MM Bi-Annual Performance Report

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Overview

MMG Bi-Annual Report Cover
MMG Bi-Annual Performance

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Sheet 1: MMG Bi-Annual Report Cover

Middle Mile Grant Program Bi-Annual Performance Report Form
This form will serve as a tool to capture the Middle Mile Grant Program Bi-Annual performance Report. The report for the Middle Mile Grant Program is due on a biannual basis for the periods ending March 31 and September 30 of each year. Reports will be due within 30 days after the end of the reporting period. Technical reports shall contain information as prescribed in 2 C.F.R. § 200.329 (http://go.usa.gov/xkVgP) and Department of Commerce Financial Assistance Standard Terms and Conditions (dated November 12, 2020), Section A.01. If you have any further questions, or require technical assistance, please reach out to your assigned Federal Program Officer.
Click on the link below to view the report form.
MMG Bi-Annual Performance Report

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Sheet 2: MMG Bi-Annual Performance

Note: Form instructions and definitions will be created to support the report. Instructional guidance and training will be developed. Numbering to be updated based on final approved form.

RECIPIENT NAME:

OMB Control No.

Expiration Date:

Middle Mile Grant Program Bi-Annual Performance Report

A. GENERAL INFORMATION

GENERAL

1a. Recipient Organization:

1h. Award Identification Number:

1b. Recipient Street Address:

1i. Report Date (MM/DD/YYYY):

1c. City, Sate, and Zip Code:

1j. Final Report:

Yes

No

1d. Unique Entity Identification (UEI) Number:

1k. Report Period Start Date (MM/DD/YYYY):

1e. Award Start Date (MM/DD/YYYY):

1l. Report Period End Date (MM/DD/YYYY):

1f. Award End Date (MM/DD/YYYY):

1g. Name of Person Completing Report:

B. PROJECT NARRATIVE

PROJECT NARRATIVE

Please use the section below to provide a project narrative of the project(s). This section aims to help reviewers better understand what project is being proposed and steps taken to achieve this goal.

2a. A brief description of the recipient's organization and scope of work/project priorities:

2b. An overview of the significant outputs and outcomes to be accomplished in the project:

2c. How would the project meet the recipient's business and/or administrative need(s)?

2d. Provide an overview of key accomplishments achieved for this reporting period on the MM infrastructure project.

2e. Provide any roadblock experienced during this reporting period impacting the expansion of the MM infrastructure project (i.e., supply chain, availability of labor).

2f. Provide any barriers to improving job quality experienced during this reporting period.

C. INFRASTRUCTURE MILESTONE CATEGORIES AND PROJECT TIMELINE

INFRASTRUCTURE MILESTONE CATEGORIES AND PROJECT TIMELINE

Please use the chart below to provide the start date and end date of your project.

OVERALL PROJECT

PROJECT DURATION

3a. PROJECT START DATE

3b. PROJECT END DATE

0

Please provide the duration for each milestone category of your project. The duration should be based on the start and end dates of each category. For example, if you expect to complete a particular milestone within two weeks, fill in the total days (14) in the duration field. Please use the table provided to indicate your EXPECTED percentage of completion on a bi-annual basis for each year of your project. Year 1 begins with your award start date. The percentage of completion should be based primarily on the expenditure of your project budget and should be reported cumulatively from award inception through the end of each semi-annual reporting period. For example, if you expect to complete a particular milestone within the first three periods of your project, the third period and all subsequent periods should state 100%. Please write “0” in the duration field if your project does not include an activity. If necessary, please insert additional milestones at the end.

ANTICIPATED PROJECT MILESTONES

Year 1 Baseline

Year 2 Baseline

Year 3 Baseline

Year 4 Baseline

Year 5 Baseline

3c. MILESTONE CATEGORIES

3d. DURATION (Days)

3e. START DATE

3f. END DATE

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Overall Project

Environmental Assessment

Network Design

Rights Of Way

Construction Permits And Other Approvals

Site Preparation

Equipment Procurement

Network Build (all components - owned, leased, Indefeasible Rights of Use, etc.)

