HomeMy WebLinkAboutIowa Homeland Security (Jamie Knutson) 5/14/2018#Tn> STATE OF IOWA
APPLICATION FOR FEDERAL / STATE ASSISTANCE
DESIGNATION OF APPLICANT'S AUTHORIZED REPRESENTATIVE
GRANT / PROGRAM
JOB TITLE
DECLARATION NUMBER
Jamie Knutson
AWARDING AGENCY
Public Assistance - CFDA 97.036
ORGANIZATION NAME
4289
E-MAIL ADDRESS
City of Waterloo
DHS -FEMA
APPLICANT LEGAL NAME
Knutson(@waterloo-ia.org
FEDERAL
EMPLOYER IDENTIFICATION #
City of Waterloo
STATE
POSTAL CODE
715 Mulberry Street
Waterloo
42-6005327
PHYSICAL ADDRESS
FACSIMILE #
CELLULAR TELEPHONE #
319-291-4312
319-291-4262
FISCAL YEAR START DATE
715 Mulberry Street
LOFFICETELEPHONE#
319-291-4571
July 1
CITY
^ DATE
STATE
POSTAL CODE
A SIGNATURE OF CHIEF FINANCE OFFICER
COUNTY
^ DATE -
Waterloo
IA
50703
Black Hawk
ORGANIZATION TYPE (check one)
❑ State Agency
County
Other > > Organization Type:
1^1
❑
City
Township
❑
Special
Private
District
Non -Profit
APPLICANT'S DESIGNATION OF AUTHORIZED REPRESENTATIVES)
The signatures of the individual(s) named below shall be recognized as certification that, to the best of their knowledge and belief,
the information on this application is complete and accurate, and that their respective designation to sign and file documents on
behalf of the applicant cited above is authorized by official resolution, code, or statute, recognized by the governing body of the
applicant as legally binding. A change of Authorized Representative will require submittal of a revised application form.
AUTHORIZED REPRESENTATIVE
NAME
JOB TITLE
Jamie Knutson
Associate Engineer
ORGANIZATION NAME
E-MAIL ADDRESS
City of Waterloo
City of waterloo
Jamie.
Knutson(@waterloo-ia.org
MAILINGADDRESS
CITY
STATE
POSTAL CODE
715 Mulberry Street
Waterloo
IA
50703
FACSIMILE #
CELLULAR TELEPHONE #
319-291-4312
319-291-4262
319-240-2563
LOFFICETELEPHONE#
319-291-4571
HORIZED REPRESENTATIVE
^ DATE
CHIEF FINANCE OFFICER
NAME
JOB TITLE
Michelle Weidner
Chief Financial Offcer
ORGANIZATION NAME
E-MAIL ADDRESS
City of waterloo
Michelle.Weidneraa.waterloo-ia.orq
MAILING ADDRESS
CITY
STATE
POSTAL CODE
715 Mulberry Street
Waterloo
IA
50703
OFFICE TELEPHONE #
FACSIMILE #
CELLULAR TELEPHONE #
319-291-4323
319-291-4571
A SIGNATURE OF CHIEF FINANCE OFFICER
^ DATE -
STATE OF IOWA
APPLICANT'S ASSURANCES AND CERTIFICATIONS
NOTE: Cenain of these assurances and certdications may not be applicable to this project or program. if you have questions, please contact the
Awarding Agency. Cenain Federal assistance Awarding Agencies may require applicants to certdy to additional assurances not included in
this document.. Applicants will be instructed by the Awarding Agency'rf additional assurances are required. '
AS THE DULY DESIGNATED AUTHORIZED REPRESENTATIVE FOR THIS APPLICANT, I DO HEREBY AGREE IN THEIR NAME AND
ON THEIR BEHALF TO ALL OF THE FOLLOWING TERMS AND CONDITIONS OF THIS GRANT.
HOLO HARMLESS AGREEMENT
Pursuant to sections 403 and 407 of the Robert T. Stafford Disaster Relief and
Emergency Assistance Act (P.L. 93-288), as amended, (42 U.S.C. §§5170 et seq.
and 5173(b)), the undersigned agrees to Indemn'rfy, hold harmless, and defend
the United States of America and the Slate of Iowa, as well as their agents and
employees, from any claims arising from the removal of debris or wreckage for
this disaster event. This applicant agrees that debris removal from public
and private property will not occur until such time as the land -owner provides
an unconditional authorization for the removal of dehris.
CERTIFICATION REGARDING LOBBYING
As required by the regulations implementing the New Restrictions on Lobbying
(44 CFR §18), this applicant hereby certdies that, to the best of their knowledge
and belief:
1. No Federal appropriated funds have been 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
employee of Congress, or an employee of a Member of Congress, in
connection with the awarding of any Federal contract, the making of any
Federal grant, the making of any Federal loan, the entering into of any
ooperative agreement, orthe extension, continuation, renewal, amend-
ment, or modification of any Federal contract, grant, loan, Or cooperative
agreement.
2. If any funds other than Federal appropriated funds have keen or will be
paid to any person for influencing ar attempting to influence an officer or
employee of any agency, a Member of Congress, an ofgcer or employee
of Congress, or an employee of a Member of Congress, in connection
wflh this Federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Farm -LLL, "Disclosure
Form to Report Lobbying", in accordance wdh its Instmctions.
3. The undersigned shall require that the language of this certTcation be
included in the award documents for all suh-awards at all tiers (including
sub -contracts, sub -grants, and contracts under grants, loans, and co-
operative agreements and that all sub -recipients shall certify and
disclose accordingly.
This cenigcatlon is a material representation of fact upon which reliance is
placed when this transaction was made or entered info. Submission of this
certification is a prerequisite for making or entering into This transaction,
imposed by §1352, Idle 31, U.S. Code. Any person who fails to file the required
certRcation shall be subject to a civil penally of not less than $10,000, and not
more than $100,000, for each such failure.
DEBARRMENT, SUSPENSION, &OTHER RESPONSIBILITY MATTERS
As required by Executive Order#12549, Oebarrment and Suspension, and
implemented by 44 CFR Part 17, for prospective participants in primary covered
transactions, as defined in 44 CFR Part 77, §17.510.
This applicant hereby cendies that d and ds principals:
1. (a) Are not presently debarred, suspended, proposed for tlebarrment
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 wdhin athree-year period preceding this application been
victed of, or had a civilJudgment rendered against them for
commission of fraud or a criminal ofrense in connection wdh obtaining,
attempting to obtain, or pertorming a public (Federal, State, or local)
transaction or contract under a public transaction; violation of Federal
or State antitmst statutes, or commission of embezzlement, theft,
forgery, brihery, faisitication or destruction of records, making false
statements, or receiving stolen progeny.
(c) Are not presently indicted for, or otherwise criminally or civilly charged by
a governmental entity (Federal, State, or locaq, with commission of any of
the offenses enumerated in the preceding paragraph of this certification.
