HomeMy WebLinkAboutEM17-514 - Original - Washington State Military Dept - EMPG Grant E18-099 - 06/01/2017 Records M
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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office. All portions are to be completed.
If you have questions, please contact City Clerk's Office.
i
Vendor Name: Washinqton State Military Dept.
Vendor Number:
JD Edwards Number
Contract Number: -M 1-7,5l+
This is assigned by City Clerk's Office
Project Name: EMPG Grant - E18-099
Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ❑ Contract
x Other: Grant
Contract Effective Date: June 1, 2017 Termination Date: 8-31-18
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: Jennifer Keizer Department: Emergency Manaqement
Contract Amount: $70.697
Approval Authority: ❑ Department Director ❑ Mayor x City Council
Detail: (i.e. address, location, parcel number, tax id, etc.):
As of: 08/27/14
Washington State Military Department
EMERGENCY MANAGEMENT PERFORMANCE GRANT AGREEMENT FACE SHEET
1, Subrecipient Name and Address: 2, Grant Agreement Amount: 3. Grant Agreement Number:
City of Kent
Emergency Management Division $70,697 E18-099
24611 116th Ave SE
Kent.WA 98030-4939
4.. Subrecipient Contact, phone/email: 5. Grant Agreement Start Date. 6. Grant Agreement End Date.
Jennifer Keizer,(253)866-4342 June 1,2017 August 31, 2018
jdkeizer0pugetsoundfire.orq 9
7. Department Contact, phone/email. 8. Data Universal Numbering System (DUNS): 9. UBI#(state revenue):
Gary Stum ph, (253)512-7483
gary.stumph@mil.wa.gov 020253613 173-000-002
10. Funding Authority.
Washington State Military Department(the"DEPARTMENT")and the U.S. Department of Homeland Security (DHS)
11. Federal Funding Identification#. 12, Federal Award Date; 13. Catalog of Federal Domestic Assistance(CFDA)#&Title.
EMS-2017-EP-00004-S01 08124/2017 97.042(17EMPG)
14. Total Federal Amount#, 15. Program Index#& OBJ/SUB-OBJ: 16. TIN
$7,306,624 773PT NZ I NIA
17. Service Districts: 18. Service Area by County(ies): 19. Women/Minority-Owned, State
(BY LEGISLATIVE DISTRICT) 11, 33,47 Certified? X N/A El
(BY CONGRESSIONAL DISTRICT): 8. 9 King ❑ YES, OMWBE#
20, Agreement Classification 21, Contract Type(check all that apply):
❑ Personal Services ❑ Client Services X Public/Local Gov't ❑ Contract X Grant X Agreement
❑ Research/Development ❑ A/E ❑ Other ❑ Intergovernmental (RCW 39.34) ❑ Interagency
22, Subrecipient Selection Process 23. Subrecipient Type(check all that apply)
X "To all who apply&qualify" ❑ Competitive Bidding ❑ Private Organization/Individual ❑ For-Profit
❑ Sole Source ❑ A/E RCW ❑ N/A X Public Organization/Jurisdiction ❑ Non-Profit
❑ Filed w10FM? ❑ Advertised? ❑ YES [INC) ❑ CONTRACTOR X SUBRECIPIENT ❑ OTHER
24. PURPOSE& DESCRIPTION:.
The purpose of the Fiscal Year(FY) 2017 Emergency Management Performance Grant(17EMPG) is to provide U.S. Department of
Homeland Security(DHS)/Federal Emergency Management Agency (FEMA) Federal award funds to local jurisdictions and tribes
with emergency management programs to assist in preparing for all hazards through sustainment and enhancement of those
'.. programs as described in the Work Plan.
The Department is the Recipient and Pass-through Entity of the 17EMPG Award EMS-2017-EP-00004-S01,which is incorporated in
and attached hereto as Attachment#1, and has made a subaward of Federal award funds to the Subrecipient pursuant to this
Agreement. The Subrecipient is accountable to the Department for use of Federal award funds provided under this Agreement
and the associated matching funds.
IN WITNESS WHEREOF, the Department and Subrecipient acknowledge and accept the terms of this Agreement, including all referenced
Exhibits and Attachments which are hereby incorporated in and made a part hereof,and have executed this Agreement as of the date below.
This Agreement Face Sheet; Special Terms & Conditions (Exhibit A)', General Terms and Conditions (Exhibit B); Work Plan (Exhibit C);
Timeline (Exhibit D), Budget (Exhibit E); and all other documents, exhibits and attachments expressly referenced and incorporated herein
contain all the terms and conditions agreed upon by the parties and govern the rights and obligations of the parties to this Agreement. No
other understandings, oral or otherwise, regarding the subject matter of this Agreement shall be deemed to exist or to bind any of the parties
hereto.
In the event of an inconsistency in this Agreement, unless otherwise provided herein, the inconsistency shall be resolved by giving
precedence in the following order.
1. Applicable Federal and State Statutes and Regulations 4. Special Terms and Conditions
2. DHS/FEMA Award and program documents 5. General Terms and Conditions, and,
3. Work Plan 6. Other provisions of the Aqreement incorporated by reference
WHEREAS, the parties hereto have executed this Agreement on the day and year last specified b f
FOR THE DEPARTMENT: FOR `J4EECIPIF.
Signature Date Curl �Dat
Dan Swisher, Chief Financial Officer Suz C ake, Mayor
Washington State Military Department
BOILERPLATE APPROVED AS TO FORM: Signature Date
(Signature on file 9/12/2017) Matthew Morris, Fire Chief
Brian E. Buchholz, Sr. Assistant Attorney General
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AS TO ORM(if applicable).
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DHS-FEMA-EMPG-FY 17 Page 1 of 35 City of Kent EMD, El8-099
Exhibit A
SPECIAL TERMS AND CONDITIONS
ARTICLE I. KEY PERSONNEL
The individuals listed below shall be considered key personnel for point of contact under this Agreement. Any
substitution of key personnel by either party shall be made by written notification to the current key personnel.
SUBRECIPIENT MILITARY DEPARTMENT
Name Jennifer Keizer Name Gary Stumph
Title EM Specialist Title Program Coordinator
E-Mail jdkeizer@pugetsoundfire.org E-Mail gary.stumph@mil.wa.gov
Phone 253-856-4342 Phone 253-512-7483
Name Matthew Morris Name Tirzah Kincheloe
Title Fire Chief Title Program Manager
E-Mail mlmorris@pugetsoundfire.org E-Mail tirzah.kincheloe@mil.wa.gov
Phone 253-856-4311 Phone 253-512-7456
Name John Madson Name Dalton Gamboa
Title Division Chief- Emergency Title Program Assistant
E-Mail jmadson@pugetsoundfire.org E-Mail dalton.gamboa@mil.wa.gov
Phone 253-856-4316 Phone 253-512-7044
ARTICLE II. ADMINISTRATIVE AND/OR FINANCIAL REQUIREMENTS
The Subrecipient shall comply with all applicable state and federal laws, rules, regulations, requirements and
program guidance identified or referenced in this Agreement and the informational documents published by
DHS/FEMA applicable to the 17EMPG Program, including, but not limited to, all criteria, restrictions, and
requirements of the "Department of Homeland Security (DHS) Notice of Funding Opportunity (NOFO) Fiscal
Year (FY) 2017 Emergency Management Performance Grant (EMPG)" document, the DHS Award Letter for
Grant No. EMS-2017-EP-00004-S01, and the federal regulations commonly applicable to DHS/FEMA grants, all
of which are incorporated herein by reference. The DHS Award Letter is incorporated in this Agreement as
Attachment 1.
The Subrecipient acknowledges that since this Agreement involves federal award funding, the period of
performance described herein may begin prior to the availability of appropriated federal funds. The Subrecipient
agrees that it will not hold the Department, the State of Washington, or the United States liable for any damages,
claim for reimbursement, or any type of payment whatsoever for services performed under this Agreement prior
to distribution of appropriated federal funds, or if federal funds are not appropriated or in a particular amount.
A. STATE AND FEDERAL REQUIREMENTS FOR DHS/FEMA PREPAREDNESS GRANTS:
The following requirements apply to all DHS/FEMA Preparedness Grants administered by the
Department.
1. SUBAWARDS & CONTRACTS BY SUBRECIPIENT
a. The Subrecipient must make a case-by-case determination whether each agreement it
makes for the disbursement of 17EMPG funds received under this Agreement casts the
party receiving the funds in the role of a subrecipient or contractor in accordance with 2
CFR 200.330.
b. If the Subrecipient becomes a pass-through entity by making a subaward to a non-federal
entity as its subrecipient:
i. The Subrecipient must comply with all federal laws and regulations applicable to
pass-through entities of 17EMPG funds, including, but not limited to, those
contained in 2 CFR 200.
ii. The Subrecipient shall require its subrecipient to comply with all applicable state
and federal laws, rules, regulations, requirements, and program guidance
identified or referenced in this Agreement and the informational documents
published by DHS/FEMA applicable to the 17EMPG Program, including, but not
DHS-FEMA-EMPG-FY 17 Page 2 of 35 City of Kent EMD, E18-099
limited to, all criteria, restrictions, and requirements of the "Department of
Homeland Security (DHS) Notice of Funding Opportunity (NOFO) Fiscal Year
2017 Emergency Management Performance Grant(EMPG)"document, the DHS
Award Letter for Grant No. EMS-2017-EP-00004-S01 in Attachment 1, and the
federal regulations commonly applicable to DHS/FEMA grants.
iii. The Subrecipient shall be responsible to the Department for ensuring that all
17EMPG federal award funds provided to its subrecipient are used in
accordance with applicable federal and state statutes and regulations, and the
terms and conditions of the federal award set forth in Attachment 1 of this
Agreement.
2, BUDGET & REIMBURSEMENT
a. Within the total Grant Agreement Amount, travel, sub-contracts, salaries, benefits,
printing, equipment, and other goods and services or other budget categories will be
reimbursed on an actual cost basis unless otherwise provided in this Agreement.
b. The maximum amount of all reimbursement requests permitted to be submitted under this
Agreement, including the final reimbursement request, is limited to and shall not exceed
the total Grant Agreement Amount.
C. If the Subrecipient chooses to include indirect costs within the Budget (Exhibit E), an
indirect cost rate agreement negotiated between the federal cognizant agency for indirect
costs and the Subrecipient establishing approved indirect cost rate(s) as described in 2
CFR 200.414 and Appendix VII to 2 CFR 200 must be submitted to the Department.