Equipment Deployment

Network Testing

Status of Procurement

Other (please specify):

% OF PROJECT COMPLETION

Please use the table provided to indicate your ACTUAL percentage of completion on a bi-annual basis for each year of your project. Year 1 begins with your award start date. The percentage of completion should be based primarily on the expenditure of your project budget and should be reported cumulatively from award inception through the end of each semi-annual reporting period. For example, if you expect to complete a particular milestone within the first three periods of your project, the third period and all subsequent periods should state 100%. Please provide a brief description of the primary activities involved in meeting each milestone (a single description should be provided for each milestone, covering all periods in years one through N). Please write “N/A” if your project does not include an activity. If necessary, please insert additional milestones at the bottom of the chart. Please add additional milestones as applicable.

ACTUAL PROJECT MILESTONES

Year 1

Year 2

Year 3

Year 4

Year 5

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

4a. MILESTONE

4b. DESCRIPTION

Actual Milestone Completion (Cumulative)

Overall Project

Environmental Assessment

Network Design

Rights Of Way

Construction Permits And Other Approvals

Site Preparation

Equipment Procurement

Network Build (all components - owned, leased, Indefeasible Rights of Use, etc.)

Equipment Deployment

Network Testing

Status of Procurement

Other (please specify):

Subrecipient and Subawards

List of Subrecipient(s) that received a subaward or subcontract from the eligible entity and a description of the specific project for which grant funds were provided. Associate projects names to any subrecipient or subaward associated with grant, approved grant funds, and expenditures to date.

5a. Project Name

5b. Project Description

5c. Subrecipient

5d. Minority Business Enterprise (MBE)

5e. Women's Business Enterprise (WBE)

5f. Labor Surplus Area Firm

5g. Awarded Funds

5h. Expenditures to Date

5i. Remaining Grant Balance

5j. % of work complete

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

D. INFRASTRUCTURE BUDGET EXECUTION DETAILS

INFRASTRUCTURE BUDGET EXECUTION DETAILS

Please provide details below on your total budget and total fund expended to date for each budget element, including detailed disbursements of both matching funds approved and federal funds obligated from project inception through end of this reporting period. Figures should be reported cumulatively from award inception to the end of the applicable reporting period.

6a. Projected Budget Element

6b. Federal Funds

6c. Non-Federal Funds

6d. Total Project Budget

6e. Total Federal Funds Expended to Date

6f. Total Non-Federal Funds Expended to Date

6g. Total Funds Expended

6h. Percent of Federal Funding Expended to Date (Cumulative)

Administrative and legal expenses

$-

$-

$-

$-

$-

$-

0%

Land, structures, rights-of way, appraisals, etc.

$-

$-

$-

$-

$-

$-

0%

Relocation expenses and payments

$-

$-

$-

$-

$-

$-

0%

Architectural and engineering fees

$-

$-

$-

$-

$-

$-

0%

Other architectural and engineering fees

$-

$-

$-

$-

$-

$-

0%

Project inspection fees

$-

$-

$-

$-

$-

$-

0%

Site work

$-

$-

$-

$-

$-

$-

0%

Demolition and removal

$-

$-

$-

$-

$-

$-

0%

Construction

$-

$-

$-

$-

$-

$-

0%

Equipment

$-

$-

$-

$-

$-

$-

0%

Miscellaneous

$-

$-

$-

$-

$-

$-

0%

Subtotal

$-

$-

$-

$-

$-

$-

0%

Contingencies

$-

$-

$-

$-

$-

$-

0%

Totals

$-

$-

$-

$-

$-

$-

0%

E. COMMUNITY BENEFIT AGREEMENT

COMMUNITY BENEFIT AGREEMENT

As stated in the MM Grant Program NOFO a Community Benefit Agreement (CBA) is an agreement signed by community benefit groups and a developer, identifying the community benefits a developer agrees to deliver, in return for community support of the project. Please use the fields below to state the Community Benefit Group and Developer Name and describe the activities in how this partnership has supported with the Middle Mile Infrastructure project (i.e. wage agreements, targeting hiring of apprentices and disadvantaged groups in labor marker, education and training opportunities, sub-contracting to local small business for construction, services, and supply chain needs).