(d) Have not within athree-year period preceding this application had one or
re public transactions (Federal, State, or locaq terminated for cause or
default.
2. Where the applicant is unable to certify to any of the statements in this
certAication, they shall attach an explanation to this application.
IV ASSURANCES-CONSTRUCTION&NON-CONSTRUCTION PROGRAMS
This duly authorized representative for this applicant does hereby certify that H:
1. Has the legal authority to apply for Federal assistance, and the instdutlonal,
anagerial, and financial capability (including funds sufficient to pay the
non -Federal share of project costs) to ensure proper planning, manage-
ment and completion of the project described in this application.
2. Will give the Awarding Agency, the Comptroller of the United States, and R
appropriate, the State, through any authorized representative, access to
and the right to examine all records, books, papers, or documents related
to the award or assistance, and will establish a proper accounting system
accordance wdh generally accepted accounting standards, or agency
directives.
3. WiII not dispose of, modify the use of or change the terms of the real
property title, or other interest in the sde and facilities wdhout permission
and insWctions from the awarding agency. Will record the Federal
interest In the ttlle of real property in accordance wdh awarding agency
directives, and will include a covenant in the title of real property in
accordance with Awarding Agency directives, and will include a covenant in
the idle of real property acquired in whole or in pan wgh Federal assistance
funds to assure non-discrimination during the useful life of the project.
4. WIII comply wdh the requirements o(the assistance awarding agency with
regard to the drafting, review, and approval of construction plans and
specdications.
5. Will provide and maintain competent, adequate engineering supervision at
all construction sites io ensure that the complete work conforms wdh the
approved plans and specifications, and will furnish progress reports and
other information as required by the assistance awarding agency, or State.
6. Will initiate and complete the work within the applicable time frame after
receipt of approval of the awarding agency.
7. Will establish safeguards to prohibH employees from using their positions
for a purpose that constdutes, or presents the appearance of personal or
organkational congict of interest, or personal gain.
e. Will comply wdh the Intergovernmental Personnel Act of 1970 (42 U.S.C.
§§4728 -4763) relating to prescribed standards for merit systems for
programs funded under one of the nineteen (19) statutes or regulations
specdietl in Appendix A of OPM's Standards for a Merit System of
Personal Administration (5 CFR §990, Sub -part F).
9. Will comply with the Lead -Based Paint Poisoning Prevention Act
(42 U.S.C. §§4801 et seq.) which prohibits the use of alead-based paint in
construction or rehabilitation of residence structures.
70. Will comply wflh ail Federal statutes relating lonon-discrimination.
These include, but are not limded to:
(a) Tttle VI of the Civil Rights Ac( of 7964 (P.L. 88-352) which prohibits
discrimination on the basis of race, color, or national origin.
(b) TKIe IX of the Education Amendments of 1972, as amended
(20 U.S.C. §§1681 - 1683 and 1fi85 - 1686), which prohibits
discrimination on the basis of sex.
(c) Section 504 of the Rehabiidation Act of 1973, as amended (U.S.C.
§794), which prohibits discrimination on the basis of handicaps.
(d) The Age Discrimination Act of 1975, as amended (42 U.S.C.
§§6101 - 6107), which prohibits discrimination on the basis of age.
(e) The Drug Abuse Office and Treatment Act of 7972 (P.L. 92-255), as
amended, relating to non-discrimination on fhe basis of drug abuse.
(f) The Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment, and Rehabildation Act of 1970 (P.L. 91-616), as amended,
relating Conon-discrimination on the basis of alcohol abuse or
alcoholism.
(g) §§523 and 527 of the Public Health Service Acl of 1912 (42 U.S.C.
§§290 dtl-3 and 290 ee-3), as ended, relating to confidentiality of
alcohol and drug abuse patient records.
(h) Tdle VIII of the Civil Rights Acl of 1968, (42 U.S.C. §§3601 el seq.), as
amended, relating tonon-discrimination in the sale, rental, orfinancing
of housing.
(i) Any other non-discrimination provisions In the specific statule(s)
under which application for Federal assistance is being made.
Q) The requirements on any other non-discrimination statutes) which
may apply to the application.
PAGE 1 OF 2
STATE OF IOWA
APPLICANT'S ASSURANCES AND CERTIFICATIONS
11. Will comply, or has already complletl, with iM1e requirements of Ttlles II and
III of the Ungortn Relocation Assistance and Real Property Acquisdion
Policies Act of 1970 (P.L. 91-64fi), which provitle forfair and equkable
treaMenl of persons displacetl or whose property is acquired as a result
of Fetleral or Federally -assisted progrems. These requirements apply to
all Interests in real property acquiretl for project purposes regardless of
Federel participation in purchases.
12. WIII comply wgh the provisions of the Hatch Act (5 U.S.C. §§1501 - 1508
and 7324 - 7328) which Iimg the political activgles of employees whose
principle employment aclivgies are funded in whole or in part wgh Federal
funds.
13. WIII comply, as applicable, with the provisions of the Davis -Baron Ad
(40 U.S.C. §§276010 2760-7), the Copeland Act (40 U.S.C. §276c and
18 U.S.C. §e74), and the Contract Work Hours and Satety Standards Acl
(40 U.S.C. §§327- 333) regarding labor standards for federally -assisted
consWction sub -agreements.
14. WIII comply with the flood insurance purchase requirements of Section
102(0) oPUle Flood Disaster Protection Acl of 1973 (P.L. 93-234) which
requires recipients in a special good hazard area to participate in Ne
program and to purchase (loetl insurance M the total cost of Insurable
cansW coon and acquisition Is $10,000 or more.
15. WIII comply with the environmental standards which may he prescribed
pursuant to the following:
(a) Instttuticn of environmental qualgy control measures underthe
National Environmental Policy Act of 1969 (P.L. 91-190 and
ExecutNe Order (EO) 11514.
(b) Notificallon of violating facilities pursuant to EO 11738.
(c) Protection of wetlands pursuant to EO 11990.
(d) Evaluation of flood hazards In flood plains in accordance with
EO 11988.
(e) Assurance of project consistency wtth the approved Slate manage-
ment program developed underthe Coastal Zane Management Acl
of 1972 (i6 U.S.C. §§1451 et seq.),
(Q Conformity of Fetleral actions to State (Clean Air) Implementation
Plans antler section 17s(c) of the Clean Air Act of 1955, as amended
(42 U.S.C. §§7401 et seq.).
(g) Protection of underground souroes of drinking water under Ne Safe
Drinking Water Act of 1974, as amended (P.L. 93-523).
(h) Protection of endangered species under the Endangered Species
Acl of 1973, as amended (P.L. 93-205).
16. Will comply with the Wlld Scenic Rivers Act of 19fi8 (16 U.S.C. §§1271
et seq.) related to protecting components or potential components of the
national wild and scenic rivers system.
17. Will assist the Awarding Agency in assuring compliance wtth Section 106
of the National Historic Preservation Act of 19fi6, as amended (16 U.S.C.