However, under 2 CFR 200.414(f), if the Subrecipient has never received a negotiated
indirect cost rate agreement establishing federally negotiated rate(s), the Subrecipient
may negotiate a rate with the Department or charge a de minimis rate of 10% of modified
total direct costs. The Subrecipient's actual indirect cost rate may vary from the approved
rate, but must not exceed the approved negotiated indirect cost rate percentage for the
time period of the expenditures. If a Subrecipient chooses to charge the 10% de minimis
rate, but did not charge indirect costs to previous subawards, a request for approval to
charge indirect costs must be submitted to the Department Key Personnel for approval
with an explanation for the change.
d. For travel costs, the Subrecipient shall comply with 2 CFR 200.474 and should consult
their internal policies, state rates set pursuant to ROW 43,03.050 and ROW 43.03,060 as
now existing or amended, and federal maximum rates set forth at htto://www.gsa.gov, and
follow the most restrictive. If travel costs exceed set state or federal limits, travel costs
shall not be reimbursed without written approval by Department Key Personnel.
e. Reimbursement requests will include a properly completed State A-19 Invoice Form and
Reimbursement Spreadsheet (in the format provided by the Department) detailing the
expenditures for which reimbursement is sought. Reimbursement requests must be
submitted to Reim bursementsgnll.wa.gov no later than the due dates listed within the
Timeline (Exhibit D), but not more frequently than monthly.
Reimbursement request totals should be commensurate to the time spent processing by
the Subrecipient and the Department. If the reimbursement request isn't substantial
enough, the Subrecipient should request prior written approval from Department Key
Personnel to waive the due date in the Timeline (Exhibit D) and instead submit those costs
on the next scheduled reimbursement due date contained in the Timeline.
f. Receipts and/or backup documentation for any approved items that are authorized under
this Agreement must be maintained by the Subrecipient consistent with record retention
requirements of this Agreement and be made available upon request by the Department
and auditors.
g. Any request for extension of a due date in the Timeline (Exhibit D) will be treated as a
request for Amendment of the Agreement and must be submitted to the Department Key
Personnel sufficiently in advance of the due date to provide adequate time for Department
DHS-FEMA-EMPG-FY 17 Page 3 of 35 City of Kent EMD, E18-099
review and consideration, and can be granted or denied within the Department's sole
discretion.
h. All work under this Agreement must end on or before the Grant Agreement End Date, and
the final reimbursement request must be submitted to the Department within 45 days after
the Grant Agreement End Date, except as otherwise authorized by written amendment of
this Agreement and issued by the Department.
i. No costs for purchases of equipment/supplies will be reimbursed until the related
equipment/supplies have been received by the Subrecipient, its contractor, or any non-
federal entity to which the Subrecipient makes a subaward and is invoiced by the vendor.
j. Failure to timely submit complete reports and reimbursement requests as required by this
Agreement (including, but not limited to, those reports in the Timeline) will prohibit the
Subrecipient from being reimbursed until such complete reports and reimbursement
requests are submitted and the Department has had reasonable time to conduct its review.
k. Final reimbursement requests will not be approved for payment until the Subrecipient is
current with all reporting requirements contained in this Agreement.
I. A written amendment will be required if the Subrecipient expects cumulative transfers to
budget categories, as identified in the Budget (Exhibit E), to exceed 10% of the Grant
Agreement Amount. Any changes to budget category totals not in compliance with this
paragraph will not be reimbursed without approval from the Department.
M. Subrecipients shall only use federal award funds under this Agreement to supplement
existing funds, and will not use them to replace (supplant) non-federal funds that have
been budgeted for the same purpose. The Subrecipient may be required to demonstrate
and document that a reduction in non-federal resources occurred for reasons other than
the receipt or expected receipt of federal funds.
3. REPORTING
a. With each reimbursement request, the Subrecipient shall report how the expenditures, for
which reimbursement is sought, relate to the Work Plan (Exhibit C) activities in the format
provided by the Department.
b. With the final reimbursement request, the Subrecipient shall submit to the Department Key
Personnel a final report describing all completed activities under this Agreement.
C. In conjunction with the final report,the Subrecipient shall submit a separate report detailing
how the EMPG Training and Exercise requirements were met for all personnel funded by
federal or matching funds under this Agreement.
d. The Subrecipient shall comply with the Federal Funding Accountability and Transparency
Act (FFATA) and related OMB Guidance consistent with Public Law 109-282 as amended
by section 6202(a) of Public Law 110-252 (see 31 U.S.C. 6101 note) and complete and
return to the Department the FFATA Form located at http://mi'l.wa.govlemergency-
ma nag ement-division/grantsfregu iredgrantforms, which is incorporated by reference and
made a part of this Agreement.
e. The Subrecipient shall participate in the State's annual capabilities assessment for the
State Preparedness Report.
4. EQUIPMENT AND SUPPLY MANAGEMENT
a. The Subrecipient and any non-federal entity to which the Subrecipient makes a subaward
shall comply with 2 CFR 200.318 — 200.326 when procuring any equipment or supplies
under this Agreement, 2 CFR 200.313 for management of equipment, and 2 CFR 200.314
for management of supplies, to include, but not limited to:
i. Upon successful completion of the terms of this Agreement, all equipment and
supplies purchased through this Agreement will be owned by the Subrecipient,
or a recognized non-federal entity to which the Subrecipient has made a
subaward, for which a contract, subrecipient grant agreement, or other means of
legal transfer of ownership is in place.
DHS-FEMA-EMPG-FY 17 Page 4 of 35 City of Kent EMD, E18-099
ii. All equipment, and supplies as applicable, purchased under this Agreement will
be recorded and maintained in the Subrecipient's inventory system.
iii. Inventory system records shall include:
A. description of the property
B. manufacturer's serial number, model number, or other identification
number
C. funding source for the equipment, including the Federal Award
Identification Number(FAIN)
D. Catalog of Federal Domestic Assistance (CFDA) number
E. who holds the title
F. acquisition date
G. cost of the equipment and the percentage of federal participation in the cost
H. location, use and condition of the equipment at the date the information
was reported
I. disposition data including the date of disposal and sale price of the
property.
iv. The Subrecipient shall take a physical inventory of the equipment, and supplies
as applicable, and reconcile the results with the property records at least once
every two years. Any differences between quantities determined by the physical
inspection and those shown in the records shall be investigated by the
Subrecipient to determine the cause of the difference. The Subrecipient shall, in
connection with the inventory, verify the existence, current utilization, and
continued need for the equipment.
V. The Subrecipient shall be responsible for any and all operational and
maintenance expenses and for the safe operation of their equipment and supplies
including all questions of liability. The Subrecipient shall develop appropriate
maintenance schedules and procedures to ensure the equipment, and supplies
as applicable, are well maintained and kept in good operating condition.
vi. The Subrecipient shall develop a control system to ensure adequate safeguards
to prevent loss, damage, and theft of the property. Any loss, damage, or theft
shall be investigated and a report generated and sent to the Department.
vii, The Subrecipient must obtain and maintain all necessary certifications and
licenses for the equipment.
viii, If the Subrecipient is authorized or required to sell the property, proper sales
procedures must be established and followed to ensure the highest possible
return.
A. For disposition, if upon termination or at the Grant Agreement End Date,
when original or replacement supplies or equipment acquired under a
federal award are no longer needed for the original project or program or
for other activities currently or previously supported by a federal awarding
agency, the Subrecipient must comply with the following procedures:
B. For Supplies: If there is a residual inventory of unused supplies exceeding
$5,000 in total aggregate value upon termination or completion of the
project or program and the supplies are not needed for any other federal
award, the Subrecipient must retain the supplies for use on other activities
or sell them, but must, in either case, compensate the federal government
for its share. The amount of compensation must be computed in the same
manner as for equipment.
DHS-FEMA-EMPG-FY 17 Page 5 of 35 City of Kent EMD, E18-099
For Equipment:
1) Items with a current per-unit fair-market value of $5,000 or less may
be retained, sold, or otherwise disposed of with no further obligation
to the federal awarding agency.
2) Items with a current per-unit fair-market value in excess of $5,000
may be retained or sold. The Subrecipient shall compensate the
federal awarding agency in accordance with the requirements of 2
CFR 200.313 (e) (2)
ix. Records for equipment shall be retained by the Subrecipient for a period of six
years from the date of the disposition, replacement, or transfer. If any litigation,
claim, or audit is started before the expiration of the six-year period, the records
shall be retained by the Subrecipient until all litigation, claims, or audit findings
involving the records have been resolved.
b. The Subrecipient shall comply with the Department's Purchase Review Process, which is
incorporated by reference and made part of this Agreement. No reimbursement will be
provided unless the appropriate approval has been received.
C. Allowable equipment categories for the EMPG Program are listed on the Authorized
Equipment List (AEL) located on the FEMA website at http://www fema.gov/authorized-
e uc im�nt-I�ost. It is important the Subrecipient and any non-federal entity to which the
Subrecipient makes a subaward regard the AEL as an authorized purchasing list
identifying items allowed under the specific grant program, and includes items that may
not be categorized as equipment according to the federal, state, local, and tribal definitions
of equipment. The Subrecipient is solely responsible for ensuring and documenting
purchased items under this Agreement are authorized as allowed items by the AEL at time
of purchase.
If the item is not identified on the AEL as allowable under EMPG, the Subrecipient must
contact the Department Key Personnel for assistance in seeking FEMA approval prior to
acquisition.
d. Unless expressly provided otherwise, all equipment must meet all mandatory regulatory
and/or DHS/FEMA adopted standards to be eligible for purchase using federal award
funds.
e. The Subrecipient must pass on equipment and supply management requirements that
meet or exceed the requirements outlined above to any non-federal entity to which the
Subrecipient makes a subaward under this Agreement.
5. ENVIRONMENTAL AND HISTORICAL PRESERVATION
a. The Subrecipient shall ensure full compliance with the DHS/FEMA Environmental
Planning and Historic Preservation (EHP) program. EHP program information can be
found at littps://www,fema.goy/office environmental lannin -and-historic- reservation,
all of which are incorporated in and made a part of this Agreement.
b. Projects that have historical impacts or the potential to impact the environment,
including, but not limited to, construction of communication towers; modification or
renovation of existing buildings, structures and facilities; or new construction including
replacement of facilities, must participate in the DHS/FEMA EHP review process prior to
initiation. Modification of existing buildings, including minimally invasive improvements
such as attaching monitors to interior walls, and training or exercises occurring outside in
areas not considered previously disturbed, also require a DHS/FEMA EHP review before
project initiation.
C. The EHP review process involves the submission of a detailed project description that
includes the entire scope of work, including any alternatives that may be under
consideration, along with supporting documentation so FEMA may determine whether
the proposed project has the potential to impact environmental resources and/or historic
properties.
DHS-FEMA-EMPG-FY 17 Page 6 of 35 City of Kent EMD, E18-099
d. The Subrecipient agrees that to receive any federal preparedness funding, all EHP
compliance requirements outlined in applicable guidance must be met. The EHP review
process must be completed and approval received by the Subrecipient before any
work is started for which reimbursement will be later requested. Expenditures for
projects started before completion of the EHP review process and receipt of approval by
the Subrecipient will not be reimbursed.
