**Rural Development**

**United States Department of Agriculture**

**RURAL DEVELOPMENT**

**UTILITIES PROGRAMS**

***Community Connect***

***Broadband Program***

***Grant Application Guide***

***Fiscal Year 2007***

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***Committed to the future of rural communities***

**Contents:**

**Page No.**

**Introduction and General Information** 2

Applying for a Grant 15

Completing the Grant Application 18

Putting It All Together 30

III. Federal Forms and Attachments 31

**Rural Development Utilities Programs**

**Community-Oriented Connectivity Broadband Grant Program**

The Community-Oriented Connectivity Broadband Grant Program is designed
to provide financial assistance to furnish broadband service in rural,
economically-challenged communities where such service does not
currently exist. Grant funds may be utilized to deploy broadband
transmission service to critical community facilities, rural residents,
and rural businesses and to construct, acquire, or expand, equip, and
operate a community center that provides free access to broadband
services to community residents for at least two years. Grants will be
awarded, on a competitive basis, to entities serving communities of up
to 20,000 inhabitants to ensure rural consumers enjoy the same quality
and range of telecommunications service as are available in urban and
suburban communities.

**For additional information concerning this grant program, please
contact:**

**Kenneth Kuchno, Director, Broadband Division, Telecommunications
Program, (202) 690-4673 or Email: <community.connect@usda.gov>.
Information about Rural Development Utilities Programs and this
application/guide can be retrieved *via the internet* at:**

[**http://www.usda.gov/rus/telecom**](http://www.usda.gov/rus/telecom)

**PART 1739---BROADBAND GRANT PROGRAM Subpart A---Community Connect
Grant Program**

Sec.\
1739.1 Purpose.\
1739.2 Funding availability and application dates and addresses. 1739.3
Definitions. 1739.4--1739.9 \[Reserved\] 1739.10 Eligible applicant.
1739.11 Eligible project. 1739.12 Eligible grant purposes. 1739.13
Ineligible grant purposes. 1739.14 Matching contributions. 1739.15
Completed application. 1739.16 Review of grant applications. 1739.17
Scoring of applications. 1739.18 Grant documents. 1739.19 Reporting and
oversight

requirements. 1739.20 Audit requirements. 1739.21 OMB control number.

**Subpart B \[Reserved\]**

**Authority:** Title III, Pub. L. 108--199, 118 Stat. 3.

**Subpart A---Community Connect Grant Program**

**§ 1739.1 Purpose.**

1.  \(a\) The provision of broadband transmission service is vital to
    the economic development, education, health, and safety of rural
    Americans. The purpose of the Community Connect Grant Program is to
    provide financial assistance in the form of grants to eligible
    applicants that will provide, on a ''community-oriented
    connectivity'' basis, broadband transmission service that fosters
    economic growth and delivers enhanced educational, health care, and
    public safety services. RUS will give priority to rural areas that
    it believes have the greatest need for broadband transmission
    services, based on the criteria contained in this subpart.

    \(b\) Grant authority will be used for the deployment of broadband
    transmission service to extremely rural, lower-income communities on
    a ''community-oriented connectivity'' basis. The
    ''community-oriented connectivity'' concept will stimulate
    practical, everyday uses and applications of broadband by
    cultivating the deployment of new broadband transmission services
    that improve economic development and provide enhanced educational
    and health care opportunities in rural areas. Such an approach will
    also give rural communities the opportunity to benefit from the
    advanced technologies that are necessary to achieve these goals.

**§ 1739.2 Funding availability and application dates and addresses.**

1.  \(a\) RUS will publish, annually in the **Federal Register**, a
    Notice of Funds Availability (hereinafter ''NOFA'') that will set
    forth the total amount of funding available; the maximum and minimum
    funding for each grant; the application submission dates; and the
    appropriate addresses and agency contact information. The NOFA will
    also outline and explain the procedures for submission of
    applications, including electronic submissions. RUS may publish more
    than one NOFA should additional funding become available.

    \(b\) Notwithstanding paragraph (a) of this section, RUS may, in
    response to a surplus of qualified eligible applications which could
    not be funded from the previous fiscal year, decline to publish a
    NOFA for the following fiscal year and fund said applications
    without further public notice.

**§ 1739.3 Definitions.**

As used in this subpart:

*Bandwidth* means the capacity of the radio frequency band or physical
facility needed to carry the Broadband Transmission Service.

*Basic Broadband Transmission Service* means the broadband transmission
service level provided by the applicant at the lowest rate or service
package level for residential or business customers, as appropriate,
provided that such service meets the requirements of this part.

*Broadband Transmission Service* means providing an information-rate
equivalent to at least 200 kilobits/ second in the consumer's connection
to the network, both from the provider to the consumer (downstream) and
from the consumer to the provider (upstream).

*Community* means any incorporated or unincorporated town, village, or
borough recognized in the U.S. Census in a Rural Area.

*Community Center* means a public building, or a section of a public
building with at least ten (10) Computer Access Points, that is used for
the purposes of providing free access to and/or instruction in the use
of broadband Internet service, and is of the appropriate size to
accommodate this purpose. The community center must be open and
accessible to area residents before, during, and after normal working
hours and on Saturday or Sunday. Examples of facilities that may be
partially used for the described purposes include school, library, or
city hall.

*Computer Access Point* means a new computer terminal with access to
Basic Broadband Transmission Service.

*Critical Community Facilities* means every public school or education
center, public library, public medical clinic, public hospital,
community college, public university, or law enforcement, fire and
ambulance stations in the proposed Service Area.

*Eligible Applicant* shall have the meaning as set forth in § 1739.10.

*Eligible Grant Purposes* shall have the meaning as set forth in §
1739.12.

*End-User Equipment* means computer hardware and software, audio or
video equipment, computer network components, telecommunications
terminal equipment, inside wiring, interactive video equipment, or other
facilities required for the provision and use of Broadband Transmission
Service.

*Matching Contribution* means the applicant's qualified contribution to
the Project, as outlined in § 1739.14.

*Project* means the applicant's proposed Basic Broadband Transmission
Service financed by the grant and Matching Contribution for the proposed
Service Area.

*Rural Area* means any area of the United States not included within the
boundaries of any incorporated or unincorporated city, village, or
borough having a population in excess of 20,000 inhabitants.

*RUS* means the Rural Utilities Service, an agency of the United States
Department of Agriculture, which is part of the Rural Development
Utilities Program.

*Service Area* means a single Community, and may include the
unincorporated areas or locally recognized communities, not recognized
in the U.S. Census, located outside and contiguous to the Community's
boundaries, in which the applicant proposes to provide Broadband
Transmission Service.

*Spectrum* means a defined band of frequencies that will accommodate the
Broadband Transmission Service.

*Telecommunications Terminal Equipment* means the assembly of
telecommunications equipment at the end of a circuit or path of a
signal, including but not limited to facilities that receive or transmit
over-the-air broadcast, satellite, and microwave, normally located on
the premises of the end user, that interfaces with telecommunications
transmission facilities, and that is used to modify, convert, encode, or
otherwise prepare signals to be transmitted via such telecommunications
facilities, or that is used to modify, reconvert, or carry signals
received from such facilities, the purpose of which is to accomplish the
goal for which the circuit or signal was established.

*USDA* means the United States Department of Agriculture.

**§§ 1739.4--1739.9 \[Reserved\]**

**§ 1739.10 Eligible applicant.**

To be eligible for a grant, the applicant must:

1.  \(a\) Be legally organized as an incorporated organization, an
    Indian tribe or tribal organization, as defined in *25 U.S.C.
    450b(b) and (c)*, a state or local unit of government, or other
    legal entity, including cooperatives or private corporations or
    limited liability companies organized on a for-profit or
    not-for-profit basis.

    \(b\) Have the legal capacity and authority to own and operate the
    broadband facilities as proposed in its application, to enter into
    contracts and to otherwise comply with applicable federal statutes
    and regulations.

**§ 1739.11 Eligible project.**

To be eligible for a grant, the Project must:

1.  \(a\) Serve a Rural Area where Broadband Transmission Service does
    not currently exist, to be verified by RUS prior to the award of the
    grant;

    \(b\) Serve one Community recognized in the latest U.S. Census.
    Additional communities located in the contiguous areas outside the
    Community's boundaries that are not recognized (due to size) in the
    U.S. Census, can be included in the applicant's proposed Service
    Area, but must be supported by documentation, acceptable to RUS, as
    to their existence;

    \(c\) Deploy Basic Broadband Transmission Service, free of all
    charges for at least 2 years, to all Critical Community Facilities
    located within the proposed Service Area;

    \(d\) Offer Basic Broadband Transmission Service to residential and
    business customers within the proposed Service Area; and

    \(e\) Provide a Community Center with at least ten (10) Computer
    Access Points within the proposed Service Area, and make Broadband
    Transmission Service available therein, free of all charges to users
    for at least 2 years.

    **§ 1739.12 Eligible grant purposes.**

Grant funds may be used to finance:

\(a\) The construction, acquisition, or leasing of facilities, including
spectrum, to deploy Broadband Transmission Service to all participating
Critical Community Facilities and all required facilities needed to
offer such service to residential and business customers located within
the proposed Service Area;

1.  \(b\) The improvement, expansion, construction, or acquisition of a
    Community Center that furnishes free access to broadband Internet
    service, provided that the Community Center is open and accessible
    to area residents before, during, and after normal working hours and
    on Saturday or Sunday. Grant funds provided for such costs shall not
    exceed the greater of five percent (5%) of the grant amount
    requested or \$100,000;

    \(c\) End-User Equipment needed to carry out the Project;

    \(d\) Operating expenses incurred in providing Broadband
    Transmission Service to Critical Community Facilities for the first
    2 years of operation and in providing training and instruction.
    Salary and administrative expenses will be subject to review, and
    may be limited by RUS for reasonableness in relation to the scope of
    the Project; and

    \(e\) The purchase of land, buildings, or building construction
    needed to carry out the Project.

**§ 1739.13 Ineligible grant purposes.**

1.  \(a\) Grant funds may not be used to finance the duplication of any
    existing Broadband Transmission Service provided by another entity.

    \(b\) Facilities financed with grant funds cannot be utilized, in
    any way, to provide local exchange telecommunications service to any
    person or entity already receiving such service.

    **§ 1739.14 Matching contributions.**

    0.  \(a\) The grant applicant must contribute a Matching
        Contribution which is at least fifteen percent (15%) of the
        grant amount requested and shall be in the form of:

        \(1\) Cash for eligible grant purposes.

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1.  \(2\) In-kind contributions for purposes that could have been
    financed with grant funds under this part. In-kind contributions
    must be new or non-depreciated assets with established monetary
    values. Manufacturers' or service providers' discounts shall not be
    considered as a Matching Contribution.

    \(3\) The rental value of space provided within an existing
    Community Center, provided that the space is provided free of charge
    to the applicant, for the first 2 years of operation.

    \(4\) Salary expenses incurred for the individual(s) operating the
    Community Center, for the first 2 years of operation.

    \(5\) Expenses incurred in operating the Community Center, for the
    first 2 years of operation.

    \(b\) Costs incurred by the applicant, or by others on behalf of the
    applicant, for facilities, installed equipment, or other services
    rendered prior to submission of a completed application shall not be
    considered as an Eligible Grant Purpose or Matching Contribution.