Description of Community Agreement

7a. Community Benefit Group Name: Please provide the name of the Community Benefit Group

7b. Developer Name: Please provide the name of the Developer

7c. Community Benefit Group and Developer Partnership: Please describe in the space below the nature of the partnership and how the MM grant funds being used are assisting to provide community support for the infrastructure project.

F. CLIMATE RESILIENCE

CLIMATE RESILIENCE

Recipients must demonstrate that they have sufficiently accounted for current and future weather and climate related risks to new MM infrastructure projects. At present, weather and climate related risks to broadband networks include wildfires, extreme heat and cold, inland and coastal flooding, and the extreme winds produced by weather events such as tornadoes, hurricanes, and other weather events. Because retrofitted and new infrastructure for broadband might be expected to have a lifetime of 20 years or more, recipients must account not only for current risks but also for how the frequency, severity, and nature of these extreme events may plausibly evolve as our climate continues to change over the coming decades.

Climate Resiliency Risk Mitigation

This purpose of this section is for the recipient to demonstrate that they have sufficiently accounted for current and future weather and climate-related risks to new MM infrastructure projects. In particular, each recipient should demonstrate how they've addressed the known and identifiable risks of current and future projected weather and climate conditions through measures such as (but not limited to) choice of a technology platform suitable to the climate risk of the region, reliance on alternatives siting of facilities (i.e., underground construction where appropriate), retrofitting, or hardening of existing assets, and use of network redundancy to safeguard against threats to infrastructure.

8a. Were any geographic areas identified for this reporting period subject to an initial and/or updated hazard screening for future weather and climate related risk? If so, please provide the date of the screening and provide related documentation as an attachment to this report.

8b Climate Resilience Category

8c. Date of Most Recent Hazard Screening

8d. Name and Title of Representative Completing Most Recent Hazard Screening

8e. Date of Report Completion

8f. Identified Risk: For your MM project, what are the potential weather and climate hazards that may be most important to be addressed that could impact the resiliency of the middle mile infrastructure deployed (i.e. wildfires, extreme heat and cold, inland and coastal flooding, extreme winds: tornadoes, hurricanes and other weather events)?

8g. Weather and Climate Hazards: Were any significant climate or weather hazards experienced during this reporting period (i.e., floods, tornados) impacting infrastructure buildout or service? Briefly describe how you monitored for weather and climate caused issues for the reliability of the system. If so, please provide the date of the disaster, location and backup documentation related (i.e., news articles).

8h. Risks to Deployment of New Infrastructure: Has the team identified any risks impacting the deployment of new or repaired infrastructure due to current and future weather and climate-related threats during this reporting period?

8i. Risk Mitigation: How will the project avoid and/or mitigate the risk identified? If not applicable, please explain why.

8j. Additional Information: Is there any additional information you would like to share during this reporting period that the grant team should be aware of regarding the management of sustainable climate resiliency for your MM project?

8k. Additional Resources Has the team utilized the available resources to assist with mitigation and long-term planning efforts for this reporting period? If so, which resources? 2018 National Climate Assessment NOAA's 2022 State Climate Summaries NOAA Disaster and Risk Mapping Tool NOAA's Storms Event Database NOAA Climate Explorer and Digital Coast FEMA National Risk Index Consulted FEMA-approved Hazard Mitigation Plans prepared by states in which they propose to build middle mile infrastructure to help identify key risk and hazards

G. Workforce

DAVIS-BACON ACT CERTIFICATION

For projects receiving over $5,000,000 (based on expected total cost), as determined by the U.S. Secretary of Labor by subchapter IV of chapter 31 of title 40, United States Code (commonly known as the "Davis-Bacon Act"), all laborers and mechanics employed by contractors and subcontractors in the performance of such project are paid wages at rates not less than those prevailing.

Davis-Bacon Act Certification

9a. Does the recipient have access to the information requested (all laborers and mechanics employed by contractors and subcontractors in the performance of such project are paid wages at rates not less than those prevailing?)

