HomeMy WebLinkAboutFORMS FOR FEMA CLAIMS - STREET DEPT 715 Mulberry Street
Waterloo, IA 50703-5783 ;¢
319-291-4323 PHONE
319-291-4571 Fax
To: Amy From: Nancy Eckert, City Clerk
Fax: Pages: 5, including this one
Phone: Date: July 20, 2007
Re: Forms for FEMA Claims-Street Dept. CC:
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STATE OF IOWA
r+ APPLICATION FOR FEDERAL/STATE ASSISTANCE
� DESIGNATION OF APPLICANTS AUTHORIZED REPRESENTATIVE
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Waterloo IA 50703 Black Hawk
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Ei County n Township n Private Non-Profit
nOther > > Organization Type:
PREFERRED PAYMENT METHOD: Check n Electronic Fund Transfer*
If Electronic Fund Transfer is selected by an applicant that has not had previous electronic transactions with the State of Iowa, it may
be necessary for them to complete and submit the"Electronic Funds Transfer Authorization Form",which is available upon request.
APPLICANTS DESIGNATION OF AUTHORIZED REPRESENTATIVE(S)
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
Nancy Eckert City Clerk
City of Waterloo nancy.eckert@waterloo-ia . org
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715 Mulberry Street Waterloo IA 50703
319-291-4323 319-291-4571
CHIEF FINANCE OFFICER
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Michelle Weidner Chief Financial Officer ll
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STATE OF IOWA
APPLICANTS ASSURANCES AND CERTIFICATIONS
NOTE: Certain of these assurances and certifications may not be applicable to this project or program. If you have questions,please contact the
Awarding Agency. Certain Federal assistance Awarding Agencies may require applicants to certify to additional assurances not included in
this document. Applicants will be instructed by the Awarding Agency if 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.
HOLD HARMLESS AGREEMENT IV ASSURANCES-CONSTRUCTION&NON-CONSTRUCTION PROGRAMS
Pursuant to sections 403 and 407 of the Robert T.Stafford Disaster Relief and This duty authorized representative for this applicant does hereby certify that it:
Emergency Assistance Act(P.L.93-288),as amended,(42 U.S.C.§§5170 et seq. 1. Has the legal authority to apply for Federal assistance.and the institutional,
and 5173(b)),the undersigned agrees to indemnify,hold harmless,and defend managerial,and financial capability(including funds sufficient to pay the
the United States of America and the State of Iowa,as well as their agents and non-Federal share of project costs)to ensure proper planning,manage-
employees,from any claims arising from the removal of debris or wreckage for ment,and completion of the project described in this application.
this disaster event. This applicant agrees that debris removal from public 2. Will give the Awarding Agency,the Comptroller of the United States,and if
and private property will not occur until such time as the land-owner provides appropriate,the State,through any authorized representative,access to
an unconditional authorization for the removal of debris. and the right to examine of records,books,papers,or documents related
to the award or assistance,and will establish a proper accounting system
it CERTIFICATION REGARDING LOBBYING in accordance with generally accepted accounting standards,or agency
As required by the regulations implementing the New Restrictions on Lobbying directives.
(44 CFR§18),this applicant hereby certifies that,to the best of their knowledge 3. Will not dispose of,modify the use of,or change the terms of the real
and belief: property title,or other interest in the site and facilities without permission
1. No Federal appropriated funds have been oriel be paid,by or on behalf of and instructions from the awarding agency Will record the Federal
the undersigned,to any person for influencing or attempting to influence interest in the title of real property in accordance with awarding agency
an officer or employee of any agency,a Member of Congress,an officer directives,and will include a covenant in tt e title of real property in
or employee of Congress,or an employee of a Member of Congress,in accordance with Awarding Agency directives,and wilt include a covenant in
connection with the awarding of any Federal contract,the making of any the title of real property acquired in whole or in part with Federal assistance
Federal grant,the making of any Federal loan,the entering into of any funds to assure non-disuinnation during the useful lite of the project.
cooperative agreement,or the extension,continuation,renewal,amend- 4. Will comply with the requirements of the assistance awarding agency with
ment,or modification of any Federal contract,grant,ban,or cooperative regard to the drafting,review,and approval of construction plans and
agreement. specifications.
