CANTON LOCAL DEVELOPMENT CORPORATION APPLICATION FOR CANTON

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					                    CANTON LOCAL DEVELOPMENT CORPORATION




        APPLICATION FOR CANTON BUSINESS LOAN FUND ASSISTANCE




CLDC Contact:          Linda McQuinn
                       Canton Office of Economic Development
                       60 Main Street
                       Canton, New York 13617
                       Telephone: (315) 386-2871 Ext. 5
                       Fax: (315) 386-1361
                       E-Mail: developer@cantonnewyork.us



 The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on
  the basis of race, color, national origin, age disability, and where applicable, sex, marital status, familial
status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because
   all or part of an individual’s income is derived from any public assistance program. (Not all prohibited
bases apply to all programs.) Persons with disabilities who require alternative means for communication of
 program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET center at 202-
720-2600 (voice and TDD). To file a complaint of discrimination write to USDA, Director, Office of Civil
   Rights, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call 800-795-3272 (voice) or
                 202-720-6382 (TDD). USDA is an equal opportunity provider and employer.



C:\personal\CLDC\CLDC Business Loan Fund Application v9-7-07.DOC
9/7/07
                                CANTON BUSINESS LOAN FUND

The Canton Business Loan Fund (BLF) is designed to assist very small businesses with capital for startups or
expansion.

Eligible borrowers include private for-profit and not-for-profit business organizations with ten or fewer full time
equivalent employees. Borrower’s principal place of business must be located in the Town of Canton including the
villages of Canton and Rensselaer Falls. All businesses must be owned by U.S. citizens or permanent residents of
the United States.

Loan funds may be used for legal activities only - including working capital, real estate development, machinery and
equipment, furniture and fixtures, or other business uses. Loan funds may not be used for agricultural production,
churches and fraternal organizations, golf courses, racetracks or gambling facilities or for real estate rentals, refi-
nancing, or down payments.

Loan funds are expected to be used for the financing of new businesses or the expansion of existing businesses.
The use of loan funds should result in the creation of new employment.

Applicants must also demonstrate that the business is not using Canton BLF as a substitute for available private
sector funds. Co-lending with a bank or other lender, however, is possible. Collateral is required, and applicants will
be asked to sign a personal guarantee of the loan.

Applicants will also be asked to discuss how their application furthers the general goals of improving the community,
by for example, improving a property, remediation of an environmental problem, creating jobs with benefits, providing
a new good or service to the community, strengthening downtown areas, or some other benefit. The purpose of this
is not to limit a business from applying, but rather to more effectively use limited loan funds to strengthen the Canton
economy.

Applicants must not have a conflict of interest with the Canton Local Development Corporation, however, members
of the Canton Local Development Corporation may be eligible for funding provided that the member/applicant does
not participate in any CLDC board discussions pertaining to their own request and that any loan made to such
applicant must be approved by 100% of the remaining members of the CLDC board. Applicants must also not be
delinquent on any state or federal obligation .

The interest rate to be charged by the Canton Business Loan Fund will be a fixed rate and will be determined based
on the date that loan documents (promissory notes, collateral agreements, etc.) are signed. The rate will be the
Prime Rate (listed as “Bank Prime Loan” in Federal Reserve Statistical Release H15) ten business days prior to the
signing less one percentage point. In the event that that Bank Prime Rate is less than three percent (3%), the loan
rate will be fixed at two percent. (http://www.federalreserve.gov/releases/H15/data.htm)

The maximum loan available will be in the amount of $30,000 and will be further limited to a maximum of 50% of total
project cost, with a borrower equity requirement of 10% of total project cost. The remaining costs may consist of
borrowings from other entities.

Completed applications, along with supporting documents, are submitted to the Office of Economic Development.
Staff of the Office will review the documents for completeness and schedule a meeting of the Loan Committee.
Applicants attend a loan committee meeting to answer questions about their application and business plan. The loan
committee will make a recommendation to the Canton Local Development Corporation (LDC), a public, non-profit
organization that has final approval of loan applications. If the LDC approves the loan, a closing is scheduled for the
signing of the loan agreement, personal guarantee, and other loan documents. The loan review process can
generally be completed in less than a month.

The Canton BLF is capitalized with funds from the U.S. Department of Housing and Urban Development. As federal
funds are involved, certain restrictions apply. If loan funds are used toward construction work, including only a
portion of construction work, Davis-Bacon prevailing wage rates for construction work apply. Prevailing wage rates
are generally higher than typical wage rates. Also, projects involving alterations to buildings on or eligible for-the
National Register of Historic places are subject to possible conditions by the State Historic Preservation Office.