§470), EO 11593 (ideniRcation antl protection of historic properties), and
the Archaeological and Historic Preservation Act of 1974 (16 U.S.C.
§§4690-1 et seq.).
18. Will compty with P.L. 93-348 regarding the protection of human subjects
involvetl In research, development, and ralaletl activtties supportetl by
this award of assistance.
19. Wtll compty 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 ofwann blootletl animals held for research, teaching, ar other
activtties supportetl by this award of assistance.
20. WIII cause to be pertormed the required financial and compliance audits in
ccerdance wdh the Single Audtt Act Amendments of 1996 and OMB
Circular No. A-133.
21. Willwmply with allapplicable requirements of all other Federal laws,
executive oMers, regulations, and policies governing this program.
CERTIFICATION OF DRUG-FREE WORKPLACE REQUIREMENTS
This ceri'rfication Is required by the regulations implementing Ne Dmg-Free
Workplace Act of 1988 and 44 CFR Parl 17, Sub -part F. The regulations,
published In the May 25, 1990 Federal Register, require certttication by
sub -grantees, prior to award, Nat Ney will maintain admg-free workplace. The
cert�calion that (allows Is a material representation of fact upon which reliance
will be placed when the Agency determines to award me grant. False cert cation
or violation of the certification shall be grounds for suspension of payments,
uspenslon or lenninatlon of grants, or government wide suspen nor
dehamment (44 CFR Part i7, subpart C, 17.300, and subpart D, 17.400).
The Sub-9renlee cert�es Ihat tt will or will continue to provide admg-free
workplace by:
(a) Publishing a statement noldyin9 employees that the unlawful
manufacture, tllstribulion, dispensing, possession, or use of a
controlled substance is prohibited in the sub -grantee's workplace
and specifying the actions that will he taken against employees for
vlaletion of such prohibition.
(b) Establishing an ongoing dmg-free awareness program to Inform
employees ahoul-
(1) The dangers of dmg abuse in the workplace.
(2) The sub -grantee's policy of malnlaining atlmg-free workplace.
(3) Any available tlmg counseling, rehabilgalion, and employee
assistance programs.
(4) The penalties That may be Imposed upon employees fortlmg
abuse violations occurring in the workplace.
(c) Making g a requirement That each employee to be engaged in the
pertormance of the grenl he given a copy of the notgication state-
ment requked by paragraph (a).
(d) Notirying the employee in the statement required by paragraph (a) That,
as a cantlgicn ofemployment underthe grant, the employeewill-
(i) Abide by the terms of the statement.
(2) Notify the employer in wrtling of his or her conviction for a
violation of a criminal dmg statute occurring in the workplace no
later than five calendar days ager such conviction.
(e) Notgying the agency in wrdin9 wtthin ten calendar tlays ager receiving
notice antler suh-paragraph (d)(2) from an employee or otherwise
receNing actual notice of such cenviclien. Employers of convicted
employees must provitle notice, inclutling pasttion line, to every grant
otgcer or other designee on whose grant activity the convicted
employee was working, unless the Fedeml agency has designated a
cenirel point for the receipt of such notices. Notice shall include the
Itlentification numher(s) of each agected grant.
(f) Taking one of the following actions wghin 30 calendar tlays of
ving notice under sub-paregraph (d)(2), wHh respect to any
employee who Is so convicted -
(1) Taking appropriate pereonnel action against such an employee,
up la and including lenninatlon of employment, consistent wtth
the requlremems of the Rehabilttation Act of 1973, as amended,
-or-
(2) Requiring the employee to participate satisfacloriy In a dmg
abuse assistance or rehabilitation pregrem approvetl for such
purposes by a Fedeml, State, or local health, law enforcement,
or other appropriate agency.
(g) Making a goad faith egort to continue to maintain a tlrug-free work-
place through implementation of paragraphs (a), (b), (c), (d), (e), & (f).
The terms antl contlgicns of this certification apply to any and all sties and
locations at which the sub -grantee works or otherwise conducts business.
THE SIGNATURE CERTIFICATION OF THIS FORM SHALL BE TREATED AS A MATERIAL REPRESENTATION OF FACT UPON WHICH RELIANCE
WILL BE PLACED WHEN THE GRANTEE DETERMINES TO AWARD THE COVERED TRANSACTION, GRANT, OR COOPERATIVE AGREEMENT.
City of Waterloo
-n��n��„r ti�mo
PAGE 2 OF 2
Grant lD
s�8��o�
1 Date
STATE OF IOWA
SINGLE AUDIT REQUIREMENTS FOR FEDERAL GRANTS
AS THE DULY DESIGNATED ALnHORiZED REPRESENTATIVE FOR THIS APPLICANT, I DO HEREBY AGREE IN THEIR NAME ANO
ON THEIR BEHALF TOALL OF THE FOLLOWING TERMS AND CONDITIONS OFTHIS GRANT.
All records of work associated with the claimed costs on every project are to be maintained for a minimum of three (3) years
from the closing date of the grant or sub -grant and are subject to State and Federal review under the "Single Audit Act, as
amended" and the "Single Audit Act Amendments of 1996, as amended".
The Code of Federal Regulations, the "Single Audit Acl, as amended", and [he "Single Audit Act
Amendments of 1996, as amended", require that Non -Federal entities that expend $750,000 or more in a year in Federal
awards shall have a single audit conducted. A program specific audit may be conducted in place of a single audit if the
auditee meets the terms specified in 2 CFR 200 §200.150, paragraph C.
The Single Audit Act provitles that the audit shall be made by an Independent auditor, and in addigon to the financial audit,
requires that the independent auditor determine and report on whether the organization has internal control systems to
provide reasonable assurance that it is manageing Federal assistance programs in compliance with applicable laws and
regulations. In order to provide this assurance the auditor must make a study and evaluation of internal control systems used
in administering Federal assistance programs. The study and evaluation must be made whether or not the auditor Intends to
place reliance on such systems.
If there is a"(finding" relating to a Federal program administered by Iowa Homeland Security and Emergency
Management Department:
A copy of the official audit must be submitted within nine (9) months of the end of the auditee's fiscal year to:
HSEMD-Recovery Bureau
7900 Hickman Road
Suite 500
Windsor Heights, IA 50324
/(there are no "findings"
A copy of the audit report is not required, but the auditee shall provide written notification that:
♦ an audit was conducted, including -
entity (auditee) name
Catalog of Federal Domestic Assistance (GFDA) number(s)
the period covered by the audit
dollar amount expended
♦ the schedule of findings and questioned costs disclosed no audit findings relating to Federal award(s) administered by
Iowa Homeland Security and Emergency Management Department
♦ the summary of schedule of prior audit findings did not report on the status of any audit findings related to Federal award(s)
administered by Iowa Homeland Security and Emergency Management Department
THE SIGNATURE CERTIFICATION OF THIS FORM SHALL BETREATEDAS A MATERIAL REPRESENTATION OF FACT UPON WHICH RELIANCE
WILL eE PLACED WHEN THE GRANTEE DETERMINES TO AWARD THE COVERED TRANSACTION, GRANT, OR COOPERATIVE AGREEMENT.