2. tf any funds other than Federal appropriated funds have been or will be 5. Will provide and maintain competent,adequate engineering supervision at
paid to any person for influencing or attempting to influence an officer or at construction sites to ensure that the complete work conforms with the
employee of any agency,a Member of Congress,an officer or employee approved plans and specifications,and wit furnish progress reports and
of Congress,or an employee of a Member of Congress,in connection other information as required by the assistance awarding agency,or State.
with this Federal contract,grant,loan,or cooperative agreement,the 6. Will initiate and complete the work within the applicable time frame after
undersigned shall complete and submit Standard Form-LLL,"Disclosure receipt of approval of the awarding agency.
Form to Report Lobbying",in accordance with its instructions. 7. Wit establish safeguards to prohibit employees from using thee positions
3. The undersigned shall require that the language of this certification be for a purpose that constitutes,or presents the appearance of personal or
included in the award documents for at sub-awards at all tiers(including organizational conflict of interest,or personal gain.
sub-contracts,sub-grants,and contracts under grants,loans,and co- 8. Will comply with the Intergovernmental Personnel Ad of 1970(42 U.S.C.
operative agreements and that all sub-recipients shall certify and §§4728-4763)relating to prescribed standards for merit systems for
disclose accordingly. programs funded under one of the nineteen(19)statutes or regulations
This certification is a material representation of fact upon which reliance is specified in Appendix A of OPM's Standards for a Merit System of
placed when this transaction was made or entered into. Submission of this Personal Administration(5 CFR§900,Sub-part F).
certification is a prerequisite for making or entering into this transaction. 9. Will comply with the Lead-Based Paint Poisoning Prevention Act
imposed by§1352,title 31,U.S.Code. Any person who faits to file the required (42 U.S.C.§§4801 et seq.)which prohb5s the use of a lead-based paint in
certification shall be subject to a civil penalty of not less than S10,000,and not construction or rehabilitation of residence structures
more than$100,000,for each such failure. 10. Will comply with at Federal statutes relating to non-discrimination.
These include,but are not fruited to:
III DEBARRMENT,SUSPENSION,&OTHER RESPONSIBILITY MATTERS (a) Title VI of the Civil Rights Act of 1964(P.L 88-352)which prohibits
As required by Executive Order#12549,Debarrment and Suspension,and discrimination on the basis of race,color,or national origin,
implemented by 44 CFR Part 17,for prospective participants in primary covered (b) Title iX of the Education Amendments of 1972,as amended
transactions,as defined in 44 CFR Part 17,§17.510. (20 U.S.C.§§1681-1683 and 1685-1686),which prohibits
This applicant hereby certifies that it and its principals: discrimination on the basis of sex.
1.(a)Are not presently debarred,suspended,proposed for debarmment, (c) Section 504 of the Rehabilitation Act of 1973.as amended(U.S.C.
declared ineligible,sentenced to a denial of Federal benefits by a State or §794),which prohbits discrimination on the basis of handicaps.
Federal court,or voluntarily excluded from covered transactions by any (d) The Age Discrimination Act of 1975,as amended(42 U.S.C.
Federal department or agency. §§6101-6107),which prohibits discrimination on the basis of age.
(b) Have not within a three-year period preceding this application been (e) The Drug Abuse Office and Treatment Act of 1972(P.L.92-255),as
convicted of,or had a civf judgment rendered against them for amended,relating to non-discrimination on the basis of drug abuse.
commission of fraud or a criminal offense n connection with obtaining. (f) The Comprehensive Alcohol Abuse and Akcnolsm Prevention,
attempting to obtain,or performing a public(Federal,State,or local) Treatment,and Rehabilitation Act of 1970(P>.91-616),as amended.
transaction or contract under a public transaction:violation of Federal relating to non-discrrnination on the basis of alcohol abuse or
or State antitrust statutes,or commission of embezzlement,theft, alcoholism.
forgery,bribery,falsification or destruction of records,making false (g) §§523 and 527 of the Public Health Service i'.ct of 1912(42 U.S.C.
statements,or receiving stolen property. §§290 dd-3 and 290 ee-3),as amended,rela-.ng to confidentiality of
(c) Are not presently indicted for,or otherwise criminally or civilly charged by alcohol and drug abuse patient records,
a governmental entity(Federal,State,or local),with commission of any of (h) Title VIII of the Civil Rights Act of 1968,(42 L S C §§3601 et seq),es
the offenses enumerated in the preceding paragraph of this certification amended,relating to non-discrimination n tie sale,rental,or financing
(d) Have not within a three-year period preceding this application had one or of housing.
more public transactions(Federal,State,or local)terminated for cause or (i) Any other non-disuirnination provisions in the specific statute(s)
default. under which application for Federal assistance is being made.