If you have questions about the Canton BLF please do not hesitate to contact the Canton Office of Economic
Development at (315) 386-2871 Ext. 5.                  2
                                     CHECKLIST OF SCHEDULES

                         Not         Not
               Included Included    Applicable

               _______ _______ ________          Schedule "A" - Business Name and Form

               _______ _______ ________          Schedule "B" - Principals and Officers

               _______ _______ ________          Schedule "C" - Resumes

               _______ _______ ________          Schedule "D" - Personal Financial Statements & Tax Returns

               _______ _______ ________          Schedule "E" - Bankruptcy, Litigation, Felony History

               _______ _______ ________          Schedule "F" - Physical Description of Project

               _______ _______ ________          Schedule "G" - Business Plan

               _______ _______ ________          Schedule "H" - Employment Plan

               _______ _______ ________          Schedule "I" - Project Costs and Financing Sources

               _______ _______ ________          Schedule "J" - Profit & Loss Statements/Balance Sheets

               _______ _______ ________          Schedule "K" - Outstanding Debt Details

               _______ _______ ________          Schedule "L" - Projected Profit & Loss Statements

               _______ _______ ________          Schedule "M" - Projected Cash Flow Statement

               _______ _______ ________          Schedule "N" - Bank References

               _______ _______ ________          Schedule "O" - Security Collateral

               _______ _______ ________          Certification and Authorization to Release Credit Information

                _______ _______     ________     Form NCA IA “Race/Ethnicity Disclosure”

               _______ _______ ________          NYS Environmental Assessment Form

               _______ _______ ________          Federal Form 1940-20 “Request for Environmental Information”




C:\personal\CLDC\CLDC Business Loan Fund Application v9-7-07.DOC
9/7/07
                           DESCRIPTION OF SCHEDULES


SCHEDULE "A" - BUSINESS NAME AND FORM

Indicate legal name, address, telephone number and Federal Employment Identification
Number if available. Indicate form of Business, (corporation, partnership, sole proprietorship)
year of organization, Federal Tax Identification Number, New York State Unemployment
Insurance Identification Number and Standard Industry Classification (SIC) Code .

SCHEDULE "B" - PRINCIPALS AND OFFICERS

Indicate names and addresses including percentage of ownership of all principals and officers.

SCHEDULE "C" - RESUMES

Attach resumes of principals including date of birth, business experience, length of association
with business, salary, other compensation and outside directorships and business affiliations.

SCHEDULE "D" - PERSONAL FINANCIAL STATEMENTS (SCHEDULE INCLUDED) & TAX
RETURNS

Provide personal financial statements for each proprietor, partner, officer, and stockholder with
ten percent or more ownership in the business. Also include copies of personal tax returns for
the last three years for each personal financial statement.

SCHEDULE "E" - BANKRUPTCY, LITIGATION, FELONY HISTORY (SCHEDULE INCLUDED)

Describe any bankruptcy history, litigation history having a material effect on the business
solvency, or convicted felony activity associated with the owners, management, or officers of the
business.

SCHEDULE "F" - PHYSICAL DESCRIPTION OF PROJECT

Indicate the address of the project and provide a narrative description of the physical
components of the business or project. Please attach diagrams and pictures if relevant.

SCHEDULE "G" - BUSINESS PLAN

Describe in detail the history of the business, location of business, management, market and
competition. Include significant developments in operation and financial condition.

SCHEDULE "H" - EMPLOYMENT PLAN (SCHEDULE INCLUDED)

Information regarding the types, number and wage levels of current and anticipated positions
must be provided for new and existing businesses.

SCHEDULE "I" - PROJECT COSTS AND FINANCING SOURCES

Provide details on total project costs and sources of financing. All costs associated with the
project should be supported by third party quotations, purchase offers, appraisals, contractors
estimates or similar documentation as is appropriate. Explain how each component of the
project will be financed, including the use of a loan through these Programs. Indicate the order
                                             4
of lien preference and all sources of financing (include participants, amounts, percent of total,
interest rate, and term). IN ALL CASES, where other lenders are proposed in the capital
structure of the project, attach commitments from banks or other lending institutions. Where
funding from these programs are the only lending source, provide documented evidence of the
unavailability of other funding.

SCHEDULE "J" - PROFIT AND LOSS STATEMENTS/BALANCE SHEETS

For existing businesses, provide profit and loss statements and balance sheets for the last three
fiscal years. Statements must include or be accompanied by separate expense schedules for
Cost of Goods Sold, Selling and General Administrative Expenses, including depreciation,
salaries, and dividends. If the most recent available statements are more than ninety (90) days
old, interim statements must be provided. Where the request represents a refinancing, or where
the business exhibits a degree of financial distress, an aging of accounts payable and
receivable should be provided. Provide business income tax returns for the last three years.

SCHEDULE "K" - OUTSTANDING DEBT DETAILS (SCHEDULE INCLUDED)

Describe outstanding debt for the business including installment loans, notes and mortgages
payable, and capitalized leases showing to whom payable, balance, interest rate, maturity date,
monthly payment, security, and whether current or delinquent. A form for the completion of this
schedule is provided herewith. Notes to existing financial statements are also sufficient
satisfaction of this requirement.

SCHEDULE "L" - PROJECTED PROFIT AND LOSS STATEMENTS

Provide projected profit and loss statements for three years in the same format as Schedule "K".
Statement must include projected interest payments and depreciation expenses. Describe
assumptions on which projections were based. The projections should be supported by and be
relevant to the narrative contained in Schedule H. Note: Different programs require projections
for different numbers of years into the future. It is important to consult program representatives
before investing in the development of financial projections.

SCHEDULE "M" - PROJECTED CASH FLOW STATEMENT

Provide projected cash flow statements, by month, for the first year of operation of the project.
Note: Different programs require projections for different numbers of years into the future. It is
important to consult program representatives before investing in the development of financial
projections.

