13-197 Resolution No. 13-197
RESOLUTION
AUTHORIZING EXECUTION OF A GRANT APPLICATION
FROM THE FEDERAL EMERGENCY MANAGEMENT AGENCY (FEMA)
ASSISTANCE TO FIREFIGHTERS GRANTS PROGRAM
FOR CARDIAC MONITORS AND RELATED COMPONENTS
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ELGIN, ILLINOIS,
that John Fahy, Fire Chief, be and is hereby authorized and directed to execute a grant
application from the Federal Emergency Management Agency (FEMA) Assistance To
Firefighters Grants Program for cardiac monitors and related components, a copy of which is
attached hereto and made a part hereof by reference.
s/ David J. Kaptain
David J. Kaptain, Mayor
Presented: December 4, 2013
Adopted: December 4, 2013
Vote: Yeas: 8 Nays: 0 Abstain: 1
Attest:
s/Kimberly Dewis
Kimberly Dewis, City Clerk
of km I ao1q - A cep
As l- ,e- aAzk" A�\� O'v\�16
YZC.1QJaA 0.`av�q w�tM
e�; S.
C
Jennifer Quinton
From: Barbara Furman
Sent: Tuesday, January 21, 2014 3:51 PM
To: Jennifer Quinton
Subject: FW: FYI - FEMA AFG Grant Item
Attachments: Fire Operations and Fire... Safety Request Details.pdf; ATT00001..txt
-----Original Message-----
From: Aaron Cosentino
Sent: Tuesday, November 26, 20131:55 PM
To: Barbara Furman
Cc: David A. Schmidt
Subject: FYI - FEMA AFG Grant Item
Barb,
Per your request, attached is a 12 page PDF that outlines the FEMA AFG grant the city will be
submitting in approximately 10 days. This is not the entire application, but this provides the request
overview, budget and certifications and assurances the city will be signing when submitting the grant.
Please let us know if this suits your purposes.
Thank you.
1
Jennifer Quinton
From: Barbara Furman
Sent: Tuesday, January 21, 2014 3:53 PM
To: Jennifer Quinton
Subject: FW: Fire Department Grants
Attachments: OSFM FY14 SEG Form.pdf; OSFM 2014 Narrative.docx
-----Original Message-----
From: David A. Schmidt
Sent: Wednesday, November 20, 2013 3:15 PM
To: Barbara Furman
Subject: RE: Fire Department Grants
Barb,
I spoke with Aaron Cosentino, who mailed the FEMA grant, and he said he did not make a copy of the
signature page before mailing it. I am attaching the Illinois Office of the State Fire Marshal small
equipment grant application and narrative. I am working on getting a copy of the FEMA grant that was
submitted.
I will be sure to scan a copy of any future grants.
Thanks,
Dave
-----Original Message-----
From: Barbara Furman
Sent: Wednesday, November 20, 2013 9:16 AM
To: David A. Schmidt
Subject: RE: Fire Department Grants
Thanks! I understand that each grant was already signed. If I get copies of each signed app before next
Monday, 11/25 that'd be great.
bf
-----Original Message-----
From: David A. Schmidt
Sent: Wednesday, November 20, 2013 8:42 AM
To: Barbara Furman
Cc:John P. Fahy
Subject: Fire Department Grants
Good morning Barb,
Just wanted to drop you a quick note that I am working on getting the toe grant applications to you
shortly. I apologize for the delay.
1
FY2013 ASSISTANCE TO FIREFIGHTERS GRANTS PROGRAM (AFG)
FUNDING OPPORTUNITY ANNOUNCEMENT (FOA)
OVERVIEW INFORMATION
Issued By
US Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA),
Grants Program Directorate (GPD)
Catalogue of Federal Domestic Assistance (CFDA) Number
97.044
CFDA Title
Assistance to Firefighters Grants
Funding Opportunity Announcement Title
Fiscal Year (FY) 2013 Assistance to Firefighters Grants (AFG)
Authorizing Authority for Program
Section 33 of the Federal Fire Prevention and Control Act of 1974, Public Law 93-498, as amended
(15 U.S.C. § 2229)
Appropriation Authority for Program
Department of Homeland Security Appropriations Act, 2013, Public Law 113-6
FOA Number
D H S-13-G P D-044-000-99
Key Dates and Time
Application Start Date: 11/4/2013 at 8:00 AM EST
Application Submission Deadline Date: 12/6/2013 at 5:00 PM EST
Anticipated Funding Selection Date: 2/3/2014
Anticipated Award Date: 2/10/2014
Other Key Dates
N/A
Intergovernmental Review
Is an intergovernmental review required? ❑Yes ® No
Application Submission Extension
Is an extension to the application submission deadline permitted? ❑Yes ® No
1
FOA EXECUTIVE SUMMARY
Program Type
Select the applicable program type:
❑ New ®Continuation ❑ One-time
Date of origin for Program
10/30/2000
Funding Opportunity Category
Select the applicable opportunity category:
® Discretionary ❑ Mandatory ® Competitive ❑ Non-competitive
Application Process
DHS makes all funding opportunities available through the common electronic
"storefront" Grants.gov, accessible on the Internet at http://www.grants.gov. If you
experience difficulties accessing information or have any questions, please call the
Grants.gov Customer Support Hotline at (800) 518-4726.
