Form Updated Appendix A Updated Appendix A Application Checklist

Rural and Tribal Assistance Pilot Program

OMB# 2105-0584

Rural and Tribal Assistance Pilot Program

Review Copy of Online Application Questions

*All fields must be completed.

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- no P.O. box numbers)*:

City*:

State*: Zip Code*:

Website address, if applicable:

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

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

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

Project is in this congressional district(s)*:

6. Below is a list of eligible entities for this program. Please select the one option that describes your eligibility*: (For local governments, political subdivisions, or states: Refer to NOFO Section II. A. Eligible Applicants and Section II. E. Definition of Rural Areas for qualification.)

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

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

8. Project location*: Must be listed as either street address, Including city and state, or as latitude/longitude. (Note: For Indian Tribes, the project location does not have to meet the non-urban area requirement.)

Address (#, street- no P.O. box numbers):

City:

State: Zip Code:

OR

Latitude: Longitude:

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.

9a. Estimated total project cost*:

10. Is the applicant delinquent on any federal debt*?

Yes

No

If yes, explain:

11. Appropriateness of services requested*: (See Section VI. B. Criterion #1 of the NOFO for review and evaluation information.)

    1. Please describe the activities/advisory services for which you are seeking program funds and how these activities will materially advance your overall project. (no more than 400 words)*

2. Requested funds from this program*:

3. Estimated cost of activities proposed*:

4. Describe what project-related development activities have been completed, if any. List N/A if none. Examples include: data or information that has been collected or activities conducted that are necessary to complete the activities funded through this Program. (no more than 250 words) *

12. Viability of grant services requested (See Section VI. B. Criterion #2 of the NOFO for review and evaluation information.)

    1. Please describe the following: Either 1) your organization's experience procuring advisory services or 2) your organization’s process for timely hiring of staff (i.e. defined job description, recruitment process). State if you have additional funds available to commit to this effort should grant funding provided prove insufficient to complete the proposed activities. If additional funds will be provided, include the amount and source of the local funding commitment. (no more than 400 words)*

2. Applicants are encouraged to seek bids or quotes, or estimate the amount of dedicated staff time 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 activities)

13. 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)*

Signature (e-signature is sufficient)* Date*