SCHEDULE "N" - BANK REFERENCES

Provide bank references including name, address, telephone number and contact person.

SCHEDULE "O" - SECURITY COLLATERAL

List any additional collateral (such as land, buildings, machinery, equipment) available for
security. Indicate cost, net book value (cost less depreciation), an estimate of present market
value and present loan balance. For each item of collateral listed, provide a description of all
associated liens thereon.




                                              5
                                                                 Schedule “D”
                                                           PERSONAL FINANCIAL STATEMENT
                                                                    As of :

Complete this form for: (1) each proprietor, or (2) each limited partner who owns 20% or more interest and each general partner, or (3) each stockholder owning 20% or
more of voting stock and each corporate officer and director, or (4) any other person or entity providing a guaranty on the loan.
Name                                                                                      Business Phone
Residence Address                                                                       Residence Phone:
City, State, & Zip Code
Business Name of Applicant/Borrower

ASSETS                                      (Omit Cents)                                LIABILITIES                                   (Omit Cents)
Cash on hands & in Banks                    $                                           Accounts Payable                              $
Savings Accounts                            $                                           Notes Payable to Banks and Others             $
IRA or Other Retirement Account             $                                                       (Describe in Section 2)
Accounts & Notes Receivable                 $                                           Installment Account (Auto)                    $
Life Insurance-Cash Surrender Value Only $                                                          Mo. Payment $
           (Complete Section 8)                                                         Installment Account (other)                   $
Stocks and Bonds                            $                                                       Mo. Payment $
           (Describe in Section 3)                                                                  Loan on Life Insurance            $
Real Estate                                 $                                           Mortgages on Real Estate                      $
           (Describe in Section 4)                                                                  (Describe in Section 4)
Automobile-Present Value                    $                                           Other Liabilities                             $
Other Assets                                $                                           (Describe in Section 7)
           (Describe in Section 5)                                                                  Total Liabilities                 $                       0.00
                                                                                        Net Worth                                     $


                                  Total     $                         0.00                                                  Total     $                       0.00
Section 1. Source of income                                                             Contingent Liabilities
Salary                                      $                                           As Endorser or Co-Maker.                      $
Net Investment Income                       $                                           Legal Claims & Judgments                      $
Real Estate Income                          $                                           Provision for Federal Income Tax              $
Other Income (Describe below)*              $                                           Other Special Debt                            $


Description of Other Income in Section 1.


____________________________________________________________________________________________________________________________________
Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.
Section 2. Notes Payable to Banks and Others.
Name and Address of Noteholder(s)        Original                 Current               Payment                 Frequency             Security Collateral
                                         Balance                  Balance               Amount              (monthly, weekly, etc.)




                                                                                    7
Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Number of Shares         Name of Securities                Cost         Market Value                           Date of                               Total Value
                                                                        Quotation/Exchange                 Quotation/Exchange
                                                                                                                                                                   0.00

                                                                                                                                                                   0.00

                                                                                                                                                                   0.00

                                                                                                                                                                   0.00

                                                                                                                                                                   0.00

                                                                                                                                                                   0.00

Section 4. Real Estate Owned.                                                    (List each parcel separately. Use attachments if necessary. Each attachment must be
identified as a part of this statement                                                                                     and signed.)
                                                        Property A                                   Property B                                    Property C
Type of Property
Name &
Address of Title Holder

Date Purchased

Original Cost

Present Market Value
Name &
Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per Month/Year

Status of Mortgage
Section 5. Other Personal Property and Other Assets. (Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of
payment, and if delinquent, describe delinquency).




Section 6. Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches).




Section 7. Other Liabilities. (Describe in detail).




Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies, name of insurance company and beneficiaries).




I authorize the Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the
statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or
guaranteeing a loan.

Signature: ___________________________________________             Date:                             Social Security Number:

Signature: ___________________________________________ Date:                                         Social Security Number:



                                                                                     8
                      SCHEDULE “E”
       BANKRUPTCY, LITIGATION AND FELONY HISTORY

Describe any bankruptcy history, litigation history having a material effect on the
business solvency, or convicted felony activity associated with the owners, management,
or officers of the business.

1. Are any of the officers, owners, or management of the business presently under
indictment, on parole, or probation?         Yes              No

If yes, describe:



2. Have any of the owners, officers, or management of the business ever been charged
with or arrested for any criminal offense other than a minor traffic infraction?
Yes                     No

If yes, describe:




3. Have any of the owners, officers, or management of the business ever been convicted
of any criminal offense, other than a minor traffic infraction? Yes       No

If yes, describe:




4. Has the business, its present owners, officers, or management ever been the subject of
bankruptcy proceedings?        Yes            No

If yes, describe:




Signed, ______________________________________________




                                      9
                                                  SCHEDULE “G”
                                                  BUSINESS PLAN

Description of the Business

         Describe the business including history if an existing business. Please be sure to include descriptions of the
following: type of business; status of business; when did (will) it start; hours of operation; who are your customers;
why is your business successful (will succeed); and any seasonal fluctuations in sales or employment. Include
significant developments in operation and financial condition. Indicate current number and titles of employees for
business startups, describe how the background of the principals will contribute to the success of the new business.

