#### U. S. DEPARTMENT OF AGRICULTURE

**Rural Development**

***Rural Utilities Service***

***Weather Radio Transmitter***

***Grant Program***

####### Fiscal Year 2001

**Contents:**

> **Page No.**

Application Form 1

Funding Certification 6

Equal Opportunity and Nondiscrimination Certification 7

Certificate Regarding Architectural Barriers 8

Certificate Regarding Flood Hazard Area Precautions 9

Uniform Relocation Assistance and Real Property Acquisition

######  Policies Act of 1970 Certification 10

Certification Regarding Drug-Free Workplace Requirements

######  Alternative I -- For Grantees Other than Individuals 11

Certification Regarding Debarment, Suspension, and Other

######  Responsibility Matters -- Primary Covered Transactions 13

Certification Regarding Lobbying for Contracts, Grants

######  Loans, and Cooperative Agreements 14

Federal Obligations Certification on Delinquent Debt 15

Please send completed applications should be mailed to:

Ms. Roberta D. Purcell

Telecommunications Program

Assistant Administrator

1400 Independence Avenue, SW

Stop 1590

Washington, D.C. 20250

# 

# *Weather Radio Transmitter Grant Program*

***Application***

(Please Print or Type)

***Applicant Information:***

Applicant's Legal Name:

Non-Profit Organizational Structure:

-   Local or State Governmental Unit

-   RUS Electric or Telecommunications Cooperative

```{=html}
<!-- -->
```
-   Federally-recognized Indian Tribe

-   Other:

Contact Person:

Title:

E-mail Address:

Phone Number: Fax Number:

Address:

***Grant Information:***

> Grant Funds Requested
>
> Matching Funds
>
> Other Supplemental Funding
>
> Total Project Cost

***Site Location:***

+----------------+----------+-------------+-------------+-------------+
| ## Deta        | **Site   | **County**  | **State**   | #           |
| iled Transmitt | Name**   |             |             | # Projected |
| er Description |          |             |             |             |
|                |          |             |             | ## Cove     |
| **(Including   |          |             |             | rage Area\* |
| M              |          |             |             |             |
| anufacturer)** |          |             |             |             |
+----------------+----------+-------------+-------------+-------------+
|                |          |             |             |             |
+----------------+----------+-------------+-------------+-------------+
|                |          |             |             |             |
+----------------+----------+-------------+-------------+-------------+
|                |          |             |             |             |
+----------------+----------+-------------+-------------+-------------+
|                |          |             |             |             |
+----------------+----------+-------------+-------------+-------------+
|                |          |             |             |             |
+----------------+----------+-------------+-------------+-------------+
| The estimated  |          |             |             |             |
| signal         |          |             |             |             |
| coverage       |          |             |             |             |
| footprint from |          |             |             |             |
| the            |          |             |             |             |
| transmitter    |          |             |             |             |
| must cover at  |          |             |             |             |
| least 60% of   |          |             |             |             |
| the            |          |             |             |             |
| hypothetical   |          |             |             |             |
| site area.     |          |             |             |             |
|                |          |             |             |             |
| The            |          |             |             |             |
| hypothetical   |          |             |             |             |
| site area is   |          |             |             |             |
| the area       |          |             |             |             |
| included       |          |             |             |             |
| within a       |          |             |             |             |
| circle with a  |          |             |             |             |
| 45-mile radius |          |             |             |             |
| around a       |          |             |             |             |
| proposed rural |          |             |             |             |
|                |          |             |             |             |
| transmitter    |          |             |             |             |
| site on the    |          |             |             |             |
| NOAA Weather   |          |             |             |             |
| Radio site     |          |             |             |             |
| listing, as    |          |             |             |             |
| published in   |          |             |             |             |
| the Notice of  |          |             |             |             |
| Funds          |          |             |             |             |
| Availability   |          |             |             |             |
| on             |          |             |             |             |
|                |          |             |             |             |
| April 4, 2001. |          |             |             |             |
+----------------+----------+-------------+-------------+-------------+

***Community Need** (Please provide a detailed discussion of the
community's need for the proposed system. Attach additional sheets, if
necessary.):*

