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					                  American Recovery and Reinvestment Act
           Energy Efficiency and Conservation Block Grants Program
                   State Government and Higher Education
                          Request for Proposal # 09-11
                         Application and Appendices




American Recovery and Reinvestment Act
Energy Efficiency and Conservation Block Grants Program: State Government and
Higher Education
Request for Proposals
Ohio Energy Office
77 S. High St. 26th Floor
P.O. Box 1001
Columbus, OH 43216-1001


                                   Proposal title:   Applicant name:


EECBG State and Higher Education                                       Page 1 of 37
                                                       CHECKLIST
Submit one original and two copies of this form and the following:
Please include all of the following forms, attachments, and exhibits in your application and initial that they
have been included:
Initial
Here      Name of Required Document
          Application Form
          Exhibit I – Planned activity or project and associated costs
          Exhibit II – Technical worksheet documentation, including completed Table 1, Table 2, Table 3, Table 4,
          Table 5, Table 6, Table 7, and Table 8, Table 9, and narratives
          Exhibit III – Contact Information Form
          Exhibit IV – Financial Liability and Certification
          Exhibit V – Budget Information and Explanation of Budget Categories
          Exhibit VI – Federal approved indirect cost rate agreement (if applicable)
          Exhibit VII – Assurances: Certification Regarding Lobbying; Debarment, Suspension, and Other
          Responsibility Matters; and Drug-Free Workplace Requirements; Nondiscrimination in Federally Assisted
          Programs; Non-Construction Programs
          Exhibit VII – Waste Stream Disposal
          Exhibit IX – Acknowledgement that you have read the Ohio Energy Office Audit Policy and have reviewed
          the following OMB Circulars for guidance:
          Units of Government: Circular # A-87, A-102, and A-133.
          Educational Institutions (higher education): Circular # A-110, A-21, and A-133.
                 These circulars can be found on the Office of Management and Budget (OMB) Federal website at:
          http://www.whitehouse.gov/omb/circulars/
          Exhibit X – Tax information Disclosure Authorization - completed and signed by applicant
          Exhibit XI – NEPA Compliance Form, EF-1 (if applicable)
          Attachment A – W-9 - completed and signed by applicant
          Attachment B – Vendor Information Form – Completed and signed by applicant
          Attachment C – Historic Preservation Compliance Form, Section 106 Review (if applicable)
          Attachment D – Extra NEPA Compliance Form, EF-1 (Only needed if you are proposing multiple activities
          that require NEPA compliance)
          Attachment E – Extra Planned Activity or project and associated (if needed)
          Attachment F – Extra Energy Savings/Displacement/Generation per Year, Table 5 (if needed)
          Attachment G – Finding of No Significant Impact (FONSI), Environmental Assessment (EA), or
          Environmental Impact Statement (EIS) Only include if you have been issued a FONSI, EA, or EIS
          Attachment H – Extra Job Creation Tables, Table 1, Table 2, Table 3, Table 4 (if needed)
          REQUIREMENTS:
          Davis-Bacon Compliance
          Buy-America Compliance
          DUNS Number, register at: http://fedgov.dnb.com/webform/displayHomePage.do
          CCR Registration, register at: https://www.bpn.gov/ccrupdate/NewRegistration.aspx. This will issue your
          Commercial And Government Entity (CAGE) code as well.




                                     Proposal title:           Applicant name:
EECBG State and Higher Education                                                      Page 2 of 37
                                          APPLICATION FORM

 Applicant Name:
 Company Legal Name: (if different from above)
 Address:
 City:                                               State:                                   Zip:                -
 Contact Person:                                                              Title:

 County:                                       Telephone:                                    Fax:

 E-Mail Address:                                                Website Address:

 Tax ID No:                                                    Congressional District:
 CAGE Code: (found at
 https://www.bpn.gov/CCR
 Search/Search.aspx)                                 DUNS #:                               NAICS #
 Business Type (as identified by CCR #):
 Employment Profile
   Job Creation: Complete Table 1: Job Creation Table. Enter total number of full and part-time jobs below.

   Current employment level as of July 1, 2009
   Total number of jobs created:
                           Full Time
                           Part Time

   Job Retention: Complete Table 2: Job Retention Table. Enter total number of full and part-time jobs below.
   Total number of jobs retained:
                           Full Time
                           Part Time
                      Current Goals:    Full Time:                                 Part Time:
 Employment Level Projected for June 30, 2011

As an authorized agent of the Applicant, I hereby submit this Application to the State of Ohio, Department of
Development, Ohio Energy Office. I understand that any false statement in this record may subject the Applicant and
Signer to criminal prosecution. I understand that additional information may be requested. I also understand that this
document in no way constitutes a commitment of funds by the State of Ohio for any of its programs.

I hereby represent and certify that the foregoing and attached information, to the best of my knowledge and belief, is true,
complete, and accurately describes the proposed activity/project for which the financial assistance is being sought. I am
aware of Ohio Revised Code Sections 9.66(C) and 2921.13(D)(1) which outline penalties for falsification which could
result in the return of all monies received and the forfeiture of all current and future financial assistance benefits as well
as a fine of not more than $1,000 and/or a term of imprisonment of not more than one hundred and eighty (180) days. I
further agree to inform the Ohio Department of Development of any changes in the foregoing information, which may
occur prior to the time the Applicant and the Ohio Department of Development execute an Agreement. Further, I hereby
authorize the Ohio Department of Development to contact the Ohio Environmental Protection Agency to confirm
statements contained within this application and to review applicable confidential records.

The undersigned warrants, certifies, and represents that certain information in their application may be subject to the
Open Public Records Act.