         If applicable, indicate the names and addresses of all concerns that may be parent companies, subsidiaries, or
affiliates of the business including concerns in which the business, or any of its principals, hold an interest greater than
ten (10%) percent.

Location of the Business

        Describe the location of the business and be sure to include information about the following: physical address
of business; is site leased or owned; physical features and characteristics of the site including size and use of space;
description of neighborhood and surrounding businesses; any renovations needed; and the reason for choosing this
location.

Management

        Describe the business background, management experience, and education for each key partner or key
manager with 10% or greater interest in the business. Include both formal and informal learning experience which have
a bearing on your managerial abilities.

        Include a description of the following: why this type of business was chosen; direct operational and/or
managerial experience in this type of business; organizational structure (including a description of who does what);
time devoted to running the business; and local resources available to management.

Market

         Describe in detail who exactly is your market; where your market is located; present size and growth potential
of the market; and the price you anticipate getting for your product or service. Also include information on how you
will attract and keep your segment of the market (including advertising); how you will promote your product or
service; trends in your industry; future goals; and how the business can expand.

        Describe business objectives in terms of production, sales, and earnings for the proposed business or project.
An emphasis should be placed on describing the specific marketing actions that the business will take to meet its
projected earnings in its competitive environment. Include letters of intent from prospective suppliers or any firm
contracts for your business. This schedule should be supported by the projections contained in later schedules.

Competition

         Describe in detail who your competition is and include information on the following: what products/services
they offer; where their business and market are located; what their reputation or image is; what their marketing
strategies are and how their business is doing. Also discuss how your operation will be different and what you have
learned from watching them.



                                                            10
                                         SCHEDULE “H”
                                       EMPLOYMENT PLAN



             A                           B              C           D            E            F           G

         Job Title                  Annual or       Current        Jobs       Jobs          Jobs        Total
                                     Hourly         Number       Created     Created:     Created     Jobs to be
                                     Wages             of         : Year      Year         : Year      Created
                                                    Positions       One        Two         Three
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0
                                                                                                            0




                                                        0            0          0             0             0
TOTALS:
                                               Instructions:
 1.   Column A: Insert the job titles that exist within the company at the time of application, as well as any job
      titles that will be established as a result of the project.

 2. Column B: Indicate the entry level wage for each listed job title either in terms of hourly pay or annual
 salary.

 3.   Column C: For each listed job title insert the number of positions that exist at the time of application.

 4.   Column D: Insert the number of jobs to be created during year one of the project for each listed job title.

 5.   Column E: Insert the number of jobs to be created during year two of the project for each listed job title.

 6.   Column F: Insert the number of jobs to be created during year three of the project for each listed job title.

 7.   Column G: Indicate the total number of jobs to be created for each listed title as a result of the project.
      (Column D + Column E + Column F = Column G)

 8.   Use as many copies of this form as necessary.



                                                      11
                                   SCHEDULE “K”
                             OUTSTANDING DEBT DETAILS

Describe outstanding debt for the business including installment loans, notes,
mortgages payable and capitalized leases, showing to whom payable, balance,
interest rate, maturity date, monthly payment, security and whether current or
delinquent. If business is a sole proprietorship, provide personal indebtedness
information. Fill out as many sections as necessary.

1. Debt Type:                                      Lender:
             (installment loan, mortgage, lease, etc)        (bank , individual, etc.)
Term:                    months        Interest Rate:     %
Date
Maturity Date:
Original Amount: $              Current Balance: $
Collateral Supporting Debt:
Monthly Payment: $                     Current?       Yes   No
___________________________________________________________

2. Debt Type:                                      Lender:
             (installment loan, mortgage, lease, etc)        (bank , individual, etc.)
Term:                    months        Interest Rate:                                    %
Date
Maturity Date:
Original Amount: $              Current Balance: $
Collateral Supporting Debt:
Monthly Payment: $                     Current?                                  Yes         No

____________________________________________________________

3. Debt Type:                                      Lender:
             (installment loan, mortgage, lease, etc)        (bank , individual, etc.)
Term:                    months        Interest Rate:      %
Date
Maturity Date:
Original Amount: $              Current Balance: $
Collateral Supporting Debt:
Monthly Payment: $                     Current?       Yes    No
_____________________________________________________________
      Signed                                          Date
              (USE ADDITIONAL COPIES OF THIS SHEET IF NECESSARY)


                                                        12
                                     CERTIFICATION
                                          AND
                      AUTHORIZATION TO RELEASE CREDIT INFORMATION

_______________________________________, being duly sworn, deposes and says: that (s)he is the president
of ____________________________, the Project occupant (the Company) described in the foregoing
application; that (s)he has read the foregoing application and knows the contents thereof; that the same is true to
his/her own knowledge except as to the matters stated therein to be alleged upon his/her information and belief,
and as to those matters (s)he believes it to be true; that to the best of here/his knowledge (s)he is in compliance
with all federal and state legislation dealing with the hiring of illegal aliens and equal employment opportunity;
and that the execution of this application,
                                   Canton Local Development Corporation
has been duly authorized by the board of directors of the Company; and authorizes the lender to investigate and
obtain a report concerning my (our) credit for the purpose of processing and underwriting my (our) loan
application.
        _____________________________________
                                                        President, Project Occupant



_____________________________________ Applicant’s Street Address

______________________________________ Applicant’s previous address

______________________________________ City/State(province)/Country, Postal Code

______________________________________ Current Place of Employment

______________________________________ Current Employment address

______________________________________ Previous employer

______________________________________ Address previous employer

______________________________________ Applicant’s SS# or SIN#

______________________________________ Applicant’s Date of Birth

______________________________________ Spouse’s name

______________________________________ Credit Reporting Agency




                                                        13
                                               Form LDC IA

_____________________________________                                      ______________
Signature of Applicant                                                     Date


“The following information is requested by the Federal Government in order to monitor compliance with
Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not
required to furnish this information, but are encouraged to do so. This information will not be used in
evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it,
we are required to note the race/national origin of individual applicants on the basis of visual observation or
surname.”

Ethnicity:
Hispanic or Latino _____
Not Hispanic or Latino ____

Race: (Mark one or more)
White ______ Black or African American______
American Indian/Alaska Native_____ Asian_______
Native Hawaiian or Other Pacific Islander ______

Gender: Male_____ Female_____




                                                       14
                                                                       617.20
                                                        Appendix C
                                            State Environmental Quality Review
                         SHORT ENVIRONMENTAL ASSESSMENT FORM
                                                 For UNLISTED ACTIONS Only

PART I - PROJECT INFORMATION (To be completed by Applicant or Project Sponsor)
1. APPLICANT/SPONSOR                                                       2. PROJECT NAME



3. PROJECT LOCATION:

       Municipality                                                            County
4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map)




5. PROPOSED ACTION IS:
         New                 Expansion               Modification/alteration

6. DESCRIBE PROJECT BRIEFLY:




7. AMOUNT OF LAND AFFECTED:
   Initially           acres                 Ultimately                        acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
          Yes           No     If No, describe briefly



9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
            Residential Industrial           Commercial                        Agriculture   Park/Forest/Open Space   Other
   Describe:




10.      DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY
         (FEDERAL, STATE OR LOCAL)?
             Yes            No      If Yes, list agency(s) name and permit/approvals:




11.      DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
             Yes           No      If Yes, list agency(s) name and permit/approvals:




12.      AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
              Yes          No

                         I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
      Applicant/sponsor name:                                                                      Date:

      Signature:


                   If the action is in the Coastal Area, and you are a state agency, complete the
                        Coastal Assessment Form before proceeding with this assessment
                                                                      OVER
                                                                        1
PART II - IMPACT ASSESSMENT (To be completed by Lead Agency)
 A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4?                               If yes, coordinate the review process and use the FULL EAF.
       Yes       No

 B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative
    declaration may be superseded by another involved agency.
         Yes         No

 C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
     C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal,
         potential for erosion, drainage or flooding problems? Explain briefly:



     C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:



     C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:



     C4. A community’s existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly:



     C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly:



     C6. Long term, short term, cumulative, or other effects not identified in C1-C5? Explain briefly:



     C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly:



 D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL
    ENVIRONMENTAL AREA (CEA)?
        Yes       No    If Yes, explain briefly:



 E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
         Yes        No    If Yes, explain briefly:




PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
   INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each
   effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e)
   geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain
   sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked
   yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA.
           Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL
           EAF and/or prepare a positive declaration.
           Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL
           NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting this determination.



                              Name of Lead Agency                                                                         Date


          Print or Type Name of Responsible Officer in Lead Agency                                            Title of Responsible Officer


               Signature of Responsible Officer in Lead Agency                               Signature of Preparer (If different from responsible officer)
USDA                                                                          Position 3                                                                        FORM APPROVED
Form RD 1940-20                                                                                                                                                 OMB No. 0575-0094
(Rev. 6-99)                                                                                                                                   Name of Project

                                                        REQUEST FOR ENVIRONMENTAL INFORMATION

                                                                                                                                              Location



Item 1a.         Has a Federal, State, or Local Environmental Impact Statement or Analysis been prepared for this project?
                      Yes         No         Copy attached as EXHIBIT I-A.
         1b.     If ''No.'' provide the information requested in Instructions as EXHIBIT I.
Item      2.     The State Historic Preservation Officer (SHPO) has been provided a detailed project description and has been requested to submit
                 comments to the appropriate Rural Development Office.             Yes      No     Date description submitted to SHPO
Item       3.    Are any of the following land uses or environmental resources either to be affected by the proposal or located within or adjacent to
                 the project site(s)? (Check appropriate box for every item of the following checklist).

                                                            Yes   No Unknown                                                                            Yes     No Unknown

 1. Industrial.......................................                               19. Dunes............................................

 2. Commercial....................................                                  20. Estuary..........................................

 3. Residential....................................                                 21. Wetlands.........................................

 4. Agricultural.....................................                               22. Floodplain.......................................

 5. Grazing........................................                                 23. Wilderness.......................................
                                                                                         (designated or proposed under
                                                                                         the Wilderness Act)
 6. Mining, Quarrying...........................
                                                                                    24. Wild or Scenic River.........................
 7. Forests..........................................                                    (proposed or designated under the Wild
                                                                                         and Scenic Rivers Act)
 8. Recreational.....................................
                                                                                    25. Historical, Archeological Sites...........
 9. Transportation..................................                                     (Listed on the National Register of
                                                                                         Historic Places or which may be
10. Parks..............................................                                  eligible for listing)

11. Hospital...........................................                             26. Critical Habitats................................
                                                                                           (endangered/threatened species)
12. Schools..........................................
                                                                                    27. Wildlife...........................................
13. Open spaces....................................
                                                                                    28. Air Quality.....................................

14. Aquifer Recharge Area.....................                                      29. Solid Waste Management..................
15. Steep Slopes....................................                                30. Energy Supplies...............................

16. Wildlife Refuge................................                                 31. Natural Landmark............................
                                                                                          (Listed on National Registry of Natural
17. Shoreline.......................................                                      Landmarks)

18. Beaches..........................................                               32. Coastal Barrier Resources System.....
Item 4. Are any facilities under your ownership, lease, or supervision to be utilized in the accomplishment of this project, either listed or under
        consideration for listing on the Environmental Protection Agency's List of Violating Facilities?          Yes         No

                                                                                     Signed:
                                (Date)                                                                                                  (Applicant)




                                                                                                                                              (Title)
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collections is 0575-0094. The time required to complete this
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Form RD 400-1                                                                                                               FORM APPROVED
(Rev 5-00)                                  UNITED STATES DEPARTMENT OF AGRICULTURE                                         OMB No. 0575-0018

                                                  EQUAL OPPORTUNITY AGREEMENT



    This agreement, dated ______________________________________________________________________________ between

(herein called “Recipient” whether one or more) and United States Department of Agriculture (USDA), pursuant to the rules and
regulations of the Secretary of Labor (herein called the ‘Secretary’) issued under the authority of Executive Order 11246 as amended,
witnesseth:
    In consideration of financial assistance (whether by a loan, grant, loan guaranty, or other form of financial assistance) made or to be
made by the USDA to Recipient, Recipient hereby agrees, if the cash cost of construction work performed by Recipient or a construction
contract financed with such financial assistance exceeds $10,000 - unless exempted by rules, regulations or orders of the Secretary of
Labor issued pursuant to section 204 of Executive Order 11246 of September 24, 1965.
    1. To incorporate or cause to be incorporated into any contract for construction work, or modification thereof, subject to the relevant
rules, regulations, and orders of the Secretary or of any prior authority that remain in effect, which is paid for in whole or in part with the
aid of such financial assistance, the following “Equal Opportunity Clause”:
        During the performance of this contract, the contractor agrees as follows:
        (a)	 The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex or
             national origin. The contractor will take affirmative action to ensure that applicants are employed, and that employees are
             treated during employment, without regard to their race, color, religion, sex, or national origin. Such action shall include, but
             not be limited, to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff
             or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor
             agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the
             USDA setting forth the provisions of this nondiscrimination clause.
        (b) The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all
             qualified applicants will receive consideration for employment without regard to race, color, religion, sex or national origin.
        (c)	 The contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement
             or other contract or understanding, a notice, to be provided by the USDA, advising the said labor union or workers’ representative
             of the contractor’s commitments under this agreement and shall post copies of the notice in conspicuous places available to employees and
             applicants for employment.
        (d) The contractor will comply with all provisions of Executive Order 11246 of September 24, 1965, and of all rules, regulations
             and relevant orders of the Secretary of Labor.
        (e)	 The contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, rules,
             regulations, and orders, or pursuant thereto, and will permit access to his books, records, and accounts by the USDA Civil
             Rights Office, and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules,
             regulations, and orders.
        (f)	 In the event of the contractor’s noncompliance with the nondiscrimination clauses of this contract or with any of the said rules,
             regulations, or orders, this contract may be cancelled, terminated, or suspended in whole or in part and the contractor may be
             declared ineligible for further Government contracts or federally assisted construction contracts in accordance with procedures
             authorized in Executive Order No. 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as
             provided in Executive Order No. 11246 of September 24, 1965, or by rule, regulation or order of the Secretary of Labor, or as otherwise
             provided by Law.
        (g) The contractor will include the provisions of paragraph 1 and paragraph (a) through (g) in every subcontract or purchase order, unless
             exempted by the rules, regulations, or orders of the Secretary of Labor issued pursuant to Section 204 of Executive Order No. 11246 of
             September 24, 1965, so that such provisions will be binding upon each subcontractor or vendor. The contractor will take such action with
             respect to any subcontract or purchase order as the USDA may direct as a means of enforcing such provisions, including sanctions for
             noncompliance: Provided, however, that in the event the contractor becomes involved in, or is threatened with, litigation with a
             subcontractor or vendor as a result of such direction by the USDA, the contractor may request the United States to enter into such
             litigation to protect the interest of the United States.

 According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond
 to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
 collections is 0575-0018. The time required to complete this information collection is estimated to average 10 minutes per response,
 including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
 completing and reviewing the collection of information.


                                                                                                                             RD 400-1 (Rev. 5-00)
                                                                     Position 6
2. To be bound by the above equal opportunity clause with respect to its own employment practices when it participates in federally
assisted construction work: Provided, that if the organization so participating is a State or local government, the above equal
opportunity clause is not applicable to any agency, instrumentality or subdivision of such government which does not
participate in work on or under the contract.
3. To notify all prospective contractors to file the required ‘Compliance Statement’, Form RD 400-6, with their bids.
4. Form AD-425, Instructions to Contractors, will accompany the notice of award of the contract. Bid conditions for all nonexempt
federal and federally assisted construction contracts require inclusion of the appropriate “Hometown” or “Imposed” plan affirmative
action and equal employment opportunity requirements. All bidders must comply with the bid conditions contained in the invitation to
be considered responsible bidders and hence eligible for the award.
5. To assist and cooperate actively with USDA and the Secretary in obtaining the compliance of contractors and subcontractors with
the equal opportunity clause and the rules, regulations, and relevant orders of the Secretary, that it will furnish USDA and the Secretary
such information such as, but not limited to, Form AD 560, Certification of Nonsegregated Facilities, to submit the Monthly
Employment Utilization Report, Form CC-257, as they may require for the supervision of such compliance, and that it will otherwise
assist USDA in the discharge of USDA’s primary responsibility for securing compliance.
6. To refrain from entering into any contract or contract modification subject to Executive Order 11246 of September 24, 1965, with a
contractor debarred from, or who has not demonstrated eligibility for, Government contracts and federally assisted construction
contracts pursuant to the Executive Order and will carry out such sanctions and penalties for violation of the equal opportunity clause as
may be imposed upon contractors and subcontractors by USDA or the Secretary of Labor pursuant to Part II, Subpart D, of the
Executive Order.
7. That if the recipient fails or refuses to comply with these undertakings, the USDA may take any or all of the following actions:
Cancel, terminate, or suspend in whole or in part this grant (contract, loan, insurance, guarantee); refrain from extending any further
assistance to the organization under the program with respect to which the failure or refund occurred until satisfactory assurance of
future compliance has been received from such organization; and refer the case to the Department of Justice for appropriate legal
proceedings.

Signed by the Recipient on the date first written above.




                                                   Recipient                                                                  Recipient


(CORPORATE SEAL)                                                           Name of Corporate Recipient


Attest:                                                                    By
                                                                                                                               President
                                                   Secretary
                                                                                  Position 3
USDA                                                                                                                                                  FORM APPROVED

Form RD 400-4                                                  ASSURANCE AGREEMENT
                                                                   OMB No. 0575-0018
(Rev. 3-97)                                                 (Under Title VI, Civil Rights Act of 1964)



The
                                                                            (name of recipient)

                                                                                   (address)
(“Recipient” herein) hereby assures the U. S. Department of Agriculture that Recipient is in compliance with and will continue to
comply with Title VI of the Civil Rights Act of 1964 (42 USC 2000d et. seq.), 7 CFR Part 15, and Rural Housing Service, Rural
Business-Cooperative Service, Rural Utilities Service, or the Farm Service Agency, (hereafter known as the ” Agency”) regulations
promulgated thereunder, 7 C.F.R. §1901.202. In accordance with that Act and the regulations referred to above, Recipient agrees that
in connection with any program or activity for which Recipient receives Federal financial assistance (as such term is defined in 7
C.F.R. §14.2) no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in,
be denied the benefits of, or be otherwise subjected to discrimination.
   1.	 Recipient agrees that any transfer of any aided facility, other than personal property, by sale, lease or other conveyance of
       contract, shall be, and shall be made expressly, subject to the obligations of this agreement and transferee’s assumption thereof.
   2. Recipient shall:
       (a) Keep such records and submit to the Government such timely, complete, and accurate information as the Government may
       determine to be necessary to ascertain our/my compliance with this agreement and the regulations.
       (b) Permit access by authorized employees of the Agency or the U.S. Department of Agriculture during normal business
       hours to such books, records, accounts and other sources of information and its facilities as may be pertinent to ascertaining such
       compliance.
       (c) Make available to users, participants, beneficiaries and other interested persons such information regarding the provisions
       of this agreement and the regulations, and in such manner as the Agency or the U.S. Department of Agriculture finds necessary
       to inform such persons of the protection assured them against discrimination.
   3. The obligations of this agreement shall continue:
       (a) As to any real property, including any structure, acquired or improved with the aid of the Federal financial assistance, so
       long as such real property is used for the purpose for which the Federal financial assistance is made or for another purpose which
       affords similar services or benefits, or for as long as the Recipient retains ownership or possession of the property, whichever is
       longer.
       (b) As to any personal property acquired or improved with the aid of the Federal financial assistance, so long as Recipient
       retains ownership or possession of the property.
       (c)     As to any other aided facility or activity, until the last advance of funds under the loan or grant has been made.
   4. Upon any breach or violation this agreement the Government may, at its option:
       (a) Terminate or refuse to render or continue financial assistance for the aid of the property, facility, project, service or
       activity.
       (b) Enforce this agreement by suit for specific performance or by any other available remedy under the laws of the United
       States or the State in which the breach or violation occurs.
Rights and remedies provided for under this agreement shall be cumulative.

In witness whereof,                                                                                                                                                       on this
                                                                            (name of recipient)
date has caused this agreement to be executed by its duly authorized officers and its seal affixed hereto, or, if a natural person, has
hereunto executed this agreement.

                                                                                                                                                                       Recipient
             (S E A L)
                                                                                                                                                                             Date
Attest:
                                                             Title                                                                                                            Title
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0570-0018. The time required to complete this information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
                                      U.S. DEPARTMENT OF AGRICULTURE
                                     CERTIFICATION REGARDING
                       DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)
                    ALTERNATIVE I - FOR GRANTEES OTHER THAN INDIVIDUALS
This certification is required by the regulations implementing Section 5151-5160 of the Drug-Free Workplace
Act of 1988 (Pub. L. 100-690, Title V, Subtitle D: 41 U.S.C.701 et seq.), 7 CFR Part 3017. Subpart F, Section
3017.600, Purpose. The January 13, 1989, regulations were amended and published as Part 11 of the May 25,
1990 Federal Register (pages 21681-21691). Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the grant.

         (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 3)
Alternative I

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

         (a) Publishing a statement notifying employees that the unlawful manufacture, distribution,
         dis
         dispensing, possession, or use of a controlled substance is prohibited in the grantee's workplace and specifying the
         actions that will be taken against employees for violation of such prohibition;


         (b) Establishing an ongoing drug-free awareness program to inform employees about -


                   (1) The dangers of drug abuse in the workplace;

                   (2) The grantee's policy of maintaining a drug-free workplace;

                   (3) Any available drug counseling, rehabilitation, and employee assistance programs; and

                   (4) The penalties that may be imposed upon employees for drug abuse violations occurring
                    in the workplace.

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

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

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

                   (2) Notify the employer in writing of his or her conviction for a violation of a criminal drug
                   statute occurring in the workplace no later than five calendar days after such conviction;

         (e) Notifying the agency in writing, within ten calendar days after receiving notice under
         subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction.
         Employers of convicted employees must provide notice, including position


                                                                                                             AD-1049 (REV 5/90)
         title, to every grant officer on whose grant activity the convicted employee was working, unless the Federal
         agency has designated a central point for the receipt of such notices. Notice shall include the identification
         number(s) of each affected grant;


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

                   (1) Taking appropriate personnel action against such an employee, up to and including termination,
                   consistent with the requirements of the Rehabilitation Act of 1973, as amended; or


                   (2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
                   program approved for such purposes by a Federal, State, or, local health, law enforcement, or other
                   appropriate agency;


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

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

Place of Performance (Street address, city, county, State, zip code)




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




Organization Name                                               Award Number or Project Name


Name and Title of Authorized Representative


Signature                                                              Date




                                                                                                            AD-1049 (REV 5/90)
                                    INSTRUCTIONS FOR CERTIFICATION

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

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


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

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

5.   If the workplace identified to the agency changes during the performance of the grant, the grantee shall
     inform the agency of the change(s). If it previously identified the workplaces in question (see paragraph three).


6.   Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free
     Workplace common rule apply to this certification. Grantees' attention is called, in particular, to the
     following definitions from these rules:

          ''Controlled substance'' means a controlled substance in Schedules I through V of the Controlled
          Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);


          ''Conviction'' means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or
          both, by any judicial body charged with the responsibility to determine violations of the Federal or
          States criminal drug statutes;

          ''Criminal drug statute'' means a Federal or non-Federal criminal statute involving the manufacture,
          distribution, dispensing, use, or possession of any controlled substance;

          ''Employee'' means the employee of a grantee directly engaged in the performance of work under a grant,
          including: (i) all ''direct charge'' employees; (ii) all ''indirect charge'' employees unless their impact or
          involvement is insignificant to the performance of the grant; and, (iii) temporary personnel and consultants
          who are directly engaged in the performance of work under the grant and who are on the grantee's payroll.
          This definition does not include workers not on the payroll of the grantee (e.g. volunteers, even if used to meet
          a matching requirement; consultants or independent contractors not on the grantee's payroll; or employees of
          subrecipients or subcontractors in covered workplaces)




                                                                                                        AD-1049 (REV 5/90)
                                     U.S. DEPARTMENT OF AGRICULTURE                    The Galleries of Syracuse
                                                                                       441 South Salina St., Suite 357
                                              NEW YORK                                 Syracuse, New York 13202
                                          RURAL DEVELOPMENT                            (315) 477-6430
                                                                                       FAX (315) 477-6448
                                                                                       TDD (315) 477-6447
                                                                                       www.rurdev.usda.gov/ny



                          CERTIFICATION OF NON-LOBBYING ACTIVITIES

                       CERTIFICATION FOR CONTRACTS, GRANTS, AND LOANS

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 Congress, or an employee of a
   Member of Congress in connection with the awarding of any Federal contract, the making of any Federal
   grant or Federal loan, and the extension, continuation, renewal, amendment, or modification of any Federal
   contract, grant or loan.

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 in connection with this Federal Contract, grant or loan, the undersigned
   shall complete and submit Standard Form - LLL, “Disclosure of Lobbying Activities,” in accordance with
   its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for
   all sub-awards at all tiers (including contracts, subcontracts, and sub-grants and loans) and that all sub-
   recipients shall certify and disclose accordingly.

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


                       SIGNATURE                                                           DATE


                       TITLE




(SEAL)



   Rural Development is an equal opportunity lender, provider, and employer. Complaints of discrimination
          should be sent to: USDA, Director, Office of Civil Rights, Room 326-W, Whitten Bldg.,
    1400 Independence Ave. SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD)

				
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