be connected to qualifying service |
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What is the total number of Currently Unserved Native American, Alaskan Native, or Native Hawaiian households contained in the proposed service area of the project that will be connected by completing the proposed project?
(Please refer to the definition for Unserved in the TBCP2 NOFO) |
| Total # of NA/AN/NH Businesses to be connected to qualifying service |
|
What is the total number of Native American, Alaskan Native, or Native Hawaiian Businesses contained in the proposed service area of the project that will be connected by completing the proposed project? |
| # of NA/AN/NH Businesses Unserved to be connected to qualifying service |
|
What is the total number of Native American, Alaskan Native, or Native Hawaiian Businesses that are Currently Unserved within in the proposed service area of the project that will be connected by completing the proposed project?
The number entered should refer to the number of unserved Tribal Businesses that will be connected within the proposed service area of the submitted application. (Please refer to the definition for Unserved in the TBCP2 NOFO) |
| Total # of NA/AN/NH CAIs to be connected to qualifying service |
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What is the total number of Native American, Alaskan Native, or Nativie Hawaiian Community Anchor Institutions that are within in the proposed service area of the project that will be connected by completing the proposed project? |
| # of NA/AN/NH CAIs Unserved to be connected to qualifying service |
|
What is the total number of Native American, Alaskan Native, or Nativie Hawaiian Community Anchor Institutions that are Currently Unserved within in the proposed service area of the project that will be connected by completing the proposed project?
The number entered should refer to the number of unserved Tribal CAIs that will be connected within the proposed service area of the submitted application. (Please refer to the definition for Unserved in the TBCP2 NOFO) |
| Proposed Minimum Household Speed |
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What is the proposed minumum connection speed for all households that will be connected within the proposed service area? |
| Proposed Maximum Household Speed |
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What is the proposed maximum connection speed for all households that will be connected within the proposed service area? |
| Federal Funding Information |
Are you a sponsoring tribal government previously applied for TBCP funds (Y/N)?
If yes, provide further information below. |
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Please indicate whether or not you applied for TBCP funding in 2021. Please answer regardless of having receieved an award. If you reccieved award, additional information is requested below. |
| Further information regarding previous TBCP application submitted in 2021. |
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Please list the Title and the Grants.Gov Grant Tracking Number (GRANTXXXXXXX) of the appliction submitted in 2021. (Title, GRANTID) |
Are you a sponsoring tribal government that has been awarded TBCP funding (Y/N)?
If yes, provide further information below. |
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Were you awarded funding through TBCP? |
| Further information regarding your TBCP award. |
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Enter the NIST Award Number as assigned in the NIST Grants Management Information System (GMIS). This is a unique 14 character award identifier that begins will resemble "NT22TBC029xxxx." |
Are you a sponsoring tribal government that has been awarded NTIA Digitial Equity Program funding (Y/N)?
If yes, provide further information below. |
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Were you awarded funding through the Digital Equity Program? |
| Further information regarding your Digital Equity Program award. |
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Enter the NIST Award Number as assigned in the NIST Grants Management Information System (GMIS). This is a unique 14 character award identifier that begins will resemble "NT22TBC029xxxx." |
Are you a sponsoring tribal government that has received a federal award that provides funding for broadband infrastructure deployment, planning, or use & adoption (Y/N)?
If yes, provide further information below. |
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Have you been awarded other Federal funding, either through a competitive award/grant or formula funding, that provided funding for broadband infrastructure deployment, planning, or use & adoption? |
| List the Awarding Agency and Program that provided funding for broadband planning, deployment, or adoption. |
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List the awarding agency(ies) followed by the Program separated by a comma.
(e.g. USDA, ReConnect Loan and Grant Program) |
Are you a sponsoring tribal government that has previously applied for federal funds supporting broadband planning, deployment, or adoption, but did not receive an award (Y/N)?
If yes, provide further information below. |
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Have you applied for other Federal funding, either through a competitive award/grant or formula funding, that provided funding for broadband infrastructure deployment, planning, or use & adoption? |
| List the Awarding Agency and Program that you applied for funding to support broadband planning, deployment, or adoption. |
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List the awarding agency(ies) followed by the Program separated by a comma.
(e.g. USDA, ReConnect Loan and Grant Program) |