AFG Application Home Page
Links to the AFG Application portal are available via Grants.gov, the US Fire
Administration, or the AFG Web site.
For additional details, please see Section X of the full FOA, page 18.
Eligible Applicants
The following entities are eligible to apply directly to FEMA under this solicitation:
® Fire Department ® Nonaffiliated EMS organization ® State Fire Training Academy
For additional details, please see Section III of this FOA, Eligibility Information, page 6.
Type of Funding Instrument
Select the applicable funding instrument:
®Grant ❑ Cooperative Agreement
Cost Share or Match
Select the applicable requirement:
®Cost Share ❑Cost Match ❑Voluntrary
NOTE: Grantee cost sharing, unless modifed by waiver, shall be either 5%, 10%, or
15% and shall be based on the population of the jurisdiction(s) served by the
applicant(s). For additional details, please see Appendix C, A. Cost Sharing, 2.
Economic Hardship Waivers, page 61.
2
Maintenance of Effort
Is there a Maintenance of Effort (MOE) requirement?
®Yes ❑ No
An applicant seeking an AFG Grant shall agree to maintain during the term of the grant
the applicant's aggregate expenditures relating to activities allowable under this FOA at
not less than 80 percent (80%) of the average amount of such expenditures in the two
(2) fiscal years preceding the fiscal year in which the grant amounts are received. For
additional details, please see Appendix C, A. Cost Sharing, 1. Maintenance of Effort,
page 61.
Management and Administration
No more than three percent (3%) of AFG Funds awarded may be retained by the
grantee and any funds retained are to be used solely for management and
administration (M&A) purposes associated with the AFG Award. For additional details,
please see Appendix C, B. Other Allowable Costs, 1. Administrative Costs,
Management and Administration, page 61.
Indirect Costs
Indirect costs are allowable only if the applicant has an approved indirect cost rate with
the cognizant federal agency. A copy of the approved rate (a fully executed, agreement
negotiated with the applicant's cognizant federal agency) is required at the time of
application. Indirect costs will be evaluated as part of the application for federal funds to
determine if allowable and reasonable.
For additional details, please see Appendix C, B. Other Allowable Costs, 1.
Administrative Costs and 2. Indirect Costs, page 61.
3
11/26/13 Fire Operations and Firefighter Safety Request Details
Request Details
The activities for program Operations and Safety are listed in the table below.
Activity Number of Entries Total Cost Additional Funding Action
View Details
Equipment 1 $ 101,751 $ 0 View Additional Funding
Narratives
Modify Facilities 0 $ 0 $ 0 View Details
Personal Protective Equipment 0 $ 0 $ 0 View Details
Training 0 $ 0 $ 0 View Details
Wellness and Fitness Programs 0 $ 0 $ 0 View Details
" Total Funding for all EMS requested in this application $91577
Grant-writing fee associated with the preparation of this request. $0
https://eservices.fema.gov/FemafireGrant/firegrant/jsp/fire2013/application/requestdetails/activitySummary jsp?sysAppId=991187&print=true&view=read&app_number= 111
11/26/13 View Operations and Firefighter Safety-Equipment
View Operations and Firefighter Safety - Equipment
Equipment Details
1. What equipment will your organization purchase with this grant? Monitor/ Defibrillator-12/15 leads
Please provide further description of the item selected from the drop down list. We are requesting a total grant of$91,577.00 to purchase
(3) 12 lead biphasic cardiac monitor/defibrillators. The
units selected will include the following additional
capabilities that will improve patient care capability and
efficiency: ST trending, AED, Lithium Ion batteries,
capnography, non-invasive blood pressure, pulse CO-
oximitry, pulse rate, 12 lead and 12 lead transmission,
and blue-tooth capable. This request also includes one
year of extended warranty from the manufacturer.
2. Number of units: 3 (whole number only)
3. Cost per unit: $ 33917 (whole dollar amounts only)
4.