CSirifFliaiGL1
��9�e3� r0esisnat dA moraedRenresemarve
5a�-!sr
Dale
CFDA Number 97.036
Iowa Homeland Security Emergency Management Department
Data Universal Number System (DUNS) Number
The DUNS number is a unique nine -digit identification number provided by Dun and Bradstreet (D&B).
The DUNS number is site specific giving each distinct physical location of an entity (branches, divisions,
and headquarters).
Obtaining a DUNS Number:
If you have a DUNS number please provide the nine -digit number below
If you are not sure if you have DUNS number visit http:Hfedgov.dnb.com/webform, create an account
based on the information for your agency and update or validate the information associated with the
number.
If you
do
not
have a DUNS number please
visit
http://fedgov.dnb.com/webform,
create an account
based
on
the
information for your agency
and
request a DUNS be
assigned accordingly.
You will need to provide the following information:
Legal Name
Headquarters name and address for your organization
Doing business as (DBA) or other name for which your organization is commonly known
Physical Address, City, State and Zip Code
Mailing address (is separate from Headquarters and/or physical location
Telephone Number
Contact Name and Title
Number of Employees at your physical location
Disaster Number
4289
Applicant ID
Applicant Name
013-82425-00
City of Waterloo
DUNS Number
830941576
Prepared By: �,{��,�c� /jlk/�Uiv
Continue on Reverse
The following 3 questions are required fields in the federal reporting system. All you need to do is put
an "X" next to YES or NO when answering the question.
sub Compensation Q1 "As provided to you L by your sub-awardee, in your sub-awardee's business
or organization's preceding completed fiscal year, did its business or organization (the
legal entity to which the DUNS number it provided belongs) received (1) 80 percent or
more of its annual gross revenues in U.S. federal contracts, subcontracts, loans,
grants, subgrants, and/or cooperative agreements; and (2) $25,000,000 or more in
annual gross revenues from U.S. federal contracts, subcontracts, loans, grants,
subgrants, and/or cooperative agreements?"
Put an "X" next to your answer;
Yes
x No
If your response is YES, you must provide a response to Sub Compensation Q2. If your
response is NO, you do not need to respond to the following questions,
sub compensation Q2 If you answered YES to Sub Compensation Q1, then "As provided to you [HSEMD]
by your sub-awardee, does the public have access to information about the
compensation of the executives in the sub-awardee's business or organization (the
legal entity to which the DUNS number it provided belongs) through periodic reports
filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C.
78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 1986?"
You only need to answer this if you responded YES to Sub Compensation Q1.
Put an "X" next to your answer:
Yes
No
N/A
If you answer YES,
. you do not have to provide additional information.
If you answer NO, you must provide the names and amounts of the five most highly
compensated executives of the sub-awardee's organization.
sub Tomp Employer If you answered NO to Suh Compensation Q2, then "provide the name and total
Compenstation compensation for the five (5) most highly compensated executives in the sub-
awardee's business or organization (the legal entity to which this DUNS number is
assigned)". Enter the names and total compensation of each of the top 5 executives
below.
1
2
3
4
5
Prepared By: %�21.�(s�l/J�j./L,
STATE OF IOWA
SUBSTITUTE W 9 / VENDOR UPDATE FORM
In order for the State of Iowa to process payment of the amount that is due, and to comply with Internal Revenue
Serviceregulations on reporting such payments, we must receive the Information being requested on this form. Failure to
provide this information will result In the withholding of payment.
(Please Print or tvoe all entries except forsionature)
AND
Complete the Name and Address Below:
Last Name:
First Name
Doing Business As:
Street Address:
Mail Delivery Address:
City
MI:
State: Postal Code:
Fax:
AND
Complete the Name and Address Below:
Firm:
Cir✓ /� (iJ�-� ��o
Doing Business As:
Street Address:
7/60 ffhA YCAV S(
M,ll Delivery Address:
City:
Waterloo
Phone: 319-291-4323
CERTIFICATION MUST BE SIGNED BY VENDOR
State: Postal Code:
IA 5e3s;L
Fax: 319-291-4571
Certifcation - Undar penalties of perjury, I certify that:
(1) The number shown on this farm is my correct taxpayer identification number (or I am waiting for a number to he issued to me), and (2) I am
not subject to backup withholding because: (a) 1 am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a rosut of a failure to report all interest or dividends, or (c) the IRS has notified me
that I am no longer subject to backup withholding.
Signature: YZM`t�� G{,�,f%(/! Date: b
FOR OFFICE USE ONL
C
rom:
�
Add
Dept.
BOX A
BOX B
Are you/your business: YES NO
Is your business:
YES NO
Individual [I] X
Corporation
[C]
or Sole Proprietorship [S] X
Partnership
IN
._
?Jr.
Reason:
Estate or Trust
[E]
If the answer to both was no, please complete Box B.
Public Service Corp
[U]
Government
[G]
X
If you answered yes to either item, please provide your
Other
[0]
Social Security number (Sole Proprietors may enter their
Please explain
FIN, however, the IRS prefers you use your SSN):
SSN:
Please provide your Federal Employer
sF06�3a�
Identification
number:
Or EIN:
AND
Complete the Name and Address Below:
Last Name:
First Name
Doing Business As:
Street Address:
Mail Delivery Address:
City
MI:
State: Postal Code:
Fax:
AND
Complete the Name and Address Below:
Firm:
Cir✓ /� (iJ�-� ��o
Doing Business As:
Street Address:
7/60 ffhA YCAV S(
M,ll Delivery Address:
City:
Waterloo
Phone: 319-291-4323
CERTIFICATION MUST BE SIGNED BY VENDOR
State: Postal Code:
IA 5e3s;L
Fax: 319-291-4571
Certifcation - Undar penalties of perjury, I certify that:
(1) The number shown on this farm is my correct taxpayer identification number (or I am waiting for a number to he issued to me), and (2) I am
not subject to backup withholding because: (a) 1 am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a rosut of a failure to report all interest or dividends, or (c) the IRS has notified me
that I am no longer subject to backup withholding.
Signature: YZM`t�� G{,�,f%(/! Date: b
FOR OFFICE USE ONL
C
rom:
�
Add
Dept.
Change
(include vendor cone anP
rhanoa< nnly)
Contact
Delete
Reason:
Added for Purchasing
Yes F-1 No
97.036
Iowa Homeland Security Emergency Management Department
Revenue and Expenditure Account Form
Pursuant to 44 CFR §13.20(b)(3), Effective control and accountability must be maintained for all grant and
subgrant cash, real and personal property, and other assets.
In accordance with 44 CFR §13.20 (c), An awarding agency may review the adequacy of any applicant for
financial assistance as part of a preaward review or at anytime subsquent to award. In compliance with
44 CFR §13.20, the State of Iowa is requesting Applicants to submit the unique accounting or identifying
number associated with the appropriate disaster number.