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1.  \(c\) Rental values of space provided must be substantiated by
    rental agreements documenting the cost of space of a similar size in
    a similar location.

    \(d\) Rental values, salaries, and other expenses incurred in
    operating the Community Center will be subject to review by RUS for
    reasonableness in relation to the scope of the Project.

    \(e\) Any financial assistance from federal sources shall not be
    considered as a Matching Contribution unless there is a federal
    statutory exception specifically authorizing the federal financial
    assistance to be considered as such.

**§ 1739.15 Completed application.**

A completed application must include the following documentation,
studies, reports and information in form satisfactory to RUS.
Applications should be prepared in conformance with the provisions of
this part and applicable USDA regulations including 7 CFR parts 3015,
3016, and 3019. Applicants must use the RUS Application Guide for this
[program, found at *http://www.usda.gov/ rus/telecom/* containing
instructions](http://www.usda.gov/rus/telecom/) and all necessary forms,
as well as other important information, in preparing their application.
Completed applications must include the following:

1.  \(a\) *An Application for Federal Assistance.* A completed Standard
    Form 424.

    \(b\) *An executive summary of the Project.* The applicant must
    provide RUS with a general project overview that addresses the
    following categories:

    0.  \(1\) A description of why the Project is needed;

        \(2\) A description of the applicant;

    \(3\) An explanation of the total Project cost;

    \(4\) A general overview of the broadband telecommunications system
    to be developed, including the types of equipment, technologies, and
    facilities to be used;

    \(5\) Documentation describing the procedures used to determine the
    unavailability of existing Broadband Transmission Service; and

    \(6\) A description of the participating Critical Community
    Facilities.

    \(c\) *Scoring criteria documentation.* Each grant applicant must
    address and provide documentation on how it meets each of the
    scoring criteria detailed in §1739.17.

    \(d\) *System design.* The applicant must submit a system design
    that contains the following, satisfactory to RUS:

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1.  \(1\) A narrative discussing the proposed Community Center, all
    costs of the Project, all existing and proposed facilities that are
    a part of the Project, the services to be provided by the Project,
    and the proposed Service Area;

    \(2\) Engineering design studies providing an economical and
    practical engineering design of the Project, including a detailed
    description of the facilities to be funded, technical
    specifications, data rates, and costs; and

    \(3\) A map of the proposed Service Area reflecting the proposed
    location of the Community Center and all participating Critical
    Community Facilities.

    \(e\) *Scope of work.* The scope of work must include, at a minimum:

    \(1\) The specific activities and services to be performed under the
    Project;

    \(2\) Who will carry out the activities and services;

    \(3\) The time-frames for accomplishing the Project objectives and
    activities; and

    \(4\) A budget for all capital and administrative expenditures
    reflecting the line item costs for Eligible Grant Purposes, the
    Matching Contribution, and other sources of funds necessary to
    complete the Project.

    \(f\) *Community-Oriented Connectivity Plan.* The applicant must
    provide a Community-Oriented Connectivity Plan consisting of the
    following:

    \(1\) A listing of all participating Critical Community Facilities
    to be connected. For those Critical Community Facilities in the
    Service Area which will not be included in the Project, an
    explanation of why they are not being included should be provided.
    The applicant must also provide documentation that it has consulted
    with agents of all Critical Community Facilities in the Service
    Area, and must provide statements as to their willingness to
    participate, or not to participate, in the proposed Project;

    \(2\) A description of the services available to local residents
    through the use of the Community Center;

    \(3\) A listing of the proposed Telecommunications Terminal
    Equipment, telecommunications transmission facilities, data terminal
    equipment, interactive video equipment, computer hardware and
    software systems, and components that process data for transmission
    via telecommunications, computer network components, communication
    satellite ground station equipment, or any other elements of the
    Project designed to further the deployment and use of Broadband
    Transmission Service, that the applicant intends to build or fund
    using RUS grant funds and the Matching Contribution; and

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1.  \(4\) If other telecommunications carriers (including interexchange
    carriers, cable television operators, enhanced service providers,
    providers of satellite services and telecommunications equipment
    manufacturers and distributors) are participating in the delivery of
    services, a description of the consultations and the anticipated
    role of such providers in the proposed Project.

    \(g\) *Financial information and sustainability.* The applicant must
    provide a narrative description demonstrating the sustainability of
    the Project during the first two years and after completion and the
    sufficiency of resources and expertise necessary to undertake and
    complete the Project. The following financial information is
    required:

    \(1\) Certified financial statements, if available; otherwise, the
    most current income statement and balance sheet for existing
    operations; and

    \(2\) *Pro forma* financial information for 5 years, evidencing the
    sustainability of the Project.

    \(h\) *A statement of experience.* Information on the owners' and
    principal employees' relevant work experience that would ensure the
    success of the Project. The applicant must provide a written
    narrative describing its demonstrated capability and experience, if
    any, in operating a broadband telecommunications system.

    \(i\) *Evidence of legal authority and existence.* The applicant
    must provide evidence of its legal existence and authority to enter
    into a grant agreement with RUS and to perform the activities
    proposed under the grant application.

    \(j\) *Funding commitment from other sources.* If the Project
    requires additional funding from other sources in addition to the
    RUS grant, the applicant must provide evidence that funding
    agreements have been obtained to ensure completion of the Project.

    \(k\) *Compliance with other federal statutes.* The applicant must
    provide evidence of compliance with other federal statutes and
    regulations, including, but not limited to the following:

    \(1\) 7 CFR part 15, subpart A--- Nondiscrimination in Federally
    Assisted Programs of the Department of Agriculture---Effectuation of
    Title VI of the Civil Rights Act of 1964.

    \(2\) 7 CFR part 3015---Uniform Federal Assistance Regulations.

    \(3\) 7 CFR part 3017--- Governmentwide Debarment and Suspension
    (Non-procurement).

    \(4\) 7 CFR part 3018---New Restrictions on Lobbying.

\(5\) 7 CFR part 3021--- Governmentwide Requirements for Drug-Free
Workplace (Financial Assistance).

1.  \(6\) Certification regarding Architectural Barriers.

    \(7\) Certification regarding Flood Hazard Precautions.

    \(8\) An environmental report, in accordance with 7 CFR part 1794.

    \(9\) Certification that grant funds will not be used to duplicate
    lines, facilities, or systems providing Broadband Transmission
    Service.

    \(10\) Federal Obligation Certification on Delinquent Debt.

**§ 1739.16 Review of grant applications.**

1.  \(a\) All applications for grants must be delivered to RUS at the
    address and by the date specified in the NOFA (*see* § 1739.2) to be
    eligible for funding. RUS will review each application for
    conformance with the provisions of this part. RUS may contact the
    applicant for additional information or clarification.

    \(b\) Incomplete applications as of the deadline for submission will
    not be considered. If an application is determined to be incomplete,
    the applicant will be notified in writing and the application will
    be returned with no further action.

    \(c\) Applications conforming with this part will then be evaluated
    competitively by a panel of RUS employees selected by the
    Administrator of RUS, and will be awarded points as described in the
    scoring criteria in § 1739.17. Applications will be ranked and
    grants awarded in rank order until all grant funds are expended.

    \(d\) Regardless of the score an application receives, if RUS
    determines that the Project is technically or financially
    infeasible, RUS will notify the applicant, in writing, and the
    application will be returned with no further action.

**§ 1739.17 Scoring of applications.**

1.  \(a\) All eligible applications will receive points for the
    following scoring criteria:

    \(1\) The rurality of the Project (up to 40 points);

    \(2\) The economic need of the Project's Service Area (up to 30
    points); and

    0.  \(3\) The ''community-oriented connectivity'' benefits derived
        from the proposed service (up to 30 points).

        \(b\) Scoring criteria:

    \(1\) *The rurality of the project*---up to 40 points.

    \(i\) This criterion will be used to evaluate the rurality of the
    Community served by the Project, in accordance with the following
    method of scoring.

Rurality shall be determined by the 2000 population data contained in
the

U.S. [Bureau of the Census at *http:// factfinder.census.gov.* The
following](http://factfinder.census.gov/) categories are used in the
evaluation of rurality:

1.  \(A\) Level 1 means any Community having a population of less than
    500 inhabitants.

    \(B\) Level 2 means any Community having a population of at least
    500 and not in excess of 1,000 inhabitants.

    \(C\) Level 3 means any Community having a population over 1,000 and
    not in excess of 2,000 inhabitants.

    \(D\) Level 4 means any Community having a population over 2,000 and
    not in excess of 3,000 inhabitants.

    \(E\) Level 5 means any Community having a population over 3,000 and
    not in excess of 4,000 inhabitants.

    \(F\) Level 6 means any Community having a population over 4,000 and
    not in excess of 5,000 inhabitants.

    \(G\) Level 7 means any Community having a population over 5,000 and
    not in excess of 10,000 inhabitants.

    \(H\) Level 8 means any Community having a population over 10,000
    and not in excess of 20,000 inhabitants.

    \(ii\) Each application will receive points based on the location of
    the facilities financed using the definitions in paragraphs
    (b)(1)(i)(A) through (H) of this section.

    \(A\) For a Service Area that includes a Level 1 Community, it will
    receive 40 points.

    \(B\) For a Service Area that includes a Level 2 Community, it will
    receive 35 points.

    \(C\) For a Service Area that includes a Level 3 Community, it will
    receive 30 points.

    \(D\) For a Service Area that includes a Level 4 Community, it will
    receive 25 points.

    \(E\) For a Service Area that includes a Level 5 Community, it will
    receive 20 points.

    \(F\) For a Service Area that includes a Level 6 Community, it will
    receive 15 points.

    \(G\) For a Service Area that includes a Level 7 Community, it will
    receive 10 points.

    \(H\) For a Service Area that includes a Level 8 Community, it will
    receive 5 points.

    \(2\) *The economic need of the Project Service Area*---up to 30
    points.

    \(i\) This criterion will be used to evaluate the economic need of
    the Service Area. Applicants must utilize the per capita personal
    income for the Community serviced, as determined by [the U.S. Bureau
    of the Census at *http: //factfinder.census.gov.* Applicants
    will](http://factfinder.census.gov/) be awarded points as outlined
    below for

service provided in the Community where the per capita personal income
(PCI) is less than 70 percent of the national average per capita
personal income (NAPCI):

1.  \(A\) PCI is 75 percent or greater of NAPCI; 0 points;

    \(B\) PCI is less than 75 percent and greater than or equal to 70
    percent of NAPCI; 5 points;

    \(C\) PCI is less than 70 percent and greater than or equal to 65
    percent of NAPCI; 10 points;

    \(D\) PCI is less than 65 percent and greater than or equal to 60
    percent of NAPCI; 15 points;

    \(E\) PCI is less than 60 percent and greater than or equal to 55
    percent of NAPCI; 20 points;

    \(F\) PCI is less than 55 percent and greater than or equal to 50
    percent of NAPCI; 25 points;

    1.  \(G\) PCPI is less than 50 percent of NAPCPI; 30 points;

        \(ii\) \[Reserved\]

    \(3\) *The ''community-oriented connectivity'' benefits derived from
    the proposed service*---up to 30 points.