6. PROCUREMENT
a. The Subrecipient shall comply with all procurement requirements of 2 CFR Part 200.318
through 200.326 and as specified in the General Terms and Conditions, Exhibit B, A.9.
b. For all sole source contracts expected to exceed $150,000, the Subrecipient must submit
to the Department for pre-procurement review and approval the procurement documents,
such as requests for proposals, invitations for bids and independent cost estimates. This
requirement must be passed on to any non-federal entity to which the Subrecipient makes
a subaward, at which point the Subrecipient will be responsible for reviewing and
approving sole source justifications of any non-federal entity to which the Subrecipient
makes a subaward.
7. SUBRECIPIENT MONITORING
a. The Department will monitor the activities of the Subrecipient from award to closeout. The
goal of the Department's monitoring activities will be to ensure that agencies receiving
federal pass-through funds are in compliance with this Agreement, federal and state audit
requirements, federal grant guidance, and applicable federal and state financial
regulations, as well as 2 CFR Part 200 Subpart F.
b. To document compliance with 2 CFR Part 200 Subpart F requirements, the Subrecipient
shall complete and return to the Department the "2 CFR Part 200 Subpart F Audit
Certification Form" located at http:ffmil.wa.gov/eniergencV-Management-
cliyisioii/grantsireauiredgrantforms with the signed Agreement and each fiscal year
thereafter until the Agreement is closed, which is incorporated by reference and made a
part of this Agreement.
C. Monitoring activities may include, but are not limited to:
i. review of financial and performance reports
ii. monitoring and documenting the completion of Agreement deliverables
iii. documentation of phone calls, meetings, a-mails and correspondence
iv, review of reimbursement requests and supporting documentation to ensure
allowability and consistency with Agreement work plan, budget, and federal
requirements
V. observation and documentation of Agreement related activities, such as exercises,
training, funded events, and equipment demonstrations
vi. on-site visits to review equipment records and inventories, to verify source
documentation for reimbursement requests and performance reports, and to verify
completion of deliverables.
d. The Subrecipient is required to meet or exceed the monitoring activities, as outlined
above, for any non-federal entity to which the Subrecipient makes a subaward as a pass-
through entity under this Agreement.
e. Compliance will be monitored throughout the performance period to assess risk.
Concerns will be addressed through a Corrective Action Plan.
8. LIMITED ENGLISH PROFIENCY (CIVIL RIGHTS ACT OF 1964 TITLE VI)
a. The Subrecipient must comply with the Title VI of the Civil Rights Act of 1964 (Title VI)
prohibition against discrimination on the basis of national origin, which requires that
subrecipients of federal financial assistance take reasonable steps to provide meaningful
access to persons with limited English proficiency (LEP) to their programs and services.
DHS-FEMA-EMPG+Y 17 Page 7 of 35 City of Kent EMD, E18-099
Providing meaningful access for persons with LEP may entail providing language
assistance services, including oral interpretation and written translation. Executive Order
13166, Improving Access to Services for Persons with Limited English Proficiency(August
11, 2000), requires federal agencies to issue guidance to recipients, assisting such
organizations and entities in understanding their language access obligations. DHS
published the required recipient guidance in April 2011, DHS Guidance to Federal
Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin
Discrimination Affecting Limited English Proficient Persons, 76 Fed. Reg. 21755-21768,
(April 18, 2011). The Guidance provides helpful information such as how a recipient can
determine the extent of its obligation to provide language services, selecting language
and elements services, a of an effective Ian on language assistance for LEP persons. For
p
additional assistance and information regarding language access obligations, please refer
to the DHS Recipient Guidance at hftps:/Iwww,dhs,gov/guidance-published-helg-
department-supported_or anizations- rovide-meanin ful-access- eo le-limited and
additional resources on http://www.lep.gov_.
9, NIMS COMPLIANCE
a. The National Incident Management System (NIMS) identifies concepts and principles that
answer how to manage emergencies from preparedness to recovery regardless of their
cause, size, location, or complexity. NIMS provides a consistent, nationwide approach
and vocabulary for multiple agencies orjurisdictions to work together to build, sustain, and
deliver the core capabilities needed to achieve a secure and resilient nation.
b. Consistent implementation of NIMS provides a solid foundation across jurisdictions and
disciplines to ensure effective and integrated preparedness, planning, and response.
NIMS empowers the components of the National Preparedness System, a requirement of
Presidential Policy Directive 8, to guide activities within the public and private sector and
describes the planning, organizational activities, equipping, training and exercising
needed to build and sustain the core capabilities in support of the National Preparedness
Goal.
C. In order to receive Federal Fiscal Year 2017 federal preparedness funding, to include
EMPG, the Subrecipient will ensure all NIMS objectives have been initiated and/or are in
progress toward completion. NIMS Implementation Objectives are located at
hftps;i/www,fema.gov/media-library/assets/docLimeiits/1 30743.
B. EMPG PROGRAM SPECIFIC REQUIREMENTS
1. The Department receives EMPG Program funding from DHS/FEMA, which is provided to assist
state, local, and tribal governments to enhance and sustain all-hazards emergency management
capabilities as authorized by Robert T. Stafford Disaster Relief and Emergency Assistance Act,
as amended (42 U.S.C. §§ 5121 et seq.) and Section 662 of the Post Katrina Emergency
Management Act (6 U.S.C. § 762).
2. A portion of the 17EMPG is passed through to local jurisdictions and tribes with emergency
management programs to supplement their local/tribal operating budgets to help sustain and
enhance emergency management capabilities pursuant to Washington Administrative Code
(WAC) 118-09.
3. The Subrecipient shall use the EMPG funds authorized under this Agreement only to perform
tasks as described in the Work Plan of the Subrecipient's application for funding, as approved by
the Department and incorporated into this Agreement.
4. Funding may not be used to replace or supplant existing local or tribal government funding of
emergency management programs
5. The Subrecipient shall provide a fifty percent match of $70,697 of non-federal origin. To meet
matching requirements, the Subrecipient cash matching contributions must be considered
reasonable, allowable, allocable, and necessary under the grant program and must comply with
all Federal requirements and regulations, including, but not limited to, 2 CFR Part 200. An
DHS-FEMA-EMPG-FY 17 Page 8 of 35 City of Kent EMD, E18-099
appropriate mechanism must be in place to capture, track, and document matching funds. In the
final report, the Subrecipient shall identify how the match was met and documented.
6. All personnel funded in any part through federal award or matching funds under this Agreement
shall:
a. participate in no less than three exercises in a 12-month period. The Subrecipient will
report exercise participation along with the final report;
b. complete and record proof of completion for the NIMS training requirements outlined in
the NIMS Training Program located at
hftps://www.fenia,qov/Ddf/emeraencvinimstnims training grouram odf (to include ICS
100, ICS 200, IS 700, and IS 800 for most personnel). The Subrecipient will report training
course completion by individual personnel along with the final report, and
C. complete either(1) the FEMA Professional Development Series IS 120, IS 230, IS 235, IS
240, IS 241, IS 242, and IS 244, or (2) the National Emergency Management Basic
Academy. The Subrecipient will report training course completion by individual personnel
along with the final report.
C. DHS TERMS AND CONDITIONS
As a subrecipient of 17EMPG program funding, the Subrecipient shall comply with all applicable DHS
terms and conditions of the 17EMPG Award Letter and its incorporated documents for DHS Grant No.
EMS-2017-EP-00004-S01, which are incorporated and made a part of this Agreement as Attachment 1.
DHS-FEMA-EMPG-FY 17 Page 9 cf 35 City of Kent EMD, E18-099
Exhibit B
Washington State Military Department
GENERAL TERMS AND CONDITIONS
Department of Homeland Security (DHS)I
Federal Emergency Management Agency (FEMA)
Grants
A.1 DEFINITIONS
As used throughout this Agreement, the terms will have the same meaning as defined in 2 CFR 200
Subpart A (which is incorporated herein by reference), except as otherwise set forth below:
a. "Agreement" means this Grant Agreement.
b. "Department' means the Washington State Military Department, as a state agency, any division,
section, office, unit or other entity of the Department, or any of the officers or other officials lawfully
representing that Department. The Department is a recipient of a federal award directly from a
federal awarding agency and is the pass-through entity making a subaward to a subrecipient
under this Agreement.
C. "Subrecipient' when capitalized is primarily used throughout this Agreement in reference to the
non-federal entity identified on the Face Sheet of this Agreement that has received a subaward
from the Department. However, the definition of "subrecipient' is the same as in 2 CFR 200.93
for all other purposes.
d. "Monitoring Activities" means all administrative, financial, or other review activities that are
conducted to ensure compliance with all state and federal laws, rules, regulations, authorities and
policies.
e. "Investment' means the grant application submitted by the Subrecipient describing the project(s)
for which federal funding is sought and provided under this this Agreement. Such grant
application is hereby incorporated into this Agreement by reference.
A.2ADVANCE PAYMENTS PROHIBITED
The Department shall make no payments in advance or in anticipation of goods or services to be provided
under this Agreement. Subrecipient shall not invoice the Department in advance of delivery and invoicing
of such goods or services.
A.3 AMENDMENTS AND MODIFICATIONS
The Subrecipient or the Department may request, in writing, an amendment or modification of this
Agreement. However, such amendment or modification shall not be binding, take effect or be
incorporated herein until made in writing and signed by the authorized representatives of the Department
and the Subrecipient. No other understandings or agreements, written or oral, shall be binding on the
parties.
A.4 AMERICANS WITH DISABILITIES ACT ADA OF 1990 PUBLIC LAW 101-336 42 U.S.C. 12101 ET
SEQ. AND ITS IMPLEMENTING REGULATIONS ALSO REFERRED TO AS THE "ADA" 28 CFR Part
35.
The Subrecipient must comply with the ADA, which provides comprehensive civil rights protection to
individuals with disabilities in the areas of employment, public accommodations, state and local
government services, and telecommunication.
A.5 ASSURANCES
The Department and Subrecipient agree that all activity pursuant to this Agreement will be in accordance
with all the applicable current federal, state and local laws, rules and regulations.
A.6 CERTIFICATION REGARDING DEBARMENT SUSPENSION OR INELIGIBILITY
As federal funds are a basis for this Agreement, the Subrecipient certifies that the Subrecipient is not
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participating in this Agreement by any federal department or agency.
The Subrecipient shall complete, sign, and return a Certification Regarding Debarment, Suspension,
Ineligibility, and Voluntary Exclusion form located at htt a/mil.wa. ovYemer enc -many ement-
divisionfgrantslreguiredgrantforms. Any such form completed by the Subrecipient for this Agreement
shall be incorporated into this Agreement by reference.
