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Budget Information – Non-Construction Programs OMB Approval No

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Budget Information – Non-Construction Programs OMB Approval No Powered By Docstoc
					                                                                                                              OMB Number: 4040-0004
APPLICATION FOR FEDERAL ASSISTANCE SF-424                                                  Version 02        Expiration Date: 01/31/2012
 1. Type of Submission         Application
 2. Type of Application        New
3. Date Received:                                        4. Applicant Identifier: N/A
5a. Federal Entity Identifier: N/A                       5b. Federal Award Identifier: N/A
6. Date Received by State: N/A                           7. State Application Identifier: N/A
8. APPLICANT INFORMATION
                                         a. Legal Name: Applicantname
        b. Employer/Taxpayer Identification Number
                       c. Organizational DUNS:                You must provide a “DUNS” number unless you are applying as an individual.
                                                         (Individuals are exempt.) More info on DUNS is online at:
                                                         http://www.rurdev.usda.gov/or/bizgranthelp.htm
                               d. Mailing Address:
                Physical Address (if different):
            e. Organizational Unit (Department/Division):
f. Project Contact – name & contact information of person to be contacted on matters involving this application:
                                                 Name
                                                  Title
                       Organizational Affiliation
                               Telephone Number
                                        Fax Number
                                                 Email
9. Type of Applicant                                      Select only one & delete the others:
                                                         L. Individual
                                                         M. Profit Organization
                                                         N. Other (specify)
10. Name of Federal Agency                               USDA Rural Development
11. Catalog of Federal Domestic Assistance # (Title)     10.868 (REAP Feasibility Study Grant)
12. Funding Opportunity Number: N/A                      13. Competition Identification Number: N/A
14. Areas Affected by Project (Cities, Counties,
States, etc.):
15. Descriptive Title of Applicant’s Project                  e.g. “Feasibility Study of Wind Farm for XYZ Enterprises”
16. Congressional Districts of: a. Applicant:
                                    b. Project:
     17. Proposed Project:          a. Start Date:
                                    b. End Date:
18. Estimated Funding ($)
Source                          $ Amount                    Describe
a. Federal                               $                  REAP Grant (not to exceed the lesser of 25% of total cost or $50,000)
b. Applicant                             $
c. State                               $ -                  None (not permitted for this program)
d. Local                                 $
e. Other                                 $
f. Program Income                        $
g. TOTAL                                 $
19. Is Application Subject to Review By State                    b. Program is subject to E.O. 12372 but has
Under Executive Order 12372 Process?                             not been selected by the State of Oregon for
                                                                 review.
 20. Is the Applicant Delinquent On Any Federal
 Debt? (If “Yes”, provide explanation.)
 21. By signing this application, I certify 910 to the statements contained in the list of certifications * and (2) that the
 statements herein are true, complete and accurate to the best of my knowledge. I also provide the required
 assurances * and agree to comply with any resulting terms if I accept an award. I am aware that any false,
 fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S.
 Code, Title 218, Section 1001)

 I AGREE

 * The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the
 announcement or agency specific instructions.
 Authorized Representative
 Full Name:
 Title:
 Telephone Number:
 Fax Number:
 Email:



                                                                                         March 6, 2010
 Signature of Authorized Representative                                                  Date Signed
Authorized for Local Production                                                        Standard Form 424 (Revised 10/2005)
                                                                                          Prescribed by OMB Circular A-102
                                                                                                                   OMB Approval No. 0348-0040
                                       ASSURANCES - NON-CONSTRUCTION PROGRAMS

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
    NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
          awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances.
          If such is the case, you will be notified.

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

         1.   Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability
              (including funds sufficient to pay the non-Federal share of project cost) to ensure proper planning, management and
              completion of the project described in this application.

         2.   Will give the awarding agency, the Comptroller General of the United States and, if appropriate, the State, through
              any authorized representative, access to and the right to examine all records, books, papers, or documents related to
              the award; and will establish a proper accounting system in accordance with generally accepted accounting
              standards or agency directives.

         3.   Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents
              the appearance of personal or organizational conflict of interest, or personal gain.

         4.   Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.

         5.   Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed
              standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A
              of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).

         6.   Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of
              the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin;
              (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which
              prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.
              §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended
              (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
              Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the
              Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616),
              as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the
              Public Health Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentiality of
              alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
              amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination
              provisions in the specific statute(s) under which application for Federal assistance is being made; and, (j) the
              requirements of any other nondiscrimination statute(s) which may apply to the application.

         7.   Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance
              and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of
              persons displaced or whose property is acquired as a result of Federal or federally-assisted programs. These
              requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in
              purchases.

         8.   Will comply, as applicable, with provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the
              political activities of employees whose principal employment activities are funded in whole or in part with Federal
              funds.