   Applicant Signature                        Typed Name                         Title                     Date

                                       Proposal title:        Applicant name:

EECBG State and Higher Education                                                          Page 3 of 37
                                            EXHIBIT I
                        Planned Activity and Associated Costs- Activity 1

APPLICANT INFORMATION
Name of Entity:

Applicant:                                State Government                           Higher Education

ESTIMATED FUNDING
Requested EECBG Funding
Applicant Funds (amount of leverage or match - if any)
Other (specify)
                                                                           Project Total
PROJECT INFORMATION
Project Title:
Project Location:
                                      Building or Structure is:
                                          50 years of age or older
                                          Listed on the National Register of Historic Places
Alteration of Structure or Site:
                                          Located in a historic district
                                      If you answered positively to any of the above questions, complete
                                      Attachment C - Historic Preservation Compliance Form
Projected Start Date:
Projected completion date:
                                          1. Development of an Energy Efficiency and Conservation Strategy
                                          2. Technical Consultant Services
                                          3. Residential and Commercial Building Energy Audits
                                          4. Energy Efficiency Retrofits
                                          5. Energy Efficiency and Conservation Programs for Buildings and
                                             Facilities
                                          6. Development and Implementation of Transportation Programs
                                             A. Flex time by employers
                                             B. Use of satellite work centers
                                             C. Development and promotion of zoning guidelines or
                                                 requirements that promote energy efficient development
                                             D. Synchronization of traffic signals
                                             E. State/locals/regional integrated planning activities with the goal
Activity Select only one*:
                                                 of reducing greenhouse gas emissions and vehicle miles
                                                 traveled (Complete NEPA Compliance Form, Exhibit XI)#
                                             F. Incentive programs to reduce commutes by single occupancy
                                                 vehicles (Complete NEPA Compliance Form, Exhibit XI)#
                                             G. Improvements in operational and system efficiency of the
                                                 transportation system (Complete NEPA Compliance Form,
                                                 Exhibit XI)#
                                             H. Idle-reduction technologies and/or facilities to conserve energy,
                                                 reduce harmful air pollutants, and greenhouse from freight
                                                 movement (Complete NEPA Compliance Form, Exhibit XI)#
                                             I. Installation of solar panels on interstate rights-of-way to
                                                 conserve energy in highway operations and maintenance
                                                 activities(Complete NEPA Compliance Form, Exhibit XI)#
                                             7. Building Codes and Inspections



                                    Proposal title:       Applicant name:

EECBG State and Higher Education                                                     Page 4 of 37
                                      8. Energy Distribution
                                         A. Combined heat and power
                                         B. Ground source heat pumps
                                         C. Cogeneration (Complete NEPA Compliance Form, Exhibit XI)#
                                         D. Energy storage systems (Complete NEPA Compliance Form,
                                             Exhibit XI)#
                                         E. Absorption chillers (Complete NEPA Compliance Form, Exhibit
                                             XI)#
                                         F. Desiccant humidifiers (Complete NEPA Compliance Form, Exhibit
                                             XI)#
                                         G. Micro turbines (Complete NEPA Compliance Form, Exhibit XI)#
                                         H. District heating and cooling systems (Complete NEPA Compliance
                                             Form, Exhibit XI)#
                                      9. Material Conservation Programs
                                      10. Reduction and Capture of Methane and Greenhouse Gases
                                          (Complete NEPA Compliance Form, Exhibit XI)#
                                      11. Traffic Signals and Street Lighting
                                      12. Renewable Energy Technologies on Government Buildings
                                         A. Solar PV
                                         B. Wind Turbine
                                         C. Solar Thermal Hot Water
                                         D. Biomass Thermal
                                         E. Fuel Cell (Complete NEPA Compliance Form, Exhibit XI)#
  Projected Energy Saved and/or
  Renewable Energy Generated       Savings:        Unit:     (kWh, therms, gallons, BTUs)
  (kWh/therms/gallons/BTUs)
  Projected GHG Emissions
                                          Number of CO2 Ton Equivalents
  Reduced (CO2 Ton Equivalents)
*If you are proposing more than one activity, complete additional sheets for each activity and attach as
         Attachment E.
# If you are proposing multiple activities that require NEPA Compliance FORM, EF-1, complete Attachment D




                                   Proposal title:     Applicant name:
EECBG State and Higher Education                                               Page 5 of 37
                                     EXHIBIT II
                     EECBG State Government and Higher Education
                                 Technical Worksheet
1.     PROJECT READINESS
       Provide documentation that will prove the readiness of the project. Information should
       document the engineering analysis and design of technology, and financial analysis is
       complete. Other information anticipated that includes third party vendor quotes to
       support project cost, internal capital budget appropriation, financing arrangements, etc.
       Provide a schedule or timetable of the major milestones associated with the project. If
       your government has an existing energy, climate, or other related strategy please
       attach and describe how this strategy helped to inform and prepare your project.
       Provide proof of regulatory approval or regulatory compliance, including copies of
       regulatory permits received to implement the project. Identify key staff responsible for
       the implementation of the project and the key staff responsible for the reporting of the
       project. Provide brief experiences and qualifications of each key staff.

2.     ECONOMIC IMPACT FOR OHIO
       Provide documentation on the number of all jobs created/retained, both direct and
       indirect. Provide documentation on Ohio component value of total project costs by
       dollars invested. Complete Tables 1, 2, 3, and 4.

3.     WORKER, COMMUNITY, AND/OR STUDENT EDUCATION
       Provide documentation on how the proposed work will enhance worker, community,
       and/or student education. Explain how the proposed program or project activity could
       be adopted or replicated by other agencies, or higher education entities, and explain
       your entity’s level of commitment to share lessons learned with others.

4.     COST EFFECTIVE MEASUREABLE ENERGY SAVINGS/GENERATION /EMISSION
       REDUCTIONS
       Complete Table 5 and provide documentation for project description and analysis.
       Show a “before” project implementation energy use and “after” state energy use for
       each activity and calculations to support the net energy savings identified. If multiple
       activities are proposed, complete additional sheets for each activity and attach as
       Attachment F and complete Table 6 listing NET savings of all activities.

5.     LEVERAGE/MATCH
       Include documentation that provides the expected match of grant funding. All cost
       share investments must be committed by an organization on letterhead, executed
       agreements/contracts and/or evidence of cash dedicated to the project.
       Documentation must support match amount. Match can include in-kind contribution
       (labor and direct benefits costs).

6.     BASE YEAR CONSUMPTION AND SUMMARY TABLES
       Complete Tables 7, 8, and 9.

All additional documentation provided in response to Technical Worksheet should be
attached as Exhibit II.


                                   Proposal title:   Applicant name:
EECBG State and Higher Education                                        Page 6 of 37
Installation Requirements:
Equipment installation must meet the following minimum requirements in order to qualify; proposed
deviations from the requirements will be considered, but they must be documented by the
Applicant or Installation Contractor and approved by Ohio Department of Development. These
requirements are not all encompassing and are intended only to address certain minimum safety
and efficiency standards:

A. Code Requirements
1. The installation must comply with the provisions of the National Electrical Code (NEC) and any
   other applicable local, state or federal codes or practices.
2. All required permits must be properly obtained and posted.
3. All required inspections must be performed (i.e., Electrical/NEC, Local Building codes
   Enforcement Office, etc.).

B: Equipment Information
1. Manufacturer(s):
2. Equipment model:
3. Efficiency Information:
2. Equipment Type:
3. Capacity Rating of each (KW, BTUH, etc):

C: Auxiliary Equipment
1. Type of Equipment: (absorption cooling, heat exchanger, etc. model number & capacity rating)


D: Warranty Information
1. Equipment:       Years
2. Equipment Installation:     Years
3. Parts and Labor       Years

Additional documentation provided in response to equipment should be attached as Exhibit II.


                                   Proposal title:   Applicant name:




EECBG State and Higher Education                                       Page 7 of 37
                                           EECBG State Government and Higher Education
                                                       Technical Worksheet
                                                              TABLE 1
                                                        JOB CREATION TABLE
                    A                             B                    C                  D              E                 G
                                                                                                                    Outside Training
                                              Hrs/Wk per            Wk/Yr per                                          Required
                Job Title                                                            Hourly Wage   # of Employees
                                              Employee              Employee
                                                                                                                     Yes        No
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                                                                                   FT:
                                                               Total
                                                                                                   PT:
Attach additional sheets if necessary
*Full Time Equivalent, FTE= 2080 hours per year
                                                  Proposal title:       Applicant name:


EECBG State and Higher Education                                                                                    Page 8 of 37
                                            EECBG State Government and Higher Education
                                                        Technical Worksheet
                                                             TABLE 2
                                                       JOB RETENTION TABLE
                    A                             B                    C                  D              E                 G
                                                                                                                    Outside Training
                                              Hrs/Wk per            Wk/Yr per                                          Required
                Job Title                                                            Hourly Wage   # of Employees
                                              Employee              Employee
                                                                                                                     Yes        No
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                                                                                   FT:
                                                               Total
                                                                                                   PT:
Attach additional sheets if necessary
*Full Time Equivalent, FTE= 2080 hours per year
                                                  Proposal title:       Applicant name:


EECBG State and Higher Education                                                                                    Page 9 of 37
                                            EECBG State Government and Higher Education
                                                        Technical Worksheet
                                                             TABLE 3
                                                  INDIRECT JOB CREATION TABLE
                    A                              B                    C                  D              E                 G
                                                                                                                     Outside Training
                                              Hrs/Wk per             Wk/Yr per                                          Required
                 Job Title                                                            Hourly Wage   # of Employees
                                              Employee               Employee
                                                                                                                      Yes        No
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                            FT:
                                            PT:
                                                                                                    FT:
                                                                Total
                                                                                                    PT:
Attach additional sheets if necessary
*Full Time Equivalent, FTE= 2080 hours per year
                                                   Proposal title:       Applicant name:


EECBG State and Higher Education                                                                                     Page 10 of 37
                                        EECBG State Government and Higher Education
                                                    Technical Worksheet
                                                         TABLE 4
                                              INDIRECT JOB RETENTION TABLE
                    A                          B                    C                  D              E                 G
                                                                                                                 Outside Training
                                         Hrs/Wk per              Wk/Yr per                                          Required
                 Job Title                                                        Hourly Wage   # of Employees
                                         Employee                Employee
                                                                                                                  Yes        No
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                        FT:
                                        PT:
                                                                                                FT:
                                                            Total
                                                                                                PT:
Attach additional sheets if necessary
*Full Time Equivalent, FTE= 2080 hours per year
                                               Proposal title:       Applicant name:

EECBG State and Higher Education                                                                                 Page 11 of 37
                                              EECBG State Government and Higher Education
                                                          Technical Worksheet
                                                 TABLE 5
                          ENERGY SAVINGS/DISPLACEMENT/GENERATION PER YEAR TABLE
       Activity Name:                         Energy Efficiency Measure                  Renewable Energy and Distributed Energy Measure
                                                                                                                            Renewable Energy
                                                                           Energy                                           Generated / Energy
                                         Before            After           Savings             Before              After        Displaced
Electricity
                              kWh
                              Cost
Natural Gas
              MMBTU (million BTU)
                              Cost

Coal
                           MMBTU
                              Cost

Other:
                           MMBTU
                              Cost

    Activity Summary Total
Total Energy Saved or
generated, displaced [MMBTU]
(1 kWh = 3412 Btu)
Total Value of Savings [$]
Total Implementation Cost [$]
Total Implementation Cost
Divided by Total energy Saved
or Generated, Displaced
($/MMBTU)
If you are proposing more than one activity, complete additional sheets for each activity and attach as Attachment F.
If there are multiple activities, complete Table 6, listing NET savings of all activities.
                                                          Proposal title:     Applicant name:
EECBG State and Higher Education                                                                                           Page 12 of 37
                                       EECBG State Government and Higher Education
                                                   Technical Worksheet

                                            TABLE 6
              NET ENERGY SAVINGS/DISPLACEMENT/GENERATION OF ALL ACTIVITIES PER YEAR
   Net Total of All Activities
Total Net Energy Saved or
generated, displaced [MMBTU]
(1 kWh = 3412 Btu) of all activities
Total Value of Savings [$]
Total Implementation Cost [$]
Total Implementation Cost
Divided by Total energy Saved
or Generated, Displaced
($/MMBTU)




                                           Proposal title:   Applicant name:




EECBG State and Higher Education                                                     Page 13 of 37
                                                EECBG State Government and Higher Education
                                                            Technical Worksheet
                                                   TABLE 7
                        ELECTRIC CONSUMPTION FOR BASE YEAR (INITITAL CONDITIONS) TABLE

                    Billing Period [Note 1]                                                       Energy Data [Note 1]

                 From                      To                    KWH             Measured Demand           Billed Demand   Total Cost


    1

    2

    3

    4

    5

    6

    7

    8

    9

   10

   11

   12

                        Annual Totals

        Notes:
           1. Initial conditions should be the baseline consumption of the facility.
           2. If utility data is not available, provide calculated baseline data in this table.

                                                            Proposal title:        Applicant name:

EECBG State and Higher Education                                                                                                  Page 14 of 37
                                               EECBG State Government and Higher Education
                                                           Technical Worksheet
                                             TABLE 8
                  NATURAL GAS CONSUMPTION FOR BASE YEAR (INITITAL CONDITIONS) TABLE

                                  Billing Period [Note 1]                                                Energy Data [Note 1]

                           From                              To                       Consumption (MCF)                         Total Cost

          1

          2

          3

          4

          5

          6

          7

          8

          9

          10

          11

          12

                                       Annual Totals

               Notes:
                  1. Initial conditions should be the baseline consumption of the facility.
                  2. If utility data is not available, provide calculated baseline data in this table.




                                                          Proposal title:        Applicant name:


EECBG State and Higher Education                                                                                                             Page 15 of 37
                                EECBG State Government and Higher Education
                                            Technical Worksheet
                                TABLE 9
     OTHER FUEL CONSUMPTION FOR BASE YEAR (INITITAL CONDITIONS) TABLE

                        Billing Period [Note 1]                                         Energy Data [Note 1]

                 From                              To                             Units:                  Total Cost


1

2

3

4

5

6

7

8

9

10

11

12

                             Annual Totals


     Notes:
        1. Initial conditions should be the baseline consumption of the facility.
        2. If utility data is not available, provide calculated baseline data in this table.




                                          Proposal title:        Applicant name:

EECBG State and Higher Education                                                                      Page 16 of 37
                                                  EXHIBIT III
                                           Contact Information Form

Applicant:
Certifying Officer                                           Chief Financial Officer

Name:                                                        Name:

Title:                                                       Title:

Address:                                                     Address:

City/State/Zip:                                              City/State/Zip:

Phone:                           Fax:                        Phone:                                   Fax:
E-mail                                                       E-mail
Address:                                                     Address:



Board Chair (if applicable)                                           List of Board Members/Title (if applicable)

Name:

Title:

Address:

City/State/Zip:


                     Check the appropriate box below and provide the names and total compensation of the five most
                     highly compensated officers of your organization on a separate sheet if the following applies:

                     In the applicant’s preceding fiscal year, the applicant received:

                             a.) 80 percent or more of its annual gross revenues from Federal contracts (and
                             subcontracts), loans, grants (and subgrants) and cooperative agreements; and

                             b.) $25,000,000 or more in annual gross revenues from Federal contracts (and
                             subcontracts), loans, grants (and subgrants) and cooperative agreements; and

                             c.) The public does not have access to information about the compensation of the senior
                             executives through periodic reports filed under section 13(a) or 15(d) of the Securities
                             Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d) or section 6104 of the Internal Revenue
                             code of 1986.

                         Does not apply

                         Applies (list attached)




                                          Proposal title:         Applicant name:

EECBG State and Higher Education                                                                          Page 17 of 37
                                                EXHIBIT IV
                                    Financial Liability and Certification

    Financial Liability:


    Explain any outstanding financial liabilities the applicant have with state or local governments
    in Ohio. Whether or not the amounts are being contested in a court of law, does the applicant
    owe:

        a.) Any delinquent taxes to the State of Ohio (the “State”), a state agency, or a political subdivision of the
            State such as a city or county?
                                                                                   Yes                  No


        b.) Any monies to the State or a state agency for the administration or enforcement of the environmental
        laws of the State?
                                                                                   Yes               No


        c.) Any other monies to the State, a state agency, or a political subdivision of the State that are past due?
                                                                                    Yes                  No


        d.) Is the entity subject of any existing tax lien?
                                                                                    Yes                 No


Certification:

Has the applicant, or any officers:
        a.) Been convicted of a felony
                                                                                    Yes                 No

        b.) Been convicted of or enjoined from any violation of state or federal securities law?
                                                                                    Yes                 No

        c.) Been a party to any consent order or entry with respect to an alleged state or federal securities law
        violation?
                                                                                   Yes                 No

        d.) Been a defendant in a civil or criminal action?
                                                                                    Yes                 No




If you have answered yes to any of the above, please provide a detailed explanation including, but not
limited, to the location, amounts, and case identification numbers (if applicable) on a separate sheet.

Government and Non-Profits: Provide a copy of the most recent audit report or annual report.


                                         Proposal title:      Applicant name:



EECBG State and Higher Education                                                                     Page 18 of 37
                                  Financial Liability and Certification

Financial Liability explanation:
a. If you answered yes, please explain:

b. If you answered yes, please explain:

c. If you answered yes, please explain:

d. If you answered yes, please explain:

Certification explanation:
a. If you answered yes, please explain:

b. If you answered yes, please explain:

c. If you answered yes, please explain:

d. If you answered yes, please explain:


                                      Proposal title:   Applicant name:




EECBG State and Higher Education                                          Page 19 of 37
                                              EXHIBIT V
                                           Budget Information


Applicant Name:

Proposed Project Date:        From:                          To:


SUMMARY OF BUDGET:


                       Budget Categories                 Budget Amount   Source of Funds
       1    Personnel
       2    Fringe Benefits
       3    Indirect Costs
       4    Travel/transportation
       5    Equipment
       6    Supplies
       7    Contractual/Subaward or Subrecipient
       8    Other Direct Costs
       9    Facility Assessment
      10.   Other (Identify)
                                                              $
            Total Budget Amount:                             -



Detail on each of the budget categories should be provided on the following pages titled Explanation
of Budget Categories attached.




                                   Proposal title:   Applicant name:



EECBG State and Higher Education                                                Page 20 of 37
EXPLANATION OF BUDGET CATEGORIES
1. PERSONNEL:
      Identify positions to be supported, under the proposed award. Key personnel should be identified by title. All other
      personnel should be identified either by title or a group category. State the projected amount of hours to be
      expended, the base pay rate, total direct personnel compensation and identify the rate basis (e.g. actual salary,
      labor distribution report, state civil rates, etc.).

                  Title          Hours        Pay Rate      Total Compensation         Rate Basis




                     Total personnel costs:   $

2. FRINGE BENEFITS:
      Calculate a fringe benefit rate based upon personnel costs. List the types of expenses included in the rate, e.g.
      FICA, Workers Compensation, unemployment, pensions, etc.

                                                            Total
                                           Percent of                    Personnel           Fringe
                  List of Expenses                         Percent   X                 =
                                             Cost                          Costs           Benefit Cost
                                                           of Cost




                                                         Total Fringe Benefit Costs:   $

3. INDIRECT COSTS:
   The budgeted amount equals the calculation of personnel costs times indirect cost rate. Attach a copy of the entity’s
   federally approved indirect cost rate as Exhibit VI (if applicable).
        Personnel Costs                       X Indirect Cost Rate      =   Indirect Costs



4. TRAVEL:
      Travel rules for grantees are governed by the lesser of the organization’s travel policy or the Federal travel rules.
      (www.gsa.gov)

       1. What travel rules is your organization governed by?
             State        Federal       Company/organizational

       2 . For all travel provide information in the tables below. Purpose of travel are items such as professional
            conferences, ODOD sponsored meetings, project management, local mileage etc. Foreign travel requires
            separate prior written grantor approval.




                                      Proposal title:        Applicant name:


EECBG State and Higher Education                                                                    Page 21 of 37
                                               No. of
                   Purpose of travel          Travelers        Cost Per Trip




                        Total travel costs:   $

5. EQUIPMENT:
     Generally defined as an item with an acquisition cost greater than $5,000 and a useful life expectancy of more than
     one year. Equipment purchase requires separate prior written grantor approval.

       List all of the proposed equipment below.

                    Equipment Item                Qty         Unit      Cost




                     Total equipment costs:       $

6. SUPPLIES:
      Generally defined as an item with an acquisition cost of $5,000 or less and a useful life expectancy of less than
      one year.

       Provide the information below for total supply costs that are greater than or equal to 20% of the total project costs
       or $25,000, whichever is greater.


            General Category                                  Total
              of Supplies             Qty.    Unit Cost       Cost     Justification of need




             Total cost of supplies                       $




                                       Proposal title:         Applicant name:


EECBG State and Higher Education                                                                   Page 22 of 37
 7. CONTRACTUAL/SUBAWARD:
      List all contractors used in the project and indicate the purpose of each contractor’s participation and the total
      estimated costs for each. Note: Board members and/or employees of the organization are not eligible for
      contractor services.

               Name/Organization              Purpose                             Total Projected Costs




                                                    Total Projected Costs:    $

8. OTHER DIRECT COSTS:
      Other direct costs are items of cost required for the specific project (such as meeting costs, postage, couriers or
      express mail, telephone/fax costs, printing costs, etc.), that cannot be properly included in the above categories.


        Provide the information below for other direct costs that are greater than or equal to 20% of the total project costs
        or $25,000, whichever is greater.


            General description              Cost                    Justification of need




                          Total of other direct costs:   $

9. FACILITY ASSESSMENT
   Enter costs for energy assessment.




10. OTHER (Identify)




                                       Proposal title:        Applicant name:




EECBG State and Higher Education                                                                    Page 23 of 37
                                                  EXHIBIT VI:
                                               Indirect Cost Rate


Attach a copy of the entity’s federally approved indirect cost rate as Exhibit VI (if applicable).




                                        Proposal title:         Applicant name:




EECBG State and Higher Education                                                                     Page 24 of 37
                                            EXHIBIT VII: ASSURANCES
      CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER
        RESPONSIBILTIY MATTERS; AND DRUG FREE WORKPLACE REQUIREMENTS


Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should
also review the instructions for certification included in the regulations before completing this form. Signature of this form provides for
compliance with certification requirements under 10 CFR Part 601 "New Restrictions on Lobbying," 10 CFR Part 606 "Governmentwide
Debarment and Suspension (Nonprocurement) and 10 CFR Part 607 “Governmentwide Requirements for Drug-Free Workplace
(Grants)." The certifications shall be treated as a material representation of fact upon which reliance will be placed when the Department
of Energy determines to award the covered transaction, grant, or cooperative agreement.

1.       LOBBYING
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, the making of any Federal 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.

(3)      The undersigned shall require that the language of this certification be included in the award documents for all subawards at all
         tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all
         subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into.
Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code.
Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than
$100,000 for each such failure.

2.       ADDITIONAL LOBBYING REPRESENTATION
Applicant organizations which are described in section 501(c)(4) of the Internal Revenue Code of 1986 and engage in lobbying activities
after December 31, 1995, are not eligible for the receipt of Federal funds constituting an award, grant, or loan.

As set forth in section 3 of the Lobbying Disclosure Act of 1995 as amended, (2 U.S.C. 1602), lobbying activities are defined broadly to
include, among other thins, contacts on behalf of an organization with specified employees of the Executive Branch and Congress with
regard to Federal legislative, regulatory, and program administrative matters.

Check the appropriate block:

The applicant is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986?                      No

If you checked “Yes” above, check the appropriate block:

The applicant represents that after December 31, 1995 it           has      has not engaged in any lobbying activities as defined in the
Lobbying Disclosure Act of 1995, as amended.




                                            Proposal title:          Applicant name:




EECBG State and Higher Education                                                                               Page 25 of 37
3.       DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS

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

         (a)      Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
                  covered transactions by any Federal department or agency;

         (b)      Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against
                  them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a
                  public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust
                  statutes or commission of embezzlement, theft, forgery, bribery. falsification or destruction of records, making false
                  statements, or receiving stolen property;

         (c)      Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local)
                  with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

         (d)      Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal,
                  State or local) terminated for cause or default.

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

4.       DRUG-FREE WORKPLACE

This certification is required by the Drug-Free Workplace Act of 1988 (Pub.L. 100-690, Title V, Subtitle D) and is implemented through
additions to the Debarment and Suspension regulations, published in the Federal Register on January 31, 1989, and May 25, 1990.