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Further, the Subrecipient agrees to comply with all applicable federal regulations concerning the federal
debarment and suspension system, including 2 CFR Part 180. The Subrecipient certifies that it will
ensure that potential contractors or subrecipients or any of their principals are not debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participation in "covered
transactions" by any federal department or agency. "Covered transactions' include procurement
contracts for goods or services awarded under a non-procurement transaction (e.g. grant or cooperative
agreement) that are expected to equal or exceed $25,000, and subawards to subrecipients for any
amount. With respect to covered transactions, the Subrecipient may comply with this provision by
obtaining a certification statement from the potential contractor or subrecipient or by checking the System
for Award Management (http://www.sam.gov) maintained by the federal government. The Subrecipient
also agrees not to enter into any arrangements or contracts with any party on the Washington State
Department of Labor and Industries' "Debarred Contractor List"
(https://secure ini.wa.00v/debaragggtrukg/ContractorDebarLlst aspx). The Subrecipient also agrees not
to enter into any agreements or contracts for the purchase of goods and services with any party on the
Department of Enterprise Services' Debarred Vendor List
htt :/(www.cues.wa. ovlseryicesFContractin Purchasin lBusiness(Pa esNendor-Debarment.as
A.7 CERTIFICATION REGARDING RESTRICTIONS ON LOBBYING
As required by 44 CFR Part 18, the Subrecipient hereby certifies that to the best of its knowledge and
belief: (1) no federally appropriated funds have been paid or will be paid by or on behalf of the
Subrecipient to any person for influencing or attempting to influence an officer or employee of an 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)
that 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
Agreement, grant, loan, or cooperative agreement, the Subrecipient will complete and submit Standard
Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions; (3) and that, as
applicable, the Subrecipient will require that the language of this certification be included in the award
documents for all subawards at all tiers (including sub-contracts, sub-grants, 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, and is a prerequisite for making or entering into this transaction imposed by section
1352, title 31, U.S. Code.
A.8 CONFLICT OF INTEREST
No officer or employee of the Department; no member, officer, or employee of the Subrecipient or its
designees or agents; no member of the governing body of the jurisdiction in which the project is
undertaken or located; and no other official of the Subrecipient who exercises any functions or
responsibilities with respect to the project during his or her tenure, shall have any personal or pecuniary
gain or interest, direct or indirect, in any contract, subcontract, or the proceeds thereof, for work to be
performed in connection with the project assisted under this Agreement.
The Subrecipient shall incorporate, or cause to incorporate, in all such contracts or subawards, a
provision prohibiting such interest pursuant to this provision.
A.9 COMPLIANCE WITH APPLICABLE STATUTES RULES AND DEPARTMENT POLICIES
The Subrecipient and all its contractors and subrecipients shall comply with, and the Department is not
responsible for determining compliance with, any and all applicable federal, state, and local laws,
regulations, executive orders, OMB Circulars, and/or policies. This obligation includes, but is not limited
to: nondiscrimination laws and/or policies, Energy Policy and Conservation Act(PL 94-163, as amended),
the Americans with Disabilities Act (ADA), Age Discrimination Act of 1975, Title VI of the Civil Rights Act
of 1964, Civil Rights Act of 1968, the Robert T. Stafford Disaster Relief and Emergency Assistance Act,
(PL 93-288, as amended), Ethics in Public Service (RCW 42.52), Covenant Against Contingent Fees (48
CFR Section 52.203-5), Public Records Act (RCW 42.56), Prevailing Wages on Public Works (RCW
39.12), State Environmental Policy Act(RCW 43.21C), Shoreline Management Act of 1971 (RCW 90.58),
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State Building Code (RCW 19.27), Energy Related Building Standards (RCW 19.27A), Provisions in
Buildings for Aged and Handicapped Persons (RCW 70.92), and safety and health regulations.
In the event of noncompliance or refusal to comply with any applicable law, regulation, executive order,
OMB Circular or policy by the Subrecipient, its contractors or subrecipients, the Department may rescind,
cancel, or terminate the Agreement in whole or in part in its sole discretion. The Subrecipient is
responsible for all costs or liability arising from its failure, and that of its contractors and subrecipients, to
comply with applicable laws, regulations, executive orders, OMB Circulars or policies.
A.10 CONTRACTING & PROCUREMENT
a. The Subrecipient shall use a competitive procurement process in the procurement and award of
any contracts with contractors or sub-contractors that are entered into under the original contract
award. The procurement process followed shall be in accordance with 2 CFR Part 200.318
General procurement standards through 200.326 Contract Provisions.
As required by Appendix II to 2 CFR Part 200, all contracts entered into by the Subrecipient under
this Agreement must include the following provisions, as applicable:
1) Contracts for more than the simplified acquisition threshold currently set at $150,000, which
is the inflation adjusted amount determined by the Civilian Agency Acquisition Council and
the Defense Acquisition Regulations Council (Councils) as authorized by 41 U.S.C. 1908,
must address administrative, contractual, or legal remedies in instances where contractors
violate or breach contract terms, and provide for such sanctions and penalties as appropriate.
2) All contracts in excess of$10,000 must address termination for cause and for convenience
by the non-federal entity including the manner by which it will be effected and the basis for
settlement.
3) Equal Employment Opportunity. Except as otherwise provided under 41 CFR Part 60, all
contracts that meet the definition of"federally assisted construction contract" in 41 CFR Part
60-1.3 must include the equal opportunity clause provided under 41 CFR 60-1.4(b), in
accordance with Executive Order 11246, "Equal Employment Opportunity" (30 FIR 12319,
12935, 3 CFR Part, 1964-1965 Comp., p. 339), as amended by Executive Order 11375,
"Amending Executive Order 11246 Relating to Equal Employment Opportunity," and
implementing regulations at 41 CFR part 60, "Office of Federal Contract Compliance
Programs, Equal Employment Opportunity, Department of Labor."
4) Davis-Bacon Act, as amended (40 U.S.C. 3141-3148). When required by Federal program
legislation, all prime construction contracts in excess of $2,000 awarded by non-federal
entities must include a provision for compliance with the Davis-Bacon Act (40 U.S.C. 3141-
3144, and 3146-3148) as supplemented by Department of Labor regulations (29 CFR Part
5, "Labor Standards Provisions Applicable to Contracts Covering Federally Financed and
Assisted Construction"). In accordance with the statute, contractors must be required to pay
wages to laborers and mechanics at a rate not less than the prevailing wages specified in a
wage determination made by the Secretary of Labor. In addition, contractors must be
required to pay wages not less than once a week. The non-federal entity must place a copy
of the current prevailing wage determination issued by the Department of Labor in each
solicitation. The decision to award a contract or subcontract must be conditioned upon the
acceptance of the wage determination. The non-federal entity must report all suspected or
reported violations to the federal awarding agency. The contracts must also include a
provision for compliance with the Copeland "Anti-Kickback" Act (40 U.S.C. 3145), as
supplemented by Department of Labor regulations (29 CFR Part 3, "Contractors and
Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or
Grants from the United States"). The Act provides that each contractor or subrecipient must
be prohibited from inducing, by any means, any person employed in the construction,
completion, or repair of public work, to give up any part of the compensation to which he or
she is otherwise entitled. The non-federal entity must report all suspected or reported
violations to the federal awarding agency.
5) Contract Work Hours and Safety Standards Act (40 U.S.C. 3701-3708). Where applicable,
all contracts awarded by the non-federal entity in excess of $100,000 that involve the
employment of mechanics or laborers must include a provision for compliance with 40 U.S.C.
3702 and 3704, as supplemented by Department of Labor regulations (29 CFR Part 5). Under
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40 U.S.C. 3702 of the Act, each contractor must be required to compute the wages of every
mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of
the standard work week is permissible provided that the worker is compensated at a rate of
not less than one and a half times the basic rate of pay for all hours worked in excess of 40
hours in the work week. The requirements of 40 U.S.C. 3704 are applicable to construction
work and provide that no laborer or mechanic must be required to work in surroundings or
under working conditions which are unsanitary, hazardous or dangerous. These
requirements do not apply to the purchases of supplies or materials or articles ordinarily
available on the open market, or contracts for transportation or transmission of intelligence.
6) Rights to Inventions Made Under a Contract or Agreement. If the federal award meets the
definition of"funding agreement' under 37 CFR §401.2 (a) and the recipient or subrecipient
wishes to enter into a contract with a small business firm or nonprofit organization regarding
the substitution of parties, assignment or performance of experimental, developmental, or
research work under that"funding agreement,"the recipient or subrecipient must comply with
the requirements of 37 CFR Part 401, "Rights to Inventions Made by Nonprofit Organizations
and Small Business Firms Under Government Grants, Contracts and Cooperative
Agreements," and any implementing regulations issued by the awarding agency.
7) Clean Air Act (42 U.S.C. 7401-7671q.) and the Federal Water Pollution Control Act (33
U.S.C. 1251-1387), as amended—Contracts and subgrants of amounts in excess of
$150,000 must contain a provision that requires the non-federal award to agree to comply
with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42
U.S.C. 7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C.
1251-1387). Violations must be reported to the federal awarding agency and the Regional
Office of the Environmental Protection Agency (EPA).
8) Debarment and Suspension (Executive Orders 12549 and 12689)—A contract award (see 2
CFR 180.220) must not be made to parties listed on the government-wide exclusions in the
System forAward Management(SAM), in accordance with the OMB guidelines at 2 CFR 180
that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR
part 1989 Comp., p. 235), "Debarment and Suspension." SAM Exclusions contains the
names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties
declared ineligible under statutory or regulatory authority other than Executive Order 12549.
9) Byrd Anti-Lobbying Amendment(31 U.S.C. 1352)—Contractors that apply or bid for an award
exceeding $100,000 must file the required certification. Each tier certifies to the tier above
that it will not and has not used federal appropriated funds to pay any person or organization
for influencing or attempting to influence an officer or employee of any agency, a member of
Congress, officer or employee of Congress, or an employee of a member of Congress in
connection with obtaining any federal contract, grant or any other award covered by 31
U.S.C. 1352. Each tier must also disclose any lobbying with non-federal funds that takes
place in connection with obtaining any federal award. Such disclosures are forwarded from
tier to tier up to the non-federal award.
10) Procurement of recovered materials -- As required by 2 CFR 200.322, a non-federal entity
that is a state agency or agency of a political subdivision of a state and its contractors must
comply with section 6002 of the Solid Waste Disposal Act, as amended by the Resource
Conservation and Recovery Act. The requirements of Section 6002 include procuring only
items designated in guidelines of the Environmental Protection Agency (EPA) at 40 CFR part
247 that contain the highest percentage of recovered materials practicable, consistent with
maintaining a satisfactory level of competition, where the purchase price of the item exceeds
$10,000 or the value of the quantity acquired during the preceding fiscal year exceeded
$10,000, procuring solid waste management services in a manner that maximizes energy
and resource recovery; and establishing an affirmative procurement program for
procurement of recovered materials identified in the EPA guidelines.
11) Notice of awarding agency requirements and regulations pertaining to reporting.
12) Federal awarding agency requirements and regulations pertaining to copyrights and rights in
data.
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13) Access by the Department, the Subrecipient, the federal awarding agency, the Comptroller
General of the United States, or any of their duly authorized representatives to any books,
documents, papers, and records of the contractor which are directly pertinent to that specific
contract for the purpose of making audit, examination, excerpts, and transcriptions.
14) Retention of all required records for six years after the Subrecipient has made final payments
and all other pending matters are closed.