***Environmental Impact** (Please provide a description of the internal
modifications or equipment additions, the size of the site in hectares,
and the general nature of the proposed use of the facilities once the
project is completed including any hazardous materials to be used,
created or discharged, any substantial amount of air emissions,
wastewater discharge, or solid waste that will be generated. Attach
additional sheets, if necessary.)**:***

### Grant Limitations Per Site

+--------+-------+--------+-------+-------+--------+--------+--------+
| ##     | ##    | #      | *     | **A   | ## Ma  | **Elig | **Matc |
|  Site  |  Comm | # Per  | *Proj | llowa | tching | ible** | hing** |
|        | unity | Capita | ect** | ble** |        |        |        |
| #      |       |        |       |       | #      | ##     | ##     |
| # Name | ##    | ## In  | **C   | ##    | # Fund |  Grant |  Funds |
|        | Popul | come\* | ost** | Grant |        |        |        |
| \(a\)  | ation |        |       |       | #      | **Am   | **Requ |
|        |       | \(c\)  | \(d\) | **Pe  | # Perc | ount** | ired** |
|        | \(b\) |        |       | rcent | entage |        |        |
|        |       |        |       | age** |        | (d x   | (d x   |
|        |       |        |       |       | \(f\)  | e)     | f)     |
|        |       |        |       | \(e\) | =      |        |        |
|        |       |        |       |       | (100 - |        |        |
|        |       |        |       |       | e)     |        |        |
+--------+-------+--------+-------+-------+--------+--------+--------+
|        |       |        |       |       |        |        |        |
+--------+-------+--------+-------+-------+--------+--------+--------+
|        |       |        |       |       |        |        |        |
+--------+-------+--------+-------+-------+--------+--------+--------+
|        |       |        |       |       |        |        |        |
+--------+-------+--------+-------+-------+--------+--------+--------+
|        |       |        |       |       |        |        |        |
+--------+-------+--------+-------+-------+--------+--------+--------+
|        |       |        |       |       |        |        |        |
+--------+-------+--------+-------+-------+--------+--------+--------+
| > [All |       |        |       |       |        |        |        |
| owable |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
|  Grant |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
|  Perce |       |        |       |       |        |        |        |
| ntage] |       |        |       |       |        |        |        |
| {.unde |       |        |       |       |        |        |        |
| rline} |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| > If   |       |        |       |       |        |        |        |
| > Com  |       |        |       |       |        |        |        |
| munity |       |        |       |       |        |        |        |
| > Popu |       |        |       |       |        |        |        |
| lation |       |        |       |       |        |        |        |
| > is   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| 12,000 |       |        |       |       |        |        |        |
| > or   |       |        |       |       |        |        |        |
| > less |       |        |       |       |        |        |        |
| > and  |       |        |       |       |        |        |        |
| > Per  |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Capita |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Income |       |        |       |       |        |        |        |
| > is   |       |        |       |       |        |        |        |
| > less |       |        |       |       |        |        |        |
| > than |       |        |       |       |        |        |        |
| > \$   |       |        |       |       |        |        |        |
| 36,000 |       |        |       |       |        |        |        |
| > 75   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| > If   |       |        |       |       |        |        |        |
| > Com  |       |        |       |       |        |        |        |
| munity |       |        |       |       |        |        |        |
| > Popu |       |        |       |       |        |        |        |
| lation |       |        |       |       |        |        |        |
| > is   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| 20,000 |       |        |       |       |        |        |        |
| > or   |       |        |       |       |        |        |        |
| > less |       |        |       |       |        |        |        |
| > and  |       |        |       |       |        |        |        |
| > Per  |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Capita |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Income |       |        |       |       |        |        |        |
| > is   |       |        |       |       |        |        |        |
| > less |       |        |       |       |        |        |        |
| > than |       |        |       |       |        |        |        |
| > \$   |       |        |       |       |        |        |        |
| 38,000 |       |        |       |       |        |        |        |
| > 65   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| > If   |       |        |       |       |        |        |        |
| > Com  |       |        |       |       |        |        |        |
| munity |       |        |       |       |        |        |        |
| > Popu |       |        |       |       |        |        |        |
| lation |       |        |       |       |        |        |        |
| > is   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| 50,000 |       |        |       |       |        |        |        |
| > or   |       |        |       |       |        |        |        |
| > less |       |        |       |       |        |        |        |
| > and  |       |        |       |       |        |        |        |
| > Per  |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Capita |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Income |       |        |       |       |        |        |        |
| > is   |       |        |       |       |        |        |        |
| > less |       |        |       |       |        |        |        |
| > than |       |        |       |       |        |        |        |
| > \$   |       |        |       |       |        |        |        |
| 40,000 |       |        |       |       |        |        |        |
| > 55   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| > \*   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Obtain |       |        |       |       |        |        |        |
| > from |       |        |       |       |        |        |        |
| > the  |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| Bureau |       |        |       |       |        |        |        |
| > of   |       |        |       |       |        |        |        |
| > Ec   |       |        |       |       |        |        |        |
| onomic |       |        |       |       |        |        |        |
| > An   |       |        |       |       |        |        |        |
| alysis |       |        |       |       |        |        |        |
| > w    |       |        |       |       |        |        |        |
| ebsite |       |        |       |       |        |        |        |
| > at:  |       |        |       |       |        |        |        |
|        |       |        |       |       |        |        |        |
| http:  |       |        |       |       |        |        |        |
| //www. |       |        |       |       |        |        |        |
| bea.do |       |        |       |       |        |        |        |
| c.gov/ |       |        |       |       |        |        |        |
| bea/re |       |        |       |       |        |        |        |
| gional |       |        |       |       |        |        |        |
| /reis/ |       |        |       |       |        |        |        |
|        |       |        |       |       |        |        |        |
| > \*\* |       |        |       |       |        |        |        |
| > Not  |       |        |       |       |        |        |        |
| > to   |       |        |       |       |        |        |        |
| >      |       |        |       |       |        |        |        |
| exceed |       |        |       |       |        |        |        |
| > \$8  |       |        |       |       |        |        |        |
| 0,000. |       |        |       |       |        |        |        |
+--------+-------+--------+-------+-------+--------+--------+--------+