2 Where the applicant is unable to certify to any of the statements in this (1) The requirements on any other non-discrmraten statute(s)which
certification,they shall attach an explanation to this application. may apply to the application.
PAGE 1 OF 2
STATE OF IOWA
APPLICANT'S ASSURANCES AND CERTIFICATIONS
11. Wit comply,or has already complied,with the requirements of Titles II and V CERTIFICATION OF DRUG-FREE WORKPLACE REQUIREMENTS
III of the Uniform Relocation Assistance and Real Property Acquisition This certification is required by the regulations implementing the Drug-Free
Policies Act of 1970(F.L.91-646),which provide for fair and equitable Workplace Act of 1968 and 44 CFR Part 17,Sub-part F. The regulations,
treatment of persons displaced or whose property is acquired as a result published in the May 25,1990 Federal Register,require certification by
of Federal or Federally-assisted programs. These requirements apply to sub-grantees,prior to award,that they will maintain a drug-free workplace. The
all interests in real property acquired for project purposes regardless of certification that follows is a material representation of fact upon which reliance
Federal participation in purchases. will be placed when the Agency determines to award the grant. False certification
12. Will comply with the provisions of the Hatch Act(5 U.S.C.§§1501-1508 or violation of the certification shall be grounds for suspension of payments,
and 7324-7328)which limit the political activities of employees whose suspension or termination of grants,or government wide suspension or
principle employment activities are funded in whole or in part with Federal debarrment(44 CFR Part 17,subpart C,17.300,and subpart D,17.400).
funds.
13. Will comply,as applicable,with the provisions of the Davis-Bacon Act 1. The Sub-grantee certifies that it will or will cantinue to provide a drug-free
(40 U.S.C.§§276a to 276a-7),the Copeland Act(40 U.S.C.§276c and workplace by:
18 U.S.C.§874),and the Contract Work Hours and Safety Standards Act (a) Publishing a statement notifying emp-rryees that the unlawful
(40 U.S.C.§§327-333)regarding tabor standards for federally-assisted manufacture,distribution,dispensing possession,or use of a
construction sub-agreements. controlled substance is prohibited in he sub-grantee's workplace
14. Wit comply with the flood insurance purchase requirements of Section and specifying the actions that will be taken against employees for
102(a)of the Flood Disaster Protection Act of 1973(P.L.93-234)which violation of such prohibition.
requires recipients in a special flood hazard area to participate in the (b) Establishing an ongoing drug-free awareness program to inform
program and to purchase flood insurance if the total cost of insurable employees about-
construction and acquisition is$10,000 or more. (1) The dangers of drug abuse in the workplace.
15. Will comply with the environmental standards which may be prescribed (2) The sub-grantee's policy of maintaining a drug-free workplace.
pursuant to the following: (3) Any evadable drug counseling,rehabilitation,and employee
(a) Institution of environmental quality control measures under the assistance programs.
National Environmental Policy Act of 1969(P.L.91-190 and (4) The penalties that may be imposed upon employees for drug
Executive Order(EO)11514. abuse violations occurring in the workplace.
(b) Notification of violating facilities pursuant to EO 11738. (c) Making it a requirement that each employee to be engaged in the
(c) Protection of wetlands pursuant to EO 11990. performance of the grant be given a copy of the notification state-
(d) Evaluation of flood hazards in flood plains in accordance with ment required by paragraph(a).
EO 11988. (d) Notifying the employee in the statement required by paragraph(a)that,
(e) Assurance of project consistency with the approved State manage- as a condition of employment under the grant,the employee will-
ment program developed under the Coastal Zone Management Act (1) Abide by the terms of the statement.
of 1972(16 U.S.C.§§1451 et seq.). (2) Notify the employer in writing of his or her conviction for a
(f) Conformity of Federal actions to State(Clean Air)Implementation violation of a criminal drug statute occurring in the workplace no
Plans under section 176(c)of the Clean Air Act of 1955,as amended later than five calendar days after such conviction.