15) Mandatory standards and policies relating to energy efficiency which are contained in the
state energy conservation plan issued in compliance with the Energy Policy and
Conservation Act (Pub. L. 94-163, 89 Stat. 871).
b. The Department reserves the right to review the Subrecipient procurement plans and documents,
and require the Subrecipient to make changes to bring its plans and documents into compliance
with the requirements of 2 CFR Part 200.318 through 200.326. The Subrecipient must ensure
that its procurement process requires contractors and subcontractors to provide adequate
documentation with sufficient detail to support the costs of the project and to allow both the
Subrecipient and Department to make a determination on eligibility of project costs.
C. All contracting agreements entered into pursuant to this Agreement shall incorporate this
Agreement by reference
A.11 DISCLOSURE
The use or disclosure by any party of any information concerning the Department for any purpose not
directly connected with the administration of the Department's or the Subrecipient's responsibilities with
respect to services provided under this Agreement is prohibited except by prior written consent of the
Department or as required to comply with the state Public Records Act, other law or court order.
A.12 DISPUTES
Except as otherwise provided in this Agreement, when a bona fide dispute arises between the parties
and it cannot be resolved through discussion and negotiation, either party may request a dispute
resolution panel to resolve the dispute. A request for a dispute resolution board shall be in writing, state
the disputed issues, state the relative positions of the parties, and be sent to all parties. The panel shall
consist of a representative appointed by the Department, a representative appointed by the Subrecipient
and a third party mutually agreed upon by both parties. The panel shall, by majority vote, resolve the
dispute. Each party shall bear the cost for its panel member and its attorney fees and costs, and share
equally the cost of the third panel member.
A.13 LEGAL RELATIONS
It is understood and agreed that this Agreement is solely for the benefit of the parties to the Agreement
and gives no right to any other party. No joint venture or partnership is formed as a result of this
Agreement.
To the extent allowed by law, the Subrecipient, its successors or assigns, will protect, save and hold
harmless the Department, the State of Washington, and the United States Government and their
authorized agents and employees, from all claims, actions, costs, damages or expenses of any nature
whatsoever by reason of the acts or omissions of the Subrecipient, its sub-contractors, subrecipients,
assigns, agents, contractors, consultants, licensees, invitees, employees or any person whomsoever
arising out of or in connection with any acts or activities authorized by this Agreement.
To the extent allowed by law, the Subrecipient further agrees to defend the Department and the State of
Washington and their authorized agents and employees in any litigation; including payment of any costs
or attorneys' fees for any claims or action commenced thereon arising out of or in connection with acts
or activities authorized by this Agreement.
This obligation shall not include such claims, costs, damages or expenses which may be caused by the
sole negligence of the Department, provided, that if the claims or damages are caused by or result from
the concurrent negligence of(1) the Department, and (2) the Subrecipient, its agents, or employees, this
indemnity provision shall be valid and enforceable only to the extent of the negligence of the Subrecipient,
or Subrecipient's agents or employees.
Insofar as the funding source, the Department of Homeland Security (DHS)/Federal Emergency
Management Agency (FEMA), is an agency of the Federal government, the following shall apply:
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44 CFR, 206.9 Non-IiabiNit . The Federal government shall not be liable for any claim based upon the
exercise or performance of, or the failure to exercise or perform a discretionary function or duty on the
part of a federal agency or an employee of the Federal government in carrying out the provisions of the
Stafford Act.
A.14 LIMITATION OF AI�T140PITV_ At ITHOPIZED SIGNATURE
The signatories to this Agreement represent that they have the authority to bind their respective
organizations to this Agreement. Only the Department's Authorized Signature representative and the
Authorized Signature representative of the Subrecipient or Alternate for the Subrecipient, formally
designated in writing, shall have the express, implied, or apparent authority to alter, amend, modify, or
waive any clause or condition of this Agreement. Any alteration, amendment, modification, or waiver of
any clause or condition of this Agreement is not effective or binding unless made in writing and signed
by both parties' Authorized Signature representatives.
Further, only the Authorized Signature representative or Alternate for the Subrecipient shall have
signature authority to sign reimbursement requests, time extension requests, amendment and
modification requests, requests for changes to projects or work plans, and other requests, certifications
and documents authorized by or required under this Agreement.
A.15 LOSS OR REDUCTION OF FUNDING
In the event funding from state, federal, or other sources is withdrawn, reduced, or limited in any way
after the effective date of this Agreement and prior to normal completion or end date, the Department
may unilaterally reduce the scope of work and budget or unilaterally terminate all or part of the Agreement
as a "Termination for Cause"without providing the Subrecipient an opportunity to cure. Alternatively, the
parties may renegotiate the terms of this Agreement under "Amendments and Modifications" to comply
with new funding limitations and conditions, although the Department has no obligation to do so.
A.16 NONASSIGNABILITY
Neither this Agreement, nor any claim arising under this Agreement, shall be transferred or assigned by
the Subrecipient.
A.17 NONDISCRIMINATION
The Subrecipient shall comply with all applicable federal and state non-discrimination laws, regulations,
and policies. No person shall, on the grounds of age, race, creed, color, sex, sexual orientation, religion,
national origin, marital status, honorably discharged veteran or military status, or disability (physical,
mental, or sensory) be denied the benefits of, or otherwise be subjected to discrimination under any
project, program, or activity, funded, in whole or in part, under this Agreement.
A.18 NOTICES
The Subrecipient shall comply with all public notices or notices to individuals required by applicable local,
state and federal laws and regulations and shall maintain a record of this compliance.
A.19 OCCUPATIONAL SAFETY/HEALTH ACT and WASHINGTON INDUSTRIAL SAFETY/ HEALTH ACT
(OSHANVISHA,)
The Subrecipient represents and warrants that its work place does now or will meet all applicable federal
and state safety and health regulations that are in effect during the Subrecipient's performance under this
Agreement. To the extent allowed by law, the Subrecipient further agrees to indemnify and hold harmless
the Department and its employees and agents from all liability, damages and costs of any nature,
including, but not limited to, costs of suits and attorneys' fees assessed against the Department, as a
result of the failure of the Subrecipient to so comply.
A.20 OWNERSHIP OF PROJECT/CAPITAL FACILITIES
The Department makes no claim to any capital facilities or real property improved or constructed with
funds under this Agreement, and by this subaward of funds does not and will not acquire any ownership
interest or title to such property of the Subrecipient. The Subrecipient shall assume all liabilities and
responsibilities arising from the ownership and operation of the project and agrees to indemnify and hold
the Department, the state of Washington and the United States government harmless from any and all
causes of action arising from the ownership and operation of the project.
A.21 POLITICAL ACTIVITY
No portion of the funds provided herein shall be used for any partisan political activity or to further the
election or defeat of any candidate for public office or influence the approval or defeat of any ballot issue.
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A.22 PROHIBITION AGAINST PAYMENT OF BONUS OR COMMISSION
The assistance provided under this Agreement shall not be used in payment of any bonus or commission
for the purpose of obtaining approval of the application for such assistance or any other approval or
concurrence under this Agreement provided, however, that reasonable fees or bona fide technical
consultant, managerial, or other such services, other than actual solicitation, are not hereby prohibited if
otherwise eligible as project costs.
A.23 PUBLICITY
The Subrecipient agrees to submit to the Department prior to issuance all advertising and publicity
matters relating to this Agreement wherein the Department's name is mentioned or language used from
which the connection of the Department's name may, in the Department's judgment, be inferred or
implied. The Subrecipient agrees not to publish or use such advertising and publicity matters without the
prior written consent of the Department. The Subrecipient may copyright original work it develops in the
course of or under this Agreement; however, pursuant to 2 CFR Part 200.315, FEMA reserves a royalty-
free, nonexclusive, and irrevocable license to reproduce, publish or otherwise use, and to authorize
others to use the work for government purposes.
Publication resulting from work performed under this Agreement shall include an acknowledgement of
FEMA's financial support, by CFDA number, and a statement that the publication does not constitute an
endorsement by FEMA or reflect FEMA's views.
A.24 RECAPTURE PROVISION
In the event the Subrecipient fails to expend funds under this Agreement in accordance with applicable
federal, state, and local laws, regulations, and/or the provisions of the Agreement, the Department
reserves the right to recapture funds in an amount equivalent to the extent of noncompliance. Such right
of recapture shall exist for the life of the project following Agreement termination. Repayment by the
Subrecipient of funds under this recapture provision shall occur within 30 days of demand. In the event
the Department is required to institute legal proceedings to enforce the recapture provision, the
Department shall be entitled to its costs and expenses thereof, including attorney fees from the
Subrecipient.
A.25 RECORDS
a. The Subrecipient agrees to maintain all books, records, documents, receipts, invoices and all
other electronic or written records necessary to sufficiently and properly reflect the Subrecipient's
contracts, subawards, grant administration, and payments, including all direct and indirect
charges, and expenditures in the performance of this Agreement (the "records").
b. The Subrecipient's records related to this Agreement and the projects funded may be inspected
and audited by the Department or its designee, by the Office of the State Auditor, DHS, FEMA or
their designees, by the Comptroller General of the United States or its designees, or by other
state or federal officials authorized by law, for the purposes of determining compliance by the
Subrecipient with the terms of this Agreement and to determine the appropriate level of funding
to be paid under the Agreement.
C. The records shall be made available by the Subrecipient for such inspection and audit, together
with suitable space for such purpose, at any and all times during the Subrecipient's normal
working day.
d. The Subrecipient shall retain and allow access to all records related to this Agreement and the
funded project(s) for a period of at least six (6) years following final payment and closure of the
grant under this Agreement. Despite the minimum federal retention requirement of three (3)
years, the more stringent State requirement of six (6) years must be followed.
A.26 RESPONSIBILITY FOR PROJECT/STATEMENT OF WORKNVORK PLAN
While the Department undertakes to assist the Subrecipient with the project/statement of work/work plan
(project) by providing federal award funds pursuant to this Agreement, the project itself remains the sole
responsibility of the Subrecipient. The Department undertakes no responsibility to the Subrecipient, or
to any third party, other than as is expressly set out in this Agreement.
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The responsibility forthedesign, development, construction, implementation, operation and maintenance
of the project, as these phrases are applicable to this project, is solely that of the Subrecipient, as is
responsibility for any claim or suit of any nature by any third party related in any way to the project.
Prior to the start of any construction activity, the Subrecipient shall ensure that all applicable federal,
state, and local permits and clearances are obtained, including, but not limited to, FEMA compliance with
the National Environmental Policy Act, the National Historic Preservation Act, the Endangered Species
Act, and all other environmental laws, regulations, and executive orders.
The Subrecipient shall defend, at its own cost, any and all claims or suits at law or in equity, which may
be brought against the Subrecipient in connection with the project. The Subrecipient shall not look to the
Department, or to any state or federal agency, or to any of their employees or agents, for any
performance, assistance, or any payment or indemnity, including, but not limited to, cost of defense
and/or attorneys' fees, in connection with any claim or lawsuit brought by any third party related to any
design, development, construction, implementation, operation and/or maintenance of a project.
