**This is a template for a "simple" [§9006 Energy Efficiency grant
application]{.underline}.** ("Simple" applications are those involving
total project costs of ≤\$200,000 and §9006 grants of ≤\$50,000.) It was
developed by USDA Rural Development-Oregon to help Oregonians prepare a
complete §9006 application.

**[BEFORE STARTING YOUR APPLICATION!]{.underline}**

*[1. Get an energy audit.]{.underline}* The starting point and the key
to success for anyone seeking a §9006 energy efficiency grant is to
first obtain an independent, professional energy audit or energy
assessment. This report is the foundational document that justifies the
energy efficiency improvements being proposed. The last two pages of
this template contain guidance on minimum requirements for an energy
audit or assessment. (Note: The cost of your audit can be reimbursed
with §9006 grant funds if you are ultimately successful with your
application.)

*[2. Develop a clear project budget & implementation plan.]{.underline}*
Figure out what energy efficiency improvements you want to make. Get a
few bids and determine the total project cost.

*[3. Begin lining up additional funds.]{.underline}* Once you have
defined the scope of your energy project, you will need to find other
funding sources because the §9006 grant cannot pay for more than 25% of
your total project cost. Proposals that have all of their other funding
committed are more likely to receive a §9006 grant as well. Oregon has a
number of excellent energy efficiency incentive programs including:

-   State Tax Credits:
    <http://egov.oregon.gov/ENERGY/CONS/BUS/BETC.shtml>

-   State Loan Program: <http://www.oregon.gov/ENERGY/LOANS/index.shtml>

-   Energy Trust incentives (PGE & Pacific Power users):
    <http://www.energytrust.org/>

*[4. Contact USDA Rural Development to discuss your project & the
application process.]{.underline}* Oregon's USDA Rural Development staff
can provide you with insights and ideas on how best to proceed. Feel
free to contact us!

*[5. Prepare your §9006 application.]{.underline}* We recommend using
our application template to assure your application is well-documented
and complete.

**[INSTRUCTIONS FOR USING THE §9006 APPLICATION TEMPLATE]{.underline}**

Read through the template on your computer and simply fill in the blank
fields with the appropriate information.

-   **Text in blue font** is *guidance* to help you complete the
    application. It should be *deleted* along with these initial pages
    of instructions before you finalize your application for submission.

-   **Text in black font** is the application narrative outline that you
    will need to respond to. Leave this text alone.

-   [Your inputs in the template show up as **text in underscored dark
    blue font.** (Some of the responses have been pre-filled for your
    convenience, but you are free to modify or correct these
    "boilerplate" responses as you see fit.)]{.underline}

**[Completing your application:]{.underline}** Once you are done with
the template, all of the supporting documents and attachments should be
collated with the template and organized according to the table of
contents. The application should be tabbed to match the table of
contents. Submit all applications ***in triplicate***.

**[FOR MORE INFORMATION:]{.underline}**

**Contact us:**

  -------------------- ---------- ----------- -------------- ---------------------------
  Energy Efficiency    Martin     Portland    503-414-3361   <martin.zone@or.usda.gov>
  Coordinator          Zone                                  

  Rural Energy         Don Hollis Pendleton   541-278-8049   don.hollis@or.usda.gov
  Coordinator                                 x129           

  State Office         Jeff Deiss Portland    503-414-3367   jeff.deiss@or.usda.gov
  -------------------- ---------- ----------- -------------- ---------------------------

**Or visit our web site:**

<http://www.rurdev.usda.gov/or/rbs.htm>

(4/3/2007)

COVER LETTER

Business Programs

USDA Rural Development

1201 NE Lloyd Blvd., Ste. 801,

Portland, OR 97232-1274

The enclosed application for a §9006 energy efficiency grant is
submitted using a "simple application" rather than a "full application"
because, if selected, the proposal will meet the simple application
standards:

-   Total eligible project costs will be \$200,000 or less.

-   The proposed project will use commercially available technology.

-   Construction planning and performing development will be performed
    in compliance with USDA requirements. The applicant or the
    applicant's prime contractor will assume all risks and
    responsibilities of project development.

-   The applicant or the applicant's prime contractor will be
    responsible for all interim financing.

-   The project will be scheduled to be completed within 24 months after
    entering into a grant agreement with USDA. (USDA may extend this
    period if it determines, at its sole discretion, that the applicant
    is unable to complete the project for reasons beyond the applicant's
    control.)

-   The applicant agrees not to request reimbursement from funds
    obligated under this program until after project completion,
    including all operational testing and certifications acceptable to
    USDA.

**«Applicant»**

  ------------------------------------- ------------- -------------------
                                                      November 13, 2023

  (signature)                                         (date)

                                                      

  (name & title)                                      
  ------------------------------------- ------------- -------------------

**TABLE OF CONTENTS**

Name of Applicant: **«Applicant»**

+--------------------------------------------------------------+-------+
| **Element**                                                  | **    |
|                                                              | Tab** |
+--------------------------------------------------------------+-------+
| [Forms SF 424, 424C, & 424D]{.underline}, Application for    | 1     |
| Federal Assistance, Budget Information-Construction          |       |
| Programs, & Assurances-Construction Programs.                |       |
+--------------------------------------------------------------+-------+
| [[Form AD                                                    | 2     |
| 1047]{.underline}](                                          |       |
| http://www.ocio.usda.gov/forms/download/AD1047-F-01-92.pdf), |       |
| Certification Regarding Debarment, Suspension, and Other     |       |
| Responsibility Matters -- Primary Covered Transactions.      |       |
+--------------------------------------------------------------+-------+
| [[Form AD                                                    | n/a   |
| 1048]{.underline}](                                          |       |
| http://www.ocio.usda.gov/forms/download/AD1047-F-01-92.pdf), |       |
| Certification Regarding Debarment, Suspension, Ineligibility |       |
| and Voluntary Exclusion -- Lower Tier Covered Transactions   |       |
|                                                              |       |
| *Signed by any contractor/vendor to provide over \$25,000 is |       |
| goods & services- if applicable.*                            |       |
+--------------------------------------------------------------+-------+
| [[Form AD                                                    | 3     |
| 1049]{.                                                      |       |
| underline}](http://www.usda.gov/rus/water/forms/ad1049.pdf), |       |
| Certification Regarding Drug-Free Workplace Requirements.    |       |
+--------------------------------------------------------------+-------+
| [[Exhibit A-1 of RD Instruction                              | n/a   |
| 1940-Q]{.underlin                                            |       |
| e}](http://www.rurdev.usda.gov/rbs/coops/rd1940-qeha-1.pdf), |       |
| Certification for Contract, Grants and Loans                 |       |
|                                                              |       |
| *Grant requested is ≤\$100,000 , therefore not applicable*   |       |
+--------------------------------------------------------------+-------+
| [Form SF-LLL]{.underline}, Disclosure of Lobbying            | n/a   |
| Activities.                                                  |       |
|                                                              |       |
| *No lobbying was done, therefore not applicable.*            |       |
+--------------------------------------------------------------+-------+
| [Form RD 400-1]{.underline}, Equal Opportunity Agreement.    | 4     |
+--------------------------------------------------------------+-------+
| [Form RD 400-4]{.underline}, Assurance Agreement.            | 5     |
+--------------------------------------------------------------+-------+
| [Intergovernmental consultation]{.underline}.                | n/a   |
|                                                              |       |
| *There is no intergovernmental point of contact process in   |       |
| Oregon, therefore not applicable.*                           |       |
+--------------------------------------------------------------+-------+
| [Certification of Relationship with Agency]{.underline}.     | 6     |
+--------------------------------------------------------------+-------+
| [Certification of Demonstrated Financial Need]{.underline}.  | 7     |
+--------------------------------------------------------------+-------+
| [Form RD 1940-20]{.underline}, Request for Environmental     | 8     |
| Information.                                                 |       |
+--------------------------------------------------------------+-------+
| [Organizational documents]{.underline}                       | 9     |
+--------------------------------------------------------------+-------+
| [Project Summary]{.underline} -- Title, Applicant            | 10    |
| eligibility, Project eligibility, Operation description, &   |       |
| Financial information for size determination                 |       |
+--------------------------------------------------------------+-------+
| [Matching Funds Spreadsheet]{.underline}                     | 11    |
+--------------------------------------------------------------+-------+
| [Self-Evaluation Score Sheet]{.underline}                    | 12    |
+--------------------------------------------------------------+-------+
| [Technical Report]{.underline}                               | 13    |
+--------------------------------------------------------------+-------+
| [Energy Audit]{.underline} or [Energy                        | 14    |
| Assessment]{.underline} (select whichever is applicable)     |       |
+--------------------------------------------------------------+-------+
| [Addendum -- Important Supporting Documentation]{.underline} | 15    |
+--------------------------------------------------------------+-------+