Yes

No

LOCAL HIRE PRIORITIZATION AND IMPACT

Local Hire Prioritization and Impact

Local hiring is a goal or requirement to hire people who live close to the place of work. This aim is often more specifically structured as a requirement for contractors awarded certain types of publicly funded projects to recruit a certain proportion of the people working on the project from a particular area. Please provide all direct hires and contractors supporting the MM Infrastructure project. Please use the table below to describe how the project prioritizes local hiring.

Hires by Race, Ethnicity and Gender

Number of Hires

Race/Ethnicity

9b. Hispanic or Latino

9c. Non-Hispanic/Non-Latino

Totals

9c-1. Men

9c-2. Women

9c-3. X

9b-1. Men

9b-2. Women

9b-3. X

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

Native American or Alaska Native

Two or More Races

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

Native American or Alaska Native

Two or More Races

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

Native American or Alaska Native

Two or More Races

Number of Local Direct Hires

0

Number of Non-Local Direct Hires

0

Percentage of Local Direct Hires on Award

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

Number of Local Subcontractors

0

Number of Non-Local Subcontractors

0

Percentage of Local Subcontractors on Award

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

DAVIS-BACON WAGES

Davis-Bacon Act Wages

Please confirm if wages are at least prevailing*

*As stated in the MM NOFO as determined by the U.S. Secretary Labor in accordance with subchapter IV of chapter 31 of title 40, United States Code (commonly known as the "Davis-Bacon Act"), for the corresponding classes of laborers and mechanics employed on projects of a character similar to the contract work in the civil subdivision of the State (or the District of Columbia) in which the work is to be performed.

10a. Are wage rates at least the Davis-Bacon prevailing wage for all laborers?

Yes

No

10c. Are wage rates at least the prevailing wage for all mechanics?

Yes

No

10b. Please cite your source of how this information was gathered (for 10a).

10d. Please cite your source of how this information was gathered (for 10c).

10e. If you answered "No" to either 10a. or 10c., please provide an attachment reporting the wages and benefits of workers on the project by job classification, and whether those wages are less than the prevailing wage.

WORKFORCE DEMOGRAPHICS

Workforce Demographic Data

Jobs by Race, Ethnicity and Gender

Number of Jobs

Race/Ethnicity

11-a. Hispanic or Latino

11b. Non-Hispanic/Non-Latino

Totals

11b-1. Men

11b-2. Women

11b-3. X

11a-1. Men

11a-2. Women

11a-3. X

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

Native American or Alaska Native

Two or More Races

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

Native American or Alaska Native

Two or More Races

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

Native American or Alaska Native

Two or More Races

Jobs Created

0

Jobs Retained

0

UNIONIZED WORKFORCE

12-a. Does this project include some workforce elements that are unionized?

Yes

No

12-c. Does your MM project utilize a project labor agreement?

Yes

No

12-b. Are workers provided access to union educators/organizers on employer property or during the work day?

Yes

No

12-d. Did workers receive additional information or training about their workplace rights in addition to already required notice postings?

Yes

No

H. Workforce Continuity Plan National Labor Relations Act (29 U.S.C. 158 (f)

WORKFORCE CONTUNITY PLAN NATIONAL LABOR RELATIONS ACT

As stated in the MM NOFO, if a recipient has not provided a certification that a project either will use a unionized project workforce or included a project labor agreement, meaning a pre-hire collective bargaining agreement consistent with section 8(f) of the National Labor Relations Act (29 U.S.C. 158 (f)), then the recipient must provide a project workforce continuity plan.