A.27 SEVERABILITY
If any court of rightful jurisdiction holds any provision or condition under this Agreement or its application
to any person or circumstances invalid, this invalidity does not affect other provisions, terms or conditions
of the Agreement, which can be given effect without the invalid provision. To this end, the terms and
conditions of this Agreement are declared severable.
A.28 SINGLE AUDIT ACT REQUIREMENTS (including all AMENDMENTS)
Non-federal entities, as subrecipients of a federal award, that expend $750,000 or more in one fiscal year
of federal funds from all sources, direct and indirect, are required to have a single or a program-specific
audit conducted in accordance with 2 CFR Part 200 Subpart F. Non-federal entities that spend less than
$750,000 a year in federal awards are exempt from federal audit requirements for that year, except as
noted in 2 CFR Part 200 Subpart F. As defined in 2 CFR Part 200, the term "non-federal entity" means
a State, local government, Indian tribe, institution of higher education, or non-profit organization that
carries out a federal award as a recipient or subrecipient.
Subrecipients that are required to have an audit must ensure the audit is performed in accordance with
Generally Accepted Government Auditing Standards (GAGAS) as found in the Government Auditing
Standards (the Revised Yellow Book) developed by the United States Comptroller General and the OMB
Compliance Supplement. The Subrecipient has the responsibility of notifying its auditor and requesting
an audit in compliance with 2 CFR Part 200 Subpart F, to include the Washington State Auditor's Office,
a federal auditor, or a public accountant performing work using GAGAS, as appropriate. Costs of the
audit may be an allowable grant expenditure as authorized by 2 CFR Part 200.425.
The Subrecipient shall maintain auditable records and accounts so as to facilitate the audit requirement
and shall ensure that any sub-contractors also maintain auditable records. The Subrecipient is
responsible for any audit exceptions incurred by its own organization or that of its sub-
contractors. Responses to any unresolved management findings and disallowed or questioned costs
shall be included with the audit report. The Subrecipient must respond to Department requests for
information or corrective action concerning audit issues or findings within 30 days of the date of
request. The Department reserves the right to recover from the Subrecipient all disallowed costs
resulting from the audit.
After the single audit has been completed, and if it includes any audit findings, the Subrecipient must
send a full copy of the audit and its corrective action plan to the Department at the following address no
later than nine (9) months after the end of the Subrecipient's fiscal year(s):
Contracts Office
Washington Military Department
Finance Division, Building #1 TA-20
Camp Murray, WA 98430-5032
If the Subrecipient claims it is exempt from the audit requirements of 2 CFR Part 200 Subpart F, the
Subrecipient must send a completed "2 CFR Part 200 Subpart F Audit Certification Form"
(htt s://www.mil.wa. ov/emer enc -mana ement-division/ rentsYr uired rantforms)to the Department
at the address listed above identifying this Agreement and explaining the criteria for exemption no later
than nine (9) months after the end of the Subrecipient's fiscal year(s).
DHS-FEMA-EMPG-FY 17 Page 17 of 35 City of Kent EMD, E18-099
The Department retains the sole discretion to determine whether a valid claim for an exemption from the
audit requirements of this provision has been established.
The Subrecipient shall include the above audit requirements in any subawards.
Conducting a single or program-specific audit in compliance with 2 CFR Part 200 Subpart F is a material
requirement of this Agreement. In the absence of a valid claim of exemption from the audit requirements
of 2 CFR Part 200 Subpart F, the Subrecipient's failure to comply with said audit requirements may result
in one or more of the following actions in the Department's sole discretion: a percentage of federal awards
being withheld until the audit is completed in accordance with 2 CFR Part 200 Subpart F, the withholding
or disallowing of overhead costs, the suspension of federal awards until the audit is conducted and
submitted, or termination of the federal award.
A.29 SUBRECIPIENT NOT EMPLOYEE
The parties intend that an independent contractor relationship will be created by this Agreement. The
Subrecipient, and/or employees or agents performing under this Agreement are not employees or agents
of the Department in any manner whatsoever. The Subrecipient will not be presented as, nor claim to
be, an officer or employee of the Department by reason of this Agreement, nor will the Subrecipient make
any claim, demand, or application to or for any right or privilege applicable to an officer or employee of
the Department or of the State of Washington by reason of this Agreement, including, but not limited to,
Workmen's Compensation coverage, unemployment insurance benefits, social security benefits,
retirement membership or credit, or privilege or benefit which would accrue to a civil service employee
under Chapter 41.06 RCW.
It is understood that if the Subrecipient is another state department, state agency, state university, state
college, state community college, state board, or state commission, that the officers and employees are
employed by the state of Washington in their own right and not by reason of this Agreement.
A.30 TAXES FEES AND LICENSES
Unless otherwise provided in this Agreement, the Subrecipient shall be responsible for, pay and maintain
in current status all taxes, unemployment contributions, fees, licenses, assessments, permit charges and
expenses of any other kind for the Subrecipient or its staff required by statute or regulation that are
applicable to Agreement performance.
A.31 TERMINATION FOR CONVENIENCE
Notwithstanding any provisions of this Agreement, the Subrecipient may terminate this Agreement by
providing written notice of such termination to the Department Key Personnel identified in the Agreement,
specifying the effective date thereof, at least thirty (30) days prior to such date.
Except as otherwise provided in this Agreement, the Department, in its sole discretion and in the best
interests of the State of Washington, may terminate this Agreement in whole or in part by providing ten
(10) calendar days written notice, beginning on the second day after mailing to the Subrecipient. Upon
notice of termination for convenience, the Department reserves the right to suspend all or part of the
Agreement, withhold further payments, or prohibit the Subrecipient from incurring additional obligations
of funds. In the event of termination, the Subrecipient shall be liable for all damages as authorized by
law. The rights and remedies of the Department provided for in this section shall not be exclusive and
are in addition to any other rights and remedies provided by law.
A.32 TERMINATION OR SUSPENSION FOR CAUSE
In the event the Department, in its sole discretion, determines the Subrecipient has failed to fulfill in a
timely and proper manner its obligations under this Agreement, is in an unsound financial condition so
as to endanger performance hereunder, is in violation of any laws or regulations that render the
Subrecipient unable to perform any aspect of the Agreement, or has violated any of the covenants,
agreements or stipulations of this Agreement, the Department has the right to immediately suspend or
terminate this Agreement in whole or in part.
The Department may notify the Subrecipient in writing of the need to take corrective action and provide
a period of time in which to cure. The Department is not required to allow the Subrecipient an opportunity
to cure if it is not feasible as determined solely within the Department's discretion. Any time allowed for
cure shall not diminish or eliminate the Subrecipient's liability for damages or otherwise affect any other
remedies available to the Department. If the Department allows the Subrecipient an opportunity to cure,
the Department shall notify the Subrecipient in writing of the need to take corrective action. If the
corrective action is not taken within ten (10) calendar days or as otherwise specified by the Department,
DHS-FEMA-EMPG-FY 17 Page 18 of 35 City of Kent EMD, E18-099
or if such corrective action is deemed by the Department to be insufficient, the Agreement may be
terminated in whole or in part.
The Department reserves the right to suspend all or part of the Agreement, withhold further payments,
or prohibit the Subrecipient from incurring additional obligations of funds during investigation of the
alleged compliance breach, pending corrective action by the Subrecipient, if allowed, or pending a
decision by the Department to terminate the Agreement in whole or in part.
In the event of termination, the Subrecipient shall be liable for all damages as authorized by law, including,
but not limited to, any cost difference between the original Agreement and the replacement or cover
Agreement and all administrative costs directly related to the replacement Agreement, e.g., cost of
administering the competitive solicitation process, mailing, advertising and other associated staff time.
The rights and remedies of the Department provided for in this section shall not be exclusive and are in
addition to any other rights and remedies provided by law.
If it is determined that the Subrecipient: (1) was not in default or material breach, or (2) failure to perform
was outside of the Subrecipient's control, fault or negligence, the termination shall be deemed to be a
"Termination for Convenience".
A.33 TERMINATION PROCEDURES
In addition to the procedures set forth below, if the Department terminates this Agreement, the
Subrecipient shall follow any procedures specified in the termination notice. Upon termination of this
Agreement and in addition to any other rights provided in this Agreement, the Department may require
the Subrecipient to deliver to the Department any property specifically produced or acquired for the
performance of such part of this Agreement as has been terminated.
If the termination is for convenience, the Department shall pay to the Subrecipient as an agreed upon
price, if separately stated, for properly authorized and completed work and services rendered or goods
delivered to and accepted by the Department prior to the effective date of Agreement termination, the
amount agreed upon by the Subrecipient and the Department for (i) completed work and services and/or
equipment or supplies provided for which no separate price is stated, (ii) partially completed work and
services and/or equipment or supplies provided which are accepted by the Department, (iii) other work,
services and/or equipment or supplies which are accepted by the Department, and (iv)the protection and
preservation of property.
Failure to agree with such amounts shall be a dispute within the meaning of the"Disputes" clause of this
Agreement. If the termination is for cause, the Department shall determine the extent of the liability of
the Department. The Department shall have no other obligation to the Subrecipient for termination. The
Department may withhold from any amounts due the Subrecipient such sum as the Department
determines to be necessary to protect the Department against potential loss or liability.
The rights and remedies of the Department provided in this Agreement shall not be exclusive and are in
addition to any other rights and remedies provided by law.
After receipt of a notice of termination, and except as otherwise directed by the Department in writing,
the Subrecipient shall:
a. Stop work under the Agreement on the date, and to the extent specified, in the notice;
b. Place no further orders or contracts for materials, services, supplies, equipment and/or facilities
in relation to this Agreement except as may be necessary for completion of such portion of the
work under the Agreement as is not terminated,
C. Assign to the Department, in the manner, at the times, and to the extent directed by the
Department, all of the rights, title, and interest of the Subrecipient under the orders and contracts
so terminated, in which case the Department has the right, at its discretion, to settle or pay any
or all claims arising out of the termination of such orders and contracts;
d. Settle all outstanding liabilities and all claims arising out of such termination of orders and
contracts, with the approval or ratification of the Department to the extent the Department may
require, which approval or ratification shall be final for all the purposes of this clause;
e. Transfer title to the Department and deliver in the manner, at the times, and to the extent directed
by the Department any property which, if the Agreement had been completed, would have been
required to be furnished to the Department;
DHS-FEMA-EMPG-FY 17 Page 19 of 35 City of Kent EMD, E18-099
f. Complete performance of such part of the work as shall not have been terminated by the
Department in compliance with all contractual requirements; and
g. Take such action as may be necessary, or as the Department may require, for the protection and
preservation of the property related to this Agreement which is in the possession of the
Subrecipient and in which the Department has or may acquire an interest.
A.34 UTILIZATION OF MINORITY AND WOMEN BUSINESS ENTERPRISES (MWBE)
The Subrecipient is encouraged to utilize business firms that are certified as minority-owned and/or
women-owned in carrying out the purposes of this Agreement. The Subrecipient may set utilization
standards, based upon local conditions or may utilize the state of Washington MWBE goals, as identified
in WAC 326-30-041.
A.35 VENUE
This Agreement shall be construed and enforced in accordance with, and the validity and performance
shall be governed by, the laws of the state of Washington. Venue of any suit between the parties arising
out of this Agreement shall be the Superior Court of Thurston County, Washington. The Subrecipient,
by execution of this Agreement acknowledges the jurisdiction of the courts of the State of Washington.
A.36 WAIVERS
No conditions or provisions of this Agreement can be waived unless approved in advance by the
Department in writing. The Department's failure to insist upon strict performance of any provision of the
Agreement or to exercise any right based upon a breach thereof, or the acceptance of any performance
during such breach. shall not constitute a waiver of any right under this Agreement.
DHS-FEMA-EMPG-FY 17 Page 20 of 35 City of Kent EMD, E18-099
Exhibit C
WORK PLAN
FY 2017 Emergency Management Performance Grant
..
Lmerganr:y Management Organizatfon City of Kent Emergency Management Division
The purpose of EMPG is to assist with the enhancement,sustainment and improvement of state,local,and tribal emergency management
programs.Activities conducted using EMPG funding should relate directly to the five elements of emergency management:prevention,
protection,response,recovery,and mitigation. Washington State does not require a specific number of activities to receive EMPG funding,
However,there are required capabilities that must be sustained in order to remain eligible for EMPG funding,including but not limited to
the ability to communicate and warn,educate the public,train and exercise,plan,and be NIMS compliant. The Work Plan delineates the
Emergency Management Organization's emergency management program planning and priority focus for this grant cycle(to include
17EMPG grant and local funds).
Listorganrzarlaaraf expePsesthat W18bslundouby EMPG.
Satellite Phones Copier/Punch Kit Lease f5mallTools and Equipment
I d i 8 Refreshments Offic e
Internet and Website Fees tora ge 5h e g Fee es
EmergencyFoo MRE.Water rotation Meetin R
g Printing Fees
111k L.Ar[fidg'25
Cp2! mity Outreach I public Education
WORK PLANNED WHY THE WORK IS BEING DONE RESULT OF THE WORK
1 CERY-Deliver FEMA Courses and fetresber With continued classes/trainings being offered -Larger number of CERT trained members in the
training tothe City of Kent,Covington,Puget each year,we are building our volunteer database community.
Sound Regional Fire Authority(RFA)and the and becoming a more resilient community -CERT graduates become volunteers in other
Kent/Covington School District. emergency management areas(Kent
Communications Support Team,ECG Volunteer,
Message Center Volunteer,etc.)
-Theendresultisthe community is better
prepared to respond and more resilient toa
disaster
1 fondiurcl1peGlalizel9 CERT/Pmparedness Classes TU successfully educate our community in all the Amore rie illentcommunity prepared for and able
lUcal bu9Anessw.4,neighbUrYvood3,artd 3olirldtls. a5pert5 of disaster preparedness so that they can to respond to a disaster„
help mitigate loss and help our community rebuild
after a dlsasrer.
3 Participate in muhiple community events Focus is on community safety and emergency More youth and adults interested in emergency
throughout the year with EM Logo attire such as preparedness by both adults and youth preparedness and having the knowledge of how to
Corn Day,Covington Days,National Night Out, prepare for and respond during a disaster.
Kids Safety Day,You/Me/We Event,and multiple
.•chisicil"ents)
Kern Communications Support Team KCST
WORK PLANNED WHY THE WORK IS BEING DONE RESULT OF THE WORK
1 Participate in multiple community events wearing By participating in events,it provides a chance to Better trained volunteers who are knowledgeable
KCST logo attire such as field day,Cornucopia test generators,disaster communication kits, of the setup procedures for our mobile
Days,National Night Out,The Great Shakeout, processes,as well as,provide an opportunity for communications kit and van. Finding possible
Emergency Activations and More volunteer training. gaps in communications when relying on
emergency power.
1 Purchase equipment(laptops,radios,generator) To create/enhance a redundant emergency A robust communications system to support City
for enhancement of emergency communications. communications system. and Regional emergencies and planned events,
ExerclseV Traini s
WORK PLANNED WHY THE WORK 15 BEING DONE RESULT OFTHE WORK
1 Fattici pate in the design,conduct,and evaluation To continue to enhance our oapablthes through Successful 1participation,completed AARg
of at least three exercises during the performance testing,exercise,and training. Identifying areas for improvement,and for
period. participants tc be able to better respond span
Incident/event,.
tems
and
ct any issues that May
up
l[J�Q
ileu� tdSts In ordeer to fully maximECC arise from dAsplayS etc•thattos ableetololperatereffes velyi,
cTively in
ePvice da tia ebEWes, an InCld@nt/CVent/&fI^.a5ter
DHS-FEMA-EMPG-FY 17 Page 21 of 35 City of Kent EMD, E18-099
3 1 Conduct train ings anclJor send City StafflFit TT increase job ski Its and knowledge in Emergency More fully trai red staff and vol untee rs who are
6fafi/V01unteers to career development Management functions, better able to respond to an incident/event,
workshops,seminars,conferences amd training for
Emergency Management.
MEW
Operational t'a ftflities
WORK PLANNED WHY THE,WORK IS BEING DONE RESULT OF THE WORK
I -CanUnue to identify enhancements in Dnis,exercises,and activations have identified a 'Greater communication and functional¢yto
'.functionality and capability for the Kent ECC and gap in communication sharing and the need for Increase situational awareness between ECC,
DOCS(Department Operating Centers)Including better situational awareness. DOCs,and regional partners during an
computer software, ar:tivaklon/exavxise.
-Provide network communication sharing,
Situational Awareness tracking,and Status board
sharing within the DOCs and ECC.
2 Acquire radio equipment for ECC communication To improve cache of emergencycommunlcation Increased ability to communicate during exercises
capability equipment by updating out, date equipment and activations.
and/or equipment that Is reaching Its end of life,
3 Develop and train volunteers to support multiple 70 have fully trained volunteersto assist In the Tire abilityto call upon ourtrained volunteersto
famctiori/processes within the ECC and/or ECC in both exercises and activations as per WA C assist within the ECC during preparedness,
risaster is aredness recovery 'J,:Lg'tth - _ mlGigatfon,and recovefyeffurts.
pp r _
4 Acquire equipment to im prove operational Events and acbvatIons high lighted the need for JA full functioning staging area that is able to
readiness for an outdoor staging a rea, operations l terns to assist with am scene respond to an event/incident/exercise-
activities.
5 Improve Emergency Management Mobile EM vehicles(Van/TruckJTrailer)are notfully Mobile emergency response fleet avatlableto
resource capabilities capable to support emergency operations. support operationsfor local and regional
emergency and planned events.
Public information and Warnin
WORK PLANNED WHY THE WORK IS BEING DONE RESULT OFTHE WORK
I Provide interpretation and translation services To effectively communicate disaster preparedness Disaster preparedness/emergency information
duringtralnings,exercises,and activations when and/or emergency information to a community materials will reach everyone so the community
needed, which contains limited English proficiency will be better prepared and able to respond to an
populations, event,
fnn me docurne and education purposes haw toease community awareness of hazards and Tfie community and City staff are better pregared
2 L.reaCe documents and print materials,signs,etc. To incr
tion
mat res�ppnd, to respond to an emerigency of&vent,
DHS-FEMA-EMPG-FY 17 Page 22 of 35 City of Kent EMD, E18-099
Exhibit D
TIMELINE
...--...- — — _ ...__ .......
FY 2017 Emergency Management Performance Grant
------....._
DATE TASK
June 1, 2017 Grant Agreement Start Date
......... ........_.....
May 31, 2018 Submit reimbursement request
July 31, 2018 Submit reimbursement request
__........._.
August 31, 2018 Grant Agreement End Date
October 15, 2018 Submit final reimbursement request, final report, Training and
Exercise Requirement report, and/or other deliverables.
DHS-FEMA-EMPG-FY 17 Page 23 of 35 City of Kent EMD, E18-099
Exhibit E
�........_a. _._..._. BUDGET _
FY 2017 Emergency Management Performance Grant _
17EMPG AWARD $ 70,697.00
SOLUTION -_.._......_.
AREA CATEGORY EMPG AMOUNT Match AMOUNT
�!Y1rd'd?Ir(�1i:�YU/�IUVv�.r'9 rW�,ruupkJauml'T+M1S'Sa n, , 8Pro'b�,wtiVYJ�YNk'�'rv81,'BY�Par�'tN�hH�^r�{wt�WStioikl�r'R�,�NfiSr�erfl�YWi^!at9u ,",V'Sl��u�r®r1AVw's � �Ouw�lurwum+rnuu�lrwrM�i Gtt&Ir�f
Salaries&Benefits $ - $ -
t7
ZZ Consultants/Contractors $ $
..... ."
Z Goods&Services $ - $
..... ....._..r....___$ ....... $
a Travel/Per Diem - ..,.... "_-.._.
Subtotal -
Z Salaries&Benefits $ $ 70,697
0 Overtime/Backfill $ -
a Consultants/Contractors $ $ -
^—� Goods&Services $ 23,500
Q Travel/Per Diem $ $ _
(7 �m............. _.........." --....... f.. .......
o:
0 Subtotal $ 23,500 $ 70,697
Salaries&Benefits $ - $..
w Overtone/Backfill $ $
Ci Consultants/Contractors $ - $.
w Goods&Services _ $
w Travel/Per Diem $ $ m
Subtotal $
Salaries&Benefits $
................................_._._..._....----- __..._m........._.______
l7 Overtime/Backfill $ 3 pqD $
Z Consultants/Contractors $ 4,397 $
Goods&Services
Travel/Per Diem --
.........._ $ 3,500 $ -
Subtotal $ 11,697 $
Lquup rnent $ 135�500 'Subtotal $ __,Salaries&Benefits $Overtime/Backfill $Consultants/Contractors__...._...__.._._........_..._ __'__...�..w$Goods&Services $...._..........,.............._.......... _.-......--------------iem $Subtotal $Indirect $ ._.
Indirect Cast Rate on f(le 0%
uirernrvrwvnnswtwmumu,nnisawsmwdNZOu,!ro�w�us'mnir ^r t', ,ur uo°mu wohremrro�rsruriisrmnairrU,nmr�!vane
TOTAL Grant Agreement AMOUNT: $ 7p,69 �
7 $ 70,697
• The Subrecipient will provide a match of$70,697 of non-federal origin, 50% of the total project cost(Local budget plus
EMPG award).
• Cumulative transfers to budget categories in excess of 10% of the grant agreement amount will not be reimbursed
without prior written authorization from the Department.