Disaster Number
Applicant Name
4289
City of Waterloo
PA ID
013-82425-00
Expenditure
Account
Number
or
Identifying
Number
The City of Waterloo uses project accounting.
Disaster -related expenditures and revenues should be coded to the project code
01FL16-Flood September 2016
Revenue Account
Number or Identifying
Number
The City of Waterloo uses project accounting.
Disaster -related expenditures and revenues should be coded to the project code
OSFL36-Flood September 2016
I hereby certify the above Account Numbers or Identifying Numbers will be used for all future revenue
and expenditure activity associated to the above disaster number.
Remit Form to:
HSEMD -Recovery Bureau
7900 Hickman Road
Suite 500
Windsor Heights, IA 50324
STATE OF IOWA
APPLICATION FOR FEDERAL 1 STATE ASSISTANCE
DESIGNATION OF APPLICANT'S AUTHORIZED REPRESENTATIVE
GRANT/PROGRAM
JOB TITLE
OECLARATIONNUMEER
Chief Financial Officer
AWARDING AGENCY
Public Assistance - CFDA 97.036
E-MAIL ADDRESS
City of waterloo
4289
michellemgeidller(cr7waterlDD-i a.,Ura
MAILING ADDRESS
DNS -FEMA
APPLICANT LEGAL NAME
POSTAL CODE
715 Mulberry Street
Waterloo
FEDERAL EMPLOYER IDENTIFICATION
City of Waterloo
OFFICE TELEPHONE #
FACSIMILE #
CELLULAR TELEPHONE #
42-6005327
PHYSICAL ADDRESS.
FISCAL YEAR START DATE
715 Mulberry Street
^DATE
July 1
CITY
STATE "I
POSTAL CODE
ICOUNTY
Waterloo
IA
50703
81ack Hawk
ORGANIZATION TYPE (aback one)
M State Agency
County
E] Other > > Organization Type:
7
R
City
Township
❑
Special District
Private Non -Profit
APPLICANT'S DESIGNATION OF AUTHORIZED REPRESENTATIVES)
The signatures of the Individual(s) named below shall be recognized as certification that, to the best of their knowledge and belief,
the information on this application Is complete and accurate, and that their respective designation to sign and file documents on
behalf of the applicant cited above is authorized by official resolution, code, or statute, recognized by the governing body of the
applicant as legally binding. A change of Authorized Representative will require submittal of a revised application form.
AUTHORIZED REPRESENTATIVE
NAME
JOB TITLE
Michelle Weidner
Chief Financial Officer
ORGANIZATION NAME
-:
E-MAIL ADDRESS
City of waterloo
michellemgeidller(cr7waterlDD-i a.,Ura
MAILING ADDRESS
CITY
STATE
POSTAL CODE
715 Mulberry Street
Waterloo
IA
50703
OFFICE TELEPHONE #
FACSIMILE #
CELLULAR TELEPHONE #
(319) 291-4323
(319) 291-4571
^ SIGNATURE OF AUTHORIZED REPRESENTATIVE':
^DATE
CHIEF FINANCE OFFICER
,..
LIIR���,
STATE OF IOWA
APPLICANT'S ASSURANCES AND CERTIFICATIONS
NO Certen of these assurances antl eer6ficmlonamerynoi beapp8cablo In ihisMaleclorprogmm, f you hconquest iolls,pleaseconlaclthe
Awarding Agency. Gamin Federal asshience AwaMnH Agencres may require appiicanlsto ierllly to eddWonsaewramers natimdudad In
this document. ApplIcembf V49 be mahucted by the Awarding Agency 11 additional assurances are reggired,
AS THE DULY DESIGNATED AUTHORIZED REPRESENTATIVE FOR THIS APPLICANT, 100 HEREBY AGREE IN THEIR NAME AND
ON THEIR BEHALF TO ALL Or THE FOLLOWING TERMS AND CONDITIONS OF THS GRANT,
HOLD HARMLESS AGREEMENT
Pursuant to sections 403 and 407 of the Robed T. Stallard Disaster Relief and
Emergency A8918b this Ad (I 93-288), as amended, (42 U.S.G.§96170 at seq.
and 5173(b)), the underslgnad agrees to indamnly, hold hormion, and defend
the United Slates of America and the Slate of Iowa, as well as their agents and
employees, from any cern® arising from the removal of debris or Wreckage for
this disamer event. This applicant agrees that debris removal from public
and private property will not occur unlit such time as The land -owner provides
an uncoadiltonal concussion for the removal of debris.
CERTIFICATION REGAROMG LOgIgYING
As required by the regulations implemenflng the New Restrictions on Lobbying
(44 CPR §16), this applicant hereby codifies (hal, to the best of their knowledge
and belief-,
1. No Federal appmpfored funds have been orw91 be paid, by order behalf of
the undarsigned, Is any personfor influencing or attempting to influence
an ogkeror 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 awarding of any Federal contend, the making of any
Federal grout, the mating of any Federal loan, the entering Into of any
cooperni agm did rt, or the extension, continuation, renewal, amend
men[, or modifialbn of any Federal contract, grant loan, or cooperative
agreement.
2. If any funds other than Federal appropelaled (nude have been or will be
ped 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
Win this Federal content(, grant, loin, or cooperative agreement, the
undersigned shall complete and submit Standard Form - LLL, "Disclosure
Farm (o Report Labbyhrg", in accordance with Its InsUuogons.
3. The undersigned shall require the the language of this certification be
Included In the award documents for an we awards at atm lien (including
aub-cenvacis, nub -grants, and coloreds under grants, loans, and co-
operative agreements and that as aub{adpiania shall aonity and
disclose aceoteNngly.
This cedthcallare Is a maledal Mpresenlallon of fact upon which reliance Is
placed when this Inns ionwas made or entered into. 61.1101681060llda
ceNf anon Is a prerequisite for macng or adding into this transaction,
imposed by §1352, this 31, U.S. Cade. Any Raised Who (alis to file the required
carniva on shag be subled to n civil penalty of net lass than $10,0111), end net
mora than $100,000, for each such before.
OERARRMENT, SUSPENSION, & OTHER RESPONSIBILITY MATTERS
As mquhed by Executive Older N12649, Debarment and
Suspension, and
implemedea by 44 CFR Ped 17, for praspedive participants In primary covered
lm osections, as defined in 44 CFR Pad 17, §17.510.
This applicant hereby coffee (hat IF and Its pdnnlpes:
t. (a) Are not presently debarred, suspended, proposed far debamand,
declared megglbie, sentenced to a denial of Federal benefits by a Stale or
Federal noun, or voluntarily excluded from covered transactions by any
Federal department or agency,
(b) Have not within a thme-yearperiod preceding this applleation been
convicted of, or Fred a civil judgment rendered annual them far
commission of fraud ora cdm red offeree In connection with obtaining,
attempting to obtain, or pedorrning a public (Federal. State, orlocaq
transadbn or contract under a Fulda Imnsaalion, violation of Federal
or Siete adhmatstaiule5, or commission of embevzlement, thel,
forgery, bribery, falsification ordeslmal of records, making false
statements, or receiving stolen property,
(c) Are not feaengy Indicted for, orathnwlse admiringly or svillychorged by
a governmental entity (Federal, State, orloca§, with commission of any of
the dimes commanded In the preceding paragraph of this cedihcalion
(d) Have nor w whin es three-year period preceding this application had one or
mote public Irenaotions (f acted, Slate, or local) temninaled for cause or
default.
2. Where the applicant is unable to codifyto any of the statements In this
cedifcagen, they shall attach an explareallon to this application.
A56URANCES -CONSTRUCTION 8NON-CONSTRUCTION PROGRAMS
This duly authorized! repmsemative for this applicant done hereby codify then lit:
t. Has Melege Immunity to apply for Federal assistancq and the inslifulionel,
merger al, and financial capability (Including funds sufficient to pay the
eral
non-Fedshare of Funded costs) to ensure Manor planning, manage-
ment, and enmpletton of the project described m this application.
2. Will give the Awarding Agency, the Comptroller ofthe UNod Stales, and 11
appropriate, the Stale, through any authorized representative, access to
and (he right to examine all records, books, papers, or documents related
to the award or assismnca, and will establish a proper accoumin i 9yslem
In accordance with generally accepted accounting standards, or agency
dlaofves,
3. Will not dispose of, modify the use of, or change terms or tsr the real
property lige, or ogler Interest in the age and facilities without permission
and Instructions from the awarding agency, Wil record the Federal
In(arost In (he line of real property in accordance with awarding agency
directives, and will Include a covenant in the line of real property In
accordance with Awarding Agency dnclevi s, and VAN forces a covenant In
Me the of real property acquired In whole or in pad with Federal assistance
funds to assure non-dsanminalion during the aseful he of the proles
4. Wit comply w in the requirements of the asslstenee awerdling agency with
regard to the dealing, review, and approval of construction pians and
specification,
5. W h provide and Modesto competent' adequate engineering supervision at
all construction ones Io ensure the the complete work conforms with the
approved pians and Ipecthcatidns, and will furnish progress reports and
other Irdormaflon as required by the assistance awarding agency, or Slate.
0, WIN lnlilee and complete the wodr within that applicable Loan reams after
receipt of approval of the awarding agency,
7. Will establish safeguards to prohibit employees from using their passions
for a purpose that constdutes, or presents the appearance or personal or
organizational conflict of Interest, or personal gen.
8, Will comply with the Intergovernmental Personnel Act of 1070 142 U.5.C.
§§4728 -4783) rending to prescribed standards for mem systems for
programs funded under one of the nineteen (19) statutes or moulaflana
specified in Appendix A of CPU* Standards For a Mem System of
Personal AdMdatrallon (5 CFR §991)1 Sub -pad F).
9. Wil comply with the Lead -Based paint Poisoning Pravedion Act
142 U.S.C. §§4801 at sML) which prohlbris the use d a lead-based paint in
construction or rehabilitation of residence structures.
10. W9l comply with all Federal statutes relating to nonElsolminallon.
These Include, but are met island to:
(a) The VI of the Civil Rights Ad Of 1904(P.L. 88352) which prohlbils
discrimination an the basis of race, Boor, or national arigim
(b) Title IX of the Education Amendments of 1872, no amended
(20 U.S.C, §§1081-1883 and 1986- Loan). which prohibits
discrimination on the basis of sex.
(a) Section 504 of the RehabN8allon Ad of 1973, its; amended (U.S.C,
9794), which prohlbils discrimina(lon on the basis of handicaps.
(d) The Age Dlscdminmlon Act of 1975, as amended (42 U.S.C.
§§8101-6107), which proh@fls discrimination on the basis of age.
(e) The Drug Abuse Once and Treatment Act of 1972(P.L. 92-255), as
mended, relating to nen-dlvorlminaGan an the basis of drug abuse.
(g The Comprebeneive Alcohol Muss and Alcoholism Prevention,
Treatment, and Rehabilitation Act of 1970 (P.L. 91-616), as amended,
(elafng 10 hOnidBCominaflan on the basis Of a'cohol abuse or
surrealism.
(g) 1§523 and 627 of the Points Health Service Act of 1912 (42 U.S.C.
§§290 dd-3 and 290 as -3)0 as amended, rsa8ng to ru nfidenllafdy of
alcohol and drug abuse pagan( records.
(h) TWO VIII of the Civf Rights Act of 1968, (42 U.S.C. §§3801 of eaq.), as
amended, tooling to non-dlscriminallon in the freeRefunding, rental, erRefundingofreUsng.
(I) Any other non-discrimiruflon provisions in the specific annelids)
under which application for Federal assistance Is being made,
0) The requirements on any other norvdecdmlmourn aieulb(a)which
may apply to the application.
PAGE 1 OF 2
STATE OF IOWA
APPLICANT'S ASSURANCES AND CERTIFICATIONS
11. Wll comply, or has already compiled, with the requirements of Titles 11 ar10
III of the Uniform Rini Assistance and Real Property ACQnlscion
Policies Act of 1970 (P.L. 91 .646)p which provide far fair and equitable
treatment of persons displaced or whose property is acquired as a result
of Federal or Fetlerally-asslsled programs. These fequgemems apply to
all interests in reel property acquired for project purposes regardless of
Federal participates in purchases.
12. WAIT comply with the provisions of the Hatch Act (6 U S.C- §§1501 -150B
and 7324 - 7328) which limit the political activities of employees whose
principle employment sardines are funded in whole or In part vdlh Federal
funs.
13. Will comply, as applicable, wile the provisions of the Davis -Bacon Act
(40 U.So, §§276a to 276a-7), the Copeland Act (40 U.S.C. §270c an
10 U,S.C, §374), and tiro Contract Work Home and Safely Standards Act
(40 U.S.C. §§327 -333) regarding labor standards for fedemfly-assisted
onstruclion sub -agreements.
14. Will comply win the good 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 good hazard area to participate In the
program and To purchase good Insurance it the land cast of insurable
construction and acquisition is $1%000 or more.
S. Will comply with the environmental standards which may be prescribed
pursuant to lire following:
(a) Inabrilion of environmental quality control measures under the
National Environmental Policy Art of 1069 (P.L. 91-190 and
Executive Order (ED) I IW4.
gn Notification of violating [213441 pursuant to ED 11738,
(c) Pmleclion of wetlands pursuant to ED 11990.
(d) Evaluation of flood hazards In rood Maros In accordance wilh
ED I I age.
(e) Assurance of project consistency with the approved Slate manage-
ment program developed entire the Coastal Zone Management Act
of 1972 (16 U.S.C. §§1461 at seq.).
(D Conformity of Federal actions to State (Clean Air) Implementation
Plans tinder section 176(c) of the Clean Air Act of 1955, as amended
(42 U.S.C. §§7401 or seq,).
(g) Protection d underground sources of drinking water under the Safe
Deinking Water Act or 1974, as amended (P.L. 93-523).
(h) Pmtecllen of endangered species undur etre Endangered Species
Act of 1973, as amended (P.L. 93-205).
16. Will comply with the W Id Scenic Rivers Ad of 1969 (16 U.S.C. §91271
at seq.) related to protecting components or potential components of The
national wild and scenic rivers system.
17. Will assist the Awarding Agency In assuring compliance with Section 106
of the National Historic Preservalion Act of 1968, as amended (16 U.S.C.
§4701 EO 11593 (identification and prolydern of historic properties), and
the Archaeological and Historic Preservation Ad of 1974 (16 U.S.C.
§§469a-1 at meq.).
18. WIII comply with P.L, 93.348 regartling the protection of human subjects
Involved in research, development, and related acfvilies supported by
this award of assistance.
19. Will comply with the Laboratory Animal Welfare Act of 1066 (P.L. 89-544,
as amended, 7 U.S.C. §92131 at seq.) pertaining to the care, handling, and
treatment of worm birodetl animals hold for research, leaching, or other
ridialias supported by this award of assistance.
20. 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-1331
21. WIII comply with all applicable requirements of all other Federal laws,
executive orders, regulatons, and policies governing this program.
CERTIFICATION OF ORUGFREE WORKPLACE REOVIREMENTS
Tllis codification Is required by the regulations implementing the DoiWorkplace After less and 44 CFR Pad 17, Sub -pad F. The regulations,
published in the May 25, 1990 Federal Register, require codification by
sub -grantees, prior to award, that they will maintain a drug-free workplace, The
cee111icallen that follows Is a material representation of fad upon which reNance
Noll bo Placed when the Agency determines to award the grant. False codification
rvlelapse of the confirmation shall be grounds for suspension of payments,
suspension or termination of grants, or government Wide suspension at
tiebaparent (44 CFR Pad 17, subpart C,17.300, and subpart D,17.400).
The Sub -gonias certires that ii wilt arwtii continue to pmvitle a tlmglree
workplace by:
la) Publishing a statement notifying employees that he unlawful
manufacture, distribution, dispensing, possession, or use of antee's
controlled substance Is prohibited in the sub-gravearkpiaca
and specifying the actions that wil be taken against emplayees for
violation of ouch prohbilion.
(b) Establishing an ongoing drug-free awareness program to inform
employees about -
if) The dangers of drug abuse in the workplace,
(2) The sub-grontee's policy of maintaining a drug-free workplace.
0) Any available drug counseling, rehabilitation, and employee
assistance programs.
(4) The penalliss 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 lite
performance of the giant be given a copy of the reellgcatbn state-
mirequired by paragraph (a).
(tl) Notifying the employee In the statement required by paragraph(a)Il i,
as a comdilion of employment tinder the giant, the employee will -
(i) Abide by the terms of the statement.
(2) Nollfy the employer in willing of his ar her conviction fora
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 len calendar days after receiving
notice under subparagraph (d)(2) from an employee or olharwiae
receiving actual notice of such conviction. Employers of convicted
employees most provide colica, including position line, to every grant
offwr or other designee on whose grant activity the convicted
employee was worldng, unless the Federal agency has designated a
central point for the convict of such notices. Notice shell include the
identification gaucherie) of each allacted grant,
(D Taking one of the following actions within 30 calendar days of
receiving notice under sub -paragraph (d)(2), with rasped to any
employee who is so convicted -
(1) Taking appropriate personnel action against such an employee,
up to and Including termination of employment, consistent with
the requirements of the Rehabililafion Act of 191 as amended.
(2) Requiring the employee to participate satisfactorily in a drug
abuse assistance or rehabithallon program approved for such
purposes by a Federal, State, or local health, law enforcement,
or other appropriate agency.
(g) Making a good faille effort to continue to maintain a drug-free work.
place through implementation of paragraphs (a), (b), (o), (d), (e), & (g.
Tne terms and consignees of Ihls cedl0callon apply to any and all sites and
loralions al welch lire subgrantee works or olhenvise conucla business,
TI IE SIGNATURE CCRTIfICATION OF THI6 FORM SHALL BE TREATED AS A MATERIAL REPRESENTATIpN OF FACT UPON WHICH RELIANCE
WILL BE PLgCED WHEN THE GRANTEE DETERMINES TO AWARD THE COVERED TRANSACTION, GRANT, OR COOPERATIVE AGREEMENT.
City of Waterloo
Applicant Name
6lgnelure of Dasignalntl Authorized Representative
PAGE 2 OF 2
GranllD
Dale
STATE OF IOWA
SINGLE AUDIT REQUIREMENTS FOR FEDERAL GRANTS
A6 THEDULYALFt ALL
OF MEFILL INOTEENSANEFONITIOAPPLICANT,iANNeM1eaY AGREEINTNEIR NM!E ANO
GN THEN BEHALF to ALL 01 fHE EOLLOWINa TEPIAS PNO caNnlTlnNs OF clic GRANT.
All records of work assoclaled with the claimed Costs on every projeCl Bre to be maNidlnetl fOr a mlNmum of Ihlee (3) years
tram the closing dale of the grant of sub -grant and are subject to State and Federal review under the "Single Audit Act, as
amended" and the "Single Audit Act Amendments of 19980 as amended".
The Omce of Management and Budget Circular A-733, the "510gie Autlil Acl, ae amended",and Ice "Bingle Au01lAc1
Amendments of 1996, as amended", require that Non-Fetlaral entities that expand $500,000,00 or more in a year in Federal
wards shall have a single audit conducled. A program specific aucit may be conducted in place of a single audit if the
audilee meets the terms specified in Office of Management and Budget Circular A-1 33 §_200, paragraph C.
The Single Audit Act provides That the audit snail be made by an Independent auditor, and In addition to the fnanciai audit,
requires that the independent auditor determine and report on whether the organization has Internal control systems to
provide reasonable assurance that It Is manageing Federal assistance programs in compliance with applicable laws and
regulations. In order to provide this assurance the auditor must make a study and evaluation of internal control systems used
n administering Federal assistance programs. The study and evaluation must be made whether or not the auditor intends to
place reliance on such systems.
fl there is a "Ifntlfng"refagng fo a Federal program adminlsfefed by IowFl HomelOrtd Securfly and Emergency
Management DopartmenC
A copy of the official audit must be submitted within nine (0) months of the end of the mai fiscal year to:
HSEMD - Recovery
Bureau
79001114kman Road
Suite 590
Windsor Heights, IA 50324
Il fllere are po "flndlnys"
A copy of Iho audit repod is not required, but the audilee shall provide written nofficalion Thal:
e an audit was conducted, Including -
carry (audilee) name
Catalog of Federal Domestic Assistance (CFDA) number(s)
the period covered by the audit
dollar amount expended
o the schedule of findings and questioned costs disclosed no audit findings relating to Federal award(s) administered by
Iowa Homeland Security and Emergency Management Department
e the summary of schedule of prior auditimaings did not report on the status of any audit findings related to Federal award(s)
administered by Iowa Homeland Security and Emergency Management Department
THIS FOnM SHALL BE iREATCAPS A
'MLL 6E PLACEO WNEN 1HE GRANTEE OETEPMINE9 TOAWAROTHEGOVEREOTRANSAGTI9N, aPAM.