(42 U.S.C.§§7401 et seq.). (e) Notifying the agency in writing within ten calendar days after receiving
(g) Protection of underground sources of drinking water under the Sate notice under sub-paragraph(dX2)from an employee or otherwise
Drinking Water Act of 1974,as amended(P.L.93-523). receivng actual notice of such conviction. Employers of convicted
(h) Protection of endangered species under the Endangered Species employees must provide notice,including position title,to every grant
Act of 1973,as amended(P.L.93-205). officer or other designee on whose grant activity the convicted
16. Will comply with the Wild Scenic Rivers Ad of 1968(16 U.S.C.§§1271 employee was working,unless the Federal agency has designated a
et seq.)related to protecting components or potential components of the central point for the receipt of such notices. Notice shall inckide the
national wild and scenic rivers system. identification number(s)of each affected grant.
17. Will assist the Awarding Agency in assuring compliance with Section 106 (f) Taking one of the following actions within 30 calendar days of
of the National Historic Preservation Act of 1966,as amended(16 U.S.C. receiving notice under sub-paragraph(dX2),with respect to any
§470),EO 11593(identification and protection of historic properties),and employee who is so convicted-
the Archaeological and Historic Preservation Act of 1974(16 U.S.C. (1) Taking appropriate personnel action against such an employee.
§§469a-1 et seq.). up to and including termination of employment,consistent with
18. Will comply with P.L.93-348 regarding the protection of human subjects the requirements of the Rehabilitation Act of 1973,as amended,
involved in research,development,and related activities supported by -ar-
this award of assistance. (2) Requiring the employee to partk:ipate satisfactorily in a drug
19. Will comply with the Laboratory Animal Welfare Act of 1966(P.L.89-544, abuse assistance or rehabilitat on program approved for such
as amended,7 U.S.C.§§2131 et seq.)pertaining to the care,handling,and purposes by a Federal,State, :r local health,law enforcement,
treatment of warm blooded animals held for research,teachng,or other or other appropriate agency.
activities supported by this award of assistance. (g) Making a good faith effort to contra a to maintain a drug-free work-
20. WM cause to be performed the required financial and compliance audits in place through implementation of paragraphs(a),(b),(c),(d),(e),8(f).
accordance with the Seigle Audit Act Amendments of 1996 and OMB
Circular No.A-133.
21. Will comply with all applicable requirements of all other Federal laws. The terms and conditions of this certification apply to any and all sites and
executive orders,regulations,and policies governing this program. 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 AWARDED THE COVERED TRANSACTION,GRANT.OR COOPERATIVE AGREEMENT.
C i 4 y o e r I O o DR-0000
Applicant Name J Grant ID
G - q-d7
Signature of Desrgna ut orized Representative 7 V Date
PAGE 2 OF 2
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 Service
regulations 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)
BOXA BOXB
Are you /your business: YES NO Is your business: YES NO
Individual [I] Corporation [C]
or Sole Proprietorship [S] Partnership [P]
Estate or Trust [E]
If the answer to both was no, please complete Box B. Public Service Corp [U]
Government [G] XX
If you answered yes to either item, please provide your Other [0]
Social Security number: Please explain
Please provide your Federal Employer Identification number:
AND 42-6005327
Complete the Name and Address Below: AND
Last Name:
Complete the Name and Address Below:
First Name: MI: Firm:
City of Waterloo
Doing Business As: Doing Business As:
715 Mulberry Street
Address: Address:
Address: Address:
Waterloo IA 50703
City: State: Postal Code: City: State: Postal Code:
CERTIFICATION MUST BE SIGNED BY VENDOR
Certification-Under penalties of perjury, I certify that:
(1)The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me), and
(2) I 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 failure to report all interest or dividends, or
(c)the IRS has notified me that I am no longer subject to backup withholding.
Signature: C).Q, Date: 1p - g D 7
OFFICE USE ONLY(Ref r o Procedure 270.450 for more details
From: Add
Dept. Ei Change
(Include vendor code and
changes only)
Contact
❑ Delete
Reason:
Added for Purchasing
Yes No