5.      SIGNATURE

As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications.

Name of Applicant:

Printed Name and Title of
Authorized Representative:




SIGNATURE                                                        DATE




                                            Proposal title:            Applicant name:



EECBG State and Higher Education                                                                                   Page 26 of 37
DOE F 1600.5                                             U.S. Department of Energy                                         OMB Control No.
(06-94)                                                                                                                        1910-0400
All Other Editions are Obsolete                           Assurance of Compliance

                                        Nondiscrimination in Federally Assisted Programs

                                                  OMB Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to Office of Information Resources Management Policy, Plans, and Oversight,
Records Management Division, HR-422 - GTN, Paperwork Reduction Project (1900-0400), U.S. Department of Energy, 1000
Independence Avenue, S.W., Washington, DC 20585; and to the Office of Management and Budget (OMB), Paperwork Reduction
Project (1900-0400), Washington, DC 20503.

                                                                                                     (Hereinafter called the “Applicant”)

HEREBY AGREES to comply with Title VI of the Civil Rights Act of 1964 (Pub. L.88-352), Section 16 of the Federal Energy
Administration Act of 1974 (Pub.L.93-275), Section 401 of the Energy Reorganization Act of 1974 (Pub.L.93-438), Title IX of the
Education Amendments of 1972, as amended (Pub.L.92-318, Pub.L.93-568, and Pub.L.94-482), Section 504 of the Rehabilitation Act
of 1973 (Pub.L.93-112), the Age Discrimination Act of 1975 (Pub.L.94-135), Title VIII of the Civil Rights Act of 1968 (Pub.L.90-284), the
Department of Energy Organization Act of 1977 (Pub.L.95-91), and the Energy Conservation and Production Act of 1976, as amended
(Pub.L.94-385) and Title 10, Code of Federal Regulations, Part 1040. In accordance with the above laws and regulations issued
pursuant thereto, the Applicant agrees to assure that no person in the United States shall, on the ground of race, color, national origin,
sex, age, or disability, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under
any program or activity in which the Applicant receives Federal assistance from the Department of Energy.

Applicability and Period of Obligation
In the case of any service, financial aid, covered employment, equipment, property, or structure provided, leased, or improved with
Federal assistance extended to the Applicant by the Department of Energy, this assurance obligates the Applicant for the period during
which Federal assistance is extended. In the case of any transfer of such service, financial aid, equipment, property, or structure, this
assurance obligates the transferee for the period during which Federal assistance is extended. If any personal property is so provided,
this assurance obligates the Applicant for the period during which it retains ownership or possession of the property. In all other cases,
this assurance obligates the Applicant for the period during which the Federal assistance is extended to the Applicant by the
Department of Energy.

Employment Practices
Where a primary objective of the Federal assistance is to provide employment or where the Applicant's employment practices affect the
delivery of services in programs or activities resulting from Federal assistance extended by the Department, the Applicant agrees not to
discriminate on the ground of race, color, national origin, sex, age, or disability, in its employment practices. Such employment
practices may include, but are not limited to, recruitment advertising, hiring, layoff or termination, promotion, demotion, transfer, rates of
pay, training and participation in upward mobility programs; or other forms of compensation and use of facilities.

Subrecipient Assurance
The Applicant shall require any individual, organization, or other entity with whom it subcontracts, subgrants, or subleases for the
purpose of providing any service, financial aid, equipment, property, or structure to comply with laws cited above. To this end, the
subrecipient shall be required to sign a written assurance form, however, the obligation or both recipient and subrecipient to ensure
compliance is not relieved by the collection or submission of written assurance forms.

Data Collection and Access to Records
The Applicant agrees to compile and maintain information pertaining to programs or activities developed as a result of the Applicant's
receipt of Federal assistance from the Department of Energy. Such information shall include, but is not limited to, the following: (1) the
manner in which services are or will be provided and related data necessary for determining whether any persons are or will be denied
such services on the basis of prohibited discrimination; (2) the population eligible to be served by race, color, national origin, sex, age,
and disability; (3) data regarding covered employment including use or planned use of bilingual public contact employees serving
beneficiaries of the program where necessary to permit effective participation by beneficiaries unable to speak or understand English;
(4) the location of existing or proposed facilities connected with the program and related information adequate for determining whether
the location has or will have the effect of unnecessarily denying access to any person on the basis of prohibited discrimination; (5) the
present or proposed membership by race, color, national origin, sex, age, and disability, in any planning or advisory body which is an
integral part of the program; and (6) any additional written data determined by the Department of Energy to be relevant to its obligation
to assure compliance by recipients with laws cited in the first paragraph of this assurance.

                                           Proposal title:           Applicant name:


EECBG State and Higher Education                                                                    Page 27 of 37
DOE F 1600.5                                                                                                               OMB Control No.
(06-94)                                                                                                                        1910-0400
All Other Editions are Obsolete


The Applicant agrees to submit requested data to the Department of Energy regarding programs and activities developed by the
Applicant from the use of Federal assistance funds extended by the Department of Energy, Facilities of the Applicant (including the
physical plants, building, or other structures) and all records, books, accounts, and other sources of information pertinent to the
Applicant's compliance with the civil rights laws shall be made available for inspection during normal business hours on request of an
officer or employee of the Department of Energy specifically authorized to make such inspections. Instructions in this regard will be
provided by the Director, Office of Civil Rights, U.S. Department of Energy.

This assurance is given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts (excluding
procurement contracts), property, discounts or other Federal assistance extended after the date hereto, to the Applicants by the
Department of Energy, including installment payments on account after such data of application for Federal assistance which are
approved before such date. The Applicant recognizes and agrees that such Federal assistance will be extended in reliance upon the
representation and agreements made in this assurance and that the United States shall have the right to seek judicial enforcement of
this assurance. This assurance is binding on the Applicant, the successors, transferees, and assignees, as well as the person(s)
whose signature appears below and who are authorized to sign this assurance on behalf of the Applicant.

Applicant Certification
The Applicant certifies that it has complied, or that, within 90 days of the date of the grant, it will comply with all applicable requirements
of 10 C.F.R. § 1040.5 (a copy will be furnished to the Applicant upon written request to DOE).

Designated Responsible Employee

                                                                                               (      )       -
 Name and Title (Printed to Typed)                                                             Telephone Number




 Signature                                                                                     Date




                                                                                               (      )       -
 Applicant’s Name                                                                              Telephone Number



 Address:                                                                                      Date




 Authorized Official:
 President, Chief Executive Officer
 or Authorized Designee

            ,                                                                                  (      )       -
 Name and Title (Printed to Typed)                                                             Telephone Number




 Signature                                                                                     Date




                                           Proposal title:            Applicant name:



EECBG State and Higher Education                                                                                     Page 28 of 37
                                            ASSURANCES - NON-CONSTRUCTION PROGRAMS
                                                                                                                          OMB Approval No. 0348-0040
 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:                            (Insert Name of
Proposer):

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 nineteen statutes or regulations specified in
   Appendix A of O.P.M.'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.
   33601 et seq.), as amended, relating to non discrimination 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 with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political
   activities of employees whose principal employment activities are funded in whole or in part with Federal funds.

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.

                                           Proposal title:            Applicant name:


EECBG State and Higher Education                                                                                      Page 29 of 37
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 (Clear 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 systems.

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 of
    1996, or 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.

Printed Name and Title of
Authorized Representative:


SIGNATURE                                                         DATE
                                                                                                Standard Form 424B (74/972)
                                                                                 Prescribed by OMB Circular A-1




                                    Proposal title:        Applicant name:




EECBG State and Higher Education                                                                   Page 30 of 37
                                             EXHIBIT VIII:
                                       Waste Stream Compliance


   Prior to the expenditure of Federal funds to dispose of sanitary or hazardous waste, the Recipient is required to
   provide documentation demonstrating that it has prepared a disposal plan for sanitary or hazardous waste
   generated by the proposed activities. Sanitary or hazardous waste includes, but is not limited to, old light bulbs,
   lead ballasts, piping, roofing material, discarded equipment, debris, asbestos, etc.

   The DOE Contracting Officer shall consider compliance with this clause complete only after the Recipient has
   submitted adequate documentation to DOE for its review, and DOE has provided written approval to the Recipient
   of its proposed plan to dispose of its sanitary or hazardous waste.

   Please explain how your project would dispose of sanitary or hazardous wastes:




                                    Proposal title:        Applicant name:




EECBG State and Higher Education                                                                   Page 31 of 37
                                             EXHIBIT IX:
                                    Ohio Energy Office Audit Policy
        The Ohio Energy Office (OEO) will follow Federal standards set forth in the U.S. Office of Management and
Budget issued Circular No. A-133, Audits of States, Local Governments, and Non-Profit Organizations, June 27, 2003.

        State and local governments, institutions of higher education, hospitals and other nonprofits organizations are
required to arrange for an audit of their financial operations, including compliance with all Federal laws and regulations
every year. Upon receipt of the annual audit performed by an independent auditor, grantees will be required to submit
a copy of the audit report to OEOE at the end of the current grant period. These audits reports will be reviewed by the
Ohio Department of Development Audit Office and, to the extent possible, will rely on the results of these grantee-
arranged audits.

         The OEO will employ the following guidelines in determining the audit requirements for non-profit agencies.
These are highlights of the Audits Policy (in some instances, the policy set forth by the OEO is more stringent than that
set forth in A-133).
      Single audits are generally required when an agency covered by the OMB Circular A-133 received more than
         $500,000 in Federal financial assistance. The grantees are required to send the OEO a copy of the annual
         agency-wide audit report for each of the agency’s fiscal years in which the grant is open. The independent
         auditor shall provide the reports on the grantee’s financial statements on legal compliance with the significant
         terms of the agreement, and on the grantee’s internal accounting and administrative controls.

       Agencies not covered by the Single Audit Act and receiving Federal financial assistance under $500,000, need
        not obtain an audit, but will continue to be monitored by the OEO and are required to perform an audit if one is
        requested.

       Federal financial assistance is defined as any assistance provided by a Federal agency to a recipient or sub-
        recipient to carry out a program. Such assistance my be in the form of: Grants, Contracts, Cooperative
        Agreements, Loans, Loan Guarantees, Property, Interest Subsidies, Insurance, Direct Appropriations, and
        Other Non-cash Assistance. Such assistance does not include direct Federal cash assistance to individuals.
        Such assistance included awards receive directly from the Federal agencies, or indirectly when sub-recipients
        receive funds identified as Federal funds by the recipients. The granting agency is responsible for indentifying
        the source of funds awarded to recipients; the recipient is responsible for identifying the source of the funds
        awarded to sub-recipients
       Agency-wide audits must be performed annually.

       Audits costs associated with A-133 are allowable costs of the Federal award.

       Auditors are to be selected in accordance with the procurement standards of OMB Circular A-110. These
        currently require competitive bidding for purchases in excess of $25,000.

     Auditors must meet GAO audits standards.
The Applicant certifies that it has reviewed the above audit policy and certifies that is has reviewed the following OMB
Circulars: Units of Government: Circular # A-87, A-102, and A-133. Educational Institutions (higher education): Circular
# A-110, A-21, and A-133.
        These OMB circulars can be found on the Office of Management and Budget (OMB) Federal website at:
        http://www.whitehouse.gov/omb/circulars/

Name of Applicant:



SIGNATURE                                                DATE




                                     Proposal title:        Applicant name:



EECBG State and Higher Education                                                                     Page 32 of 37
                                                 EXHIBIT X:
                TAX INFORMATION DISCLOSURE AUTHORIZATION



                                                               (the individual/company) hereby
      irrevocably authorizes the Tax Commissioner of the Ohio Department of Taxation or
      any agent designated by the Tax Commissioner of the Ohio Department of Taxation
      from the date below until           (one year from the date below) to disclose to the
      Director of the Ohio Department of Development or any designated employee of the
      Director the amounts of any or all outstanding liabilities for corporation franchise tax,
      individual income tax, employer withholding tax, sales, use tax or excise tax which are
      currently unpaid and certified to the Attorney General of the State of Ohio for collection.

      The Applicant expressly waives notice of the disclosure(s) to the Ohio Department of
      Development by either the Tax Commissioner of the Ohio Department of Taxation or by
      any agent designated by the Tax Commissioner of the Ohio Department of Taxation.
      The applicant expressly waives the confidentiality provisions of the Ohio law
      which would otherwise prohibit disclosure and agrees to hold the Department of
      Taxation and its employees harmless with respect to the limited disclosure
      authorized herein.

      This authorization is to be liberally interpreted and construed; any ambiguity shall be
      resolved in favor of the Tax Commissioner or the Ohio Department of Taxation. This
      authorization is binding on any and all heirs, beneficiaries, survivors, assigns,
      executors, administrators, successors, receivers, trustees, or other fiduciaries.

      A photocopy of this authorization is as valid as the original.


      Name of Applicant (including any DBA)




      Signed:

      Title:


      Date:



INSTRUCTIONS TO APPLICANT: Please fill in the Tax Identification Numbers on the next page.




                               Proposal title:       Applicant name:


EECBG State and Higher Education                                                    Page 33 of 37
     Applicant Full Legal Name and Address




Names and Addresses of any Affiliates

  (If necessary, attach a separate form for each
   affiliate listing each of the numbers set forth
                        below.)




        Federal Tax Identification Number




Ohio Franchise Tax I.D. Number or other Ohio Tax
                  I.D. Number




                                  Proposal title:    Applicant name:




EECBG State and Higher Education                                       Page 34 of 37
                                                            EXHIBIT XI:
                                              NEPA COMPLIANCE FORM, EF-1
If you are proposing multiple activities that require NEPA Compliance FORM, EF-1, complete Attachment D.
GO-EF1

                                       U.S. DEPARTMENT OF ENERGY
(2/06/02)

                                         GOLDEN FIELD OFFICE
                                     ENVIRONMENTAL CHECKLIST
                                  (To Be Completed by Potential Recipient)

PART I: General Information
                                                                                               Date:
Project Title:                                                                                 State:
Organization Name:

1. Please describe the intended use of DOE funding in your proposed project. For example, would the funding be applied to the
entire project or only support a phase of the project? Describe the activity as specifically as possible, i.e. planning, feasibility
study, design, data analysis, education or outreach activities, construction, capital purchase and/or equipment installation or
modification.




2. Does any part of your project require review and/or permitting by any other federal, state, regional, local, environmental, or
regulatory agency?     Yes      No



3, Has any review (e.g., NEPA documentation, permits, agency consultations) been completed?
    Yes     No If yes, is a finding or report available and how can a copy be obtained?



4. Is the proposed project part of a larger scope of work? Yes No If yes, please describe.
Do you anticipate requesting additional federal funding for subsequent phases of this project?
    Yes      No If yes, please describe.




5. Does the scope of your project only involve one or more of the following:
    Information gathering such as literature surveys, inventories, audits,
    Data analysis including computer modeling,
    Document preparation such as design, feasibility studies, analytical energy supply and demand studies, or
    Information dissemination, including document mailings, publication, distribution, training, conferences, and informational
programs.


Recipient Preparer:                            Recipient Phone:             Recipient Email:
Recipient Contact:                             Recipient Phone:             Recipient Email:




                                          Proposal title:           Applicant name:



EECBG State and Higher Education                                                                                  Page 35 of 37
PART II: Environmental Considerations
  Table A. Please indicate if any of the following conditions or special areas is present, required, or could be affected
           by your project:
Item                                                            Specific nature or type of activity or condition. If a
No. Description                                      Yes/No consultation, approval, or permit applies, please
                                                                describe.
1     Clearing or Excavation (indicate if greater
      than 1 acre)
2     Dredge and/or Fill. Specify the number of
      acres involved.
3     New or Modified Federal/State Permits
      And/or Requests for Exemptions
4     Pre-Existing Contamination

5      Asbestos

6      Criteria Pollutants

7      Non-Attainment Areas

8      Class I Air Quality Control Region

9      Navigable Air Space

10     Areas with Special Designation (e.g.,
       National Forests, Parks, Trails)
11     Prime, Unique or Important Farmland

12     Archeological/Cultural Resources

13     Threatened/Endangered Species and/or
       Critical Habitat
14     Other Protected Species (Wild Burros,
       Migratory Birds)
15     Floodplains

16     Special Sources of Groundwater (e.g., Sole
       Source Aquifer)
17     Underground Extraction/Injection (non-
       hazardous substances)
18     Wetlands

19     Coastal Zones

20     Public Issues or Concerns

21     Noise

22     Depletion of a Non-Renewable Resource

23     Aesthetics



                                     Proposal title:        Applicant name:

EECBG State and Higher Education                                                                    Page 36 of 37
    Table B. Would your project use, disturb, or produce any chemicals or biological substances? (i.e., pesticides,
                       industrial process, fuels, lubricants, bacteria) If not, skip to Section C.
           Please indicate if any of the materials or processes listed below applies.
Item Description                              Yes/No Quantity Permit                      Specific type, use, or condition
No.                                                                   required?
                                                                      Type?
1     Polychlorinated Biphenyls (PCBs)

2      Import, Manufacture, or Processing
       of Toxic Substances
3      Chemical Storage, Use, and
       Disposal
4      Pesticide Use

5      Hazardous, Toxic, or Criteria
       Pollutant Air Emissions
6      Liquid Effluent

7      Underground
       Extraction/Injection(hazardous
       substances)
8      Hazardous Waste

9      Underground Storage Tanks

10     Biological Materials. Indicate if
       genetically altered materials are
       involved

  Table C. Would your project require or produce any radiological materials? If not, skip to Table C.
           Please indicate if any of the materials listed below applies.
Item Description                             Yes/No Quantity Permit                   Specific nature of use
No.                                                                  required?
                                                                     Type?
1     Radioactive Mixed Waste

2      Radioactive Waste

3      Radiation Exposures




                                     Proposal title:        Applicant name:




EECBG State and Higher Education                                                                     Page 37 of 37
                                               Type?
1     Radioactive Mixed Waste

2      Radioactive Waste

3      Radiation Exposures




                                     Proposal title:         Applicant name:




EECBG State and Higher Education                                                                     Page 37 of 37

				
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