***[Tab 1:]{.underline}*** Version 7/03

<table>
<colgroup>
<col style="width: 13%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 14%" />
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 23%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4"><strong>APPLICATION FOR</strong></td>
<td colspan="5"><strong>2. DATE SUBMITTED</strong></td>
<td>Applicant Identifier</td>
</tr>
<tr class="even">
<td colspan="4"><strong>FEDERAL ASSISTANCE</strong></td>
<td colspan="5">November 13, 2023</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>1. TYPE OF SUBMISSION:</strong></td>
<td colspan="5"><strong>3. DATE RECEIVED BY STATE</strong></td>
<td>State Application Identifier</td>
</tr>
<tr class="even">
<td colspan="4">Application Preapplication</td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"> Construction  Construction</td>
<td colspan="5"><strong>4. DATE RECEIVED BY FEDERAL AGENCY</strong></td>
<td>Federal Identifier</td>
</tr>
<tr class="even">
<td colspan="4"> Non-Construction  Non-Construction</td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>5. APPLICANT INFORMATION</strong></td>
</tr>
<tr class="even">
<td colspan="5">Legal Name:</td>
<td colspan="5"><strong>Organizational Unit</strong>: Department:</td>
</tr>
<tr class="odd">
<td colspan="5"><strong>«Applicant»</strong></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="5">Organizational DUNS:</td>
<td colspan="5">Division:</td>
</tr>
<tr class="odd">
<td colspan="5">### You must provide a “DUNS” number unless you are
applying as an individual. (Individuals are exempt.) Guidance on
obtaining a DUNS number can be found at: <a
href="http://www.whitehouse.gov/omb/grants/duns_num_guide.pdf">www.whitehouse.gov/omb/grants/duns_num_guide.pdf</a></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>Address:</strong></td>
<td colspan="5"><strong>Name &amp; telephone number of person to be
contacted</strong></td>
</tr>
<tr class="odd">
<td colspan="5">Street:</td>
<td colspan="5"><strong>on matters involving this application (give area
code)</strong></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="2">Prefix:</td>
<td colspan="3">First Name:</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="5">City:</td>
<td colspan="5">Middle Name</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="5">County</td>
<td colspan="5">Last Name</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="3">State:</td>
<td colspan="2">Zip Code</td>
<td colspan="5">Suffix:</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="5">Country</td>
<td colspan="5">Email:</td>
</tr>
<tr class="odd">
<td colspan="5">USA</td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>6. EMPLOYER IDENTIFICATION NUMBER</strong>
<em>(EIN)</em></td>
<td colspan="4">Phone Number (give area code)</td>
<td>Fax Number (give area code)</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="5"><strong>8. TYPE OF APPLICATION:</strong></td>
<td colspan="5"><strong>7. TYPE OF APPLICANT:</strong></td>
</tr>
<tr class="odd">
<td colspan="5"> New  Continuation  Revision</td>
<td colspan="5"><p>Select <u>only one</u> of the following &amp; delete
the others:</p>
<blockquote>
<p>L. Individual <strong><u>or</u></strong> M. Profit Organization
<strong><u>or</u></strong></p>
<p>N. Other (specify)</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="5"><p><strong>10. CATALOG OF FEDERAL DOMESTIC
ASSISTANCE</strong></p>
<p><strong>NUMBER</strong></p></td>
<td colspan="5"><p><strong>9. NAME OF FEDERAL AGENCY:</strong></p>
<p>USDA Rural Business-Cooperative Service</p></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>10-775</strong></td>
<td colspan="5"><strong>11. DESCRIPTIVE TITLE OF APPLICAN’T
PROJECT:</strong></td>
</tr>
<tr class="even">
<td colspan="5"><p>TITLE (Name of Program):</p>
<p>§9006 Energy Efficiency Improvement Grant</p></td>
<td colspan="5">Use a short title that describes the basics of the
project – e.g. “Efficient irrigation pumps for XYZ Farms”</td>
</tr>
<tr class="odd">
<td colspan="5"><strong>12. AREAS AFFECTED BY PROJECT</strong> (Cities,
Counties, States):</td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="5">Oregon</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>13. PROPOSED PROJECT</strong></td>
<td colspan="5"><strong>14. CONGRESSIONAL DISTRCITS OF:</strong></td>
</tr>
<tr class="even">
<td colspan="2">Start Date:</td>
<td colspan="3">Ending Date:</td>
<td colspan="3">a. Applicant</td>
<td colspan="2">b. Project</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>15. ESTIMATED FUNDING:</strong></td>
<td colspan="5"><strong>16. IS APPLICATION SUBJECT TO REVIEW BY
STATE</strong></td>
</tr>
<tr class="odd">
<td colspan="3">a. Federal</td>
<td colspan="2">$</td>
<td colspan="5"><strong>EXECUTIVE ORDER 12372 PROCESS?</strong></td>
</tr>
<tr class="even">
<td colspan="3">§9006 grant</td>
<td colspan="2"></td>
<td colspan="5">THIS PREAPPLICATION/APPLICATION WAS</td>
</tr>
<tr class="odd">
<td colspan="3">b. Applicant</td>
<td colspan="2">$</td>
<td colspan="5">a. Yes.  MADE AVAILABLE TO THE STATE</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="5">EXECUTIVE ORDER 12372 PROCESS FOR</td>
</tr>
<tr class="odd">
<td colspan="3">c. State</td>
<td colspan="2">$</td>
<td colspan="5">REVIEW ON</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="5">DATE: not applicable</td>
</tr>
<tr class="odd">
<td colspan="3">d. Local</td>
<td colspan="2">$</td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="5">b. No.  PROGRAM NOT COVERED BY E.O. 12372</td>
</tr>
<tr class="odd">
<td colspan="3">e. Other</td>
<td colspan="2">$</td>
<td colspan="5"> OR PROGRAM HAS NOT BEEN SELECTED</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="5">BY STATE FOR REVIEW</td>
</tr>
<tr class="odd">
<td colspan="3">f. Program Income</td>
<td colspan="2">$</td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="5"><strong>17. IS APPLICANT DELINQUENT ON ANY FEDERAL
DEBT?</strong></td>
</tr>
<tr class="odd">
<td colspan="3">g. TOTAL</td>
<td colspan="2">$</td>
<td colspan="5"> Yes. If “Yes”, attach an explanation  No</td>
</tr>
<tr class="even">
<td colspan="10"><strong>18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL
DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT. THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT
AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE
ASSISTANCE IS AWARDED.</strong></td>
</tr>
<tr class="odd">
<td colspan="10">a. Authorized Representative</td>
</tr>
<tr class="even">
<td>Prefix</td>
<td colspan="5">First Name</td>
<td colspan="4">Middle Name</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="6">Last Name</td>
<td colspan="4">Suffix</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="6">b. Title</td>
<td colspan="4">c. Telephone Number (give area code)</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="6">d. Signature of Authorized Representative</td>
<td colspan="4">e. Date Signed</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="4">November 13, 2023</td>
</tr>
<tr class="even">
<td colspan="6">Previous Editions Usable Authorized for Local
Reproduction</td>
<td colspan="4">Standard Form 424 (Rev. 9-2003) Prescribed by OMB
Circular A-102</td>
</tr>
</tbody>
</table>

> OMB Approval No. 0348-0041

**BUDGET INFORMATION -- Construction Programs**

NOTE: Certain Federal assistance programs require additional
computations to arrive at the Federal share of project costs eligible
for participation. If such is the case, you will be notified

+---------------------------------+----+----+----------+---+-----------+
| COST CLASSIFICATION             | a  |    | b\.      | c |           |
|                                 | \. |    | Costs    | \ |           |
|                                 | T  |    | Not      | . |           |
|                                 | ot |    | A        | T |           |
|                                 | al |    | llowable | o |           |
|                                 | Co |    |          | t |           |
|                                 | st |    | for      | a |           |
|                                 |    |    | Parti    | l |           |
|                                 |    |    | cipation | A |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | o |           |
|                                 |    |    |          | w |           |
|                                 |    |    |          | a |           |
|                                 |    |    |          | b |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | C |           |
|                                 |    |    |          | o |           |
|                                 |    |    |          | s |           |
|                                 |    |    |          | t |           |
|                                 |    |    |          | s |           |
|                                 |    |    |          |   |           |
|                                 |    |    |          | ( |           |
|                                 |    |    |          | C |           |
|                                 |    |    |          | o |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | u |           |
|                                 |    |    |          | m |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | s |           |
|                                 |    |    |          | a |           |
|                                 |    |    |          | - |           |
|                                 |    |    |          | b |           |
|                                 |    |    |          | ) |           |
+---------------------------------+----+----+----------+---+-----------+
| Both columns will normally be   |    |    |          |   |           |
| identical  Provide a breakdown |    |    |          |   |           |
| of the use of funds  .         |    |    |          |   |           |
+---------------------------------+----+----+----------+---+-----------+
| 1\. Administrative and legal    | [\ |    | n/a      | [ |           |
| expenses                        | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 2\. Land, structures,           | [\ |    | n/a      | [ |           |
| rights-of-way, appraisals, etc. | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 3\. Relocation expenses and     | [\ |    | n/a      | [ |           |
| payments                        | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 4\. Architectural and           | [\ |    | n/a      | [ |           |
| engineering fees                | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 5\. Other architectural and     | [\ |    | n/a      | [ |           |
| engineering fees                | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 6\. Project inspection fees     | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 7\. Site work                   | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 8\. Demolition and removal      | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 9\. Construction                | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 10\. Equipment                  | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| 11\. Miscellaneous              | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| **12. SUBTOTAL**                | ** |    | **[n/    | * |           |
|                                 | [\ |    | a]{.unde | * |           |
| *(sum of lines 1-11)*           | $] |    | rline}** | [ |           |
|                                 | {. |    |          | \ |           |
|                                 | un |    |          | $ |           |
|                                 | de |    |          | ] |           |
|                                 | rl |    |          | { |           |
|                                 | in |    |          | . |           |
|                                 | e} |    |          | u |           |
|                                 | ** |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
|                                 |    |    |          | * |           |
|                                 |    |    |          | * |           |
+---------------------------------+----+----+----------+---+-----------+
| 13\. Contingencies              | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
| **14. SUBTOTAL**                | ** |    | **[n/    | * |           |
|                                 | [\ |    | a]{.unde | * |           |
|                                 | $] |    | rline}** | [ |           |
|                                 | {. |    |          | \ |           |
|                                 | un |    |          | $ |           |
|                                 | de |    |          | ] |           |
|                                 | rl |    |          | { |           |
|                                 | in |    |          | . |           |
|                                 | e} |    |          | u |           |
|                                 | ** |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
|                                 |    |    |          | * |           |
|                                 |    |    |          | * |           |
+---------------------------------+----+----+----------+---+-----------+
| 15\. Project (program) income   | [\ |    | n/a      | [ |           |
|                                 | $] |    |          | \ |           |
|                                 | {. |    |          | $ |           |
|                                 | un |    |          | ] |           |
|                                 | de |    |          | { |           |
|                                 | rl |    |          | . |           |
|                                 | in |    |          | u |           |
|                                 | e} |    |          | n |           |
|                                 |    |    |          | d |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | r |           |
|                                 |    |    |          | l |           |
|                                 |    |    |          | i |           |
|                                 |    |    |          | n |           |
|                                 |    |    |          | e |           |
|                                 |    |    |          | } |           |
+---------------------------------+----+----+----------+---+-----------+
|  Income from the grant project |    |    |          |   |           |
| itself during the term         |    |    |          |   |           |
|                                 |    |    |          |   |           |
| of the work funded by the       |    |    |          |   |           |
| grant.                          |    |    |          |   |           |
|                                 |    |    |          |   |           |
| This figure must match 15.f on  |    |    |          |   |           |
| previous page; usually this     |    |    |          |   |           |
| figure is"\$0"                  |    |    |          |   |           |
+---------------------------------+----+----+----------+---+-----------+
| **16. TOTAL PROJECT COSTS**     | ** |    | **[n/    | * |           |
|                                 | \$ |    | a]{.unde | * |           |
| *(subtract #15 from #14)*       | ** |    | rline}** | \ |           |
|                                 |    |    |          | $ |           |
|                                 |    |    |          | * |           |
|                                 |    |    |          | * |           |
+---------------------------------+----+----+----------+---+-----------+
|  This total must match 15.g on |    |    |          |   |           |
| previous page                  |    |    |          |   |           |
+---------------------------------+----+----+----------+---+-----------+
| FEDERAL FUNDING                 |    |    |          |   |           |
+---------------------------------+----+----+----------+---+-----------+
| #17 is **25%** of the #16 total |    |    |          |   |           |
| or **\$250,000** , whichever is |    |    |          |   |           |
| **LESS**                       |    |    |          |   |           |
+---------------------------------+----+----+----------+---+-----------+
| 17\. Federal assistance         |    | E  |          |   | **\$**    |
| requested, calculate as         |    | nt |          |   |           |
| follows: (Consult Federal       |    | er |          |   |           |
| agency for Federal percentage   |    | el |          |   |           |
| share.) Enter the resulting     |    | ig |          |   |           |
| Federal share                   |    | ib |          |   |           |
|                                 |    | le |          |   |           |
|                                 |    | c  |          |   |           |
|                                 |    | os |          |   |           |
|                                 |    | ts |          |   |           |
|                                 |    | fr |          |   |           |
|                                 |    | om |          |   |           |
|                                 |    | li |          |   |           |
|                                 |    | ne |          |   |           |
|                                 |    | 16 |          |   |           |
|                                 |    | c. |          |   |           |
|                                 |    |    |          |   |           |
|                                 |    | Mu |          |   |           |
|                                 |    | lt |          |   |           |
|                                 |    | ip |          |   |           |
|                                 |    | ly |          |   |           |
|                                 |    | X  |          |   |           |
|                                 |    | *  |          |   |           |
|                                 |    | *[ |          |   |           |
|                                 |    | 25 |          |   |           |
|                                 |    | %] |          |   |           |
|                                 |    | {. |          |   |           |
|                                 |    | un |          |   |           |
|                                 |    | de |          |   |           |
|                                 |    | rl |          |   |           |
|                                 |    | in |          |   |           |
|                                 |    | e} |          |   |           |
|                                 |    | ** |          |   |           |
+---------------------------------+----+----+----------+---+-----------+

**Previous Edition Usable Authorized for Local Reproduction Standard
Form 424C (Rev. 7-97)**

> **Prescribed by OMB Circular A-102**

OMB Approval No. 0348-0042

**ASSURANCES - CONSTRUCTION PROGRAMS**

Public reporting burden for this collection of information is estimated
to average 15 minutes per response, including time for reviewing

instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of

information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for

reducing this burden, to the Office of Management and Budget, Paperwork
Reduction Project (0348-0042), Washington, DC 20503.

**PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
AND BUDGET.**

**SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.**

**NOTE**: Certain of these assurances may not be applicable to your
project or program. If you have questions, please contact the

Awarding Agency. Further, certain Federal assistance awarding agencies
may require applicants to certify to additional

assurances. If such is the case, you will be notified.

As the duly authorized representative of the applicant, I certify that
the applicant:

1\. Has the legal authority to apply for Federal assistance

and the institutional, managerial and financial capability

(including funds sufficient to pay the non-Federal share

of project cost) to ensure proper planning, management

and completion of the project described in this

application.

2\. Will give the awarding agency, the Comptroller General

of the United States and, if appropriate, the State,

through any authorized representative, access to and

the right to examine all records, books, papers, or

documents related to the assistance; and will establish a

proper accounting system in accordance with generally

accepted accounting standards or agency directives.

3\. Will not dispose of, modify the use of, or change the

terms of the real property title, or other interest in the

site and facilities without permission and instructions

from the awarding agency. Will record the Federal

interest in the title of real property in accordance with

awarding agency directives and will include a covenant

in the title of real property acquired in whole or in part

with Federal assistance funds to assure non-discrimination

during the useful life of the project.

4\. Will comply with the requirements of the assistance

awarding agency with regard to the drafting, review and

approval of construction plans and specifications.

5\. Will provide and maintain competent and adequate

engineering supervision at the construction site to

ensure that the complete work conforms with the

approved plans and specifications and will furnish

progress reports and such other information as may be

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 prohibit employees from

using their positions for a purpose that constitutes or

presents the appearance of personal or organizational

conflict of interest, or personal gain.

8\. Will comply with 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 19 statutes or regulations specified in

Appendix A of OPM's Standards for a Merit System of

Personnel Administration (5 C.F.R. 900, Subpart F).

9\. Will comply with the Lead-Based Paint Poisoning

Prevention Act (42 U.S.C. §§4801 et seq.) which

prohibits the use of lead-based paint in construction or

rehabilitation of residence structures.

10\. Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to: (a)

Title VI of the Civil Rights Act of 1964 (P.L. 88-352)

which prohibits discrimination on the basis of race,

color or national origin; (b) Title IX of the Education

Amendments of 1972, as amended (20 U.S.C. §§1681-

1683, and 1685-1686), which prohibits discrimination

on the basis of sex; (c) Section 504 of the

Rehabilitation Act of 1973, as amended (29 U.S.C.

§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 1972 (P.L. 92-255), as

amended, relating to nondiscrimination on the basis of

drug abuse; (f) the Comprehensive Alcohol Abuse and

Alcoholism Prevention, Treatment and Rehabilitation

Act of 1970 (P.L. 91-616), as amended, relating to

nondiscrimination on the basis of alcohol abuse or

alcoholism; (g) §§523 and 527 of the Public Health

Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-

3), as amended, relating to confidentiality of alcohol

and drug abuse patient records; (h) Title VIII of the

Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as

amended, relating to nondiscrimination in the sale,

rental or financing of housing; (i) any other

nondiscrimination provisions in the specific statute(s)

under which application for Federal assistance is being

made; and, (j) the requirements of any other

nondiscrimination statute(s) which may apply to the

application.

**Previous Edition Usable Standard Form 424D (Rev. 7-97)**

> **Authorized for Local Reproduction Prescribed by OMB Circular A-102**

11\. Will comply, or has already complied, with the

requirements of Titles II and III of the Uniform Relocation

Assistance and Real Property Acquisition Policies Act of

1970 (P.L. 91-646) which provide for fair and equitable

treatment of persons displaced or whose property is

acquired as a result of Federal and federally-assisted

programs. These requirements apply to all interests in real

property acquired for project purposes regardless of

Federal participation in purchases.

12\. Will comply with the provisions of the Hatch Act (5 U.S.C.

§§1501-1508 and 7324-7328) which limit the political

activities of employees whose principal employment

activities are funded in whole or in part with Federal funds.

13\. Will comply, as applicable, with the provisions of the Davis-

Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act

(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract

Work Hours and Safety Standards Act (40 U.S.C. §§327-

333\) regarding labor standards for federally-assisted

construction subagreements.

14\. Will comply with flood insurance purchase requirements of

Section 102(a) of the Flood Disaster Protection Act of 1973

(P.L. 93-234) which requires recipients in a special flood

hazard area to participate in the program and to purchase

flood insurance if the total cost of insurable construction

and acquisition is \$10,000 or more.

15\. Will comply with environmental standards which may be

prescribed pursuant to the following: (a) institution of

environmental quality control measures under the

National Environmental Policy Act of 1969 (P.L. 91-

190\) and Executive Order (EO) 11514; (b) notification

of violating facilities pursuant to EO 11738; (c)

protection of wetlands pursuant to EO 11990; (d)

evaluation of flood hazards in floodplains in accordance

with EO 11988; (e) assurance of project consistency

with the approved State management program

developed under the Coastal Zone Management Act of

1972 (16 U.S.C. §§1451 et seq.); (f) conformity of

Federal actions to State (Clean Air) Implementation

Plans under Section 176(c) of the Clean Air Act of

1955, as amended (42 U.S.C. §§7401 et seq.); (g)

protection of underground sources of drinking water

under the Safe Drinking Water Act of 1974, as

amended (P.L. 93-523); and, (h) protection of

endangered species under the Endangered Species Act

of 1973, as amended (P.L. 93-205).

16\. Will comply with the Wild and Scenic Rivers Act of

1968 (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

with Section 106 of the National Historic Preservation

Act of 1966, as amended (16 U.S.C. §470), EO 11593

(identification and protection of historic properties), and

the Archaeological and Historic Preservation Act of

1974 (16 U.S.C. §§469a-1 et seq.).

18\. Will cause to be performed the required financial and

compliance audits in accordance with the Single Audit

Act Amendments of 1996 and OMB Circular No. A-133,

\"Audits of States, Local Governments, and Non-Profit

Organizations.\"

19\. Will comply with all applicable requirements of all other

Federal laws, executive orders, regulations, and policies

governing this program.

  -------------------------------------- ------- ---------------------------
  SIGNATURE OF AUTHORIZED CERTIFYING     TITLE   
  OFFICIAL                                       

                                                 

  APPLICANT ORGANIZATION                         DATE SUBMITTED

  **«Applicant»**                                November 13, 2023
  -------------------------------------- ------- ---------------------------

**Standard Form 424D (Rev. 7-97) Back**

***[Tab 2:]{.underline}* U.S. DEPARTMENT OF AGRICULTURE**

**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 (pages 4722-4733). Copies of the
regulations may be obtained by contacting the

Department of Agriculture agency offering the proposed covered
transaction.

**(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)**

\(1\) 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 three-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 three-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.

  ------------------------------------------------ ----------------------
  **«Applicant»**                                  §9006 Grant

  Organization Name                                PR/Award Number or
                                                   Project Name

                                                   

  Name(s) and Title(s) of Authorized               
  Representative(s)                                

                                                   November 13, 2023

  Signature(s)                                     Date
  ------------------------------------------------ ----------------------

Form AD-1047 (1/92)

***[Tab 3:]{.underline}***

**U.S. DEPARTMENT OF AGRICULTURE**

**CERTIFICATION REGARDING**

**DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)**

**ALTERNATIVE I - FOR GRANTEES OTHER THAN INDIVIDUALS**

**This certification is required by the regulations implementing Section
5151-5160 of the Drug-Free Workplace**

**Act of 1988 (Pub. 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 13, 1989, regulations were amended and
published as Part 11 of the May 25,**

**1990 Federal Register (pages 21681-21691). Copies of the regulations
may be obtained by contacting the**

**Department of Agriculture agency offering the grant.**

**(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 3)**

**[Alternative I]{.underline}**

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

**(a) Publishing a statement notifying employees that the unlawful
manufacture, distribution,**

**dispensing, possession, or use of a controlled substance is prohibited
in the grantee\'s workplace and specifying the actions that will be
taken against employees for violation of such prohibition;**

**(b) Establishing a 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 five calendar days
> after such conviction;**

**(e) Notifying the agency in writing, within ten 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**

Form AD-1049 (REV 5/90)

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;

(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)

  -----------------------------------------------------------------------
  See "Project Summary" narrative

  -----------------------------------------------------------------------

Check ⁪ If there are workplaces on file that are not identified here.

  ----------------------------------------------- -----------------------
  **«Applicant»**                                 §9006 Grant

  Organization Name                               Award Number or Project
                                                  Name

                                                  

  Name and Title of Authorized Representative     

                                                  November 13, 2023

  Signature                                       Date
  ----------------------------------------------- -----------------------

Form AD-1049 (REV 5/90)

**INSTRUCTIONS FOR CERTIFICATION**

**1. By signing and submitting this form, the grantee is providing the
certification set out on pages 1 and 2.**

**2. The certification set out on pages 1 and 2 is a material
representation of fact upon which reliance is placed when the agency
awards the grant. If it is later determined that the grantee knowingly
rendered a false certification, or otherwise violates the requirements
of the Drug-Free Workplace Act, the agency, in addition to any other
remedies available to the Federal Government, may take action authorized
under the Drug-Free Workplace Act.**

**3. Workplaces under grants, for grantees other than individuals, need
not be identified on the certification. If known, they may be identified
in the grant application. If the grantee does not identify the
workplaces at the time of application, or upon award, if there is no
application, the grantee must keep the identity of the workplace(s) on
file in its office and make the information available for Federal
inspection. Failure to**

**identify all known workplaces constitutes a violation of the
grantee\'s drug-free workplace - requirements.**

**4. Workplace identifications must include the actual address of
buildings (or parts of buildings) or other sites where work under the
grant takes place. Categorical descriptions may be used (e.g., all
vehicles of a mass transit authority or State highway department while
in operation, State employees in each local unemployment office,
performers in concert halls or radio studios).**