Glly of waterloo
Applitanl Namo Gmnl iD
z;:Jr'..
SlAnelure of Daslgnalad Authorized Represanlnlive Dal
- CFDANumber: `.e 97.096
Data Universal Number System (DUNS) Number
The DUNS number is a unique nine -digit Identification numher provided by Dun and Bradstreet (D&B).
The DUNS number is site specific giving each distinct physical location of an entity (branches, divisions,
and headquarters),
Obtaining a DUNS Number:
If you have a DUNS number please provide the nine -digit number below
If you are not sure if you have DUNS numher visit http://fedgov.dnb.com/webform, create an account
based on the information for your agency and update or validate the information associated with the
number.
If you
do
not
have a DUNS numher please
visit
http://fedgov.dnb.com/webform, create an account
based
on
the
information for your agency
and
request a DUNS be assigned accordingly.
You will need to provide the following information:
Legal Name
Headquarters name and address for your organization
Doing business as (DBA) or other name for which your organization is commonly known
Physical Address, City, State and Zip Code
Mailing address (is separate from Headquarters and/or physical location
Telephone Number
Contact Name and Title
Number of Employees at your physical location
Prepared
ay:
Michelle Weidner � ��,�
li
..
.
-l-city
of Waterloo
I
Prepared
ay:
Michelle Weidner � ��,�
���_ l a_1,+.��4L�-rL
1 Continue on Reverse
Tire following a questions are required fields in the federal reporting system. All you need to do is put
an "X" next to YES or NO when answering the question.
sub Compensation Q1 "As provided to you [HSEMD] by your sub-awardee, in your sub-awardee's business
or organization's preceding completed fiscal year, did its business or organization (the
legal artily to which the DUNS number it provided belongs) received (1) 80 percent or
more of its annual gross revenues in U.S. federal contracts, subcontracts, loans,
grants, subgrants, and/or cooperative agreements; and (2) $25,000,000 or more in
annual gross revenues from U.S. federal contracts, subcontracts, loans, grants,
subgrants, and/or cooperative agreements?'
Put an "X" next to your answer:
E Yes
x No
If your response is YES, you must provide a response to Sub Compensation Q2, If your
response Is NO, you do not need to respond to the following questions.
sub Compensation Qz If you answered YES to Sub Compensation Q1, then "As provided to you [HSEMD)
by your sub-awardee, does the public have access to information about the
compensation of the executives in the sub-awardee's business or organization (the
legal entity to which the DUNS number it provided belongs) through periodic reports
filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C.
78m(a), 78o(d)) or section 6104 of the Internal Revenue Code of 19867'
You only need to answer this if you responded YES to Sub Compensation 01.
Put an "X" next to your answer:
B yes
No
ivj'ai
If you answer YES, you do not have to provide additional information.
If you answer NO, you must provide the names and amounts of the five most highly
compensated executives of the sub-awardee's organization.
sub romp Employer If you answered NO to Sub Compensation Q2, then "provide the name and total
eompenstetion compensation for the five (5) most highly compensated executives in the sub-
awardee's business or organization (the legal entity to which this DUNS number is
assigned)". Enter the names and total compensation of each of the top 5 executives
below.
1
2
3
4
S
!, CFDA.Number 92036
Iowa Homeland Security Emergency Management Department
Revenue and Expenditure Account Form
Pursuant to 44 CFR 413.20(b)(3), Effective control and accountability must be maintained for all grant and
subgrant cash, real and personal property, and other assets.
In accordance with 44 CFR §13.20 (c), An awarding agency may review the adequacy of any applicant for
financial assistance as part of a preaward review or at any time subsgUent to award. In compliance with
A4 CFR §13.20, the State of Iowa is requesting Applicants to submit the unique accounting or identifying
number associated with the appropriate disaster number.
'Disaster Numbee
>' ApplicankName
4289
PA ID
0
City of Waterloo
Expenditure
Account Number or Identifying Number
The City of Waterloo uses
project accounting.
Disaster -related expenditures and revenues should be coded to the project code
OIFL16 - Flood September 2016.
Revenue Account Number or Identifying Number
The city of Waterloo uses
project accounting.
Disaster -related expenditures and revenues should he coded to the project code
OIFL16 - Flood September 2016.
I hereby certify the above Account Numbers or IdentiFying Numbers will be used for all future revenue
and expenditure activity associated to the above disaster number.
Remit Form to:
HSEMD -Recovery Bureau
7900 Hickman Road
Suite 500
Windsor Heights, IA 50324
STATE of IowA
SUBSTITUTE W 0 f VENDOR UPDATE FORM
In order far the State of Iowa to process payment of the amount that Is due, and to comply with Internal Revenue
Setviceregulations on reporting such payments, we must receive the information being requested on this form. Failure to
provide this information will result In the withholding of payment.
(Please print or type all entries except for signature)
BOX A T BOX B
Are you / your business: YES NO
Individual [I] x
or Sole Proprietorship ]S] X
If the answer to both was no, please complete Box 0.
If you answered yes to either item, please provide your
Social Security number (Sole Proprietors may enter their
EIN, however, the IRS prefers you use your SSN):
SSN:
Or EIN:
AND
Complete the Name and Address Below:
last Name:
First Name: MI:
Doing Business As:
Street Address:
Mall Delivery Address:
Is your business:
YES
Corporation
(C)
Partnership
IN X _
Estate or Trust
[E)
Public Service Corp
[U] _
Government
IG] X _
Other
[0] _
Please explain
Please provide your Federal Employer Identlflcatlon number
Complete [he Name and Address below:
Fhm:
City of Waterloo
Doing Business As:
Street Address:
715 Mulberry Street
Mail Delivery Address:
NO
City: State: Postal Code: City: State: Postal Code:
_ Waterloo IA SD703
Phone: Fax: Phone: (319)291-41323 Fax: (319)291-4571
CERTIFICATION MUST BE SIGNED BY VENDOR
Certification -Under penalties of perjury, I cedily that:
(1) The number shown on this form Is my correct taxpayer identification number (or I am walling for a number to be issued to me), and (2) 1 am
not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a resut of a fallurelo report all interest or dividends, or(c) the IRS has notified me
Thal l am no longer subject to backup withholding.
Signature /r� I�<:oi r%GL luf t.,fi�LGI /<�J Date:
FOR OFFICE USE ONLY (Refer to Procedure 270.450 for more details
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Reason:
Added for Purchasing
Yes F-1 No