***Matching Funds:***

+---------------+-----------------+-----------------+----------------+
| ## Site Name  | **Contributor's | **Description** | **Amount**     |
|               | Name**          |                 |                |
|               |                 |                 |                |
|               | **(If           |                 |                |
|               | Applicant, So   |                 |                |
|               | State)**        |                 |                |
+---------------+-----------------+-----------------+----------------+
|               |                 |                 |                |
+---------------+-----------------+-----------------+----------------+
|               |                 |                 |                |
+---------------+-----------------+-----------------+----------------+
|               |                 |                 |                |
+---------------+-----------------+-----------------+----------------+
|               |                 |                 |                |
+---------------+-----------------+-----------------+----------------+
|               |                 |                 |                |
+---------------+-----------------+-----------------+----------------+
| Attach all    |                 |                 |                |
| binding       |                 |                 |                |
| commitments   |                 |                 |                |
| from the      |                 |                 |                |
| applicant and |                 |                 |                |
| the tower and |                 |                 |                |
| site owners,  |                 |                 |                |
| if other than |                 |                 |                |
| the           |                 |                 |                |
| applicant,    |                 |                 |                |
| that tower    |                 |                 |                |
| space and     |                 |                 |                |
| electrical    |                 |                 |                |
| power         |                 |                 |                |
| utilized as   |                 |                 |                |
| matching      |                 |                 |                |
| funds will be |                 |                 |                |
| provided,     |                 |                 |                |
| irrespective  |                 |                 |                |
| of changes in |                 |                 |                |
| ownership of  |                 |                 |                |
| the           |                 |                 |                |
| facilities,   |                 |                 |                |
| without       |                 |                 |                |
| charge for    |                 |                 |                |
| the life of   |                 |                 |                |
| the           |                 |                 |                |
| transmitter.  |                 |                 |                |
| If tower and  |                 |                 |                |
| equipment     |                 |                 |                |
| building      |                 |                 |                |
| space,        |                 |                 |                |
| donated       |                 |                 |                |
| power,        |                 |                 |                |
| co            |                 |                 |                |
| mmunications, |                 |                 |                |
| or standby    |                 |                 |                |
| power are     |                 |                 |                |
| utilized as   |                 |                 |                |
| matching      |                 |                 |                |
| funds, please |                 |                 |                |
| provide the   |                 |                 |                |
| calculation   |                 |                 |                |
| of each value |                 |                 |                |
| in the space  |                 |                 |                |
| below:        |                 |                 |                |
|               |                 |                 |                |
| **Donated     |                 |                 |                |
| Equipment:**  |                 |                 |                |
|               |                 |                 |                |
| **Donated     |                 |                 |                |
| Power:**      |                 |                 |                |
|               |                 |                 |                |
| **Other:**    |                 |                 |                |
+---------------+-----------------+-----------------+----------------+

##### *Budget:*

+---------------------+-------+--------+--------+----------+----------+
| # Eq                | #     | ## Uni | **T    | **RUS    | **Ma     |
| uipment Description | # Qua | t Cost | otal** | Grant**  | tching** |
|                     | ntity |        |        |          |          |
|                     |       |        |        | **Funds  | *        |
|                     |       |        |        | Req      | *Funds** |
|                     |       |        |        | uested** |          |
+---------------------+-------+--------+--------+----------+----------+
| Site Name:          |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| ## Total Site Cost  |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| Site Name:          |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| ## Total Site Cost  |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| Site Name:          |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| ## Total Site Cost  |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| Site Name:          |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| ## Total Site Cost  |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| Site Name:          |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| ## Total Site Cost  |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+
| **Total Project     |       |        |        |          |          |
| Costs**             |       |        |        |          |          |
+---------------------+-------+--------+--------+----------+----------+

***Funding Certification***

The
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Grantee), as a prospective recipient under the Weather Radio
Transmitter Grant Program, certifies that:

a.  It will execute a grant agreement containing technical and other
    standards satisfactory to RUS;

b.  It is unable to finance a new National Oceanic and Atmospheric
    Administration Weather Radio Transmitter from its own resources, or
    through commercial credit at reasonable rates and terms, or other
    funding sources without grant assistance.

c.  The transmitter(s) covers the specified percentage of the
    hypothetical site area for each of the following:

Site Name Percentage of Hypothetical Site Area

1.  
2.  
3.  
4.  
5.  

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*(Date) (Signature)*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*(Type or Print Name)*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*(Title)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Equal Opportunity and Nondiscrimination Certification***

All grants made under the Weather Radio Transmitter Grant Program are
subject to the nondiscrimination provisions of Title VI of the Civil
Rights Act of 1964, as amended, (7 CFR Part 15); Section 504 of the
Rehabilitation Act of 1973, as amended, (29 U.S.C. 901 *et seq*;\
7 CFR Part 15b); and Age Discrimination of 1975, as amended (42 U.S.C.
6101 *et seq.*; 45 CFR Part 90); and as amended by Executive Order 11375
Amending Executive Order 11246, Relating to Equal Employment Opportunity
(3 CFR, 1966, 1970 Comp., p. 684).

All recipients of financial assistance from RUS, the prospective primary
participant commits to carry out RUS' established policy to comply with
the requirements of the above laws and executive orders to the effect
that no person in the United States shall, "on the basis of race, color,
national origin, handicap, or age, be excluded from participation in, be
denied the benefits of, or be otherwise subjected to discrimination
under the Weather Radio Transmitter Grant Program.

The
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Grantee)

hereby certifies that, as a prospective recipient under the said Weather
Radio Transmitter Grant Program, it will comply with the above reference
laws and executive orders.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*(Date (Authorized Representative's Signature)*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*(Name Typed or Printed)*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

*(Title)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Certificate Regarding Architectural Barriers***

All facilities financed with RUS grants that are open to the public, or
in which physically handicapped persons may be employed or reside, must
be designed, constructed, and/or altered to be readily accessible to,
and usable by handicapped persons. Standards for these facilities must
comply with the Architectural Barriers Act of 1968, as amended, 42
U.S.C. 4151 *et seq.*) and with the Uniform Federal Accessibility
Standards (UFAS), (Appendix A to 41 CFR subpart 101-19.6).

As a prospective primary participant recipient of financial assistance
from RUS, this organization commits to carry out RUS' established policy
to comply with the requirements of the above referenced law to the
effect that all facilities must be readily accessible to and usable by
handicapped persons.