**5. If the workplace identified to the agency changes during the
performance of the grant, the grantee shall**

**inform the agency of the change(s). If it previously identified the
workplaces in question (see paragraph three).**

**6. Definitions of terms in the Nonprocurement Suspension and Debarment
common rule and Drug-Free**

**Workplace common rule apply to this certification. Grantees\'
attention is called, in particular, to the**

**following definitions from these rules:**

**\'\'Controlled substance\'\' means a controlled substance in Schedules
I through V of the Controlled**

**Substances Act (21 U.S.C. 812) and as further defined by regulation
(21 CFR 1308.11 through 1308.15);**

**\'\'Conviction\'\' means a finding of guilt (including a plea of nolo
contendere) or imposition of sentence, or**

**both, by any judicial body charged with the responsibility to
determine violations of the Federal or**

**States criminal drug statutes;**

**\'\'Criminal drug statute\'\' means a Federal or non-Federal criminal
statute involving the manufacture,**

**distribution, dispensing, use, or possession of any controlled
substance;**

**\'\'Employee\'\' means the employee of a grantee directly engaged in
the performance of work under a grant, including: (i) all \'\'direct
charge\'\' employees; (ii) all \'\'indirect charge\'\' employees unless
their impact or involvement is insignificant to the performance of the
grant; and, (iii) temporary personnel**

**and consultants who are directly engaged in the performance of work
under the grant and who are on**

**the grantee\'s payroll. This definition does not include workers not
on the payroll of the grantee (e.g. volunteers, even if used to meet a
matching requirement; consultants or independent contractors not on the
grantee\'s payroll; or employees of subrecipients or subcontractors in
covered workplaces)**

**AD-1049 (REV 5/90)**

+---------+----------------------------------------------+------------+
| Form RD | ***[Tab 4:]{.underline}***                   | FORM       |
| 400-1   |                                              | APPROVED   |
|         | **UNITED STATES DEPARTMENT OF AGRICULTURE**  |            |
| (Rev.   |                                              | OMB No.    |
| 5-00)   |                                              | 0575-0018  |
+---------+----------------------------------------------+------------+

**EQUAL OPPORTUNITY AGREEMENT**

  ----------------- ------------------------------------------------ ---------
  This agreement,   November 13, 2023                                between
  dated                                                              

  **«Applicant»**                                                    
  ----------------- ------------------------------------------------ ---------

(herein called \'\'Recipient\'\' whether one or more) and United States
Department of Agriculture (USDA), pursuant to the rules and

regulations of the Secretary of Labor (herein called the \'Secretary\')
issued under the authority of Executive Order 11246 as amended,
witnesseth:

In consideration of financial assistance (whether by a loan, grant, loan
guaranty, or other form of financial assistance) made or to be

made by the USDA to Recipient, Recipient hereby agrees, if the cash cost
of construction work performed by Recipient or a construction

contract financed with such financial assistance exceeds \$10,000 -
unless exempted by rules, regulations or orders of the Secretary of

Labor issued pursuant to Section 204 of Executive Order 11246 of
September 24, 1965.

1\. To incorporate or cause to be incorporated into any contract for
construction work, or modification thereof, subject to the

relevant rules, regulations, and orders of the Secretary or of any prior
authority that remain in effect, which is paid for in whole or in part

with the aid of such financial assistance, the following \"Equal
Opportunity Clause\":

During the performance of this contract, the contractor agrees as
follows:

\(a\) The contractor will not discriminate against any employee or
applicant for employment because of race, color, religion, sex or

national origin. The contractor will take affirmative action to ensure
that applicants are employed, and that employees are

treated during employment, without regard to their race, color,
religion, sex or national origin. Such action shall include, but

not be limited, to the following: employment, upgrading, demotion or
transfer; recruitment or recruitment advertising; layoff

or termination; rates of pay or other forms of compensation; and
selection for training, including apprenticeship. The contractor

agrees to post in conspicuous places, available to employees and
applicants for employment, notices to be provided by the

USDA setting forth the provisions of this nondiscrimination clause.

\(b\) The contractor will, in all solicitations or advertisements for
employees placed by or on behalf of the contractor, state that all

qualified applicants will receive consideration for employment without
regard to race, color, religion, sex or national origin.

\(c\) The contractor will send to each labor union or representative of
workers with which he has a collective bargaining agreement

or other contract or understanding, a notice, to be provided by the
USDA, advising the said labor union or workers\'

representative of the contractor\'s commitments under this agreement and
shall post copies of the notice in conspicuous places

available to employees and applicants for employment.

\(d\) The contractor will comply with all provisions of Executive Order
11246 of September 24,1965, and of all rules, regulations

and relevant orders of the Secretary of Labor.

\(e\) The contractor will furnish all information and reports required
by Executive Order 11246 of September 24, 1965, rules,

regulations, and orders, or pursuant thereto, and will permit access to
his books, records, and accounts by the USDA Civil

Rights Office, and the Secretary of Labor for purposes of investigation
to ascertain compliance with such rules,

regulations, and orders.

\(f\) In the event of the contractor\'s noncompliance with the
nondiscrimination clauses of this contract or with any of the said
rules,

regulations, or orders, this contract may be cancelled, terminated, or
suspended in whole or in part and the contractor may be

declared ineligible for further Government contracts or federally
assisted construction contracts in accordance with procedures

authorized in Executive Order No. 11246 of September 24, 1965, and such
other sanctions may be imposed and remedies

invoked as provided in Executive Order No. 11246 of September 24, 1965,
or by rule, regulation or order of the Secretary of

Labor, or as otherwise provided by Law.

\(g\) The contractor will include the provisions of paragraph 1 and
paragraph (a) through (g) in every subcontract or purchase order,

unless exempted by the rules, regulations, or orders of the Secretary of
Labor issued pursuant to Section 204 of Executive Order

No. 11246 of September 24, 1965, so that such provisions will be binding
upon each subcontractor or vendor. The

contractor will take such action with respect to any subcontract or
purchase order as the USDA may direct as a means of

enforcing such provisions, including sanctions for noncompliance:
Provided, however, that in the event the contractor becomes

involved in, or is threatened with, litigation with a subcontractor or
vendor as a result of such direction by the USDA, the

contractor may request the United States to enter into such litigation
to protect the interest of the United States.

*According to the Paperwork Reduction Act of 1995, an agency may not
conduct or sponsor, and a person is not required to respond*

*to, a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information*

*collections is 0575-0018. The time required to complete this
information collection is estimated to average 10 minutes per response,*

*including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and*

*completing and reviewing the collection of information.*

*Position 6* RD 400-1 (Rev. 5-00)

2\. To be bound by the above equal opportunity clause with respect to
its own employment practices when it participates in federally

assisted construction work: Provided, that if the organization so
participating is a State or local government, the above equal

opportunity clause is not applicable to any agency, instrumentality or
subdivision of such government which does not participate in

work on or under the contract.

3\. To notify all prospective contractors to file the required
\'Compliance Statement\', Form RD 400-6, with their bids.

4\. Form AD-425, Instructions to Contractors, will accompany the notice
of award of the contract. Bid conditions for all nonexempt

federal and federally assisted construction contracts require inclusion
of the appropriate \'\'Hometown\'\' or \'\'Imposed\'\' plan affirmative

action and equal employment opportunity requirements. All bidders must
comply with the bid conditions contained in the invitation to

be considered responsible bidders and hence eligible for the award.

5\. To assist and cooperate actively with USDA and the Secretary in
obtaining the compliance of contractors and subcontractors with

the equal opportunity clause and rules, regulations, and relevant orders
of the Secretary, that will furnish USDA and the Secretary such

information such as , but not limited to, Form AD-560, Certification of
Nonsegregated Facilities, to submit the Monthly Employment

Utilization Report, Form CC-257, as they may require for the supervision
of such compliance, and that it will otherwise assist USDA in

the discharge of USDA\'s primary responsibility for securing compliance.

6\. To refrain from entering into any contract or contract modification
subject to such Executive Order 11246 of September 24, 1965,

with a contractor debarred from, or who has not demonstrated eligibility
for, Government contracts and Federally assisted construction

contracts pursuant to the Executive Order and will carry out such
sanctions and penalties for violation of the equal opportunity clause as

may be imposed upon contractors and subcontractors by USDA or the
Secretary of Labor pursuant to Part II, Subpart D, of the

Executive Order.

7\. That if the recipient fails or refuses to comply with these
undertakings, the USDA may take any or all of the following actions:

Cancel, terminate, or suspend in whole or in part this grant (contract,
loan, insurance, guarantee); refrain from extending any further

assistance to the organization under the program with respect to which
the failure or refund occurred until satisfactory assurance of

future compliance has been received from such organization; and refer
the case to the Department of Justice for appropriate legal

proceedings.

Signed by the Recipient on the date first written above.

  ------------------------------- ---- ----------------- --------------------------------
  **«Applicant»**                      **«Applicant»**   

  Recipient                            Recipient         

  (CORPORATE SEAL)                     **«Applicant»**   

                                       Name of Corporate 
                                       Recipient         

  Attest:                                                

                                  By                     

  Secretary                            President         
  ------------------------------- ---- ----------------- --------------------------------

+---------+-----------------------------------------------+-----------+
| *       | *Position 3*                                  | FORM      |
| *USDA** |                                               | APPROVED  |
|         | ***[Tab 5:]{.underline}***                    |           |
| Form RD |                                               | OMB No.   |
| 400-4   | **ASSURANCE AGREEMENT**                       | 0575-0018 |
|         |                                               |           |
| (Rev.   | (Under Title VI, Civil Rights Act of 1964)    |           |
| 3-97)   |                                               |           |
+---------+-----------------------------------------------+-----------+

  ----- -------------------------------------------------------------------
  The   **«Applicant»**

        *(name of recipient)*

        

        *(address)*
  ----- -------------------------------------------------------------------

(\'\'Recipient\'\' herein) hereby assures the U. S. Department of
Agriculture that Recipient is in compliance with and will continue to

comply with Title VI of the Civil Rights Act of 1964 (42 USC 2000d et.
seq.), 7 CFR Part 15, and Rural Housing Service, Rural

Business-Cooperative Service, Rural Utilities Service, or the Farm
Service Agency, (hereafter known as the \"Agency\") regulations

promulgated thereunder, 7 C.F.R. § 1901.202. In accordance with that Act
and the regulations referred to above, Recipient agrees

that in connection with any program or activity for which Recipient
receives Federal financial assistance (as such term is defined in

7 C.F.R. § 14.2) no person in the United States shall, on the ground of
race, color, or national origin, be excluded from participation

in, be denied the benefits of, or be otherwise subjected to
discrimination.

1\. Recipient agrees that any transfer of any aided facility, other than
personal property, by sale, lease or other conveyance of

contract, shall be, and shall be made expressly, subject to the
obligations of this agreement and transferee\'s assumption thereof.

2\. Recipient shall:

\(a\) Keep such records and submit to the Government such timely,
complete, and accurate information as the Government may

determine to be necessary to ascertain our/my compliance with this
agreement and the regulations.

\(b\) Permit access by authorized employees of the Agency or the U.S.
Department of Agriculture during normal business

hours to such books, records, accounts and other sources of information
and its facilities as may be pertinent to ascertaining

such compliance.

\(c\) Make available to users, participants, beneficiaries and other
interested persons such information regarding the provisions

of this agreement and the regulations, and in such manner as the Agency
or the U. S. Department of Agriculture finds

necessary to inform such persons of the protection assured them against
discrimination.

3\. The obligations of this agreement shall continue:

\(a\) As to any real property, including any structure, acquired or
improved with the aid of the Federal financial assistance, so

long as such real property is used for the purpose for which the Federal
financial assistance is made or for another purpose

which affords similar services or benefits, or for as long as the
Recipient retains ownership or possession of the property,

whichever is longer.

\(b\) As to any personal property acquired or improved with the aid of
the Federal financial assistance, so long as Recipient

retains ownership or possession of the property.

\(c\) As to any other aided facility or activity, until the last advance
of funds under the loan or grant has been made.

4\. Upon any breach or violation this agreement the Government may, at
its option:

\(a\) Terminate or refuse to render or continue financial assistance for
the aid of the property, facility, project, service or

activity.

\(b\) Enforce this agreement by suit for specific performance or by any
other available remedy under the laws of the United

States or the State in which the breach or violation occurs.

Rights and remedies provided for under this agreement shall be
cumulative.

  ----------- ------------------------------------------------------ ------
  In witness  **«Applicant»**                                        on
  whereof,                                                           this

              *(name of recipient)*                                  
  ----------- ------------------------------------------------------ ------

date has caused this agreement to be executed by its duly authorized
officers and its seal affixed hereto, or, if a natural person, has

hereunto executed this agreement.

  --------- ----------------------- --- --------------------------------------
                                        **«Applicant»**

                                        *Recipient*

            (SEAL)                      November 13, 2023

                                        *Date*

  Attest:                               

            *Title*                     *Title*
  --------- ----------------------- --- --------------------------------------

*According to the Paperwork Reduction Act of I 995, no persons are
required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB*

*control number for this information collection is 0570-0018. The time
required to complete this information is estimated to average 15 minutes
per response, including the time for*

*reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection
of information.*

***[Tab 6:]{.underline}***

## Certification of Relationship with Agency (§9006)

The undersigned has applied for grant assistance from USDA Rural
Development's Section 9006 Renewable Energy Generation & Energy
Efficiency Improvement Grant program.

It is hereby certified by the applicant that the applicant has no known
relationship or association with any USDA Rural Development employee
other than as set forth below:

⁪None

⁪
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

To the best of my knowledge and belief, this certification is true and
correct. The document has been duly authorized by the governing body of
the applicant.

**«Applicant»**

  ----------------------------------- ------------ -----------------------
                                                   November 13, 2023

  (signature)                                      (date)

                                                   

  (name & title)                                   
  ----------------------------------- ------------ -----------------------

***[Tab 7:]{.underline}***

## Certification of Demonstrated Financial Need (§9006)

The undersigned has applied for grant assistance from USDA Rural
Development's Section 9006 Renewable Energy Generation & Energy
Efficiency Improvement Grant program.

It is hereby certified by the applicant that the applicant is unable to
finance the project from its own and commercially available resources
without grant assistance, or that the project proposed by the applicant
cannot achieve the income and cashflows to sustain it financially over
the long term without grant assistance.

The applicant understands and agrees that USDA may request the applicant
to provide sufficient information to allow USDA to make its own
determination of the applicant's financial need.

To the best of my knowledge and belief, this certification is true and
correct. The document has been duly authorized by the governing body of
the applicant.

**«Applicant»**

  ----------------------------------- ------------ -----------------------
                                                   November 13, 2023

  (signature)                                      (date)

                                                   

  (name & title)                                   
  ----------------------------------- ------------ -----------------------

+------------+--------------------------------------+----+------------+
| **USDA**   | *Position 3*                         |    | FORM       |
|            |                                      |    | APPROVED   |
| Form RD    | ***[Tab 8:]{.underline}***           |    |            |
| 1940-20    |                                      |    | OMB No.    |
|            | **REQUEST FOR ENVIRONMENTAL          |    | 0575-0094  |
| (Rev.      | INFORMATION**                        |    |            |
| 4-06)      |                                      |    |            |
+------------+--------------------------------------+----+------------+
|            |                                      | Na |            |
|            |                                      | me |            |
|            |                                      | of |            |
|            |                                      | P  |            |
|            |                                      | ro |            |
|            |                                      | je |            |
|            |                                      | ct |            |
+------------+--------------------------------------+----+------------+
|            |                                      |    |            |
+------------+--------------------------------------+----+------------+
|            |                                      | Lo |            |
|            |                                      | ca |            |
|            |                                      | ti |            |
|            |                                      | on |            |
+------------+--------------------------------------+----+------------+
|            |                                      |    |            |
+------------+--------------------------------------+----+------------+

**Item 1a**. Has a Federal, State, or Local Environmental Impact
Statement or Analysis been prepared for this project?

>  Yes  No  Copy attached as EXHIBIT I-A.

**1b.** If "No." provide the information requested in Instructions as
EXHIBIT I.

**Item 2.** The State Historic Preservation Officer (SHPO) has been
provided a detailed project description and has been requested to submit
comments to the appropriate Rural Development Office.  Yes  No Date
description submitted to SHPO \_\_\_\_\_\_\_\_

**Item 3.** Are any of the following land uses or environmental
resources either to be affected by the proposal or located within or
adjacent to the project site(s)? *(Check appropriate box for every item
of the following checklist).*

+--------------------+------------+----------------------+-----------+
|                    | **Yes No   |                      | **Yes No  |
|                    | Unknown**  |                      | Unknown** |
+--------------------+------------+----------------------+-----------+
| 1\. Industrial     |         | 19\. Dunes           |        |
| .........          |            | ........             |           |
| .................. |            | .................... |           |
+--------------------+------------+----------------------+-----------+
| 2\. Commercial     |         | 20\. Estuary         |        |
| ......             |            | .......              |           |
| .................. |            | .................... |           |
+--------------------+------------+----------------------+-----------+
| 3\. Residential    |         | 21\. Wetlands        |        |
| ........           |            | .....                |           |
| .................. |            | .................... |           |
+--------------------+------------+----------------------+-----------+
| 4\. Agricultural   |         | 22\. Floodplain      |        |
| .......            |            | ...                  |           |
| .................. |            | .................... |           |
+--------------------+------------+----------------------+-----------+
| 5\. Grazing        |         | 23\. Wilderness      |        |
| .............      |            | ..                   |           |
| ..............\... |         | .................... |           |
|                    |            |                      |           |
| 6\. Mining,        |            | *(designated or      |           |
| Quarrying          |            | proposed under the   |           |
| .................  |            | Wilderness Act)*     |           |
+--------------------+------------+----------------------+-----------+
| 7\. Forests        |         | 24\. Wild or Scenic  |        |
| .............      |            | River ...........    |           |
| .................. |         |                      |           |
|                    |            | *(designated or      |           |
| 8\. Recreational   |            | proposed under the   |           |
| ......             |            | Wild and Scenic      |           |
| .................. |            | Rivers Act)*         |           |
+--------------------+------------+----------------------+-----------+
| 9\. Transportation |         | 25\. Historical,     |        |
| ....               |            | Archeological Sites  |           |
| .................. |         |                      |           |
|                    |            | *(Listed on the      |           |
| 10\. Parks         |            | National Register of |           |
| .............      |            | Historical Places or |           |
| .................. |            | which may be         |           |
|                    |            | eligible for         |           |
|                    |            | listing)*            |           |
+--------------------+------------+----------------------+-----------+
| 11\. Hospital      |         | 26\. Critical        |        |
| ..........         |            | Habitats             |           |
| .................. |            | ................     |           |
|                    |            | *(e                  |           |
|                    |            | ndangered/threatened |           |
|                    |            | species)*            |           |
+--------------------+------------+----------------------+-----------+
| 12\. Schools       |         | 27\. Wildlife        |        |
| ..........         |            | ......               |           |
| .................. |            | .................... |           |
+--------------------+------------+----------------------+-----------+
| 13\. Open spaces   |         | 28\. Air Quality     |        |
| .....              |            | ..                   |           |
| .................. |            | .................... |           |
+--------------------+------------+----------------------+-----------+
| 14\. Aquifer       |         | 29\. Solid Waste     |        |
| Recharge Area      |            | Management ...\...   |           |
| \...........       |            |                      |           |
+--------------------+------------+----------------------+-----------+
| 15\. Steep Slopes  |         | 30\. Energy Supplies |        |
| .....              |            | ................     |           |
| .................. |            |                      |           |
+--------------------+------------+----------------------+-----------+
| 16\. Wildlife      |         | 31\. Natural         |        |
| Refuge             |            | Landmark             |           |
| .                  |         |                      |           |
| .................. |            | *(Listed on National |           |
|                    |            | Registry of Natural  |           |
| 17\. Shoreline     |            | Landmarks)*          |           |
| .........          |            |                      |           |
| .................. |            |                      |           |
+--------------------+------------+----------------------+-----------+
| 18\. Beaches       |         | 32\. Coastal Barrier |        |
| \...........       |            | Resources System .   |           |
| .................. |            |                      |           |
+--------------------+------------+----------------------+-----------+

**Item 4.** Are any facilities under your ownership, lease, or
supervision to be utilized in the accomplishment of this project, either
listed or under consideration for listing on the Environmental
Protection Agency's List of Violating Facilities?  Yes  No

  --------------------- ------ --------- -----------------------------------
  November 13, 2023            Signed:   

  *(Date)*                               *(Applicant)*

                                         

                                         *(Title)*
  --------------------- ------ --------- -----------------------------------

*According to the Paperwork Reduction Act of 1995, an agency may not
conduct or sponsor, and a person is not required to respond to, a
collection of information*

*unless it displays a valid OMB control number. The valid OMB control
number for this information collections is 0575-0094. The time required
to complete this*

*information collection is estimated to average 6 to 10 hours per
response, including the time for reviewing instructions, searching
existing data sources,*

*gathering and maintaining the data needed, and completing and reviewing
the collection of information.*

***[Tab 9:]{.underline}***

**Organizational documents**

Except for sole proprietors, each applicant must submit a copy of their
legal organizational documents as appropriate for applicant entity type
-- e.g., partnership agreement, articles of incorporation, by-laws, etc.
Place them here under "tab 10".

***[Tab 10:]{.underline}***

**PROJECT SUMMARY**

§9006 Energy Efficiency Improvements Simple Grant Application

Name of Applicant: **«Applicant»**

Amount Requested: [\$]{.underline}

**[(i) Title:]{.underline}**

(Use the same title as #11 on Form SF 424, describing the basics of the
project -- e.g. "Energy efficiency improvements for ABC Enterprises,
Inc. in Enterprise, Oregon")

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**[(ii) Applicant eligibility]{.underline}**

1.  [Agricultural producer or rural small business.]{.underline}

Explain which category describes the applicant and why.

+-----------------------------------------------------------------------+
| [The applicant is an agricultural producer because the applicant is   |
| directly engaged in the production of agricultural products. Last     |
| year, 50% or more of the applicant's gross income was derived from    |
| these operations. This is documented in the attached tax              |
| return.]{.underline}                                                  |
|                                                                       |
| **OR**                                                                |
|                                                                       |
| [The applicant is a rural small business. The business is "rural" as  |
| explained in part (iii)4. below. The business meets SBA "small        |
| business" criteria as explained in part (v) below.]{.underline}       |
+-----------------------------------------------------------------------+

2.  [US-control.]{.underline}

Explain that the applicant is at least 51% owned, directly or
indirectly, by individuals who are either US citizens or permanent
residents. For entities, address this requirement for each owner as
well.

+-----------------------------------------------------------------------+
| [The applicant is entirely owned by US citizens.]{.underline}         |
|                                                                       |
| **OR**                                                                |
|                                                                       |
| [The applicant fulfills this criteria as follows...]{.underline}      |
+-----------------------------------------------------------------------+

3.  [Delinquent on Federal debt?]{.underline}

Affirm that the applicant, including each individual owner, is not in
delinquent. For entities, address this requirement for each owner as
well.

  -----------------------------------------------------------------------
  [Neither the applicant nor any individual owner of the applicant is
  delinquent on Federal debt.]{.underline}

  -----------------------------------------------------------------------

4.  [Debarred from receiving Federal assistance?]{.underline}

Affirm that the applicant, including each individual owner, is not
debarred. For entities, address this requirement for each owner as well.

  -----------------------------------------------------------------------
  [Neither the applicant nor any individual owner of the applicant is
  debarred from receiving Federal assistance.]{.underline}

  -----------------------------------------------------------------------

5.  [Demonstrated financial need?]{.underline}

  -----------------------------------------------------------------------
  The applicant has certified that they have a demonstrated financial
  need for the grant being sought. See tab 8. No additional documentation
  is required per RD Instruction 4280-B, §4280.109(b)(2), though
  additional documentation can be provided upon request.

  -----------------------------------------------------------------------

**[(iii) Project eligibility.]{.underline}**

1\. [Type of project proposed.]{.underline}

Indicate whether the project will be a Renewable Energy System or an
Energy Efficiency Improvement. Briefly describe the system or
improvement.

  -----------------------------------------------------------------------
  [The project proposed is an Energy Efficiency Improvement, consisting
  of]{.underline}

  -----------------------------------------------------------------------

2\. [Commercially available or pre-commercial technology.]{.underline}\
Explain how the project's technology will only consist of "commercially
available" technology. "[Commercially available]{.underline}" means, A
system that has a proven operating history specific to the proposed
application. Such a system is based on established design, and
installation procedures and practices. Professional service providers,
trades, large construction equipment providers, and labor are familiar
with installation procedures and practices. Proprietary and balance of
system equipment and spare parts are readily available. Service is
readily available to properly maintain and operate the system. An
established warranty exists for parts, labor, and performance.

+-----------------------------------------------------------------------+
| [The project proposed will deploy only commercially available         |
| technology. The design is well-established as are the installation    |
| procedures and practices. Professional service providers, trades,     |
| large construction equipment providers, and labor are familiar with   |
| installation procedures and practices. Proprietary and balance of     |
| system equipment and spare parts are readily available. Service is    |
| readily available to property maintain and operate the system. An     |
| established warranty exists for parts, labor, and                     |
| performance.]{.underline}                                             |
|                                                                       |
| **OR**                                                                |
+-----------------------------------------------------------------------+

3\. [Technical merit.]{.underline}

Explain the technical merit of the technology to be used in the project.

  -----------------------------------------------------------------------
  The project's technical merit is sound as set forth in the Technical
  Report and Energy Audit. See Tabs 14 and 15.

  -----------------------------------------------------------------------

4\. [Rural location.]{.underline}

Identify the location of the project and show that it is not located
within the boundaries of a Metropolitan Statistical Area.

  -----------------------------------------------------------------------
  [The project will be located at]{.underline} [. This location is not
  within the boundaries of a Metropolitan Statistical Area.]{.underline}

  -----------------------------------------------------------------------

5\. [Ownership & control of the project and its revenues & expenses,
including operation & maintenance.]{.underline}

Explain how the applicant will have both ownership and control of the
project. (Note: Third-party operation & maintenance contracts are
permitted, but these must be described in this section.)

+-----------------------------------------------------------------------+
| [The applicant will have both full ownership and control of the       |
| project.]{.underline}                                                 |
|                                                                       |
| [The following third-party operation & maintenance contracts will be  |
| in force for the project:]{.underline}                                |
+-----------------------------------------------------------------------+

6\. [Site control.]{.underline}

Explain how the applicant has site control of the site where the project
will be developed.

  -----------------------------------------------------------------------
  [The applicant has control of the project site. This has been achieved
  in the following manner:]{.underline}

  -----------------------------------------------------------------------

7\. [Sufficient revenue.]{.underline}

Delineate the sources and amounts of revenue that will be available to
provide for the operation, management, maintenance, & debt service on
the project for the duration of the project.

  -----------------------------------------------------------------------
  [The project will save or generate sufficient revenue to support the
  operation, management, maintenance, and debt service of the project for
  the duration of the project. The economic assessment of the project is
  set forth in section (f) of the Technical Report. See Tab
  14.]{.underline}

  -----------------------------------------------------------------------

**[(iv) Operation description.]{.underline}**

1\. Describe the applicant's total farm/ranch/business operation and the
relationship of the proposed project to it.

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

2\. Provide a description of the ownership of the applicant, including a
list of individuals and/or entities with ownership interest, names of
any corporate parents, affiliates, and subsidiaries, as well as a
description of the relationship, including products, between these
entities.

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**[(v) Financial information for size determination.]{.underline}**

Describe how the applicant-business meets the §9006 eligibility criteria
for either a rural small business and/or an agricultural producer:

**EITHER**

[Complete this section only if applying **as an agricultural producer --
otherwise delete it**.]{.underline}

(An "agricultural producer" is an applicant directly engaged in the
production of agricultural products including crops, livestock, forestry
products, hydroponics, nursery stock, or aquaculture, whereby 50% or
more of their gross income is derived from the operations.)

[As set forth in the table below, the applicant-business meets the §9006
eligibility criteria as an agricultural producer. Supporting
documentation, such as tax returns, will be provided upon
request.]{.underline}

[The applicant-business is engaged in the following type of agricultural
production:]{.underline}

As demonstrated below, 50% or more of the applicant's gross income is
derived from the production of agricultural products, including crops,
livestock, forestry, hydroponics, nursery stock, or aquaculture.

  ---------------- -------------- --------------- ------------ ----------------------
  Gross market     Total annual   Total annual    Year of      Source of data
  value of         gross receipts nonfarm income  these        
  applicant's      from           from all other  receipts     
  agricultural     agricultural   sources                      
  products in      production in  (including                   
  immediately      immediately    nonfarm income               
  previous year    previous year  and custom                   
                                  work) in                     
                                  immediately                  
                                  previous year                

  \$               \$             \$                           [IRS-filed tax
                                                               returns]{.underline}
  ---------------- -------------- --------------- ------------ ----------------------

**OR**

[Complete this section only if applying **as a small business --
otherwise delete it**:]{.underline}

(A "small business" is an applicant who meets the Small Business
Administration SBA size standards.)

[As set forth in the tables below, the applicant-business meets the
§9006 eligibility criteria as a small business. Supporting
documentation, such as tax returns, will be provided upon
request.]{.underline}

[The NAICS code which best describes the applicant-business
is]{.underline} [, which is the NAICS code for the "]{.underline} ["
business category.]{.underline}

Your NAICS (North American Industry Classification System) code and
title is typically reported on your business tax return as the code that
best describes your principal business or profession. You can look up
your NAICS code and title at:
<http://www.census.gov/epcd/www/naics.html>

[The SBA size standard for this business category is: not more
than]{.underline} [in total annual gross receipts.]{.underline}

or

[The SBA size standard for this business category is: not more
than]{.underline} [in total employees.]{.underline}

The SBA size standard for your NAICS category is either based on annual
receipts or employees. You can look up your NAICS code and SBA size
standard at: <http://www.sba.gov/size/sizetable2002.html>

[As demonstrated below, the applicant business meets the SBA size
standard:]{.underline}

Complete the tables below to demonstrate this. Although usually only one
table or the other will be needed to establish eligibility, depending on
the applicable SBA size criteria, both annual gross receipts and
employee information are needed for a complete §9006 application.

**Total annual gross receipts:**

Demonstration that total annual gross receipts is less than SBA "small
business" size standard:

  --------------- -------------- -------- ------------- ------------ ------------
  Name of         Relationship   NAICS    Total annual  Year of      Source of
  Business        to applicant   Code     gross         these        data (e.g.
                                          receipts in   receipts     tax returns)
                                          immediately                
                                          previous year              

                  Applicant               \$                         

                  Parent of               \$                         
                  applicant                                          

                  Subsidiary of           \$                         
                  applicant                                          

                  Affiliate of            \$                         
                  applicant                                          

  **Total**                               **\$**                     
  --------------- -------------- -------- ------------- ------------ ------------

**Total employees:**

Demonstration that total employees is less than SBA "small business"
size standard:

  ------------------ -------------- --------- -------------- --------------
  Name of Business   Relationship   NAICS     \# employees   Year
                     to applicant   Code      in immediately 
                                              previous year  

                     Applicant                               

                     Parent of                               
                     applicant                               

                     Subsidiary of                           
                     applicant                               

                     Affiliate of                            
                     applicant                               

  **Total**                                                  
  ------------------ -------------- --------- -------------- --------------

***[Tab 11:]{.underline}*** **Matching Funds Spreadsheet**

§9006 Energy Efficiency Improvements Simple Grant Application

Name of Applicant: **«Applicant»**

Name of Project:

Note: A §9006 grant cannot contribute more than 25% of the total project
cost. The combined contribution of a §9006 grant and §9006 guaranteed
loan cannot exceed 50% of the total project cost.

+----------+--------+------------+----------+---------+--------------+
| *        | **F    | **Status   | *        | **Phone | **E-mail     |
| *Funding | unding | of this    | *Contact | \# of   | address of   |
| Source** | Am     | funding**  | person   | contact | contact      |
|          | ount** |            | at this  | p       | person**     |
|          |        | (          | funding  | erson** |              |
|          |        | committed; | source** |         |              |
|          |        | a          |          |         |              |
|          |        | pplication |          |         |              |
|          |        | submitted; |          |         |              |
|          |        | to be      |          |         |              |
|          |        | applied    |          |         |              |
|          |        | for; etc.) |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| USDA     | \$     | A          | USDA     | 503-4   |              |
| Rural    |        | pplication | Rural    | 14-3366 |              |
| Dev      |        | submitted, | Dev      |         |              |
| elopment |        | decision   | elopment |         |              |
| §9006    |        | pending    | Oregon   |         |              |
| Grant    |        |            | State    |         |              |
|          |        |            | Office   |         |              |
+----------+--------+------------+----------+---------+--------------+
| USDA     | \$     |            | USDA     | 503-4   |              |
| Rural    |        |            | Rural    | 14-3366 |              |
| Dev      |        |            | Dev      |         |              |
| elopment |        |            | elopment |         |              |
| §9006    |        |            | Oregon   |         |              |
| Gu       |        |            | State    |         |              |
| aranteed |        |            | Office   |         |              |
| Loan     |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| Oregon   | \$     |            |          |         |              |
| State    |        |            |          |         |              |
| Business |        |            |          |         |              |
| Energy   |        |            |          |         |              |
| Tax      |        |            |          |         |              |
| Credits  |        |            |          |         |              |
| (BETC)   |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| Oregon   | \$     |            |          |         |              |
| State    |        |            |          |         |              |
| Energy   |        |            |          |         |              |
| Loan     |        |            |          |         |              |
| Program  |        |            |          |         |              |
| (SELP)   |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| Oregon   | \$     |            |          |         |              |
| Energy   |        |            |          |         |              |
| Trust    |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| Co       |        |            |          |         |              |
| mmercial |        |            |          |         |              |
| loan     |        |            |          |         |              |
| from:    |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
|          | \$     |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
|          | \$     |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| Other:   |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
|          | \$     |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
|          | \$     |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| A        | \$     |            |          |         |              |
| pplicant |        |            |          |         |              |
| equity   |        |            |          |         |              |
| cont     |        |            |          |         |              |
| ribution |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| A        | \$     |            |          |         |              |
| pplicant |        |            |          |         |              |
| in-kind  |        |            |          |         |              |
| cont     |        |            |          |         |              |
| ribution |        |            |          |         |              |
| (≤10%)   |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+
| **TOTAL  | **\$** |            |          |         |              |
| PROJECT  |        |            |          |         |              |
| COST**   |        |            |          |         |              |
+----------+--------+------------+----------+---------+--------------+

Attach applications, correspondence, or other written communication
between applicant and matching fund source to document the standing of
the funding sources. Note that the §9006 gives preference to projects
that provide documentation to show a higher percentage of committed
funds.