Generally the equipment purchased under this grant program will:
Replace old, obsolete, damaged equipment with equipment that meets current standards
If you selected "replacing equipment' (from Q4) above, please specify the age of equipment in 7 years
years.
5.
Generally the equipment purchased under this grant program is:
Will bring the organization into voluntary compliance with a national standard, e.g. compliance Explanation
with NFPA, OSHA, etc. We have limited ability to monitor CO in patients. With
Please explain how this equipment will bring the organization into voluntary compliance in the this grant, all patients (100%)will have the benefit of CO
space provided to the right. monitoring. NFPA 1584 Standard on Rehabilitation
Process for Members During Emergency Operations and
Training Exercises, states CO monitoring is a necessary
piece of rehabilitation and monitoring operations. We have
protocols for treatment of CO poisoning, but we do not
have enough CO assessment tools to assist in treatment
that are within the life expectancy recommended by Zoll.
6. Yes
Is your department trained in the proper use of this equipment being requested?
7• No
Are you requesting funding for training? (Funding for requested training should be requested in
the Equipment Additional Funding section).
https://e servicesSema.gov/FemaFireGrant/firegrant/jsp/fire2013/appl ication/requestdetails/equipmentl oad.do?sysApp1d=991187&c ate goryCode=1&rowId=I537706&action=view&print=true&view=readFire Departme... 1/2
11/26/13 View Operations and Firefighter Safety-Equipment
8. Yes
If you are not requesting training funds through this application, will you obtain training for this
equipment through other sources?
Close Window
https://e se rvices.fema.gov/FemaFireGrant/firegrant/jsp/fire2013/application/requeWet ails/equipme ntl oad.d0sysAppId=9911 87&c ate goryCode=1&rowId=I537706&action=view&print=true&view=readfire Departme... 2/2
11/26/13 Budget
Budget
Budget Object Class
a. Personnel $ 0
b. Fringe Benefits $ 0
c. Travel $ 0
d. Equipment $ 101,751
e. Supplies $ 0
f. Contractual $ 0
g. Construction $ 0
h. Other $ 0
i. Indirect Charges $ 0
j. State Taxes $ 0
Federal and Applicant Share
Federal Share $ 91,576
Applicant Share $ 10,175
Federal Rate Sharing (%) 90/10
'Non-Federal Resources (The combined Non-Federal Resources must equal the Applicant Share of $ 10,175)
a. Applicant $ 10175
b. State $ 0
c. Local $ 0
d. Other Sources $ 0
If you entered a value in Other Sources other than zero (0), include your explanation below. You can use this space to provide information on the project,
cost share match, or if you have an indirect cost agreement with a federal agency.
Total Budget $ 101,751
https://eservicesfema.gov/FemaFireGrant/firegrant/jsp/fire2013/application/budgeLtotal jsp?sysAppld=991187&view=print&print=true&app_number= 1/1
11/26/13 Assurances and Certifications
Assurances and Certifications
FEMA Form SF 4248
You must read and sign these assurances. These documents contain the Federal requirements attached to all Federal grants including the right of the
Federal government to review the grant activity. You should read over the documents to become aware of the requirements. The Assurances and
Certifications must be read, signed, and submitted as a part of the application.
Note: Fields marked with an " are required.
O.M.B Control Number 4040-0007
Assurances Non-Construction Programs
Note: Certain of these assurances may not be applicable to your project or program. If you have any questions, please contact the awarding agency.
Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant I certify that the applicant:
1. Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability (including funds
sufficient to pay the non-Federal share of project costs)to ensure proper planning, management and completion of the project
described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized
representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a
proper accounting system in accordance with generally accepted accounting standards or agency directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of
personal or organizational conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. Section 4728-4763) relating to prescribed standards for merit
systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM's Standards for a Merit
System of Personnel Administration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a)Title VI of the Civil Rights
Act of 1964 (P.L. 88-352)which prohibits discrimination on the basis of race, color or national origin; (b)Title IX of the Education
Amendments of 1972, as amended (20 U.S.C. Sections 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex;
(c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. Section 794), which prohibits discrimination on the basis of
handicaps; (d)the Age Discrimination Act of 1975, as amended (42 U.S.C. Sections 6101-6107), which prohibits discrimination on the
basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the
basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L.
91-016), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g)§§523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient
records; (h)Title VIII of the Civil Rights Acts of 1968 (42 U.S.C. Section 3601 et seq.), as amended, relating to nondiscri mination in the
sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for
https://eservices.fema.gov/FlemaFireGrant/firegrant/jsp/fire2013/application/assurances_forms_combined jsp?sysAppld=991187&view=print&print=true&app_number= 1/8
11/26/13 Assurances and Certifications
Federal assistance is being made; and Q)the requirements of any other nondiscrimination statute(s)which may apply to the
application.