Workforce Continuity Plan

13a. Please describe the steps taken to ensure the project has ready access to a sufficient supply of appropriately skilled and unskilled labor to ensure construction is completed skillfully throughout the project's life (as required in Section III.B of the MM NOFO). As stated in the MM NOFO, the middle mile grant recipient is capable of carrying out the proposed project in a competent manner, including a plan to attract or retain an appropriate skilled and credentialed workforce. For your MM project, please provide a brief description of efforts made to attract, train or retain a skilled and credentialed workforce. Has the team offered any of the following resources to assist with maintaining a sufficient supply of appropriately skilled labor force for this reporting period? If so, which resources (please provide a brief description of any of the following that apply): Professional Certifications In-House Training Registered Apprenticeships Labor-Management Partnerships Partnerships with entities like unions, community colleges, or community-based groups

13b. Please describe below, the steps taken to minimize risks of labor disputes and disruptions that would jeopardize the timeliness and cost-effectiveness of completing the MM project.

13c. Please describe below the steps to ensure a safe and healthy workplace that avoids delays and costs associated with workplace illnesses, injuries, and fatalities.

13d. For your MM project, please provide a brief description below of efforts made to ensure a safe and healthy workplace. Has the team offered any of the following resources to assist with maintaining a safe and healthy workplace for this reporting period? If so, which resources (please provide a brief description of any of the following that apply): Safety Training Certifications and/or Licensure Requirements for all relevant works (e.g., OSHA 10, OSHA 30, confined space, traffic control, or other training required of workers employed by contractors) Issues raised by workplace safety committees and their resolutions

13e. Please provide the name(s) below of any subcontracted entities performing work on the project, and the total number of workers employed by each entity.

13e-1. Name of Subcontracted Entity Performing Work

13e-2. Total Number of Workers within this Subcontract

13e-3. Job Categories of Workers Supporting Project within this Subcontract

13f. Please describe below the steps taken to ensure that workers on the project receive wages and benefits sufficient to secure an appropriately skilled workforce in the context of the local and regional labor market.

I. ANCHOR INSTITUTIONS

ANCHOR INSTITUTIONS

Please provide Anchor Institution (AI) data for the current period only (not cumulative). Please add rows as needed.

14a. Anchor Institution Name

14b. Street Address

14c. City

14d. State

14e. Type of Anchor Institution

14f. Interconnection within 1,000 Feet of AI Enabling Gig Symmetrical Service

14g. Narrative Description of how the Anchor Institution may benefit from the Grant Funded Infrastructure

J. BROADBAND ACCESS KEY INDICATOR: SUBSCRIBERS AND SPEED

PROJECTED NUMBER OF SUBSCRIBERS AND SPEED

Please use the following table to provide anticipated key indicators with the projected totals for each beneficiary category, access type and speed category for your infrastructure service or project. Except as indicated, information should be reported cumulatively from award inception through the end of the semi-annual period for Semi-Annual Indicators. Please write “N/A” if your project does not include this indicator.

PROJECTED NUMBER OF SUBSCRIBERS AND SPEED

Year 1

Year 2

Year 3

Year 4

Year 5

SUBSCRIBER TYPE

ACCESS TYPE

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

15a. Anchor Institutions (AIs)

15a-1. Total number of AIs passed

15a-2. Number of AIs within 1,000 feet of the middle mile infrastructure

15a-3. Total number of AIs served

15a-4. AIs with new access

15a-5. AIs with improved access

15a-6. Total number of AIs served with speeds of at least 1/1Gbps

15b. Broadband Wholesalers or Last Mile Providers

15b-1.Total number of broadband wholesalers or last mile providers served

15b-2. Broadband wholesalers or last mile providers with new access

15b-3. Broadband wholesalers or last mile providers with improved access

15b-4. Total number of broadband wholesalers or last mile providers offering speeds of at least 25/3 Mbps

15b-5. Total number of broadband wholesalers or last mile providers offering speeds of at least 100/20 Mbps

15b-6. Total number of broadband wholesalers or last mile providers offering speeds of at least 1/1 Gbps

K. BROADBAND ACCESS KEY INDICATOR: NETWORK BUILD PROGRESS

NETWORK BUILD PROGRESS

Please use the following table to provide anticipated key indicators and progress of your Infrastructure project. Except as indicated, information should be reported cumulatively from award inception through the end of the semi-annual period. Please write “N/A” if your project does not include this indicator.