***[Tab 12:]{.underline}*** **Self-Evaluation Score Sheet**

§9006 Energy Efficiency Improvements Simple Grant Application

Name of Applicant: **«Applicant»**

Name of Project:

Type of Technology: [Energy Efficiency Improvement]{.underline}

Funding Request: [\$]{.underline}

Final Total Score -- sum of all categories below (1 through 9):

(This is your opportunity to "self-score" your proposal and to draw
attention to the particular strengths of your project that should be
taken into consideration by USDA's independent reviewers when they
complete the official score that will be used to rank your request for
funds. Be sure that your self-scoring claims are justified by
documentation that is included within your §9006 application. Your
Technical Report (tab 14) and your Energy Audit (tab 15) are the primary
supporting document for your assertions and the applicable sections
should be specifically referenced as appropriate. Additional sources may
be cited too when applicable, and if so, they should be attached or
referenced.)

**(1) Quantity of Energy Saved**

> (Award yourself 0, 5, 10, or 15 points based on your justification.)

+-------------------------------------------------------------+--------+
| \(1\) **The estimated energy expected to be saved** by the  | **Po   |
| installation of the energy efficiency improvements will be  | ints** |
| from:                                                       |        |
|                                                             |        |
| 20% up to but not including 30%, award 5 points.            |        |
+-------------------------------------------------------------+--------+
| 30% up to but not including 35%, award 10 points.           |        |
+-------------------------------------------------------------+--------+
| 35% or greater, award 15 points.                            |        |
+-------------------------------------------------------------+--------+

> [**Justification**: The energy efficiency savings expected for this
> §9006 project are expected to be]{.underline} [%. This is based
> on]{.underline} (e.g., a professional energy audit,
> professionally-developed vendor information, etc. as applicable)
> [prepared by]{.underline} [, whose credentials and expertise
> are]{.underline} [. Documentation substantiating this savings level is
> included in this application in tab 15.]{.underline}
>
> (Award yourself 0 or 5 points based on your justification.)

+-------------------------------------------------------------+--------+
| \(2\) **Additional points**                                 | **Po   |
|                                                             | ints** |
| The project has total eligible project costs of \$50,000 or |        |
| less AND opts to obtain a professional energy audit, award  |        |
| an additional 5 points.                                     |        |
+-------------------------------------------------------------+--------+

> **[Justification]{.underline}**: (Claim 5 points if your project costs
> ≤\$50,000 and you have obtained and included an energy audit at tab
> 15.)

**(2) Environmental benefits**

> (As explained below, it is always appropriate to claim 10 points in
> this category for Oregon projects.)

+-------------------------------------------------------------+--------+
| **Environmental benefits.** If the purpose of the proposed  | **Po   |
| system contributes to the environmental goals and           | ints** |
| objectives of other Federal, State, or local programs,      |        |
| award 10 points.                                            | **     |
|                                                             | [10]{. |
|                                                             | underl |
|                                                             | ine}** |
+-------------------------------------------------------------+--------+

> [**Justification**: This energy efficiency project will contribute to
> the State of Oregon's energy efficiency goals. The Oregon Department
> of Energy's "State of Oregon Energy Plan 2005-2007" sets forth the
> state's energy goals, which prominently support business energy
> efficiency improvements. This §9006 project is expressly in keeping
> with Goal #5 of "Energy's Action Plan" set forth on pages 36-37 of the
> Plan:]{.underline}
>
> ["5. **Encourage businesses to invest in cost-effective energy
> efficiency and renewable resources.** Tax credits are available to
> businesses for investments in energy efficiency and renewable
> resources to help them overcome the higher first-costs. ODOE evaluates
> the performance of the Business Energy Tax Credit program, identifies
> priority target markets and implements improvements. ODOE also will
> use the State Energy Loan Program AND WORK WITH OTHERS \[emphasis
> added\] to leverage tax credit benefits for Oregon businesses. The
> loan program is targeting at least \$5 million per year in efficiency
> investments in commercial buildings."]{.underline}
>
> [Reference:
> http://egov.oregon.gov/ENERGY/docs/EnergyPlan05.pdf]{.underline}
>
> [The support of the State of Oregon for this project is further
> demonstrated by]{.underline} (e.g., its award of Business Energy Tax
> Credit to this project, the award of a State Energy Loan Program loan
> to this project, an attached letter of support, etc. as applicable)

**(3) Commercial availability**

> (Award yourself 0, 5 or 10 points based on your justification.)

  --------------------------------------------------------------- ------------
  **Commercial availability.** If the proposed system or          **Points**
  improvement is currently commercially available and replicable, 
  award 5 points.                                                 

  If the proposed system or improvement is commercially available 
  and replicable and is also provided with a 5-year or longer     
  warranty providing the purchaser protection against system      
  degradation or breakdown or component breakdown, award 10       
  points.                                                         
  --------------------------------------------------------------- ------------

> [**Justification**: As indicated in the Project Summary (tab 11,
> section iii.2.), this §9006 project will use commercially-available
> technology. The proposed §9006 energy efficiency
> improvements]{.underline} (will/will not) [be covered by a 5-year or
> longer warranty. A copy of the warranty information, reflecting the
> term of the warranty is appended to the end of this Self-Evaluation
> Score Sheet.]{.underline}

**(4) Technical Merit**

> (Award yourself 0 to 3.5 points based on your justification.)

  -------------------------------------------------------------- --------
  \(A\) **Qualifications of the project team.** The applicant    Points
  has described the project team service providers, their        
  professional credentials, and relevant experience. The         
  description supports that the project team service, equipment, 
  and installation providers have the necessary professional     
  credentials, licenses, certifications, or relevant experience  
  to develop the proposed project. Maximum possible score 3.5    
  points.                                                        

  [**Justification:** The qualifications of the project team are 
  contained in Section "a" of the Technical Report (tab 14) and  
  the appendix to the Energy Audit (tab 15). In this regard, the 
  following strengths of the team should be noted:]{.underline}  
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(B\) **Agreements and Permits**. The applicant has described  Points
  the necessary agreements and permits required for the project  
  and the schedule for securing those agreements and permits.    
  Maximum possible score 1.75 points.                            

  [**Justification:** The agreements and permits required for    
  this project are discussed in Section "b" of the Technical     
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 3.5 points based on your justification.)

  -------------------------------------------------------------- --------
  \(C\) **Energy or Resource Assessment.** The applicant has     Points
  described the quality and availability of a suitable renewable 
  resource or an assessment of expected energy savings for the   
  proposed system. Maximum possible score 3.5 points.            

  [**Justification:** The energy assessment for this project's   
  expected energy savings are discussed in Section "c" of the    
  Technical Report (tab 14) and the Energy Audit (tab 15). In    
  this regard, the following strengths of this project should be 
  noted:]{.underline}                                            
  -------------------------------------------------------------- --------

> (Award yourself 0 to 10.5 points based on your justification.)

  -------------------------------------------------------------- --------
  \(D\) **Design and Engineering**. The applicant has described  Points
  the design, engineering, and testing needed for the proposed   
  project. The description supports that the system will be      
  designed, engineered, and tested so as to meet its intended    
  purpose, ensure public safety, and comply with applicable      
  laws, regulations, agreements, permits, codes, and standards.  
  Maximum possible score 10.5 points.                            

  [**Justification:** The design and engineering requirements    
  for this project are discussed in Section "d" of the Technical 
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(E\) **Project Development Schedule.** The applicant has      Points
  described the development method, including the key project    
  development activities and the proposed schedule for each      
  activity. The description identifies each significant task,    
  its beginning and end, and its relationship to the time needed 
  to initiate and carry the project through to successful        
  completion. The description addresses grantee or borrower      
  project development cashflow requirements. Maximum possible    
  score 1.75 points.                                             

  [**Justification:** The project development schedule aspects   
  of this project are discussed in Section "e" of the Technical  
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 7 points based on your justification.)

  -------------------------------------------------------------- --------
  \(F\) **Project Economic Assessment.** The applicant has       Points
  described the financial performance of the proposed project,   
  including the calculation of simple payback. The description   
  addresses project costs and revenues, such as applicable       
  investment and production incentives, and other information to 
  allow the assessment of the project's cost effectiveness.      
  Maximum possible score 7.0 points.                             

  [**Justification:** An economic assessment of this project is  
  contained in Section "f" of the Technical Report (tab 14) and  
  the Energy Audit (tab 15). In this regard, the following       
  strengths of this project should be noted:]{.underline}        
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(G\) **Equipment Procurement.** The applicant has described   Points
  the availability of the equipment required by the system. The  
  description supports that the required equipment is available, 
  and can be procured and delivered within the proposed project  
  development schedule. Maximum possible score 1.75 points.      

  [**Justification:** The equipment procurement requirements of  
  this project are contained in Section "g" of the Technical     
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(H\) **Equipment Installation.** The applicant has described  Points
  the plan for site development and system installation. Maximum 
  possible score 1.75 points.                                    

  [**Justification:** The equipment installation requirements of 
  this project are contained in Section "h" of the Technical     
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(I\) **Operations and Maintenance.** The applicant has        Points
  described the operations and maintenance requirements of the   
  system necessary for the system to operate as designed over    
  the design life. Maximum possible score 1.75 points.           

  [**Justification:** The O&M requirements of this project are   
  contained in Section "i" of the Technical Report (tab 14). In  
  this regard, the following strengths of this project should be 
  noted:]{.underline}                                            
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(J\) **Dismantling and disposal of project components.** The  Points
  applicant has described the requirements for dismantling and   
  disposing of project components at the end of their useful     
  lives and associated wastes. Maximum possible score 1.75       
  points.                                                        

  [**Justification:** The decommissioning requirements of this   
  project are contained in Section "j" of the Technical Report   
  (tab 14). In this regard, the following strengths of this      
  project should be noted:]{.underline}                          
  -------------------------------------------------------------- --------

> (Total all of the recommended scores in "A" through "J" above.)