    1.  \(i\) This criterion will be used to score applications based on
        the documentation in support of the need for services, benefits
        derived from the services proposed by the Project, and local
        community involvement in planning and implementation of the
        Project. Applicants may receive up to 30 points for documenting
        the need for services and benefits derived from service as
        explained in this section.

        \(ii\) RUS will consider:

    \(A\) The extent of the applicant's documentation explaining the
    economic, education, health care, and public safety issues facing
    the community and the applicant's proposed plan to address these
    challenges on a community-wide basis;

    \(B\) The extent of the Project's planning, development, and support
    by local residents, institutions, and community facilities will be
    considered. This includes evidence of community-wide involvement, as
    exemplified in community meetings, public forums, and surveys. In
    addition, applicants should provide evidence of local residents'
    participation in the Project planning and development;

    \(C\) The extent to which the Community Center will be used for
    instructional purposes including Internet usage, Web-based
    curricula, and Web page development; and

    \(D\) Web-based community resources enabled or provided by the
    applicant, such as community bulletin boards, directories, and
    public web-hosting.

**§ 1739.18 Grant documents.**

The terms and conditions of grants shall be set forth in grant documents
prepared by RUS. The documents shall require the applicant to own all
equipment and facilities financed by the grant. Among other matters, RUS
may prescribe conditions to the advance of funds that address concerns
regarding the Project feasibility and sustainability. RUS may also
prescribe terms and conditions applicable to the construction and
operation of the Project and the delivery of Broadband Transmission
Service to Rural Areas, as well as other terms and conditions applicable
to the individual Project.

**§ 1739.19 Reporting and oversight requirements.**

1.  \(a\) A project performance activity report will be required of all
    recipients on an annual basis until the Project is complete and the
    funds are expended by the applicant. Recipients are to submit an
    original and one copy of all project performance reports, including,
    but not limited to, the following:

    \(1\) A comparison of actual accomplishments to the objectives
    established for that period;

    \(2\) A description of any problems, delays, or adverse conditions
    which have occurred, or are anticipated, and which may affect the
    attainment of overall Project objectives, prevent the meeting of
    time schedules or objectives, or preclude the attainment of
    particular Project work elements during established time periods.
    This disclosure shall be accompanied by a statement of the action
    taken or planned to resolve the situation; and

    \(3\) Objectives and timetable established for the next reporting
    period.

    \(b\) A final project performance report must be provided by the
    recipient. It must provide an evaluation of the success of the
    Project in meeting the objectives of the program. The final report
    may serve as the last annual report.

    \(c\) RUS will monitor recipients, as it determines necessary, to
    assure that Projects are completed in accordance with the approved
    scope of work and that the grant is expended for Eligible Grant
    Purposes.

    \(d\) Recipients shall diligently monitor performance to ensure that
    time schedules are being met, projected work within designated time
    periods is being accomplished, and other performance objectives are
    being achieved.

**§ 1739.20 Audit requirements.**

A grant recipient shall provide RUS with an audit for each year,
beginning with the year in which a portion of the financial assistance
is expended, in accordance with the following:

1.  \(a\) If the recipient is a for-profit entity, an existing
    Telecommunications or Electric Borrower with RUS, or any other
    entity not covered by the following paragraph, the recipient shall
    provide an independent audit report in accordance with 7 CFR part
    1773, ''Policy on Audits of RUS Borrowers.''

    \(b\) If the recipient is a State or local government, or non-profit
    organization, the recipient shall provide an audit in accordance
    with 7 CFR part 3052, ''Audits of States, Local Governments, and
    Non-Profit Organizations.''

**§ 1739.21 OMB control number.**

The information collection requirements in this part are approved by the
Office of Management and Budget (OMB) and assigned OMB control number
0572--012

**Subpart B---\[Reserved\]**

> Dated: July 16, 2004.

**Hilda Gay Legg,**

*Administrator, Rural Utilities Service.*

\[FR Doc. 04--17105 Filed 7--27--04; 8:45 am\]

**BILLING CODE 3410--15--P**

**When and Where to Submit Your Application:**

**GRANT** applications must be postmarked by:

An **[original and two copies]{.underline}** of a **completed**
**application** must be posted, shipped, or hand-delivered by the
deadline date. **Applications must be submitted to:**

**Director, Broadband Division**

**Rural Development Utilities Programs**

> **STOP 1599, Room 2868**

**1400 Independence Ave., SW**

**Washington, D.C. 20250-1599**

Due to the possible disruptions in mail delivery service, applicants are
strongly encouraged to submit applications via express mail or hand
delivery to our office.

## Applications Delivered by Mail:

Applications must show proof of shipping consisting of one of the
following:

1.  A legibly dated U.S. Postal Service (USPS) postmark;

2.  A legible mail receipt with the date of mailing stamped by the USPS;
    or

3.  A dated shipping label, invoice, or receipt from a commercial
    carrier.

If an application is sent through the USPS, neither of the following
will be accepted as proof of mailing:

1.  A private metered postmark; or

2.  A mail receipt that is not dated by the USPS.

Applicants should note that the USPS does not uniformly provide a dated
postmark. Before relying on this method, an applicant should check with
its local post office.

## Applications Delivered by Hand:

Applications delivered by hand will be accepted daily between 8:00 a.m.
and 4:30 p.m. (Eastern Standard Time), except Saturdays, Sundays, and
Federal holidays. Individuals delivering applications must provide
proper identification to enter the building.

**Late applicants will be notified that their applications will not be
considered for funding and their applications will be returned.**

**Applications Submitted Electronically:**

**Electronic applications will only be accepted when submitted through
the Grants.gov website.** Applications will not be accepted via
facsimile machine transmission or electronic mail.

[www.grants.gov](http://www.grants.gov/)

If you want to submit an application on-line, Rural Development
Utilities Programs strongly encourages you to obtain all the necessary
sign-ups, credentials and authorizations well in advance of the
deadline. You will need a Central Contractor Registry (CCR) registration
before you can submit electronically. In addition, Grants.gov requires
some one-time credentialing and online authentication procedures. These
procedures may take several business days to complete. Please ensure
that your credentials and authorizations are up-to-date if you went
through the process within the last year. Some or all of Grants.gov\'s
requirements call for an annual update.

The Grants.gov website, like all web facilities, has finite capacity. If
several federal grant programs have the same application deadline date,
periods of site overloading can be experienced. Please plan accordingly.

Please follow the instructions at Grants.gov. If you experience a
technical problem retrieving or submitting an electronic application,
contact the Grants.gov customer support resources (click the \"Customer
Support\" tab on any page of Grants.gov to get started). Rural
Development Utilities Programs staffers do not control the technical
aspects of Grants.gov and won\'t be able to help you if you experience a
problem. However, we are available to answer questions about the Program
and the contents of an application.

With an electronic application you do not need to submit two copies as
required from mailed applications. However, we may request original
signatures on paper later.

**New for 2007:**

Rural Development clarifies that in order to qualify as an eligible
costs for grant coverage or matching fund contributions, operating
expenses incurred in providing Broadband Transmission Service to
Critical Facilities for the first two (2) years of operation and in
providing training and instruction must be for the following purposes
subject to the specified maximum amounts:

a.  Salary for operations manager, not to exceed \$30,000 per year.

b.  Salary for technical support staff, not to exceed \$30,000 per year.

c.  Salary for community center staff, not to exceed \$25,000 per year.

d.  Bandwidth expenses, not to exceed \$25,000 per year.

e.  Training courses on the use of the Internet, not to exceed \$15,000
    per year.

The operating costs to be funded by grant or used as matching
contributions cannot exceed in the aggregate of \$250,000. No other
operating expenses are eligible for grant funding or to be considered as
matching funds.

**The minimum grant request amount is: \$50,000**

**The maximum grant request amount is: \$1,000,000**

**[Other pertinent information:]{.underline}**

**Matching Funds: For individual budget categories, matching funds can
not exceed the monetary limits of the specific category set forth in the
regulation or the NOFA.**

1.  **For the community center, the aggregate total of requested grant
    and matching funds are required to comply with the \$100,000
    limit.**

2.  **For operating expenses, the aggregate total of requested grant and
    matching funds cannot exceed \$250,000 and the aggregate total for
    the eligible operating expenses categories cannot exceed the amounts
    contained in the NOFA.**

**Organization of the application:**

**[We ask that all information relevant to a category be included under
that category\'s tab.]{.underline}** The volume of applications makes it
impractical for reviewers to search through the entire application to
find required information. **[If that information is relevant to another
category, it should be repeated under that category.]{.underline}**

**Applying for a Grant**

**Grant Processing**

Completed applications must be postmarked no later than[, August 20
2007]{.underline}, or be received by Grants.gov by that date to be
considered for funding. Grant applications will be scored in accordance
with the provisions of 7 CFR 1739.

**Applicant Eligibility**

To be eligible for a grant, the applicant must:

-   Be legally organized as an incorporated organization, an Indian
    tribe or tribal organization, as defined in [[25 U.S.C. 450b(b) and
    (c)]{.underline}](http://www.westlaw.com/Find/Default.wl?rs=++++1.0&vr=2.0&DB=1000546&DocName=25USCAS450B&FindType=L),
    a state or local unit of government, or other legal entity,
    including cooperatives or private corporations or limited liability
    companies organized on a for profit or not-for profit basis.

-   Have the legal capacity and authority to own and operate the
    broadband facilities as proposed in its application, to enter into
    contracts and to otherwise comply with applicable federal statutes
    and regulations.

**Note: The applicant may not be an individual or partnership.**

**Project Eligibility**

To be eligible for a grant, the Project must:

-   Serve a Rural Area throughout which Broadband Transmission Service
    does not currently exist, to be verified by Rural Development
    Utilities Programs prior to the award of the grant.

-   Serve one and only one Community recognized in the latest U.S.
    Census. Additional communities located in the contiguous areas
    outside the Community's boundaries that are not recognized (due to
    size) in the U.S. Census, can be included in the applicant's
    proposed Service Area, but must be supported by documentation,
    acceptable to Rural Development Utilities Programs, as to their
    existence (and these additional non-Census communities must meet the
    qualification of not having any broadband available);

-   Deploy Basic Broadband Transmission Service, free of all charges for
    at least 2 years, to all Critical Community Facilities located
    within the proposed Service Area;

-   Offer Basic Broadband Transmission Service to residential and
    business customers within the proposed Service Area; and

-   Provide a Community Center with at least ten (10) Computer Access
    Points within the proposed Service Area, and make Broadband
    Transmission Service available therein, free of all charges to users
    for at least 2 years.

    **!! COMMUNITY CENTER !!**

***The community center must have at least 10 Computer Access Points***

###### Rurality Requirement

The proposed project must provide broadband transmission service to a
rural area that does not currently have such service anywhere in the
proposed service area. A "Rurality Calculation Table" is provided for
this computation (See attachment 2), and should be based upon 2000
Census Data.

####### Eligible Grant Purposes

Grants funds may be used to finance:

1.  The construction, acquisition, or lease of facilities, including
    spectrum, to deploy broadband transmission services to all critical
    community facilities and to offer such service to all residential
    and business customers located within the proposed service area.

2.  The improvement, expansion, construction, or acquisition of a
    community center that furnishes free access to broadband Internet
    service, provided that the community center is open and accessible
    to area residents before, during, and after normal working hours and
    on Saturday or Sunday. Grant funds provided for the community center
    are limited to the greater of \$100,000 or 5% of the grant amount
    requested. The costs of the computer access points, their
    installation, connection to the broadband transmission system are
    not included in this limitation.

3.  End-user equipment needed to carry out the project.

4.  Operating expenses incurred in providing broadband transmission
    service to critical community facilities for the first 2 years of
    operations and to provide training and instruction shall not exceed
    \$250,000. Salary and administrative expenses will be subject to
    review, and may be limited, by Rural Development Utilities Programs,
    for reasonableness in relation to the scope of the project.

5.  The purchase of land, buildings, or building construction needed to
    carry out the project.

**Grant Funds may not be used to finance the duplication of any existing
broadband services provided by other entities; *and***

**Facilities financed may not be used, in any way, to provide local
exchange telecommunications service to any person or entity where it
currently exists.**

###### 

###### Matching Funds Requirement

The applicant's minimum matching contribution must be for **eligible
purposes** and equal 15% of the grant amount requested. All matching
funds must be eligible for funding under the grant program. Matching
funds are subject to dollar amount limitations as provided for the
Community Center and Operating Expenses. The aggregate total of match
and grant funds can not exceed limitations set forth in regulation. The
total amount available to be used for grant and matching funds for the
community center is \$100,000. The total amount available to be used for
grant and matching funds for operating expenses is \$250,000.

-   Cash for eligible grant purposes; and

-   In-kind contributions of eligible grant purposes.

In-kind contributions include:

-   New or non-depreciated assets with established monetary values.
    **Manufacturers' or service providers' discounts are not matching
    contributions**.

-   The value of rental income for donated space in a community center,
    calculated for the entire term of the donation;

**Costs incurred by the applicant, or others on behalf of the applicant,
for facilities or equipment installed, or other services rendered prior
to submission of a completed application, shall not be considered as an
eligible matching contribution.**

The source and amount of matching funds must be identified in the
application. All matching funds provided by the applicant or a third
party, must be documented and the applicants or the third party's
commitment must be included in the application.

Any financial assistance from Federal sources will not be considered as
matching contributions unless there is a Federal statutory exception
authorizing the Federal financial assistance to be considered as a
matching contribution.

**Completing the Grant Application**

This section addresses all of the information that must be submitted for
an application to be complete and considered for financing:

+----------------------------------+-----------------------------------+
| *A. A Completed Application for  | G.  *Financial Information and    |
| Federal Assistance (Standard     |     Sustainability*               |
| Form 424)*                       |                                   |
|                                  | H.  *A Statement of Experience*   |
| B.  *An Executive Summary of the |                                   |
|     Project*                     | I.  *Evidence of Legal Authority  |
|                                  |     and Existence*                |
| C.  *Scoring Criteria            |                                   |
|     Documentation*               | J.  *Funding Commitments from     |
|                                  |     Other Sources*                |
| D.  *System Design*              |                                   |
|                                  | K.  *Compliance with Other        |
| E.  *Scope of Work*              |     Federal Statutes and          |
|                                  |     Regulations*                  |
| F.  *Community-Oriented          |                                   |
|     Connectivity Plan*           |                                   |
+----------------------------------+-----------------------------------+

A. A Completed Standard Form 424, "Application for Federal Assistance"

Use the Standard Form 424, Application for Federal Assistance (SF 424),
to apply for Community Connect Broadband grants. You can find a copy of
the form in the Federal Forms and Attachments section. It is important
that you complete every relevant entry. Please use the following notes
in conjunction with the SF-424 instruction page.

**Block 1:** Select "Application"

**Block 2:** Select "New"

**Block 3:** For Rural Development Utilities Programs use - leave blank

**Block 4:** For Rural Development Utilities Programs use - leave blank

**Block 5: (a) and (b):** For Rural Development Utilities Programs use -
leave blank

**Block 6:** Not Applicable

**Block 7**: Not Applicable

**Block 8**: There are multiple entries in this block. We will use the
contact information provided in this box for all contact and
correspondence. Please complete this in full and attach a sheet if you
want to provide additional contacts. It is crucial that we have accurate
information, including a reliable fax number for rapid correspondence.
If you do not have a fax number, we will need a reliable e-mail address.
Otherwise, correspondence will be sent by mail. You must provide full,
accurate contact information for someone with the authority to answer
any questions Rural Development Utilities Programs staff may have about
your application.

If you wish to supply a contact from outside your organization, attach a
letter immediately behind the SF-424 listing these items: person\'s
name, organization, contact information (phone, fax, e-mail, mailing
address), relationship to your organization. Make sure the letter
contains language granting authority to the person to answer our
questions or provide additional information on your behalf, and any time
limit you wish to apply to that person\'s authority. This letter must be
signed by the signatory on the SF-424.

As required by the Office of Management and Budget, **all applicants for
grants must supply a Dun and Bradstreet Data Universal Numbering System
(DUNS) number**. Obtaining a DUNS number costs nothing but requires a
telephone call to Dun and Bradstreet (1-866-705-5711). Please see this
website for more information:

<http://www.whitehouse.gov/omb/grants/duns_num_guide.pdf>

**Block 9**: Refer to Instructions; Select Appropriate Letter (A-X)

**Block 10:** The Name of the Federal Agency is Rural Utilities Service

**Block 11**: The Catalog of Federal Assistance Number is **10.863**

**Block 12:** Funding Opportunity Number is **RDUP-06-01-CC**

The Title is "**Community Connect Grant Program**"

**Block 13:** Not Applicable

**Block 14:** Please provide the name of the community (city, town,
village, borough, or CDP), county, and state.

**Block 15:** Brief descriptive title of project

**Block 16:** Please provide the Congressional District of the community
you are in, and if different provide the Congressional District for the
community you are proposing to service in your project.

**Block 17:** Self Explanatory

**Block 18:** (Estimated Funding)

a\. Federal Show the amount requested from Rural Development Utilities
Programs as grant

b\. Applicant Show the total matching contributions, regardless of
source

c, d, e, & f. Leave Blank

g\. TOTAL Show *Total Eligible Community Connect Grant + Matching
Purposes* (this should be the sum of a. and b. above - and it should
also equal the Total Eligible Grant and Matching Purposes shown in your
budget under the Scope of Work Section E.)

**Block 19:** Please select "C" "Program is not covered by E.O. 12372".
Per regulation 7 CFR 1739-Supplementary Information, this program is not
subject to the requirements of Executive Order 12372.

**Block 20:** You must supply an explanation of the delinquency if you
check \"yes\".

**Block 21: Please be sure to check "I agree".** The application must be
signed by an authorized representative of the organization that will own
and operate the project if a grant is awarded. If the signer is not a
corporate officer, you must include evidence that the signer is
authorized to obligate the organization.

*Please note: Additional instructions can be found with the SF-424.*

**B. An Executive Summary of the Project**

The Executive Summary of the project is one of the most important parts
of the application. It gives reviewers their first overall view of the
area to be served, what problems the residents face, and how the
proposed project will help alleviate those problems, increase quality of
life, and provide enhanced opportunities for rural residents. This is
your opportunity to discuss the core aspects of the project. Be clear
and provide convincing links between the project and the benefits to the
community.

**[The Executive Summary must provide a general project overview
covering the following six categories:]{.underline}**

1.  A description of the community and why the project is needed;

2.  A description of the applicant;

3.  The goals of the project;

4.  A general overview of the telecommunications system to be developed,
    including the types of equipment, technologies, and facilities used;

5.  Documentation describing the procedures used to determine the
    unavailability of existing broadband service; and

6.  A description of the participating community organizations and
    partners (such as schools, health care providers, police and fire
    departments, etc.).

**\*\*\*Number each paragraph as shown above.**

**C. Scoring Criteria Documentation**

There are three scoring categories that must be addressed by applicant
in order to be considered for funding. They are:

1.  The rurality of the community served by the project (up to 40
    points) as determined by the population of the community, as
    determined by the U.S. Bureau of the Census, U.S. Department of
    Commerce, at
    [http://factfinder.census.gov](http://factfinder.census.gov/) (up to
    40 points);

2.  The economic need of the project's service area as determined by per
    capita personal income of the community, as determined by the U.S.
    Bureau of the Census, U.S. Department of Commerce, at
    [http://factfinder.census.gov](http://factfinder.census.gov/) (up to
    30 points); and

3.  The benefits derived from the proposed service area (up to 30
    points).

The first two categories are objective criteria. The objective criteria
are straightforward indicators that measure the rurality and economic
need of the service area.

***1. Rurality of the Project Service Area:***

A rurality table is provided in this application guide to assist you
with this process (Attachment 3). An applicant must base this
calculation on 2000 U.S. Census data. Instructions for determining the
correct census data:

1.  Go to [http://factfinder.census.gov](http://factfinder.census.gov/)

2.  Locate the heading \"Fast Access to Information\" and the search box
    titled \"Get a fact sheet for your community\". Enter your community
    and select your state from the state list, then click on \"go\"

3.  At the top of your community fact sheet, check to confirm that your
    community is: city, town, village, borough, or CDP

4.  The total population for your community is listed at the top in the
    first row of data of the fact sheet

The following table outlines the definitions used in evaluating
rurality:

  ------------- ----------------- --------------------- --------------------
  Community                                             
  Having a                                              
  Population:                                           

  Level         Over              Not in Excess of      Points

  1                               499                   40

  2             499               1,000                 35

  3             1,000             2,000                 30

  4             2,000             3,000                 25

  5             3,000             4,000                 20

  6             4,000             5,000                 15

  7             5,000             10,000                10

  8             10,000            20,000                5
  ------------- ----------------- --------------------- --------------------

Points are awarded based on the population of the community located
within the service area:

**For example, a project proposes to serve the town of Belle Haven,
Virginia. In accordance with U.S. Bureau of the Census statistics, the
town of Belle Haven, Virginia has a population of 480. A population of
480 is a Level 1 community eligible to receive 40 points, as follows:**

  ------------------------------------ ------------------------------ ------------------------- --------------------------
  **[Service Area                      **[Population]{.underline}**   **[Level]{.underline}**   **[Points]{.underline}**
  Community]{.underline}**                                                                      

  **Belle Haven town, Virginia**       **480**                        **1**                     **40**
  ------------------------------------ ------------------------------ ------------------------- --------------------------

Instructions for Native American Indian Reservations: If your eligible
community is an Indian Reservation (per explanation on page 6 of this
application guide), follow these instructions for determining the
correct population:

1.  Go to [http://factfinder.census.gov](http://factfinder.census.gov/)

2.  Scroll down the web page to find the \"Special Interest\" heading on
    the right and click on \"American Indian and Alaska Native\"

3.  Under the \"Census 2000\" heading, click on \"Fast access to popular
    data\"

4.  Select the state where the reservation is located and type an
    asterisk \"\*\" in the reservation box

5.  Select your reservation from the list

6.  The total population for your reservation is listed at the top in
    the first row of data of the fact sheet

7.  Use the rurality evaluation table above to determine the correct
    points for your reservation\'s population

***2. Economic Need of the Project Service Area (up to 30 points):***

An "Economic Need Calculation Worksheet" is provided in this application
guide to assist you in this calculation (Attachment 4). This criterion
measures the economic need of the service area based upon the per capita
income (PCI) of the Community as determined by the U.S. Bureau of the
Census, U.S. Department of Commerce. An applicant must base this
calculation on 2000 U.S. Census data. Instructions for determining the
correct census data:

1.  Go to [http://factfinder.census.gov](http://factfinder.census.gov/)

2.  Locate the heading \"Fast Access to Information\" and the search box
    titled \"Get a fact sheet for your community\". Enter your community
    and select your state from the state list, then click on \"go\"

3.  Scroll down to \"Economic Characteristics\" and look for \"Per
    capita income (dollars)\"

4.  Use that figure to calculate the community\'s PCI as a percentage of
    the National Average using Attachment 4 of this guide

Points are awarded for service provided in a Community where the PCI is
less than 75 percent of the national average per capita personal income
(NAPCI) and according to the following scale:

  -------------------------- ---------------------------- ----------------
  PCI is:                                                 

  Percent of NACPI Less      Percent of NAPCI Greater     Points Awarded
  than:                      than or equal to:            

                             75                           0

  75                         70                           5

  70                         65                           10

  65                         60                           15

  60                         55                           20

  55                         50                           25

  50                                                      30
  -------------------------- ---------------------------- ----------------

Instructions for Native American Indian Reservations: If the eligible
community is an Indian Reservation (per explanation on page 6), follow
these instructions for determining the correct per capita income

1.  Go to [http://factfinder.census.gov](http://factfinder.census.gov/)

2.  Scroll down the web page to find the \"Special Interest\" heading on
    the right and click on \"American Indian and Alaska Native\"

3.  Under the \"Census 2000\" heading, click on \"Fast access to popular
    data\"

4.  Select the state where the reservation is located and type an
    asterisk \"\*\" in the box

5.  Select your reservation from the list

6.  Scroll down to page with the heading \"Profile of Selected Economic
    Characteristics\" (usually page 3 of the fact sheet) and locate the
    per capita income (dollars) - usually on the lower right of the
    table. Use that figure to calculate the community\'s PCI as a
    percentage of the national average using Attachment 4 of this guide

7.  Determine correct points for your reservation based on the table
    above

***3. Benefits derived from the proposed service (up to 30 points):***

The "benefits derived from the proposed service area" is a subjective
scoring category for which applicants may receive up to 30 points. This
criterion will be scored based on the documentation in support of the
need for services, benefits derived from the services proposed by the
project, and local community involvement in planning and implementing of
the project.

Rural Development Utilities Programs will consider:

1.  The extent of the applicant's documentation explaining the economic,
    educational, health care, and public safety issues and challenges
    facing the community and the applicant's proposed plan to address
    these challenges on a community-oriented basis.

2.  The extent of the project's planning, development, and support by
    local residents,

> institutions, and community facilities. This includes evidence of\
> community-oriented involvement, as exemplified in community meetings,
> public forums, and surveys. In addition, applicants should provide
> evidence of local residents' participation in the project planning and
> development.

3.  The extent to which the community center will be used for
    educational or instructional purposes.

4.  Web-based community resources enabled or provided by the applicant,
    such as community bulletin boards, directories, public web-hosting,
    notices, etc.

In addressing this scoring criterion, applicants must describe the
unique circumstances involving their proposed project and how they
propose to utilize Federal financing provided from this program in
conjunction with any other resources to meet their community's needs.
When addressing this criterion, applicants should specifically discuss
all aspects of the application that contribute to the scoring criterion.

Applicants should attempt to quantify benefits in terms of outcomes from
the project; that is, ways in which peoples' lives, or the community,
will be improved. Try to provide estimates of the number of people
affected by the benefits arising from the project.

Use as many pages as is necessary to address the subjective criterion.

**D. System Design**

The system design must contain the following information:

1.  A narrative discussing the proposed community center and all costs
    of the project, all existing and proposed facilities that are a part
    of the project, the services to be provided by the project, and the
    proposed service area;

2.  Engineering design studies providing an economical and practical
    engineering design of the project, including a detailed description
    of the facilities to be funded, technical specifications, data
    rates, and costs; and

3.  A map of the proposed service area reflecting the proposed location
    of the community center and critical community facilities.

**E. A Scope of Work**

The scope of work must include, at a minimum:

1.  The specific activities and services to be performed under the
    project;

2.  Who will carry out the activities and services;

3.  The time-frames for accomplishing the project objectives and
    activities; and

4.  A budget for all capital and operating expenditures reflecting the
    line item costs for eligible purposes for the grant funds, the
    matching contributions, and other sources of funds necessary to
    complete the project.

> **A sample budget has been provided on the following page. A fill in
> the blank budget has been provided in the Application Guide as
> Attachment 6**. We strongly recommend you use the budget provided.

+---------------------------+---------+--------+----------------------+
| **BUDGET ITEM**           | **E     |        | **Remarks**          |
|                           | STIMATE |        |                      |
|                           | OF      |        |                      |
|                           | COSTS** |        |                      |
+---------------------------+---------+--------+----------------------+
|                           | **      | > **G  |                      |
|                           | Match** | rant** |                      |
+---------------------------+---------+--------+----------------------+
| **[NETWORK & ACCESS       |         |        |                      |
| EQUIPMENT]{.underline}**  |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Base Station              |         | 10,000 |                      |
+---------------------------+---------+--------+----------------------+
| CPE                       |         | 5,000  |                      |
+---------------------------+---------+--------+----------------------+
| Router(s)                 |         | 1,000  |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Network & Access  | **-**   | **16   |                      |
| Equipment**               |         | ,000** |                      |
+---------------------------+---------+--------+----------------------+
| **[OUTSIDE                |         |        |                      |
| PLANT]{.underline}**      |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Generally N/A for         |         |        |                      |
| Wireless                  |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Outside Plant**   | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| **                        |         |        | \$800 at 24 months   |
| [BUILDINGS]{.underline}** |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Community Center Rent     | 19,200  |        |                      |
+---------------------------+---------+--------+----------------------+
| Renovations               | 10,000  |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Buildings**       | **2     | \-     |                      |
|                           | 9,200** |        |                      |
+---------------------------+---------+--------+----------------------+
| **[LAND]{.underline}**    |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Land for Tower            | 3,500   |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Land**            | **      | \-     |                      |
|                           | 3,500** |        |                      |
+---------------------------+---------+--------+----------------------+
| **[TOWERS]{.underline}**  |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Cost of Tower             |         | 50,000 |                      |
| Construction              |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Towers**          | **-**   | **50   |                      |
|                           |         | ,000** |                      |
+---------------------------+---------+--------+----------------------+
| **[OPERATING              |         |        | Community Paying     |
| EXPENSES]{.underline}**   |         |        | first year of Salary |
|                           |         |        | Grant funds Paying   |
|                           |         |        | Second year          |
|                           |         |        |                      |
|                           |         |        | Two year Salary      |
|                           |         |        |                      |
|                           |         |        | Two years of         |
|                           |         |        | Bandwidth            |
|                           |         |        |                      |
|                           |         |        | \*\*\*\*Note grant   |
|                           |         |        | and match funds must |
|                           |         |        | not exceed the       |
|                           |         |        | Limitations          |
|                           |         |        | set\*\*\*\*          |
+---------------------------+---------+--------+----------------------+
| Community Center          | 25,000  | 25,000 |                      |
| Personnel                 |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Technician Salary         |         | 60,000 |                      |
+---------------------------+---------+--------+----------------------+
| Bandwidth                 |         | 25,000 |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Operating         | **2     | **110  |                      |
| Expenses**                | 5,000** | ,000** |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **[OPERATING              |         |        | 10 Computers and     |
| EQUIPMENT]{.underline}**  |         |        | Printers             |
|                           |         |        |                      |
|                           |         |        | 10 workstations      |
+---------------------------+---------+--------+----------------------+
| Computers                 |         | 15,000 |                      |
+---------------------------+---------+--------+----------------------+
| Office Furniture          |         | 10,000 |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **[Total Operating        | **-**   | **25   |                      |
| Equipment]{.underline}**  |         | ,000** |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **SUMMARY OF BUDGET       | **E     |        |                      |
| CATEGORIES**              | STIMATE |        |                      |
|                           | OF      |        |                      |
|                           | COSTS** |        |                      |
+---------------------------+---------+--------+----------------------+
|                           | **      | **G    |                      |
|                           | Match** | rant** |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        | \*\*\*Remember match |
|                           |         |        | must be 15% or more  |
|                           |         |        | of the grant funds   |
|                           |         |        | requested! If you    |
|                           |         |        | have questions call  |
|                           |         |        | our office\*\*\*     |
+---------------------------+---------+--------+----------------------+
| NETWORK & ACCESS          | \-      | 16,000 |                      |
| EQUIPMENT                 |         |        |                      |
+---------------------------+---------+--------+----------------------+
| OUTSIDE PLANT             | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| BUILDINGS                 | 29,200  | \-     |                      |
+---------------------------+---------+--------+----------------------+
| LAND                      | 3,500   | \-     |                      |
+---------------------------+---------+--------+----------------------+
| TOWERS                    | \-      | 50,000 |                      |
+---------------------------+---------+--------+----------------------+
| OPERATING EXPENSES        | 25,000  | 1      |                      |
|                           |         | 10,000 |                      |
+---------------------------+---------+--------+----------------------+
| OPERATING EQUIPMENT       | \-      | 25,000 |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| TOTAL                     |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           | 57,700  | 2      |                      |
|                           |         | 01,000 |                      |
+---------------------------+---------+--------+----------------------+

**F. Community-Oriented Connectivity Plan**

The provision of broadband service is vital to the economic development,
education, health, and safety of rural Americans. To further this
objective, Rural Development Utilities Programs will provide financial
assistance to eligible entities that propose, on a "community-oriented
connectivity" basis, to provide broadband service that fosters economic
growth and delivers enhanced educational, health care, and public safety
services. The "community-oriented connectivity" concept integrates the
deployment of broadband infrastructure with the practical, everyday uses
and applications of the facilities.

Specifically, Rural Development Utilities Programs will provide
financial assistance to eligible entities that are proposing to deploy
broadband transmission service in a rural community where such service
does not currently exist; who will connect the critical community
facilities including the local schools, libraries, hospitals, police,
fire and rescue services; and who will operate a community center that
provides free and open access to residents. A state-of-the-art community
center will not only provide improved access but will aid rural
residents in developing on-line businesses and will allow them to reap
the benefits of Internet-based advanced placement courses, and
continuing adult education. Priority will be given to rural areas that
have the greatest need for broadband services. The applicant must
provide a community-oriented connectivity plan consisting of the
following:

1.  A listing of all critical community facilities located in the
    service area, including public schools, public libraries, public
    medical clinics, public hospitals, community colleges, public
    universities, law enforcement, and fire and ambulance stations. The
    applicant must provide documentation of consultation with these
    groups, including commitments to participate in the proposed
    project;

2.  A description of the services available to local residents through
    the use of the community center;

3.  A listing of the proposed telecommunications terminal equipment,
    telecommunications transmission facilities, data terminal equipment,
    interactive video equipment, computer hardware and software systems,
    and components that process data for transmission via
    telecommunications, computer network components, communication
    satellite ground station equipment, or any other elements of the
    telecommunications system designed to further the deployment and use
    of broadband services, that the applicant intends to build or fund
    using Rural Development Utilities Programs grant funds and matching
    contributions; and

4.  A description of the consultations with the appropriate
    telecommunications carriers (including inter-exchange carriers,
    cable television operators, enhanced service providers, providers of
    satellite services, and telecommunication equipment manufacturers
    and distributors) and the anticipated role of such providers in the
    proposed telecommunications system.

**G. Financial Information and Sustainability**

The applicant must provide a narrative description demonstrating
sustainability of the project, including having sufficient resources and
expertise necessary to undertake and complete the project and how the
project will be sustained following completion. The following financial
information is required:

1.  Certified financial statements, if available; otherwise, the most
    current income statement and balance sheet for existing operations;
    and

2.  5 years of pro-forma financial information for the project, or for
    the applicant taking into consideration the conclusion of the
    project, including income statements, balance sheets, cash flow
    statements. Applicants must include sufficient pro-forma financial
    data to demonstrate the financial capability of the project
    participants to continue a sustainable project for a minimum of 5
    years after completion of the project.

This documentation should include non-contingent sources of income or
revenues that are sufficient to pay all operating expenses including
system maintenance, salaries, training, and any other general operating
expenses, and provide for replacement of depreciable items. Applicants
must also include depreciation rates, based upon current industry
standards, for the equipment being financed. All assumptions in support
of the pro-forma must be clearly identified.

> **A sample Income Statement has been provided below. A fill in the
> blank Income Statement has been provided in the Application Guide as
> Attachment 5. We strongly recommend you use the Income Statement
> provided.**

  ----------------------- ------------ -------------- ---------- ---------- ----------
  **Income Statement**    Grantee\'s   ** Broadband                         
                          Name:        Company**                            

                                                                            

                          City, State: ** Rural Town,                       
                                       USA**                                

                                                                            

                          **Year 1**   **Year 2**     **Year 3** **Year 4** **Year 5**

  **Revenues**                                                              

  Data Revenues           \$ 30,000    \$ 33,000      \$ 36,000  \$ 39,000  \$ 42,000

  Installation Revenues   \$ 3,750     \$ 375         \$ 375     \$ 375     \$ 375

  Other Revenues          \$ 1,000     \$ 1,100       \$ 1,210   \$ 1,331   \$ 1,464

  Uncollectible Revenues  \$ 500       \$ 500         \$ 500     \$ 500     \$ 500

                                                                             

  **Total Revenues**      **\$         **\$ 33,975**  **\$       **\$       **\$
                          34,250**                    37,085**   40,206**   43,339**

                                                                             

  **Expenses**                                                               

  Cost of Sales           \$ 4,000     \$ 4,400       \$ 4,840   \$ 5,324   \$ 5,856

  Selling, General, and   \$ 6,000     \$ 6,600       \$ 6,930   \$ 7,277   \$ 7,640
  Administrative                                                            

  Salaries                \$ 22,000    \$ 22,000      \$ 22,000  \$ 22,000  \$ 22,000

  Community Center        \$ 1,800     \$ 1,800       \$ 1,800   \$ 1,800   \$ 1,800

  Other Operating Expense \$ 500       \$ 500         \$ 500     \$ 500     \$ 500

                                                                             

  **Total Operating       **\$         **\$ 35,300**  **\$       **\$       **\$
  Expenses**              34,300**                    36,070**   36,901**   37,797**

  **Net Income (Loss)**   **\$ (50)**  **\$ (1,325)** **\$       **\$       **\$
                                                      1,015**    3,306**    5,542**
  ----------------------- ------------ -------------- ---------- ---------- ----------

**H. A Statement of Experience**

An applicant must provide a written narrative describing its
demonstrated capability and experience, if any, in operating a
telecommunications system, or any project similar to the

proposed project. The applicant must include the owner's and principal
employees' relevant work experience that would ensure the success of the
project.

**I. Evidence of Legal Authority and Existence**

The applicant must provide evidence of its legal existence and authority
to enter into a grant agreement with the Rural Development Utilities
Programs and perform the activities proposed under the grant
application.

Satisfactory documentation of legal authority includes, but is not
limited to: articles of incorporation, bylaws, board resolutions,
excerpts from state statutes, or an attorney's opinion of counsel.

Satisfactory documentation of legal existence includes, but is not
limited to, certificates from the Secretary of State, state statutes or
laws establishing your organization. Letters from the IRS awarding
tax-exempt status are not considered adequate evidence.

**J. Funding Commitments from Other Sources**

If the project requires additional funding from other sources in
addition to the Rural Development Utilities Programs grant, the
applicant must provide evidence that funding agreements have been
obtained to ensure completion of the project. These agreements shall be
sufficient to ensure:

1.  Payment of all proposed expenditures for the project;

2.  All required matching contributions;

3.  Any additional matching funding; and

4.  Any other funds necessary to complete the project.

A letter from the organization providing the matching funds or in-kind
contributions is an example of the evidence required. In the case of
in-kind contributions of equipment, the letter should include a
description of the items, value, and date purchased. For donations of
space for the community center, the letter should include the dimensions
of the space and a calculation of the value of the foregone rental
income, and a commitment to provide the space for a minimum of two (2)
years. For donations of space, evidence of the value of the donation is
required. For donations of operating and administrative expenses of the
community center, the letter should include detailed calculations of the
individual expense line items used to determine the value.

**K. Compliance with Other Federal Statutes and Regulations**

The applicant is required to submit evidence that it is in compliance
with other Federal statutes and regulations as follows:

-   E.O. 11246, Equal Employment Opportunity, as amended by E.O. 11375
    and as supplemented by regulations contained in 41 CFR part 60,
    Attachment 4;

-   Architectural barriers, Attachment 5;

-   Flood hazard are precautions, Attachment 6;

-   Assistance and Real Property Acquisition Policies Act of 1970,
    Attachment 7;

-   Drug-Free Workplace Act of 1998 (41 U.S.C. 701), Attachment 8;

-   E.O.s 12549 and 12689, Debarment and Suspension; **(See 7 CFR
    3017.510)**, Attachment 9;

-   Byrd Anti-Lobbying Amendment (31 U.S.C. 1352), Attachment 10;

```{=html}
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```
-   If the applicant is engaged in lobbying activities, the applicant
    must submit a completed disclosure form, "Disclosure of Lobbying
    Activities" **(See 7 CFR Part 3018)**";

```{=html}
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```
-   Non Duplication of Services Certificate, Attachment 11;

-   Federal Obligations Certification on Delinquent Debt, Attachment 12;
    and

-   Environmental Impact Report, in accordance with 7 CFR 1794,
    Attachment 13 (see further information below).

    ***Environmental Impact and Historic Preservation:***

> *Details of the project's impact on the environment and historic
> preservation must be provided. The application must contain a separate
> section entitled "Environmental Impact of the Project."*
>
> *An "Environmental Questionnaire/Certification" may be used by
> applicants to assist in complying with the requirements of this
> section. Attachment 13.*
>
> ***For a proposed project that only involves internal modifications or
> equipment additions to buildings or other structures,** the
> environmental information normally required includes a description of
> the internal modifications or equipment additions, the size of the
> site in hectares, and the general nature of the proposed use of the
> facilities once the project is completed, including any hazardous
> materials to be used, created or discharged, any substantial amount of
> air emissions, wastewater discharge, or solid waste that will be
> generated.*

**Putting It All Together**

The GRANT application should be **assembled** and **tabbed** in the
following order listed below. Material not located under the proper tab
will not be considered by reviewers. If material is relevant under more
than one tab, it should be repeated under each relevant tab. Any
supplemental information that the applicant wants to submit should be
included under the relevant tab. Numbered attachments are provided at
the end of this guide for your use. Use only the applicable attachments
listed below.

A.  An Application for Federal Assistance: Completed Standard Form 424,
    Attachment 1

B.  An Executive Summary of the Project

C.  Scoring Criteria Documentation

    1.  Rurality Calculation Table, Attachment 2

    2.  Economic Need Calculation Worksheet, Attachment 3

    3.  The Benefits Derived from Services

D.  System Design

E.  Scope of Work

F.  Community-Oriented Connectivity Plan

G.  Financial Information and Sustainability

    1.  Certified Financial Statements, if available

    2.  Pro-Forma Financial Statements

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```
H.  Statement of Experience

I.  Evidence of Legal Existence & Legal Authority to Contract with the
    Government

J.  Evidence of Funding Commitments from all sources, if applicable

K.  Compliance with Other Federal Statutes and Regulations

    1.  Equal Opportunity and Nondiscrimination Certification,
        Attachment 4

    2.  Certificate Regarding Architectural Barriers, Attachment 5

    3.  Certificate Regarding Flood Hazard Area Precautions, Attachment
        6

    4.  Uniform Relocation Assistance and Real Property Acquisition
        Policies Act of 1970 Certification, Attachment 7

    5.  Certification Regarding Drug-Free Workplace Requirements,
        Alternative I -- For Grantees Other than Individuals, Attachment
        8

    6.  Certification Regarding Debarment and Suspension, and Other
        Responsibility Matters -- Primary Covered Transactions,
        Attachment 9

    7.  Certification Regarding Lobbying for Contracts, Grants, Loans,
        and Cooperative Agreements, Attachment 10

        -   If the applicant is engaged in lobbying activities, the
            applicant must submit a completed disclosure form,
            "Disclosure of Lobbying Activities" **(See 7 CFR Part
            3018)**"

    8.  Non Duplication of Services Certificate, Attachment 11

    9.  Federal Obligations Certification on Delinquent Debt, Attachment
        12

    10. Environmental Questionnaire/Certification, Attachment 13

*Sample certificates and forms are included for your use*

**Rural Development Utilities Programs**

***Community Connect***

***Broadband Grant Program***

***Federal Forms and Attachments***

***Fiscal Year 2007***

**Contents :**

**Attachment** **Page No.**

1 Application for Federal Assistance 32

2 Survey Ensuring Equal Opportunity for Applicants 38

3 Rurality Calculation Table 40

4 Economic Need Calculation Worksheet 41

5 Income Statement 42

6 Budget 43 7 Equal Opportunity and Nondiscrimination Certification 44

> 8 Certificate Regarding Architectural Barriers 45

9 Certificate Regarding Flood Hazard Area Precautions 46

> 10 Uniform Relocation Assistance and Real Property\
> Acquisition Policies Act of 1970 Certification 47
>
> 11 Certification Regarding Drug-Free Workplace\
> Requirements 48
>
> 12 Certification Regarding Debarment, Suspension, and Other
> Responsibility Matters -- Primary Covered Transactions 50
>
> 13 Certification Regarding Lobbying for Contracts,\
> Grants, Loans, and Cooperative Agreements 51

14 Non Duplication of Services Certificate 52

15 Federal Obligations Certification on Delinquent Debt 53

> 16 Community-Oriented Connectivity Environmental\
> Questionnaire/Certification 54

###### 

###### 

###### 

**Placeholder for SF424 Face Page**

**(The official version of the SF424 is only available as a PDF
document. Please see The PDF version of this application guide for a
copy)**

**Attachment 1**

###### 

###### 

###### 

**Placeholder for SF424 Face Page**

**(The official version of the SF424 is only available as a PDF
document. Please see The PDF version of this application guide for a
copy)**

**Attachment 1**

###### 

###### 

###### 

**Placeholder for SF424 Face Page**

**(The official version of the SF424 is only available as a PDF
document. Please see The PDF version of this application guide for a
copy)**

**Attachment 1**

###### 

###### 

###### 

**Placeholder for SF424 Face Page**

**(The official version of the SF424 is only available as a PDF
document. Please see The PDF version of this application guide for a
copy)**

**Attachment 1**

###### 

###### 

###### 

**Placeholder for SF424 Instructions Page**

**(The official version of the SF424 is only available as a PDF
document. Please see The PDF version of this application guide for a
copy)**

**Attachment 1**

###### 

###### 

###### 

**Placeholder for SF424 Instructions Page**

**(The official version of the SF424 is only available as a PDF
document. Please see The PDF version of this application guide for a
copy)**

**Attachment 1**

**Applicant's (Organization) Name:      **

**Applicant's DUNS Number:**      

**Federal Program:      **

**CFDA Number:      **

1\. Has the applicant ever received a grant or contract from the Federal
government?

Yes No

2\. Is the applicant a faith-based organization?

Yes No

3\. Is the applicant a secular organization?

Yes No

4\. Does the applicant have 501(c)(3) status?

Yes No

5\. Is the applicant a local affiliate of a national\
organization?

Yes No

6\. How many full-time equivalent employees does the applicant have?
*(Check only one box).*

> 3 or Fewer 15-50
>
> 4-5 51-100
>
> 6-14 over 100

7\. What is the size of the applicant's annual budget? *(Check only one
box.)*

Less Than \$150,000

\$150,000 - \$299,999

\$300,000 - \$499,999

\$500,000 - \$999,999

\$1,000,000 - \$4,999,999

\$5,000,000 or more

# Survey Instructions on Ensuring Equal Opportunity for Applicants 

> **Provide the applicant's (organization) name and DUNS number and the
> grant name and CFDA number**

1.  Self-explanatory.

2.  Self-identify.

3.  Self-identify.

> 4\. 501(c)(3) status is a legal designation provided on application to
> the Internal Revenue Service by eligible organizations. Some grant
> programs may require nonprofit applicants to have 501(c)(3) status.
> Other grant programs do not.
>
> 5\. Self-explanatory.
>
> 6\. For example, two part-time employees who each work half-time equal
> one full-time equivalent employee. If the applicant is a local
> affiliate of a national organization, the responses to survey
> questions 2 and 3 should reflect the staff and budget size of the
> local affiliate.
>
> 7\. Annual budget means the amount of money your organization spends
> each year on all of its activities.

**Paperwork Burden Statement**

According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control
number for this information collection is 1890-0014. The time required
to complete this information collection is estimated to average five (5)
minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review
the information collection. **If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form,
please write to:** The Agency Contact listed in this grant application
package.

> OMB No. 1890-0014 Exp. 02/28/09

**Attachment 2**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

***Rurality Calculation Table***

Please list the proposed Community to be served with the proceeds of the
Community Connect Broadband Grant, its population based upon 2000 Census
data, and its rurality level.

  ------------------------------------ ------------------------------ --------------------------- --------------------------
  **[Service Area                      **[Population]{.underline}**   **[Level\*]{.underline}**   **[Points]{.underline}**
  Community]{.underline}**                                                                        

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

*\* Denote Level based on the following table:*

  ------------- ----------------- --------------------- --------------------
  Community                                             
  Having a                                              
  Population:                                           

  Level         Over              Not in Excess of      Points

  1                               499                   40

  2             499               1,000                 35

  3             1,000             2,000                 30

  4             2,000             3,000                 25

  5             3,000             4,000                 20

  6             4,000             5,000                 15

  7             5,000             10,000                10

  8             10,000            20,000                5
  ------------- ----------------- --------------------- --------------------

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 3**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

***Economic Need Calculation Worksheet***

Applicants are awarded points for providing service in a Community where
the per capita personal income (PCI) is less than 75% of the national
average per capita income (NAPCI) of 21,587. Enter the Community name
and it's PCI in dollars (found at
[http://factfinder.census.gov](http://factfinder.census.gov/)) and
calculate the percentage of the NAPCI in the table below.

+----------------+-----------------+-----------------+-----------------+
| **Service Area | **(a)**         | **(b)**         | **(a) ÷ (b)**   |
| Community**    |                 |                 |                 |
|                | **Community PCI | **NAPCI in      | **PCI as % of   |
|                | in Dollars**    | Dollars**       | NAPCI**         |
+----------------+-----------------+-----------------+-----------------+
|                | \$              | \$21,587        | \_\_\_\_\_\_    |
|                | \_\_\_\_\_\_\_\ |                 | \_\_\_\_\_\_\_% |
|                | _\_\_\_\_\_\_\_ |                 |                 |
+----------------+-----------------+-----------------+-----------------+

***Using the scale below, award the appropriate number of points in the
box below for the community on PCI as a percent of NAPCI:***

**0 pts**. if ≥ 75%

**5 pts.** If ≥ 70% but \< 75%

**10 pts**. if ≥ 65% but \< 70%;

**15 pts.** if ≥ 60% but \< 65%;

**20 pts**. if ≥ 55% but \< 60%;

**25 pts.** if ≥ 50% but \< 55%;

**30 pts**. if \< 50%.

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 4**

  ----------------------- ------------ -------------- --------- ---------- ---------
  **Income Statement**    Grantee\'s   ** Broadband                        
                          Name:        Company**                           

                                                                           

                          City, State: ** Rural Town,                      
                                       USA**                               

                                                                           

                          **Year 1**   **Year 2**     **Year    **Year 4** **Year
                                                      3**                  5**

  **Revenues**                                                             

  Data Revenues                                                            

  Installation Revenues                                                    

  Other Revenues                                                           

  Uncollectible Revenues                                                   

                                                                            

  **Total Revenues**                                                       

                                                                            

  **Expenses**                                                              

  Cost of Sales                                                            

  Selling, General, and                                                    
  Administrative Expense                                                   

  Salaries                                                                 

  Community Center                                                         

  Other Operating Expense                                                  

                                                                            

  **Total Operating                                                        
  Expenses**                                                               

  **Net Income (Loss)**                                                    
  ----------------------- ------------ -------------- --------- ---------- ---------

**Attachment 5**

+---------------------------+---------+--------+----------------------+
| **Budget**                | **E     |        | **Remarks**          |
|                           | STIMATE |        |                      |
|                           | OF      |        |                      |
|                           | COSTS** |        |                      |
+---------------------------+---------+--------+----------------------+
|                           | **      | > **G  |                      |
|                           | Match** | rant** |                      |
+---------------------------+---------+--------+----------------------+
| **[NETWORK & ACCESS       |         |        |                      |
| EQUIPMENT]{.underline}**  |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Any electronic equipment  |         |        |                      |
| used to provide access to |         |        |                      |
| broadband services. This  |         |        |                      |
| includes, but is not      |         |        |                      |
| limited to, ADSL          |         |        |                      |
| equipment, wireless       |         |        |                      |
| equipment (including      |         |        |                      |
| CPE), fiber equipment,    |         |        |                      |
| etc.                      |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Network & Access  | **-**   | **-**  |                      |
| Equipment**               |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **[OUTSIDE                |         |        |                      |
| PLANT]{.underline}**      |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Any cable construction    |         |        |                      |
| related to providing      |         |        |                      |
| broadband service.        |         |        |                      |
| Includes fiber or copper  |         |        |                      |
| (coaxial or twisted pair) |         |        |                      |
| construction. This        |         |        |                      |
| category will not be      |         |        |                      |
| applicable to all         |         |        |                      |
| projects.                 |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Outside Plant**   | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| **                        |         |        |                      |
| [BUILDINGS]{.underline}** |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Any buildings costs,      |         |        |                      |
| including renovations or  |         |        |                      |
| new construction, if      |         |        |                      |
| applicable.               |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Buildings**       | **-**   | \-     |                      |
+---------------------------+---------+--------+----------------------+
| **[LAND]{.underline}**    |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Any land costs, if        |         |        |                      |
| applicable.               |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Land**            | **-**   | \-     |                      |
+---------------------------+---------+--------+----------------------+
| **[TOWERS]{.underline}**  |         |        |                      |
+---------------------------+---------+--------+----------------------+
| The cost of building a    |         |        |                      |
| new communications tower  |         |        |                      |
| goes in this category, if |         |        |                      |
| applicable.               |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Towers**          | **-**   | **-**  |                      |
+---------------------------+---------+--------+----------------------+
| **[OPERATING              |         |        |                      |
| EXPENSES]{.underline}**   |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Includes bandwidth        |         |        |                      |
| expenses, salaries of an  |         |        |                      |
| operations manager,       |         |        |                      |
| technical support staff,  |         |        |                      |
| community center staff,   |         |        |                      |
| and training courses on   |         |        |                      |
| the use of the Internet.  |         |        |                      |
| Refer to the NOFA for the |         |        |                      |
| dollar limits placed on   |         |        |                      |
| each of these items.      |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **Total Operating         | **-**   | **-**  |                      |
| Expenses**                |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **[OPERATING              |         |        |                      |
| EQUIPMENT]{.underline}**  |         |        |                      |
+---------------------------+---------+--------+----------------------+
| Includes, but is not      |         |        |                      |
| limited, to the computer  |         |        |                      |
| equipment used in the     |         |        |                      |
| Community Center,         |         |        |                      |
| furniture purchased as    |         |        |                      |
| part of the grant         |         |        |                      |
| project, and any other    |         |        |                      |
| piece of equipment used   |         |        |                      |
| in the day-to-day         |         |        |                      |
| operation of the grant    |         |        |                      |
| project.                  |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **[Total Operating        | **-**   | **-**  |                      |
| Equipment]{.underline}**  |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| **SUMMARY OF BUDGET       | **E     |        | **REMARKS**          |
| CATEGORIES**              | STIMATE |        |                      |
|                           | OF      |        |                      |
|                           | COSTS** |        |                      |
+---------------------------+---------+--------+----------------------+
|                           | **      | **G    |                      |
|                           | Match** | rant** |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| NETWORK & ACCESS          | \-      | \-     |                      |
| EQUIPMENT                 |         |        |                      |
+---------------------------+---------+--------+----------------------+
| OUTSIDE PLANT             | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| BUILDINGS                 | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| LAND                      | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| TOWERS                    | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| OPERATING EXPENSES        | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
| OPERATING EQUIPMENT       | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+
|                           |         |        |                      |
+---------------------------+---------+--------+----------------------+
| TOTAL                     |         |        |                      |
+---------------------------+---------+--------+----------------------+
|                           | \-      | \-     |                      |
+---------------------------+---------+--------+----------------------+

**Attachment 6**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

***Equal Opportunity and Nondiscrimination Certification***

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

All recipients of financial assistance from Rural Development Utilities
Programs, the prospective primary participant commits to carry out Rural
Development Utilities Programs established policy to comply with the
requirements of the above laws and executive orders to the effect that
no person in the United States shall, "on the basis of race, color,
national origin, handicap, or age, be excluded from participation in, be
denied the benefits of, or be otherwise subjected to discrimination
under the Community-Oriented Connectivity Broadband Grant Program.

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

hereby certifies that, as a prospective recipient under the said
Community-Oriented Connectivity Broadband Grant Program, it will comply
with the above reference laws and executive orders.

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

*(Date (Authorized Representative's Signature)*

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

*(Name Typed or Printed)*

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

*(Title)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 7**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

***Certificate Regarding Architectural Barriers***

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

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

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

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

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

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

*(Name Typed or Printed)*

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

(*Title)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 8**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

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

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

Please check the appropriate line below:

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

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

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

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

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

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

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

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

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

*(Name Typed or Printed)*

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

*(Title)*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 9**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

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

***Policies Act of 1970 Certification***

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

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

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

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

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

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 10**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

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

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

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

**ALTERNATIVE I**

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

> \(a\) Publishing a statement notifying employees that unlawful
> manufacture, distribution, dispensing, possession, or use of a
> controlled substance is prohibited in the grantee's workplace and
> specifying the actions that will be taken against employees for
> violation of such prohibition;
>
> \(b\) Establishing an ongoing drug-free awareness program to inform
> employees about:
>
> \(1\) The dangers of drug abuse in the workplace;
>
> \(2\) The grantee's policy of maintaining a drug-free workplace;
>
> \(3\) Any available drug counseling, rehabilitation, and employee
> assistance programs; and
>
> \(4\) The penalties that may be imposed upon employees for drug abuse
> violations occurring in the workplace;

\(c\) Making it a requirement that each employee to be engaged in the
performance of the grant be given a copy of the statement required by
paragraph (a);

> \(d\) Notifying the employee in the statement required by paragraph
> (a) that, as a condition of employment under the grant, the employee
> will:

\(1\) Abide by the terms of the statement; and

> \(2\) Notify the employer in writing of his or her conviction for a
> violation of a criminal drug statute occurring in the workplace no
> later than 5 calendar days after such conviction;
>
> \(e\) Notifying the Agency in writing, within 10 calendar days after
> receiving notice under subparagraph (d) (2) from an employee or
> otherwise receiving actual notice of such
>
> conviction. Employers of convicted employees must provide notice,
> including position title, to every grant officer on whose grant
> activity the convicted employee was working, unless the Federal agency
> has designated a central point for the receipt of such notices. Notice
> shall include the identification number(s) of each affected grant;

*Page 1 of 2*

> **Attachment 11**

\(f\) Taking one of the following actions, within 30 calendar days of
receiving notice under subparagraph (d)(2), with respect to any employee
who is so convicted:

> \(1\) Taking appropriate personnel action against such an employee, up
> to and including termination, consistent with the requirements of the
> Rehabilitation Act of 1973, as amended; or
>
> \(2\) Requiring such employee to participate satisfactorily in a drug
> abuse assistance or rehabilitation program approved for such purposes
> by a Federal, State, or local health, law enforcement, or other
> appropriate agency; and

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

B. The grantee may insert in the space provided below the site(s) for
the performance of work done in connection with the specific grant:

**Place of Performance:**

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

*Street Address City*

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

*County State Zip Code*

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

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

*Organization Name*

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

*Authorized Representative's Signature Date*

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

*Name Typed or Printed*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

*Page 2 of 2*

**U.S. Department of Agriculture**

Rural Development Utilities Programs

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

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

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

> \(a\) are not presently debarred, suspended, proposed for Debarment,
> declared ineligible, or voluntarily excluded from covered transactions
> by any Federal department or agency;
>
> \(b\) have not within a 3-year period preceding this proposal been
> convicted of or had a civil judgment rendered against them for
> commission of fraud or a criminal offense in connection with
> obtaining, attempting to obtain, or performing a public (Federal,
> State, or local) transaction or contract under a public transaction;
> violation of Federal or State antitrust statutes or commission of
> embezzlement, theft, forgery, bribery, falsification or destruction of
> records, making false statements, or receiving stolen property;
>
> \(c\) are not presently indicted for or otherwise criminally or
> civilly charged by a governmental entity (Federal, State, or local)
> with commission of any of the offenses enumerated in paragraph (1)(b)
> of this certification; and
>
> \(d\) have not within a 3-year period preceding this
> application/proposal had one or more public transactions (Federal,
> State, or local) terminated for cause or default.

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

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

*Organization Name*

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

*Authorized Representative's Signature Date*

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

*Name Typed or Printed*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 12**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

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

***Loans, and Cooperative Agreements***

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

> \(1\) No Federal appropriated funds have been paid or will be paid, by
> or on behalf of the undersigned, to any person for influencing or
> attempting to influence an officer or employee of any agency, a Member
> of Congress, an officer or employee of Congress, or an employee of a
> Member of Congress in connection with the awarding of any Federal
> contract, the making of any Federal grant or loan, the entering into
> of any cooperative agreement, and the extension, continuation,
> renewal, amendment, or modification of any Federal contract, grant,
> loan, or cooperative agreement.
>
> \(2\) If any funds other than Federal appropriated funds have been
> paid or will be paid to any person for influencing or attempting to
> influence an officer or employee of any agency, a Member of Congress,
> an officer or employee of Congress, or an employee of a Member of
> Congress in connection with this Federal contract, grant, loan, or
> cooperative agreement, the undersigned shall complete and submit
> Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance
> with its instructions. (Copies of this form may be obtained from Rural
> Development Utilities Programs.)
>
> \(3\) The undersigned shall require that the language of this
> certification be included in the award documents for all sub-awards at
> all tiers (including subcontracts, sub-grants, and contracts under
> grants, loans, and cooperative agreements) and that all sub-recipients
> shall certify and disclose accordingly.
>
> This certification is a material representation of fact upon which
> reliance was placed when this transaction was made or entered into.
> Submission of this certification is a prerequisite for making or
> entering into this transaction imposed by section 1352, title 31, U.S.
> Code. Any person who fails to file the required certification shall be
> subject to a civil penalty of not less than \$10,000 and not more than
> \$100,000 for each such failure.

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

*Organization Name*

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

*Authorized Representative's Signature Date*

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

*Name Typed or Printed*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 13**

**U.S. Department of Agriculture**

Rural Utilities Service

***Non Duplication of Services Certificate***

As a prospective primary participant recipient of assistance from Rural
Development Utilities Programs, this organization certifies that
facilities financed under the Community-Oriented Connectivity Broadband
Grant Program will provide broadband service only in areas where it does
not currently exist.

The
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(Grantee/Borrower) hereby certifies that as a prospective recipient
under the said Community-Oriented Connectivity Broadband Grant Program,
that it will not use Rural Development Utilities Programs grant funds to
duplicate any established broadband services or facilities as referenced
above.

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

*(Date)* *(Signature)*

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

*(Name Typed or Printed)*

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

*(Title)*

(*This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

**Attachment 14**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

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

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

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

**If Yes, provide explanatory information.**

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

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

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

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

**[Certification]{.underline}**

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

Signed:

Title:

Company:

Date:

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.*

**Attachment 15**

**U.S. Department of Agriculture**

Rural Development Utilities Programs

***Community-Oriented Connectivity Broadband*** ***Grant Program***

***Environmental Questionnaire/Certification***

**Environmental Project Summary:**

***(This description should encompass all construction in the project,
no matter the source of funding. It should provide details of how the
project will impact the environment (wetlands, farmlands, floodplain,
cultural environment, endangered species, environmental quality, and
historic preservation). If additional space is needed, continue on white
bond paper and insert between the first and second pages.)***

***If the construction proposed in this application, as described above,
will not impact the environment or historic preservation, [you may sign
the certification indicating that no adverse impact and skip filling out
the questionnaire]{.underline}***.

**CERTIFICATION**

**I hereby certify that the construction proposed in this application
will not adversely impact the environment or historic preservation.**

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

**^(Signature\ and\ Date)^**

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

**^(Print\ or\ Type\ Title)^**

*Page 1 of 4*

> **Attachment 16**

**QUESTIONNAIRE**

*Note: It is extremely important to respond to all questions completely
to ensure expeditious processing of the Community-Oriented Connectivity
Broadband* *Grant Program application. The information herein is
required by Federal law*.

*Important:* *[Any activity related to the project that may adversely
affect the environment or limit the choice of reasonable development
alternatives shall not be undertaken prior to the completion of Rural
Utilities Service's environmental review process]{.underline}*.

Legal Name of Applicant

Signature *(Type, sign, & date)*

*The applicant's representative certifies to the best of his/her
knowledge and belief that the information contained herein is accurate.
Any false information may result in disqualification for consideration
of financial assistance or the rescission of financial assistance.*

**I. Project Description** - **Detailing construction, including, but
not limited to internal modifications of existing structures, and/or
installation of telecommunications transmission facilities including
satellite uplinks or downlinks, microwave transmission towers, and
cabling.**

> 1\. Describe the portion of the project, and site locations (including
> legal ownership of real property), involving internal modifications,
> or equipment additions to buildings or other structures (e.g.,
> relocating interior walls or adding computer facilities) for
> [each]{.underline} site.

*Page 2 of 4*

2\. Describe the portion of the project, and site locations (including
legal ownership or real property), involving construction of
transmission facilities, including cabling, microwave towers, satellite
dishes, or disturbance of property of .99 acres or greater for
[each]{.underline} project site.

3\. Describe the nature of the proposed use of the facilities and
whether any hazardous materials, air emissions, wastewater discharge, or
solid waste will result.

4\. State whether or not any project site(s) contain or are near
properties listed or eligible for listing in the National Register of
Historic Places, and identify any historic properties. (The applicant
must supply evidence that the State Historic Preservation Officer (SHPO)
has cleared development regarding any historical properties).

5\. Provide information whether or not any facility(ies) or site(s) are
located in a 100-year floodplain. A National Flood Insurance Map should
be included reflecting the location of the project site(s).

*Page 3 of 4*

**II. For projects that involve construction of transmission facilities,
including cabling, microwave towers, satellite dishes, or physical
disturbance of real property of .99 acres or greater, the following
information must be submitted.**

> 1\. A map (*preferably a U.S. Geological Survey map*) of the area for
> each site affected by construction (include as an attachment).
>
> 2\. A description of the amount of property to be cleared, excavated,
> fenced, or otherwise disturbed by the project and a description of the
> current land use and zoning and any vegetation for each project site
> affected by construction.
>
> 3\. A description of buildings or other structures (i.e., transmission
> facilities), including dimensions, to be constructed or modified.
>
> 4\. A description of the presence of wetlands or existing agricultural
> operations and/or threatened or endangered species or critical
> habitats on or near the project site(s) affected by construction.
>
> 5\. Describe any actions taken to mitigate any environmental impacts
> resulting from the proposed project (use attachment if necessary).

*Note: The applicant may submit a copy of any environmental review,
study assessment, report or other document that has been prepared in
connection with obtaining permits, approvals, or other financing for the
proposed project from State, local or other Federal bodies. Such
material, to the extent relevant, may be used to meet the requirements
herein.*

*(This is not an official Government form. It has been prepared to
assist and expedite the application process and is only intended for use
in the Community-Oriented Connectivity Broadband Grant Program.)*

*Page 4 of 4*

The U.S. Department of Agriculture prohibits discrimination in its
programs on the basis of race, color, National origin, sex, religion,
age disability, political beliefs, and marital or family status. (Not
all bases apply to all programs.) Persons with disabilities who require
alternative means for communications of program information (Braille,
large print, audiotape, etc.) should contact USDA's TARGET Center on
(202) 720-1127 (TDD). USDA is an equal opportunity employer.