7. Will comply, or has already complied, with the requirements of Title II and III of the Uniform Relocation Assistance and Real Property
Acquisition Policies Act of 1970 (P.L. 91-646)which provide for fair and equitable treatment of persons displaced or whose property is
acquired as a result of Federal or federally-assisted programs. These requirements apply to all interest in real property acquired for
project purposes regardless of Federal participation in purchases.
8. Will comply, as applicable, with provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328)which limit the political activities of
employees whose principal employment activities are funded in whole or in part with Federal funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act (40 U.S.C.
§276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§327-333), regarding labor standards
for federally-assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a)of the Flood Disaster Protection Act of 1973
(P.L. 93-234)which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the
total cost of insurable construction and acquisition is $10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality
control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order(EO) 11514; (b) notification of
violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains
in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the
Coastal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State(Clean Air)
Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of
underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (P.L. 93-523); and, (h) protection of
endangered species under the Endangered Species Act of 1973, as amended (P.L. 93-205).
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. Section 1271 et seq.) related to protecting components or potential
components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended
(16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of
1974 (16 U.S.C. 469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and related activities
supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the care,
handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. Section 4801 et seq.)which prohibits the use of lead
based paint in construction or rehabilitation of residence structures.
17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996
and OMB Circular No. A-133, "Audits of States, Local Governments, and Non-Profit Organizations."
18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.
Signed by John Fahy on
https://eservices.fema.gov/FemaFireGrant/firegranttjsp/fire2013/application/assurances-forms_combined jsp?sysAppId=991187&view=print&print=true&app_number= 2/8
11/26/13 Assurances and Certifications
https://eservices.fema.gov/FemaFireGrant/firegrant/jsp/fire2013/application/assuranccs_forms_combined jsp?sysAppld=991187&view=print&print=true&app_number= 3/8
11/26/13 Assurances and Certifications
Form 20-16C
You must read and sign these assurances.
Certifications Regarding Lobbying, Debarment, Suspension and Other Responsibility Matters and Drug-Free Workplace Requirements.
Note: Fields marked with an * are required.
O.M.B Control Number 1660-0025
Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the
instructions for certification included in the regulations before completing this form. Signature on this form provides for compliance with certification
requirements under 44 CFR Part 18, "New Restrictions on Lobbying; and 44 CFR Part 17, "Govemment-wide Debarment and Suspension (Non-
procurement) and Govemment-wide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a material representation of
fact upon which reliance will be placed when the Department of Homeland Security (DHS) determines to award the covered transaction, grant, or
cooperative agreement.
1. Lobbying
A. As required by the section 1352, Title 31 of the US Code, and implemented at 44 CFR Part 18 for persons (entering) into a grant or cooperative
agreement over$100,000, as defined at 44CFR Part 18, the applicant certifies that:
(a) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned to any person for influencing or attempting
to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member
of Congress in connection with the making of any Federal grant, the entering into of any cooperative agreement and extension, continuation,
renewal amendment or modification of any Federal grant or cooperative agreement.
(b) If any other funds than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence
an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress
in connection with this Federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure
of Lobbying Activities", in accordance with its instructions.
(c) The undersigned shall require that the language of this certification be included in the award documents for all the sub awards at all tiers
(including sub grants, contracts under grants and cooperative agreements and sub contract(s)) and that all sub recipients shall certify and
disclose accordingly.
2. Debarment, Suspension and Other Responsibility Matters (Direct Recipient)
A. As required by Executive Order 12549, Debarment and Suspension, and implemented at 44CFR Part 67, for prospective participants in primary covered
transactions, as defined at 44 CFR Part 17, Section 17.510-A, the applicant certifies that it and its principals:
(a)Are not presently debarred, suspended, proposed for debarment, declared ineligible, sentenced to a denial of Federal benefits by a State
or Federal court, or voluntarily excluded from covered transactions by any Federal department or agency.
(b) Have not within a three-year period preceding this application been convicted of or had a civilian judgment rendered against them for
commission of fraud or a criminal offense in connection with obtaining, attempting to obtain or perform a public (Federal, State, or local)
transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.
https://eservices.fema.gov/F,emaFireGrant/firegrant ljsp/fire2013/applicadon/assurances_forms_combined jsp?sysAppId=991187&view=print&print=true&app_number= 4/8
11/26/13 Assurances and Certifications
(c)Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, or local)with commission
of any of the offenses enumerated in paragraph (1)(b) of this certification: and
(d) Have not within a three-year period preceding this application had one or more public transactions (Federal, State, or local)terminated for
cause or default; and
B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application.