+--------------------------------------------------------------+--------+
| **Technical Merit Subtotal**                                 | **Po   |
|                                                              | ints** |
| **(**Maximum possible Technical Merit subtotal score 35      |        |
| points)                                                      |        |
+--------------------------------------------------------------+--------+
| [The sum of the above recommend technical merit scores       |        |
| is:]{.underline}                                             |        |
+--------------------------------------------------------------+--------+

**(5) Readiness**

> (Award yourself 0, 5, 10, or 15 points based on your justification.)

+-------------------------------------------------------------+--------+
| **Readiness** Applicant has written commitments from the    | **Po   |
| source(s) confirming commitment of:                         | ints** |
|                                                             |        |
| 50% up to, but not including, 75% of the matching funds,    |        |
| award 5 points.                                             |        |
+-------------------------------------------------------------+--------+
| 75% up to, but not including, 100% of the matching funds,   |        |
| award 10 points.                                            |        |
+-------------------------------------------------------------+--------+
| 100% of the matching funds, award 15 points.                |        |
+-------------------------------------------------------------+--------+

> [**Justification:** The funding sources for this §9006 project are set
> forth in the funding spreadsheet (tab 12). As indicated on the
> spreadsheet,]{.underline} [% of the financing sources have provided
> written commitments.]{.underline}

**(6) Small Agricultural Producer/Very Small Rural Business**

> (Award yourself 0, 5, or 10 points based on your justification.)

  -------------------------------------------------------------- ------------
  **Applicant size.** The applicant is an agricultural producer  **Points**
  producing agricultural products with a gross market value of   
  less than \$600,000 in the preceding year, award 5 points.     

  The applicant is an agricultural producer producing            
  agricultural products with a gross market value of less than   
  \$200,000 in the preceding year, award 10 points.              

  The applicant a Very Small Rural Business as defined in        
  4280.103 (a business with less than 15 employees and less than 
  \$1 million in annual receipts), award 10 points.              
  -------------------------------------------------------------- ------------

> **[Justification:]{.underline}**
>
> Pick the one that is applicable. EITHER
>
> [As indicated in the Project Summary (tab 11), **the applicant is an
> agricultural producer**. As further certified there in section (v),
> the gross market value of the agricultural products produced by the
> applicant was \$]{.underline} [.]{.underline}
>
> OR
>
> [As indicated in the Project Summary (tab 11), **the applicant is a
> small business**. As further certified there, the applicant's total
> annual gross receipts in the previous year was \$]{.underline} [and
> the applicant's number of employees is]{.underline} [.]{.underline}

**(7) Simplified application**

> (If you are using this template and your project's total cost is
> ≤\$200,000, you can claim the 5 "simplified application" points.)

+--------------------------------------------------------------+-------+
| **Simplified application.** If an applicant is eligible for  | **Poi |
| and uses the simplified application process or if the        | nts** |
| project has total eligible project costs of \$200,000 or     |       |
| less, award 5 points.                                        | **[5  |
|                                                              | ]{.un |
|                                                              | derli |
|                                                              | ne}** |
+--------------------------------------------------------------+-------+

> [**Justification:** This §9006 application is for a project with total
> eligible costs of \$]{.underline} [, and the project meets the other
> §9006 criteria for a "simplified application". Therefore the applicant
> is applying using the simplified application process.]{.underline}

**(8) Previous grantees and borrowers**

> (Assuming you have not received a previous §9006 award, you can claim
> 5 points.)

+--------------------------------------------------------------+-------+
| **Previous award.** If the applicant has not been awarded a  | **Poi |
| grant or loan under this program within the 2 previous       | nts** |
| Federal fiscal years, award 5 points.                        |       |
|                                                              | >     |
|                                                              |  **[5 |
|                                                              | ]{.un |
|                                                              | derli |
|                                                              | ne}** |
+--------------------------------------------------------------+-------+

> [**Justification:** The applicant hereby affirms that the applicant
> has not been awarded a grant or loan under the §9006 program within
> the two previous federal fiscal years.]{.underline}

**(9) Return on investment**

> (Award yourself 0, 2, 4, or 10 points based on your justification.)

+--------------------------------------------------------------+-------+
| **Payback.** The proposed project will return the cost of    | **Poi |
| investment in                                                | nts** |
|                                                              |       |
| Less than 4 years, award 10 points.                          |       |
+--------------------------------------------------------------+-------+
| 4 years up to but not including 8 years, award 4 points.     |       |
+--------------------------------------------------------------+-------+
| 8 years up to 11 years, award 2 point.                       |       |
+--------------------------------------------------------------+-------+

> [**Justification:** The energy audit (tab 15), indicates a simple
> payback of the cost of the energy efficiency improvements proposed
> in]{.underline} [months.]{.underline} (It is advisable to further
> explain the basis for this calculation.)

**TOTAL SELF-EVALUATION SCORE**

> (Add up all of the priority score categories and enter the sum.)

+--------------------------------------------------------------+-------+
| **Total Score**                                              | **Poi |
|                                                              | nts** |
| **(**Maximum possible score 120 points)                      |       |
+--------------------------------------------------------------+-------+
| [The sum of the above recommended scores is:]{.underline}    |       |
+--------------------------------------------------------------+-------+

***[Tab 13:]{.underline}* Technical Report**

§9006 Energy Efficiency Improvements Simple Grant Application

The "Technical Report" is the most critical component of your §9006
application. It is a narrative report detailing the following components
of your energy project:

a.  Qualifications of key project service providers

b.  Agreements, permits, and certifications

c.  Resource assessment

d.  Design and engineering

e.  Project development schedule

f.  Project economic assessment

g.  Equipment procurement

h.  Equipment installation

i.  Operations and maintenance

j.  Dismantling and disposal of project components

    All this is included in an NREL-developed "Section 9006, Small
    Project Energy Efficiency Technical Worksheet". This format will be
    provided to you in a separate Word document by USDA Rural
    Development. If you do not have it already, please contact us and we
    will e-mail it to you.

***[Tab 14:]{.underline}* Energy Audit or Energy Assessment (as
applicable)**

All §9006 grant applications for energy efficiency improvements must be
supported by either an Energy Audit (or an Energy Assessment) [prepared
by an independent professional]{.underline}. Since this report is
prepared by someone other than the applicant, it is not actually a part
of the business's application template. However, [the following
guidelines will serve as a template for the energy
auditor/assessor]{.underline} and should be given to the
auditor/assessor. An Energy Audit or Assessment (described in turn
below) must provide adequate and appropriate evidence of energy savings
expected when the system is operated as designed. It is an integral part
of the §9006 proposal's Technical Report and should be placed at Tab 14
of the application.

**Minimum Contents of an Energy Audit**

Energy audits are preferred in all cases and are mandatory when total
eligible project costs exceed \$50,000. Projects based on audits receive
a higher priority score. An energy audit is a written report by an
independent, qualified party using a methodology that meets professional
and industry standards. Audits typically involve detailed gathering of
field data and engineering analysis. The audit provides detailed project
costs and savings information with a high level of confidence. An energy
audit must cover the following:

\(i\) [Situation report]{.underline}. Provide a narrative description of
the facility or process, its energy system(s) and usage, and activity
profile. Also include price per unit of energy (electricity, natural
gas, propane, fuel oil, renewable energy, etc.) paid by the customer on
the date of the audit. Any energy conversion should be based on use
rather than source.

\(ii\) [Potential improvements]{.underline}. List specific information
on all potential energy-saving opportunities and their costs.

\(iii\) [Technical analysis]{.underline}. Discuss the interactions among
the potential improvements and other energy systems.

\(A\) Estimate the annual energy and energy costs savings expected from
each improvement identified in the potential project.

\(B\) Calculate all direct and attendant indirect costs of each
improvement.

\(C\) Rank potential improvement measures by cost-effectiveness.

\(iv\) [Potential improvement description]{.underline}. Provide a
narrative summary of the potential improvement and its ability to
provide needed benefits, including a discussion of non-energy benefits
such as project reliability and durability.

\(A\) Provide preliminary specifications for critical components.

\(B\) Provide preliminary drawings of project layout, including any
related structural changes.

\(C\) Document baseline data compared to projected consumption, together
with any explanatory notes. When appropriate, show before-and-after data
in terms of consumption per unit of production, time or area. Include at
least 1 year\'s bills for those energy sources/fuel types affected by
this project. Also submit utility rate schedules, if appropriate.

\(D\) Identify significant changes in future related operations and
maintenance costs.

\(E\) Describe explicitly how outcomes will be measured.

> \(v\) [Summary of proposed energy efficiency
> improvements]{.underline}.

(A) Estimated cost of the improvements

(B) Expected energy savings.

(C) Dollars saved per year.

(D) Payback period in years & months (total project cost divided by
    annual dollars of energy savings).

> \(vi\) [Appendix. Qualifications of the energy auditor]{.underline}.
> Typically, an energy auditor will be a Certified Energy Manager,
> Professional Engineer, or have some comparable level of expertise in
> energy efficiency improvements.

**Minimum Contents of an Energy Assessment**

Energy assessments may be submitted rather than energy audits if the
total eligible project costs do not exceed \$50,000. An energy
assessment is a brief written report by an independent, qualified party
using a methodology that meets recognized industry standards.
Assessments typically involve analyzing energy bills and briefly
surveying the target building, machinery, or system. The report
identifies and provides a savings and cost analysis of low-cost/no-cost
measures. An energy assessment must cover the following:

\(i\) [Situation report]{.underline}. Provide a narrative description of
the facility or process, its energy system(s) and usage, and activity
profile. Also include price per unit of energy (electricity, natural
gas, propane, fuel oil, renewable energy, etc.) paid by the customer.

> \(ii\) [Proposed energy efficiency improvement
> description]{.underline}. Provide a narrative summary of the
> improvements proposed and their benefits.
>
> \(iii\) [Summary of proposed energy efficiency
> improvements]{.underline}.

(A) Estimated cost of the improvements

(B) Expected energy savings.

(C) Dollars saved per year.

(D) Payback period in years & months (total project cost divided by
    annual dollars of energy savings).

> \(iv\) [Appendix. Qualifications of the energy assessor]{.underline}.
> The energy assessor should have experience and expertise in energy
> efficiency improvements, though no specific credentials are mandated.

***[Tab 15:]{.underline}* Addendum -- Important Supporting
Documentation**

The following documents should be included in your application above or
be included here as supporting documentation. They are all mentioned
above in the template as items to be provided. All too often they may be
overlooked or omitted, so this provides you with an added checklist.

**Document checklist.**

 Applicant's most recent tax returns

 Detailed project budget listing expense items/categories.

[Interim funding sources (evidence of readiness to proceed with the
project):]{.underline}

 Bank statement to document availability of borrower cash on hand for
project.

 Loan commitment letter to document availability of loan funds for
project. (if applicable)

 Commitment letter to document availability of other interim funds for
project. (if applicable)

[Post-completion incentives (evidence of public support and faster
return on investment):]{.underline}

 BETC tax credit application or preliminary award

 Energy Trust incentive application or preliminary award (if
applicable)

 Local utility incentive application or preliminary award (if
applicable)

[Technical Documentation]{.underline}

 Copy of warranties on major components

 Preliminary specifications, design drawings, and process flowcharts
for the project

 Copy of permits

 At least one-year\'s bills for those energy sources/fuel types
affected by this project

 Resume or credentials of each important technical experts (energy
auditor, project developer, etc.)