  Previous Edition Usable                                                                                   Standard Form 424B (Rev. 7-97)
                                                    Authorized for Local Reproduction                     Prescribed by OMB Circular A-102
  9.   Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland
       Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C.
       §§327-333), regarding labor standards for federally-assisted construction subagreements.

  10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
      Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the
      program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.

  11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of
      environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
      Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands
      pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of
      project consistency with the approved State management program developed under the Coastal Zone Management
      Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State (Clean Air) Implementation Plans
      under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of
      underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (P.L. 93-523); and,
      (h) protection of endangered species under the Endangered Species Act of 1973, as amended (P.L. 93-205).

  12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components
      or potential components of the national wild and scenic rivers system.

  13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of
      1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the
      Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§469a-1 et seq.).

  14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, and
      related activities supported by this award of assistance.

  15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et seq.)
      pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other
      activities supported by this award of assistance.

  16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use
      of lead-based paint in construction or rehabilitation of residence structures.

  17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
      Amendments of 1996 and OMB Circular No. A-133, "Audits of States, Local Governments, and Non-Profit
      Organizations."

  18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations, and policies
      governing this program.


SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL                         TITLE




APPLICANT ORGANIZATION                                                       DATE SUBMITTED

Applicantname                                                                March 6, 2010

                                                                                         Standard Form 424B (Rev. 7-97) Back
                     ORGANIZATIONAL DOCUMENTS


Except for sole proprietors (individuals), each applicant must submit a copy of their
  entity’s legal organizational documents as appropriate to the entity type – e.g.,
           partnership agreement, articles of incorporation, by-laws, etc.
                                                  WORK PLAN
                                       REAP Feasibility Study Grant Application


Name of Applicant:
                                Applicantname




                                             (A) Applicant Eligibility


a. Are you an agricultural producer or a rural small business?
Explain which category describes the applicant and why – CANNOT be both:

The applicant is an agricultural producer because the applicant is directly engaged in the
production of agricultural products. Last year, 50% or more of the applicant’s gross income
was derived from these operations. This is documented in the attached tax return.
OR
The applicant is a rural small business. The project is “rural” as explained in part (B) below.
The business meets SBA “small business” criteria as explained in part (G) below.


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

The applicant is entirely owned by US citizens.
OR
The applicant fulfills this criteria as follows…


c. Are you delinquent on Federal debt?
Affirm that the applicant, including each individual owner, is not in delinquent. For entities, address this requirement for
each owner as well:

Neither the applicant nor any individual owner of the applicant is delinquent on Federal debt.


d. Are you debarred from receiving Federal assistance?
Affirm that the applicant, including each individual owner, is not debarred. For entities, address this requirement for each
owner as well:

Neither the applicant nor any individual owner of the applicant is debarred from receiving
Federal assistance.


e. Have you demonstrated financial need?
The applicant certifies that they have a demonstrated financial need for the grant being
sought. No additional documentation is required per RD Instruction 4280-B, §4280.109(b)(2),
though additional documentation can be provided upon request.




                                  (B) Proposed renewable energy system
                        A brief description of the proposed system the feasibility study will evaluate;



The project is for a renewable energy system as described below:

Renewable Energy Technology

Approx. Rated Power of System

Net-metered or Selling to Grid?

Brief Summary Description of
Project

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

The project will be located at    . This location is not within the boundaries of a Metropolitan
Statistical Area. The project’s physical address is shown below.

Physical Site Address:


2. Commercially available technology or pre-commercial technology?
“Commercially available” means, A system that has a proven operating history specific to the proposed application. Such
a system is based on established design, and installation procedures and practices. Professional service providers, trades,
large construction equipment providers, and labor are familiar with installation procedures and practices. Proprietary and
balance of system equipment and spare parts are readily available. Service is readily available to properly maintain and
operate the system. An established warranty exists for parts, labor, and performance.
(Foreign technology. If the system is only available outside the US, then applicants must provide authoritative evidence of
the foreign operating history, performance, and reliability in order to demonstrate its proven operating history. For a foreign
technology to be considered “commercially available”, the applicant must provide evidence that professional service
providers, trades, large construction equipment providers and labor are readily available domestically and that they are
familiar with installation procedures and practices, and that spare parts and service are readily available in the US to
properly maintain and operate the system. All warranties must be valid in the US.)
“Pre-commercial” means, Technology that has emerged through the research and development process and has technical
and economic potential for commercial applications, but is not yet commercially available.
3. Local or State resources to implement the project
Identify any local or state programs that could assist in the construction or operation of the facility. These programs will
benefit the applicant and/or proposed project during or after the facility is constructed and operational.




                                 (C) The feasibility study to be completed
 Describe the feasibility study to be conducted. An acceptable feasibility study must address Economic Feasibility, Market
      Feasibility, Technical Feasibility, Financial Feasibility, Management Feasibility, and Qualifications of the analyst.
   Applicants must require those conducting the feasibility study to consider and document within the feasibility study the
 important environmental factors within the planning area and the potential environmental impacts of the project for which
 the feasibility study is being conducted, as well as the alternatives considered. For full details of the required elements, see
   Appendix B to the Federal Register Notice dated May 26, 2009 – http://edocket.access.gpo.gov/2009/pdf/E9-12178.pdf




                                                     (D) Timeframe
                                  Timeframe for completion of the feasibility study.
                     NOTE: The study must be completed within 2 years of the REAP grant agreement.




                                     (E) Experience of feasibility analyst
  The experience of the company/individual completing the feasibility study, including the number of similar projects the
     company/individual has performed, the number of years the company has been performing a similar service, and
                                               corresponding resumes.




# years of experience in the filed
of study for the technology type
being proposed

     Attach resumes.



                               (F) Source of funds for the feasibility study
  This table only relates to the cost of the feasibility study, not the project itself. The source and amount of other project
funds needs to be clearly identified. Agency approved written documentation/confirmation from any third party committing
                                          a specific amount of such funds is required.
                   NOTE: A REAP grant cannot contribute more than 25% of the feasibility study cost.
          NOTE: Matching funds from other Federal sources or from the State of Oregon are NOT ALLOWED.

                                                             Status of funding                Contact for this funding
Funding Source                           Amount              (e.g, committed; application             source
                                                                    submitted; etc.)              (Name, phone, & email)
                                                                                            Don Hollis
REAP Feasibility Study                                           Application
Grant                                        $                                              541-278-8049 x129
                                                                 submitted
                                                                                            don.hollis@or.usda.gov
Applicant cash
contribution                                 $
                                             $
                                             $
                                             $
                                             $
TOTAL PROJECT COST                           $

         Attach bank statements, applications, correspondence, or other written documentation to
         prove the standing of the funding sources. Note that the REAP gives preference to
         projects that provide documentation to show a higher percentage of committed funds.


   Complete section “v” below only if applying as an agricultural producer – otherwise delete it.

      (G) AGRICULTURAL PRODUCER – Information for size determination
   (An “agricultural producer” is an applicant directly engaged in the production of agricultural products including crops,
  livestock, forestry products, hydroponics, nursery stock, or aquaculture, whereby 50% or more of their gross income is
                                                derived from the operations.)

The applicant is an agricultural producer because the applicant is directly engaged in the
production of agricultural products. Last year, 50% or more of the applicant’s gross income
was derived from these operations. This is documented in the attached tax return.

The applicant-business is engaged in the
following type(s) of agricultural
production:

As demonstrated below, and as further demonstrated in last year’s tax returns (provided
elsewhere in this application), 50% or more of the applicant’s gross income is derived from
the production of agricultural products, including crops, livestock, forestry, hydroponics,
nursery stock, or aquaculture:

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



          Complete this section only if applying as small business – otherwise delete it.

                (G) SMALL BUSINESS – Information for size determination
               (A “small business” is an applicant who meets the Small Business Administration SBA size standards.)

The applicant is a rural small business. The business meets SBA “small business” criteria
as set forth below.


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

NAICS category description


b. Small Business Administration (SBA) size standard for this NAICS Category
The SBA size standard for your NAICS category is either based on annual receipts or employees. You can look up your
NAICS code and SBA size standard at: http://www.sba.gov/size/sizetable2002.html
Total annual gross receipts
                                     $
Total number of employees


As demonstrated in the tables below, and as further demonstrated in last year’s tax returns
(provided elsewhere in this application), the applicant business meets the SBA size standard:


c. Total Annual Gross Receipts
Name of Business Entity       Relation-ship       NAICS         Total annual gross  Year of these          Source of data
                               to applicant        Code             receipts in       receipts
                                                               immediately previous
                                                                       year
Applicantname                 Applicant                                   $                                Tax returns
                               Parent                                     $
                              company
                              Subsidiary                                  $
                               Affiliate                                  $
                                                                          $
           Total                                                          $
 d. Total Employees
 Name of Business Entity              Relationship       NAICS Code           # employees in immediately                Year
                                      to applicant                                  previous year
 Applicantname                         Applicant
                                        Parent
                                       company
                                      Subsidiary
                                        Affiliate

               Total



                                         (H) Intergovernmental review
    Provide any Intergovernmental review comments from the State Single Point of Contact, or evidence that the State has
                             elected not to review the program under Executive Order 12372.



 Not applicable in Oregon




                                                     (I) Certification
 A certification that the applicant has not received any other Federal or State assistance for a feasibility study for the subject
                                                    renewable energy system.



The undersigned has applied for grant assistance from USDA Rural Development’s Rural
Energy for America Program (REAP).

It is hereby certified by the applicant has not received any other Federal or State assistance for a
feasibility study for the subject renewable energy system.

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




                                                                             March 6, 2010
 (signature)                                                                 (date)


 (name & title)

				
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