The
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Grantee) hereby certifies, that, as a prospective recipient under the
Weather Radio Transmitter Grant Program, it is in compliance, or will be
in compliance upon completion of the project, with the above referenced
law.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Date)* *(Authorized Representative's Signature)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Name Typed or Printed)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(*Title)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Certificate Regarding Flood Hazard Area Precautions***

If the project is located in an area subject to flooding, flood
insurance must be provided to the extent available and required under
the National Flood Insurance Act of 1968, as amended by the Flood
Disaster Protection Act of 1973, as amended (42 U.S.C. 4001 through
4128). If applicable, the insurance must cover, in addition to the
buildings, any machinery, equipment, fixtures, and furnishings contained
in the buildings. RUS will comply with Executive Order 11988, Floodplain
Management (3 CFR, 1977 Comp., p. 117), and 7 CFR 1794.41, of this
chapter in considering the application for the project.

Please check the appropriate line below:

\_\_\_ a) The project is not located in a 100 year flood plain;
therefore, no Flood Insurance is required.

\_\_\_ b) The project is located in a 100 year flood plain and the
required insurance is or will be provided by:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Grantee) hereby certifies, that, as a prospective recipient under the
Weather Radio Transmitter Grant Program, it is in compliance, or will be
in compliance during construction and/or installation of equipment and
upon completion of the project, with the above referenced law.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Date)* *(Authorized Representative's Signature)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Name Typed or Printed)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(Title)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Uniform Relocation Assistance and Real Property Acquisition***

***Policies Act of 1970 Certification***

The
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Grantee) assures that it will comply with the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970, as
amended (Uniform Act), 42 U.S.C. 4601-4655, and with implementing
Federal regulations in 49 CFR Part 24 and 7 CFR Part 21.

Specifically, the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Grantee) assures that:

> Whenever Federal financial assistance is used to pay for any part of
> the cost of a program or project which will result in the displacement
> of any person:
>
> \(a\) Fair and reasonable relocation payments and assistance shall be
> provided to or for displaced persons in accordance with sections 202,
> 203, and 204 of the Uniform Act;
>
> \(b\) Relocation assistance programs offering the services described
> in section 205 of the Uniform Act shall be provided to displaced
> persons; and
>
> \(c\) Within a reasonable period of time prior to displacement,
> comparable replacement dwellings will be available to displaced
> persons in accordance with section 205(c) (3) of the Uniform Act.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Date* *(Authorized Representative's Signature)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Certification Regarding Drug-Free Workplace Requirements***

***Alternative I -- For Grantees Other than Individuals***

This certification is required by the regulations implementing Sections
5151-5160 of the Drug-Free Workplace Act of 1988 (P.L. 100-690, Title V,
Subtitle D; 41 U.S.C. 701 *et seq.*), 7 CFR Part 3017, Subpart F,
Section 3017.600, Purpose. The January 31, 1989, regulations were
amended and published as Part II of the May 25, 1990, [Federal
Register]{.underline} (pages 21681-21691). Copies of the regulations may
be obtained by contacting the Department of Agriculture agency offering
the grant.

**ALTERNATIVE I**

A. The grantee certifies that it will or will continue to provide a
drug-free workplace by:

> \(a\) Publishing a statement notifying employees that 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 ongoing drug-free awareness program to inform
> employees about:
>
> \(1\) The dangers of drug abuse in the workplace;
>
> \(2\) The grantee's 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 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 employer in writing of his or her conviction for a
> violation of a criminal drug statute occurring in the workplace no
> later than 5 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 every grant officer on whose grant
> activity the convicted employee was working, unless the Federal agency
> has designated a central point for the receipt of such notices. Notice
> shall include the identification number(s) of each affected grant;

\(f\) Taking one of the following actions, 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; and

\(g\) Making a good faith effort to continue to maintain a drug-free
workplace through implementation of paragraphs (a), (b), (c), (d), (e),
and (f).

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 Address City*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*County State Zip Code*

**\_\_\_\_ Check if there are workplaces on file that are not identified
here.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Organization Name*

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

*Authorized Representative's Signature Date*

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

*Name Typed or Printed*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Certification Regarding Debarment, Suspension, and Other
Responsibility Matters -- Primary Covered Transactions***

This certification is required by the regulations implementing Executive
Order 12549, Debarment and Suspension, 7 CFR Part 3017, Section
3017.510, Participants' Responsibilities. The regulations were published
as Part IV of the January 30, 1989, [Federal Register]{.underline}
(pages 4722-4733). Copies of the regulations may be obtained by
contacting the Department of Agriculture agency offering the proposed
transaction.

\(1\) The prospective primary participant certifies to the best of its
knowledge and belief, that it and its principals:

> \(a\) are not presently debarred, suspended, proposed for Debarment,
> declared ineligible, or voluntarily excluded from covered transactions
> by any Federal department or agency;
>
> \(b\) have not within a 3-year period preceding this proposal been
> convicted of or had a civil judgment rendered against them for
> commission of fraud or a criminal offense in connection with
> obtaining, attempting to obtain, or performing 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;
>
> \(c\) are not presently indicted for or otherwise criminally or
> civilly charged by a governmental 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 3-year period preceding this
> application/proposal had one or more public transactions (Federal,
> State, or local) terminated for cause or default.

\(2\) Where the prospective primary participant is unable to certify to
any of the statements in this certification, such prospective
participant shall attach an explanation to this proposal.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Organization Name*

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

*Authorized Representative's Signature Date*

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

*Name Typed or Printed*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Certification Regarding Lobbying for Contracts, Grants,***

***Loans, and Cooperative Agreements***

The undersigned certifies, to the best of his or her knowledge and
belief, that:

> \(1\) 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 awarding of any Federal
> contract, the making of any Federal grant or loan, the entering into
> of any cooperative agreement, and the extension, continuation,
> renewal, amendment, or modification of any Federal contract, grant,
> loan, or cooperative agreement.
>
> \(2\) If any funds other 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 contract, grant, loan, or
> cooperative agreement, the undersigned shall complete and submit
> Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance
> with its instructions. (Copies of this form may be obtained from RUS.)
>
> \(3\) The undersigned shall require that the language of this
> certification be included in the award documents for all subawards at
> all tiers (including subcontracts, subgrants, and contracts under
> grants, loans, and cooperative agreements) and that all subrecipients
> shall certify and disclose accordingly.
>
> This certification is a material representation of fact upon which
> reliance was placed when this transaction was made or entered into.
> Submission of this certification is a prerequisite for making or
> entering into this transaction imposed by section 1352, title 31, U.S.
> Code. Any person who fails to file the required certification shall be
> subject to a civil penalty of not less than \$10,000 and not more than
> \$100,000 for each such failure.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Organization Name*

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

*Authorized Representative's Signature Date*

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

*Name Typed or Printed*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*

***Federal Obligations Certification on Delinquent Debt***

**IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? YES NO**

**Note: Example of debts include, but are not limited to, delinquent
taxes, guaranteed or direct government loans (more than 31 days past
due) and other administrative debts.**

**If Yes, provide explanatory information.**

**[APPLICANT CERTIFICATION]{.underline}**

**[FEDERAL COLLECTION POLICIES FOR COMMERCIAL DEBT]{.underline}**

The Federal Government is authorized by law to take any or all of the
following actions in the event that a borrower's loan payments become
delinquent or the borrower defaults on its loan: (1) Report the
borrower's delinquent account to a credit bureau; (2) Assess additional
interest and penalty charges for the period of time that payment is not
made; (3) Assess charges to cover additional administrative costs
incurred by the Government to service the borrower's account; (4) Offset
amounts owed to the borrower under other Federal programs; (5) Refer the
borrower's debt to the Internal Revenue Service for offset against any
amount owed to the borrower as an income tax refund; (6) Refer the
borrower's account to a private collection agency to collect the amount
due; and (7) Refer the borrower's account to the Department of Justice
for litigation in the courts.

All of these actions can and will be used to recover any debts owed when
it is determined to be in the interest of the Government to do so.

**[Certification]{.underline}**

**I have read and understand the actions the Federal Government can take
in the event that I fail to meet my scheduled payments in accordance
with the terms and conditions of my agreements.**

Signed:

Title:

Company:

Date:

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Weather Radio Transmitter Grant Program.)*