3. Drug-Free Workplace (Grantees other than individuals)
As required by the Drug-Free Workplace Act of 1988, and implemented at 44CFR Part 17, Subpart F, for grantees, as defined at 44 CFR part 17, Sections
17.615 and 17.620:
(A) The applicant certifies that it will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a
controlled substance is prohibited in the grantee's workplace and specifying the actions that will be taken against employees
for violation of such prohibition;
(b) Establishing an on-going drug free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The grantees policy of maintaining a drug-free workplace;
(3)Any available drug counseling, rehabilitation and employee assistance programs; and
(4)The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
(c) Making it a requirement that each employee to be engaged in the performance of the grant to be given a copy of the
statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the
employee will:
(1)Abide by the terms of the statement and
(2) Notify the employee in writing of his or her conviction for a violation of a criminal drug statute occurring in the
workplace no later than five calendar days after such conviction.
(e) Notifying the agency, in writing within 10 calendar days after receiving notice under subparagraph (d)(2)from an employee or
otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position
title, to the applicable DHS awarding office, i.e. regional office or DHS office.
(f) Taking one of the following actions, against such an employee, within 30 calendar days of receiving notice under
subparagraph (d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including termination, consistent
with the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law enforcement or other appropriate agency.
(g) Making a good faith effort to continue to maintain a drug free workplace through implementation of paragraphs (a), (b), (c),
(d), (e), and (f).
https://cservices.fema.gov/FemaHireGrant/firegrant/jsp/fire2013/appl ication/assurances_forms_Combined.jsp?sysAppld=991187&view=print&print=true&app_number= 5/8
11126/13 Assurances and Certifications
(B)The grantee may insert in the space provided below the site(s)for the performance of work done in connection with the specific grant:
Place of Performance
Street City State Zip Action
If your place of performance is different from the physical address provided by you in the Applicant Information, press Add Place of Performance button
above to ensure that the correct place of performance has been specified. You can add multiple addresses by repeating this process multiple times.
Section 17.630 of the regulations provide that a grantee that is a State may elect to make one certification in each Federal fiscal year. A copy of which
should be included with each application for DHS funding. States and State agencies may elect to use a Statewide certification.
Signed by John Fahy on
https://eserviccs.fema.gov/FemafiireGrant/firegrant/jsp/fire2013/application/assurances_forms combined jsp?sysAppId=991187&view=print&print=true&app_number= 6/8
11/26/13 Assurances and Certifications
FEMA Standard Form LLL
Only complete if applying for a grant for more than $100,000 and have lobbying activities. See Form 20-16C for lobbying activities definition.
You must read and sign these assurances by providing your password and checking the box at the bottom of this page.
Note: Fields marked with an " are required.
O.M.B Control Number 0348-0046
Standard Form LLL: Disclosure of Lobbying Activities
1. ' Type of Federal Action
2. "Status of Federal Action
3. * Report Type
This subsection is for Material Change only
Year
Quarter
Date of last report:
4. ' Name and Address of Reporting Entity
*Reporting Entity Type
Tier(if known)
*Name
"Street
*City
*State
*Zip Need help for ZIP+4?
5. If Reporting Entity in No.4 is a Subawardee, enter name and address of Prime:
Name
Street
City
https://eservices.fema.gov/FemaFireGran t/firegrant/jsp/fire2013/application/assurances-jorms_combined jsp?sysAppId=991187&view=print&print=true&app_number= 7/8
11/26/13 Assurances and Certifications
State
Zip Need help for ZIP+4?
Congressional District if known
6. * Federal Department/Agency
7 *Federal Program Name/Description
CFDA Number if known
8. Federal Action Number if known:
9. Award Amount if known: $
10a. Name and address of Lobbying Registrant: (if individual, Last Name, First Name, MI)
Name
Street
City
State
Zip -
10b. Individuals Performing Services: (include address if different from No.10a) (Last Name, First Name, MI)
Name
Street
City
State
Zip
Information requested through this form is authorized by Title 31 U.S.C. Section 1352. This disclosure of lobbying activities is a material representation of
fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C.
1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required
disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
Signed by John Fahy on
https://eservices.fe ma.gov/F,emaFireGrant/firegrant/jsp/fire20l3/applica Lion/assurances_forms_combined jsp?sysAppId=991187&view=print&print=true&app_number= 8/8