NETWORK BUILD PROGRESS

Year 1

Year 2

Year 3

Year 4

Year 5

KEY INDICATOR

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

16a. Total of new fiber miles (aerial or buried)

16b. Total of fiber miles leased

16c. Total of existing fiber miles upgraded

16d. Total of new microwave links

16e. Total of new towers

16f. Total of new interconnection points

16g. Total of signed agreements with broadband wholesalers or last mile providers

16h. Total of potential agreements (i.e., agreements currently being negotiated) with broadband wholesalers or last mile providers (This Total should NOT be reported cumulatively)

L. QUANTIABLE METRICS

FIBER OPTIC BASED

Quantifiable Metrics - Section designed to assist with reporting and audit purpose to quantify how much progress was made and track the location of where the progress was made.

17a. Fiber Optic Based

Year 1

Year 2

Year 3

Year 4

Year 5

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

17a-1. Is the fiber a buried/aerial or undersea application?

17a-2. Number of strands deployed

17a-3. Number of miles of buried fiber deployed

17a-4. Number of miles of aerial fiber deployed

17a-5. Estimated capacity of fiber (i.e. throughput)

17a-6. Deployment cost per mile of buried fiber optics

17a-7. Deployment cost per mile of aerial fiber optics

17a-8. Total Spent on Buried Fiber Deployment this reporting period

17a-9. Total Spent on Aerial Fiber Deployment this reporting period

17a-10. Total spent on Fiber Deployment this reporting period

17a-11. Please provide any additional information about the Fiber Optic deployment (200 words or less)

17a-12. Please provide the digital mappings (e.g., CAD, Revit, KMZ, KML) for the microwave nodes created during this reporting period.

MICROWAVE BASED

17b. Microwave Based

Year 1

Year 2

Year 3

Year 4

Year 5

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

17b-1. How many microwave nodes have been deployed?

17b-2. How many microwave nodes are operating for reporting period?

17b-3. Installation cost per microwavable node

17b-4. Number of new towers built to support microwave structure

17b-5. If applicable, what type of tower was constructed (a) Monopole (b) Self-Support, or (c) Guyed during this reporting period?

17b-6. Average cost per tower installed

17b-7. Total spend on Tower deployment this reporting period

17b-8. Total spend on microwave deployment this reporting period

17b-9. If you answered "other" to question 5a.6 or if it is a combination of multiple types, please provide a detailed narrative description detailing what type of tower or what combination of towers is used for the project and the their associated costs. (200 words or less).

17b-10. Please provide the digital mappings (e.g., CAD, Revit, KMZ, KML) for each new aerial fiber and buried fiber equipment installed during this reporting period.

SATELLITE

17c. Satellite

Year 1

Year 2

Year 3

Year 4

Year 5

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

Period 1

Period 2

17c-1. What satellite provider is being used?

17c-2. What is the estimated capacity of the satellite link (i.e. throughput)?

17c-3. What is the associated cost to use this satellite service?

17c-4. Please provide any additional information about the Satellite deployment (200 words or less)

17c-5. Please provide the digital mappings (e.g., CAD, Revit, KMZ, KML) for each new aerial fiber and buried fiber equipment installed during this reporting period.

CERTIFICATIONS

Certifications

18. Please provide certification evidencing compliance with Federal labor and employment laws along with the requirements of Infrastructure Investment and Jobs Act and Middle Mile Grant Program, for the bi-annual period for which this report is being filed.

19. Please provide certification evidencing compliance with the Build America, Buy America Act. The Build America, Buy America Act requires that all of the iron, steel, manufactured products (including but not limited to fiber-optic communications facilities), and construction materials used in the project or other eligible activities are produced in the United States unless a waiver is granted.

MM GRANT PROGRAM BI-ANNUAL REPORT CERTIFICATION

20. I certify to the best of knowledge and belief that this report is correct and complete for performance of activities for the purposes set forth in the award documents.

20a. Typed or Printed Name and Title of Authorized Certifying Official:

20c. Telephone (area code, number and extension):

20d. Email Address:

20b. Signature of Certifying Official:

20e. Date: