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HomeProposal Submission Instructions...DRL Proposal Submission Instructions for Applications Updated January 2020

# 									DRL Proposal Submission Instructions for Applications Updated January 2020							

Bureau of Democracy, Human Rights, and Labor

						Download Instructions												[568 KB]

## 								Table of Contents							

        - SECTION I: Eligibility
        - A. Eligibility Requirements
        - B. System for Award Management (SAM.gov)
        - C.Eligible Applications
        - D. Format Requirements
        - E. Application Requirements
        - F. Additional Application Documents
        - SECTION II: Guidelines for Application Components
        - A. Office of Management and Budget (OMB) Regulations
        - B. SF-424 Forms
        - C. Cover Page
        - D. Executive Summary
        - E. Table of Contents
        - F. Proposal Narrative Guidelines
        - G. Budget Guidelines
        - H. Audit Guidelines
        - I. Logic Model Guidelines
        - J. Monitoring and Evaluation Guidelines
        - K. Risk Analysis Guidelines
        - L. Gender Analysis Guiding Questions
        - SECTION III: Proposal Submission Instructions
        - A. SAMS Domestic Applications
        - SECTION IV: Proposal Review Process
        - A. Proposal Review Criteria
        - SECTION V: Additional Information
        - A. Background Information on DRL and General DRL Funding

**Updated**: January 2020

***PLEASE REFER TO THIS DOCUMENT WHEN PREPARING AN APPLICATION.***

## Table of Contents

SECTION I: Eligibility

A. Eligibility Requirements

B. System for Award Management (SAM.gov)

C.Eligible Applications

D. Format Requirements

E. Application Requirements

F. Additional Application Documents

SECTION II: Guidelines for Application Components

A. Office of Management and Budget (OMB) Regulations

B. SF-424 Forms

C. Cover Page

D. Executive Summary

E. Table of Contents

F. Proposal Narrative Guidelines

G. Budget Guidelines

H. Audit Guidelines

I. Logic Model Guidelines

J. Monitoring and Evaluation Guidelines

K. Risk Analysis Guidelines

L. Gender Analysis Guiding Questions

SECTION III: Proposal Submission Instructions

A. SAMS Domestic Applications

SECTION IV: Proposal Review Process

A. Proposal Review Criteria

SECTION V: Additional Information

A. Background Information on DRL and General DRL Funding

## SECTION I: Eligibility

### A.   Eligibility Requirements

The Bureau of Democracy, Human Rights and Labor (DRL) welcomes applications in response to DRL Notices of Funding Opportunities (NOFOs) from:
        - S.-based and foreign-based non-profit organizations/non-government organizations (NGOs);
        - Public international organizations;
        - Private, public, or state institutions of higher education; and
        - For-profit organizations or businesses.

DRL’s preference is to work with **non-profit entities**; however, there may be occasions when a for-profit entity is best suited.

For-profit entities should be aware that their applications may be subject to additional review following the panel selection process, and that the Department of State generally prohibits profit in the form of program income under its assistance awards.  Profit is defined as any amount in excess of allowable direct and indirect costs generated by the award.  The allowability of costs incurred by commercial organizations is determined in accordance with the provisions of the Federal Acquisition Regulation (FAR) at 48 CFR §30, Cost Accounting Standards Administration, and 48 CFR §31, Contract Cost Principles and Procedures.

Please see 2 CFR 200.307 for regulations regarding program income.

Applicants must have existing, or the capacity to develop, active partnerships with thematic or in-country partners, entities, and relevant stakeholders, including private sector partners and NGOs, and have **demonstrable experience** in administering successful, and preferably similar, projects.  DRL encourages applications from foreign-based NGOs headquartered in the geographic regions/countries relevant to the applicable NOFO.  DRL reserves the right to request additional background information on applicants who do not have previous experience administering federal grant awards, and these applicants may be subject to limited funding on a pilot basis.

Applicants may **form consortia** in order to bring together organizations with varied expertise to propose a comprehensive program in one proposal.  However, one organization should be designated as the lead applicant with the other members as sub-award partners.

DRL is committed to an anti-discrimination policy in all its programs and activities.  DRL welcomes applications irrespective of an applicant’s race, ethnicity, color, creed, national origin, gender, sexual orientation, gender identity, disability, or other status.

Providing cost sharing, matching, or cost participation is not an eligibility factor or requirement and providing cost share will not result in a more favorable competitive ranking.

### B.    System for Award Management (SAM.gov)

**Note:  SAM.gov is not the same as SAMS Domestic.  SAM.gov is a regulatory requirement whereas SAMS Domestic is a Department of State-specific grants management tool.  It is free to register in****both systems****, but the****registration processes are different.**

Any applicant listed on the Excluded Parties List System (EPLS) in the System for Award Management (SAM.gov)  is not eligible to apply for an assistance award in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR, 1986 Comp., p. 189) and 12689 (3 CFR, 1989 Comp., p. 235), “Debarment and Suspension.”  Additionally, no entity listed on the EPLS can participate in any activities under an award.  All applicants are strongly encouraged to review the EPLS in SAM.gov to ensure that ineligible entities are not included in their application.

All prime organizations, whether based in the United States or in another country, must have a Unique Entity Identifier (UEI) number – formerly referred to as a DUNS (Data Universal Numbering System) number – and an active SAM.gov registration before submitting an application.  **DRL may not review applications from or make awards to applicants that have not completed all applicable UEI and SAM.gov requirements**.  A UEI is one of the data elements mandated by Public Law 109-282, the Federal Funding Accountability and Transparency Act (FFATA), for all Federal awards.  The 2 CFR 200 requires that subgrantees obtain a UEI number.  Please note the **UEI for subgrantees** is not required at the time of application but will be required before the award is processed and/or directed to a subgrantee.

All prime organizations must also continue to maintain an **active**SAM.gov registration with current information at all times during which they have an active Federal award or application under consideration by a Federal award agency.  Please note that a “pending renewal” registration status will not be considered “active.”  SAM.gov requires all entities to renew their registration once a year in order to maintain an active registration status in SAM.gov.  If an applicant has not fully complied with the requirements at the time of application, DRL may determine that the applicant is technically ineligible to receive an award and use that determination as a basis for making an award to another applicant.

**Note:  The process for obtaining or renewing a SAM.gov registration has changed.  DRL encourages all organizations to begin the process of registering or renewing with SAM.gov as early as possible.  The registration process may take anywhere from 4-8 weeks on average.****
        - If you are  based in the United States  or pay employees within the United States, prior to registering in SAM.gov you will need an Employer Identification Number (EIN) from the Internal Revenue Service (IRS), a Commercial and Government Entity (CAGE) code, and a UEI number from Dun and Bradstreet.
        - If you are based  outside of the United States  and do not pay employees within the United States, you do not need an EIN from the IRS. Prior to registering in SAM.gov you will need a NATO CAGE (NCAGE) code and UEI number from Dun and Bradstreet.

Legal Business Name and Banking Physical Address (entities must ensure that the physical address used is the same physical address used when establishing the primary banking account and that both addresses match) must be precise and MATCH EXACTLY when entering it into the IRS, D&B DUNS, NCAGE, and SAM.gov websites. Legal Business Name and Banking Physical Address given must be exactly the same—this includes spaces, parentheses, capitalization, small letters, punctuation, letters with accents or other features not commonly used in U.S. English should be avoided, etc.  A mismatch of information will cause validation to fail.

For further guidance on the registration process, please visit SAM.gov link: https://www.fsd.gov/fsd-gov/search_results.do?sysparm_search=KB0013221*or*https://uscontractorregistration.com/about-sam*/*

A complete guide to obtaining the registration (NCAGE, DUNS, and SAM.gov) may be found on DRL’s website:  https://www.state.gov/resources-for-programs-and-grants/.

An exemption from these requirements may be permitted on a case-by-case basis if:
        - An applicant’s identity must be protected due to potential endangerment of their mission, their organization’s status, their employees, or individuals being served by the applicant.

** Organizations requesting exemption from UEI or SAM.gov requirements must email the point of contact listed in the NOFO at least two weeks prior to the deadline in the NOFO providing a justification of their request.  Approval for a SAM.gov exemption must come from the warranted Grant Officer before the application can be deemed eligible for review. **

*Note:  Foreign organizations will be required to register with the NATO Support Agency (NSPA) to receive a NCAGE code in order to register in SAM.gov.  NSPA will forward your registration request to the applicable National Codification Bureau (NCB) if your organization is located in a NATO or Tier 2 Sponsored Non-NATO Nation.  As of October 2019, NATO nations included Albania, Belgium, Bulgaria, Canada, Croatia, Czech Republic, Denmark, Estonia, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Lithuania, Luxembourg, Montenegro, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Turkey, United Kingdom, and the United States of America.  As of October 2019, Tier 2 nations included Argentina, Australia, Austria, Brazil, Colombia, Finland, India, Indonesia, Israel, Republic of Korea, Malaysia, Morocco, New Zealand, Serbia, Singapore, Sweden, United Arab Emirates, and Ukraine.*

*NSPA and/or the appropriate NCB forwards all NCAGE code information to all Allied Committee 135 (AC/135) nations, which as of October 2019 also included Afghanistan, Belarus, Bosnia & Herzegovina, Brunei Darussalam, Chile, Egypt, Georgia, Japan, Jordan, North Macedonia, Oman, Peru, Qatar, Saudi Arabia, South Africa, and Thailand.  **All organizations are strongly advised to take this into consideration when assessing whether registration may result in possible endangerment.***

### C.   Eligible Applications

Technically eligible applications are those that:
        - Arrive electronically via SAMS Domestic or Grants.gov by the designated due date and time noted in the NOFO. If reasonable accommodations are granted for persons with disabilities or for security reasons, applications must still be received by DRL by the designated due date and time noted in the NOFO;
        - Are in English and all costs are in U.S. dollars. If an original document within the application is in another language, an English translation must be provided.  If any document is provided in both English and a foreign language, the English language version is the controlling version.  (Please note: the Department of State, as indicated in 2 CFR 200.111, requires that English is the official language of all award documents);
        - Heed all instructions contained in the NOFO and PSI, including length and completeness of application; and
        - Do not violate any of the guidelines stated in the NOFO and the PSI.

It is the sole responsibility of the applicant to ensure that all of the documents submitted in the grant application package are complete, accurate, and current.  **DRL strongly encourages all applicants, especially foreign or first-time applicants, to submit applications before the designated due date to ensure that the application has been received and is complete**.

### D.   Format Requirements

To be considered, all application documents should adhere to the below formatting guidelines:
        - All pages are numbered, including budgets and attachments;
        - All documents are formatted to 8 1⁄2 x 11 paper (U.S. letter size); and,
        - All documents are single-spaced, 12 point Times New Roman font, with 1-inch margins. Captions and footnotes may be 10 point Times New Roman font. Font sizes in charts and tables, including the budget, can be reformatted to fit within 1 page width.

### E.    Application Requirements

Complete applications must include the following:
        - Completed and signed  SF-424 ,  SF-424A , and  SF-424B  Please see SF-424 instructions below in Section 2B.
        - If your organization engages in lobbying the U.S. government including Congress, or pays for another entity to lobby on your behalf, the  SF-LLL  “Disclosure of Lobbying Activities” form is also required (only if applicable). Please see SF-LLL guidance in Section 2B.
        - Cover Page  (not to exceed one (1) page, preferably as a Word Document) that includes a table with the organization name, project title, target country/countries, project synopsis, and name and contact information for the application’s main point of contact. Please see  Cover Page  Section 2C below for a template and more details.
        - Executive Summary  (not to exceed one (1) page, preferably as a Word Document) that outlines project goals, objectives, activities, etc.
        - The executive summary should include a brief section that explicitly states (1) the problem statement addressed by the project, (2) research-based evidence justifying the unique project approach, and (3) quantifiable project outcomes and impacts.
        - Table of Contents  (not to exceed one (1) page, preferably as a Word Document) listing all documents and attachments, with page numbers.
        - Proposal Narrative  (not to exceed ten (10) pages, preferably as a Word Document). Please note the ten page limit  does not include  the Cover Page, Executive Summary, Table of Contents, Attachments, Detailed Budget, Budget Narrative, Audit, or NICRA.  Applicants are encouraged to combine multiple documents in a single Word Document or PDF (i.e. Cover Page, Table of Contents, Executive Summary, and Proposal Narrative in one file).  Please see  Proposal Narrative Guidelines  in Section 2F below for more details.
        - Budget  (preferably as an Excel workbook) that includes three (3) columns containing the request to DRL, any cost sharing contribution, and the total budget. A summary budget should also be included using the OMB-approved budget categories (see SF-424A as a sample) in a separate tab.  Costs must be in U.S. dollars.  Detailed line-item budgets for subgrantees should be included as additional tabs within the Excel workbook (if available at the time of submission).  Please see  Budget Guidelines  Section 2G below for more information.
        - DRL requests a programming approach dedicated to strengthening inclusive societies as a necessary pillar of strong democracies.  Please include cost associated with this commitment in the budget and budget narrative.
        - Budget Narrative  (preferably as a Word Document) that includes substantive explanations and justifications for each line-item in the detailed budget spreadsheet, as well as the source and a description of all cost-share offered. Please see  Budget Guidelines  Section 2G below for more information.
        - Your organization’s most recent  audit , if applicable. This should be a single audit program-specific audit or other audit in accordance with Generally Accepted Government Auditing Standards (GAGAS).  Please see  Audit  Section 2H below for more information.
        - Logic Model  (preferably as a Word Document). Please see  Logic Model  Section 2I below for more information.
        - Monitoring and Evaluation Narrative  (not to exceed four (4) pages, preferably as a Word Document). Please see  Monitoring and Evaluation Narrative  Section 2J below for more information.
        - Monitoring and Evaluation Plan  (preferably as a Word or Excel Document). Please see  Monitoring and Evaluation Plan  Section 2J below for more information.
        - Risk Analysis  (preferably as a Word Document). Please see  Risk Analysis  Section 2K below for more information.
        - Key Personnel  (not to exceed two (2) pages, preferably as a Word Document). Please include short bios that highlight relevant professional experience.  Given the limited space, CVs are not recommended for submission.
        - Timeline  (not to exceed one (1) page, preferably as a Word or Excel Document). The timeline of the overall proposal should include activities, evaluation efforts, and program closeout.
        - Gender Analysis  (not to exceed five (5) pages, preferably as a Word Document) that identifies and examines the relevance of gender norms and power relations in target countries and addresses how the organization will account for these dynamics throughout program design and implementation. The analysis should consider institutional practices and barriers, cultural norms, gender roles, access to and control over assets and resources, and patterns of decision-making.  In conflict settings, the gender analysis should examine how gender norms interact with other factors to drive or mitigate conflict, the differential impact of conflict on women and men, and an understanding of the roles of women and men in conflict, peacebuilding, and transitional processes.  A set of guiding questions can be found in Section L.
        - Security Plan  If applicable, please refer to the NOFO to see if this is required.
        - Contingency Plan  If applicable, please refer to the NOFO to see if this is required.
        - Lessons Learned  If applicable, please refer to the NOFO to see if this is required.
        - Psychosocial Assistance  If applicable, please refer to the NOFO to see if this is required.
        - Burma Due Diligence Assessment  If applicable, please refer to the NOFO to see if this is required.

**Applications that do not include the elements listed above will be deemed technically ineligible if required by the NOFO.**

### F.    Additional Application Documents

Strong applications will also contain the following:
        - Individual Letters of Support and/or Memorandum of Understanding. Letters of support and MOUs must be specific to the project implementation (e.g. from proposed partners or sub-award recipients) and will not count towards the page limit.

***Please refer to the application checklist and sample templates when submitting your application:******https://www.state.gov/resources-for-programs-and-grants/******.  The sample templates provided on the DRL website are suggested, but not mandatory.***

DRL reserves the right to request additional documents not included in this PSI.  Additionally, to ensure that all applications receive a balanced evaluation, the DRL Review Panel will review from the first page of each section up to the page limit and no further.

Note:  If ultimately provided with a notification of intent to make a Federal award, applicants typically have two to three weeks to provide additional information and documents requested in the notification of intent.  The deadlines may vary in each notification of intent and applicants must adhere to the stated deadline in the notification of intent.

***Additional Information Requested For Those Receiving Notification of Intent***

Successful applicants must submit after notification of intent to make a Federal award, but prior to issuance of a Federal award:
        - Written responses and revised application documents addressing conditions and recommendations from the DRL Review Panel;
        - If your organization has a NICRA and includes NICRA charges in the budget, your latest NICRA as a PDF file;
        - Completion of the Department’s Financial Management Survey, if receiving DRL funding for the first time;
        - Submission of required documents to register in the Payment Management System managed by the Department of Health and Human Services, if receiving DRL funding for the first time (unless an exemption is provided);
        - Other requested information or documents included in the notification of intent to make a Federal award or subsequent communications prior to issuance of a Federal award;
        - Applicants who submit their applications through Grants.gov will be required to create a SAMS Domestic account in order to accept the final award. Accounts must be logged in to every 60 in order to maintain an active account.

## SECTION II: Guidelines for Application Components

### A.   Office of Management and Budget (OMB) Regulations

The Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards set forth in 2 CFR 200 (Subparts A through F) shall apply to all non-Federal entities, except for assistance awards to Individuals and Foreign Public Entities.  Subparts A through E shall apply to all foreign organizations, and Subparts A through D shall apply to all U.S. and foreign for-profit entities.

The applicant/recipient of the award and any subgrantee under the award must comply with all applicable terms and conditions, in addition to the assurance and certifications made as part of the Notice of Award.  The Department’s Standard Terms and Conditions can be viewed at https://www.state.gov/bureaus-offices/under-secretary-for-management/bureau-of-administration/office-of-the-procurement-executive/.

### B.    SF-424 Forms

Organizations must fill out, sign, and submit SF-424, SF-424A, and SF-424B forms as directed on SAMS Domestic or Grants.gov.  **Please note that****all communications regarding the application will be directed to the points of contact identified on the SF-424 forms**.

#### I.  SF-424 Application for Federal Assistance:

Please refer to the following guidelines as you fill out the SF-424 form.  Complete all fields except where noted as “Leave Blank” below.
        - Type of Submission: Application.
        - Type of Application: New.
        - Date Received: Leave blank.  This will be assigned automatically.
        - Applicant Identifier: Leave blank.
        - a. Entity Identifier:  Leave blank.  b. Federal Award Identifier:  Leave blank.
        - Date Received by State:  Leave blank.  This will be assigned automatically.
        - State Application Identified:  Leave blank.  This will be assigned automatically.
        - a. Enter the legal name of the applicant organization.  Do NOT list abbreviations or acronyms unless they are part of the organization’s legal name.  b. Employer/Taxpayer ID Number:  Non-U.S. organizations that do not have an IRS EIN enter 44-4444444.  c. Enter organizational Unique Entity Identifier number (UEI) or DUNS Number.  e. Enter the headquarters address of the applicant.  f. Enter the name of the primary organizational unit (and department or division) that will undertake the assistance activity as applicable.  g. Enter the name, title, and all contact information of the person to be contacted on matters involving this application.  Please note this is the only person to receive updates on the submitted application.
        - Select an applicant type: Select the type of organization applying.
        - Enter: Office of Democracy, Human Rights and Labor
        - Select: 19.345.
        - Enter the Funding Opportunity Number and title. This title and number will already be entered on electronic applications.
        - Enter the Competition Identification Number and title. This number will already be entered on electronic applications.
        - Areas Affected by Project: Enter country or region intended for project.  Multiple countries may be entered for regional programs.
        - Enter the descriptive title of applicant’s project. Note, there is a 30 character limit including spaces.
        - a. Congressional districts of Applicant: Applicants based in the U.S. should enter congressional district. Foreign applicants should enter “90.”  b. All applicants should enter “70.”
        - Enter projected start date and projected end date. Refer to the funding opportunity for guidance on projected start dates.
        - a. Enter the amount requested for the project described in the full proposal under “Federal”;  b. enter any cost-share under “Applicant.” If not proposing cost-share, enter zeros.  c.-f. please enter zeros.  g. the total should automatically populate.
        - Select “c. Program is not covered by E.O 12372.”
        - Select the appropriate box. If the answer is “yes” to this question, provide an explanation.
        - Enter the name, title, and all contact information of the individual authorized to sign for the application on behalf of the applicant organization.

#### II. SF-424A Budget Information – Non-Construction Programs:

Please review the detailed instructions below BEFORE completing this form online.

***Please note:  The person who signs the SF-424A must have legal authority to do so on behalf of the organization*****.**

**Budget Summary**
        - Grant Program Function or Activity:  If not pre-populated, enter Democracy, Human Rights and Labor. Click Save.  Then click on the hyperlink under either “Grant Program Function or Activity” or the blue (i).
        - Catalog of Federal Domestic Assistance Number:  If not pre-populated, enter 19.345.
        - Federal (Unobligated):  Leave these fields blank.
        - Non-Federal (Unobligated):  Leave these fields blank.
        -  Federal (New/Revised):   Enter the  amount of federal funds requested  for this program.
        -  Non-Federal (New/Revised):   If voluntary cost-share is applicable, enter the  amount of any other funds the applicant will use  towards this program.
        -  Total:   If not pre-populated, enter the  total cost  of this program.

Click Save.

**Budget Categories**

**Object Class Categories A-K:**  Under the first column “Object Class Categories” click on each of the hyperlinked cost categories to enter the total cost for each class category for ‘Program (1)’.  In the total column, to the far right, the form should automatically show the sum.  Columns indicated for Program 2, 3, and 4 should be left blank.

**Object Class Categories Program Income:**  Enter 0.

Click Save.

**Non-Federal Resources***(Only complete this section if the proposal includes voluntary cost-share)*

Click the title under the Grant Program.

**Grant Program:**If not pre-populated, enter Democracy, Human Rights, and Labor.

**Applicant Column:**  If applicable, enter **cost-share** amount provided by the applicant.

**State Column:**  Leave blank.

**Other Sources Column:**  If applicable, enter the **cost-share** amount provided by other donors.

**Total Column:**  In the total column, to the far right, the form should automatically show the sum for **total amount for all non-federal resources**.

**Forecasted Cash Needs**

Forecasted Cash needs are the funds award recipients will withdraw from the Payment Management System (PMS) on an as needed basis.  Applicants may list their forecasted cash needs by year or leave it blank.*******(Forecasted cash needs by quarter are not required, only the total sum is necessary)*

**Federal Row:** Click on “Federal.”  Enter the total amount of **federal funds** requested for the program in the total column.

**Non-Federal Row:** Click on “Non-Federal.”  Enter the total amount of **non-federal funds, also known as cost-share,** you expect to expend during the program in the total column.

**Budget Estimates of Federal Funds Needed for Balance of the Program and/or Projects**

**Grant Program enter:**  Click the title entered.  If not pre-populated, enter Democracy, Human Rights, and Labor.

**First Year-Fourth Year Columns:**  Complete the estimated amounts for each year.

Click Save.

**Other Budget Information**

**Direct Charges:**Leave blank.

**Indirect Charges:** Leave blank.

**Remarks:**  Leave blank.

Click Save & Return.

#### III. SF-424B Assurances – Non-Construction Programs:

This form must be signed online in SAMS Domestic or Grants.gov.  All sections of this form must be filled out and signed.  Please note, public international organizations are required to sign the form in order to submit their proposal, but may submit an additional letter declaring the following:

“Our organization is a Public International Organization and therefore is not subject to any of the assurances and certifications referring to US law.”  Ensure the document is signed by an Authorized Official.  The Authorized Official is generally the grant signatory at the organization or business.

#### ****IV. SF-LLL Disclosure of Lobbying Activities (only if applicable):

The filing of an SF-LLL form is required pursuant to 31 U.S.C. 1352 for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action, such as the awarding of any Federal contract, the making of any Federal grant, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, or cooperative agreement.  This does not apply to payments of reasonable compensation to the extent that the payment is for agency and legislative liaison activities not directly related to a covered Federal action or for professional or technical services rendered directly in the preparation, submission, or negotiation of any bid, proposal, or application for a Federal contract, grant, or cooperative agreement or for meeting requirements imposed by or pursuant to US law as a condition for receiving a Federal contract, grant, or cooperative agreement.  Any person who fails to file the required disclosure may be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

### C.   Cover Page

****Applicants must submit a cover page (not to exceed one (1) page) that includes a table with the following information: