Version 1 Rural and Tribal Grant Application For

Rural and Tribal Assistance Pilot Program

OMB# 2105-0584

Rural and Tribal Assistance Pilot Program
Online Application Form
*All fields must be complete.

1. Name and contact information of person for matters involving this application:
First and last name*:
Title*:
Phone*:

Email*:

2. Entity name, address and website:
Organization/Entity Name*:

Address (#, street, city/county, state and zip code - no post office box numbers)*:

Website address, if applicable:

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

4. Organization/entity Unique Entity Identifier (UEI) assigned by SAM.gov*:

sam.gov number request in progress (explain):

5. Entity/Organization headquarters is in this congressional district(s)*:

Program/project is in this congressional district(s)*:

Rural and Tribal Assistance Pilot Program

6. Below is a list of eligible entities for this program. Please select the one option
that describes your eligibility*: (See Section C.1: Eligible Applicants of the Notice)
A unit of local government or political subdivision seeking to advance a project that is located
outside of an urbanized area with a population of more than 150,000 residents
A State seeking to advance a project located outside of an urban area with a population of
more than 150,000 residents
A federally recognized Indian Tribe sponsoring a project on or impacting their tribal lands
The Department of Hawaiian Home Lands to sponsor projects on or impacting Hawaiian Home
Lands
Other, please specify:

7. Project title*: (Descriptive title of project for which you see funding)

8. Project location (no more than 100 words)*: Include city and state if providing street
name(s). Latitude/longitude is also acceptable.

(See Sections C.1.i and C.1.ii: Eligible Applicants of the Notice. Note: For Indian Tribes, the project
location does not have to meet the non-urban area requirement.)

9. Briefly describe the overall project (no more than 500 words)*: Include project type

(i.e., bridge, new roadway, transit service), features to be constructed, project schedule, and
estimated total project cost. (See Section C.3: Eligible Projects of the Notice)

9a. Estimated total project cost*:

Rural and Tribal Assistance Pilot Program

10. Is the applicant delinquent on any federal debt*?
Yes
No
If yes, explain:

11. Appropriateness of services requested*: (See the table in Section A of the Notice for
examples of advisory services anticipated, and Section E.2.a: Criterion(1) of the Notice)

a. Please describe the task(s)/advisory services for which you are seeking
program funds and how these services will materially advance your
overall project. (400 words or less)*

b. Requested funds from this program*:
c. Estimated cost of task proposed*:
d. Describe what project-related development activities that are completed if any. List N/A if none. Also, list any data or information that has been
collected or activities conducted that are necessary to complete the
task(s)/advisory services. (250 words or less) *

Rural and Tribal Assistance Pilot Program

12. Viability of grant services requested (See Section E.2.b: Criterion (2) of the Notice)
a. Please describe the following: Your organization's experience
procuring advisory services and if you have additional funds
available to commit to this effort should grant funding provided prove
insufficient to complete the proposed task(s). If additional funds will
be provided, include the amount and source of the local funding
commitment. (400 words or less)*

b. Applicants are encouraged to seek bids, quotes, or estimates for the services
being requested to demonstrate the reasonableness of the requested funding in
this application. Have you obtained a bid, quote, or estimate for the
services requested in this application?*
Yes (to be submitted later if awarded grant)
No (provide statement of how you determined
estimated cost of proposed task)

13. Within the past 12 months, have you submitted this project for federal
Department of Transportation grant funding, and it was not selected?*
Yes

List program(s):

No

14.

By checking this box and submitting this application, I certify that the
statements contained 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)*

15.
____________________________________________
Signature (e-signature is sufficient)*

__________
Date*