Funding Source: U.S. Department of Homeland Security-PI#773PT—EMPG
DHS-FEMA-EMPG-FY 17 Page 24 of 35 City of Kent EMD, E18-099
Attachment 1
17EMPG Award Document
EMS-2017-EP-00004-S01
Avvirt Letlbr
U.S. Department of Homeland Security
Washington,D.C.20472
I:b
O'U 0'0��4 V I&tSV�7'
Brat Daugherty
Washington Military Department
Building 20
Camp Murray,WA98430-5122
Re Grant No.EMS-2017-EP-00004
Dear Bret Daugherty
Congratulations,on behalf ofthe Department of Homeland Security,your application for financial assistance submitted under
the Fiscal Year (FY)2017 Emergency Management Performance Grants has been approved in the amount of$7,306,624.00.
As a condition of this award,you are required to contribute a cost match in the amount of$7,306$24.00 of non-Federal funds,
or 50 percent of the total approved project costs of$14.613.24&00
Before you request and receive any of the Federal funds awarded to you,you must establish acceptance of the award By
accepting this award,you acknowledge that the terms of the following documents are incorporated into the terms of your
award:
• Agreement Articles(attached to this Award Letter)
• Obligating Document(attached to this Award Letter)
• FY 2017 Emergency Management Performance Grants Notice of Funding Opportunity.
Please make sure you read, undarsland, and maintain a copy of these documents in your official file for this award
In order to establish acceptance of the award and its terms, please followthese instructions
Step I:Please log in to the ND Grants system at tittiosJ/portaffama goy.
Stop 2:After logging in,you will see the Home page with a Pending Tasks menu.Click on the Pending Tasks menu,select the
Application sub-menu,and their click the link for'Award Offer Review"tasks.This link will navigate you to Award Packages
that are pending review.
Step 3:Click the Review Award Package icon (wrench)to review the Award Package and accept or decline the award. Please
save or print the Award Package for your records.
System for Award Management(SAM) Grant recipients are to keep all of their information up to date in SAM,in particular,
your organization's name,address, DUNS number, EIN and banking information. Please ensure thatthe DUNS number used
in SAM is the same one used to apply for all FEMA awards.Future payments will be contingent on the information provided
in the SAM; therefore,it is imperative that the information is correct The System for Award Management is located athitLI
V2V_aaMJ_Qy
If you have any questions or have updated your information in SAM, please let your Grants Management Specialist(GMS)
know as soon as possible.This will help use to make the necessary updates and avoid any interruptions in the payment
process.
DHS-FEMA-EMPG-FY 17 Page 25 of 35 City of Kent i El 8-099
SHARON LYNN LOPER Regional Administrator
DHS-FEMA-EMPG-FY 17 Page 26 of 35 City of Kent EMD, E18-099
dtge^ebmcrrf aritc�e _
Sat UctoIobbb:bd GMT 201t
U.S. Department of Homeland Security
6
s4 Washington,D.C.20472
0
uo
1Mtr 5
AGREEMENT ARTICLES
Emergency Management Performance Grants
GRANTEE: Washington Military Department
PROGRAM: Emergency Management Performance
Grants
AGREEMENT NUMBER: EMS-2017-EP-00004-S01
TABLE OF CONTENTS
Article I Whistleblower Protection Act
Article II Use of DHS Seal,Logo and Flags
Article III USA Patriot Act of 2001
Article IV Universal Identifier and System of Award Management
(SAM)
Article V Reporting of Matters Related to Recipient Integrity and
Performance
Article M Rehabilitation Act of 1973
Article VII Trafficking Victims Protection Act of 2000
Article VIII Terrorist Financing
Article IX SAFECOM
Article X Reporting Subawards and Executive Compensation
Article XI Procurement of Recovered Materials
Article XII Patents and Intellectual Property Rights
Article XIII Notice of Funding Opportunity Requirements
DHS-FEMA-EMPG-FY 17 Page 27 of 35 City of Kent EMO, E18-099
Article XIV Non-supplanting Requirement
Article XV Lobbying Prohibitions
Article XVI Limited English Proficiency(Civil Rights Act of 1964,Title VI)
Article XVII Hotel and Motel Fire Safety Act of 1990
Article XVIII Fly America Act of 1974
Article XIX Best Practices for Collection and Use of Personally
Identifiable Information(PII)
Article XX Americans with Disabilities Act of 1990
Article XXI Age Discrimination Act of 1975
Article XXII Activities Conducted Abroad
Article XXIII Acknowledgment of Federal Funding from DHS
Article XXIV Federal Leadership on Reducing Text Messaging while
Driving
Article XXV Federal Debt Status
Article XXVI False Claims Act and Program Fraud Civil Remedies
Article XXVII Energy Policy and Conservation Act
Article XXVIII Education Amendments of 1972(Equal Opportunity in
Education Act) -Title IX
Article XXIX Duplication of Benefits
Article XXX Drug-Free Workplace Regulations
Article XXXI Debarment and Suspension
Article XXXI I Copyright
Article XXXII I Civil Rights Act of 1968
Article XXXIV Civil Rights Act of 1964-Title VI
Article XXXV DHS Specific Acknowledgements and Assurances
Article XXXVI Assurances, Administrative Requirements, Cost Principles,
and Audit Requirements
DHS-FEMA-EMPG-FY 17 Page 28 of 35 City of Kent EMD, E18-099
Article XXXVII National Environmental Policy Act
Article XXXVIII Nondiscrimination in Matters Pertaining to Faith-Based
Organizations
Article XXXIX Acceptance of Post Award Changes
Article XL Prior Approval for Modification of Approved Budget
Article XLI Disposition of Equipment Acquired Under the Federal Award
Article XLII Buy American and Hire American
Article I-Whistleblower Protection Act
All recipients must comply with the statutory requirements for whistleblower protections(if applicable) at 10 U.S.C.
tM1 and 4310,
Article 11-Use of DHS Seal,Logo and Flags
All recipients must obtain permission from their DHS FAO, prior to using the DHS seal(a), logos, crests or reproductions of
flags or likenesses of DHS agency officials, including use of the United States Coast Guard seal, logo, crests or reproductions
of flags or likenesses of Coast Guard officials..
Article III-USA Patriot Act of 2001
All recipients must comply with requirements of the UEA11tr _arxi5-1ongtheauV Ar P _Ariate Tool rL _ ngp s
Sjemimd to intercept and C7bstru t Terrorism Act (USA PATi ftIC7T Ar t), which amends f<t,U.S C sect outs 175-175c.
Article IV-Universal Identifier and System of Award Management(SAM)
All recipients are required to comply with the requirements set forth in the government-wide financial assistance award term
regarding the System for Award Management and Universal Identifier Requirements located at 2 C F. -Pal_Appondix,k
the full text of which is incorporated here by reference in the terms and conditions.
Article V-Reporting of Matters Related to Recipient Integrity and Performance
If the total value of the recipienfs currently active grants, cooperative agreements, and procurement contracts from all federal
assistance offices exceeds$10,000,000 for any period of time during the period of performance of this federal financial
assistance award, you must comply with the requirements set forth in the government-wide Award Term and Condition for
Recipient Integrity and Performance Matters located at C:F,F2,-R��rL?tfQ, Af7pr rrocd ,eX,I,,q„ the full text of which is incorporated
here by reference in the award terms and conditions.
Article VI-Rehabilitation Act of 1973
All recipients must comply with the requirements of Section 504 of the Rehabilitation Act of 1973, .°.._�_ .C. seofdorl 794„as
amended, which provides that no otherwise qualified handicapped individuals in the United States will, solely by reason of the
handicap, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or
activity receiving federal financial assistance.
Article VII-Trafficking Victims Protection Act of 2000
All recipients must comply with the requirements of the government-wide award term which implements Section 106(g)of the
Trafficking Victims Protection Act of 2000, (TVPA)as amended by 22 U S C s99 N 7 9, . The award term is located at 2
aeghgn.175 7,5,the full text of which is incorporated here by reference in the award terms and conditions.
Article VIII-Terrorist Financing
DHS-FEMA-EMPG-FY 17 Page 29 of 35 City of Kent EMD, E18-099
All recipients must comply with ,0. 132?4 and U.S. law that prohibit transactions with, and the provisions of resources and
support to, individuals and organizations associated with terrorism, Red pie nts are legally responsible to ensure compliance
with the Order and laws.
Article IX-SAFECOM
All recipients receiving federal financial assistance awards made under programs that provide emergency communication
equipment and its related activities must comply with the SAFECOM Guidance for Emergency Communication Grants,
including provisions on technical standards that ensure and enhance interoperable communications.
Article X-Reporting Subawards and Executive Compensation
All recipients are required to comply with the requirements set forth in the government-wide Award Term on Reporting
Subawards and Executive Compensation located at ,F.R. Purl 170. Ap rx� -'.nuJix.g,the full text of which is incorporated here
by reference in the award terms and conditions.
Article XI-Procurement of Recovered Materials
All recipients must comply with Section 6002 of the aglid ste Dlsr?gsa.9 Aet, as amended by the Resnur C;ansprva¢ion and
EPcovery_ACt. The requirements of Section 6002 include procuring only items designated in guidelines of the Environmental
Protection Agency(EPA)at 4Q_Q E.R_FaLZA7 that contain the highest percentage of recovered materials practicable,
consistent with maintaining a satisfactory level of competition.
Article XII-Patents and Intellectual Property Rights
Unless otherwise provided by law, recipients are subject to the piaytY Io APL}putp_L_ o,&5,l7,.as amended, and codified
in ,S.C. 5ecdion 20Cy et seq. All recipients are subject to the specific requirements governing the development, reporting,
and disposition of rights to inventions and patents resulting from financial assistance awards located at)37_Q,,F.Id, mart 401 and
the standard patent rights clause located at 37 C.F.R. section 401.14.
Article Mill-Notice of Funding Opportunity Requirements
All of the instructions, guidance, limitations,and other conditions set forth in the Notice of Funding Opportunity(NOFO)for
this program are incorporated here by reference in the award terms and conditions. All recipients must comply with any such
requirements set forth in the program NOFO.
Article XIV-Non-supplanting Requirement
All recipients receiving federal financial assistance awards made under programs that prohibit supplanting by law must
ensure that federal funds do not replace(supplant)funds that have been budgeted for the same purpose through non-federal
sources„
Article XV-Lobbying Prohibitions
All recipients must comply with�_ tJseclior'i 1352,which provides that none of the funds provided under an federal
financial assistance award may be expended by the recipient to pay any person to influence,or attempt 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 any federal action concerning the award or renewal_
Article XVI-Limited English Proficiency(Civil Rights Act of 1964,Title VI)
All recipients must comply with the Title VI of the Civil Rights Act of 1964(Title VI) prohibition against discrimination on
the basis of national origin, which requires that recipients of federal financial assistance take reasonable steps to provide
meaningful access to persons with limited English proficiency(LEP)to their programs and services. For additional assistance
and information regarding language access obligations, please refer to the DHS Recipient Guidance t#pg_Fyww.dhs gnv!
!i i 'n,er rpiab6is17edfreBdPrtment-sup -oraaCiprovode-rneaninf ripAeJllmited and additional
resources on htipjh�N w l p-,ge_v.
Article XVII -Hotel and Motel Fire Safety Act of 1990
In accordance with Section 6 of the Hotel and Motel Fire Safety Act of 1990, 15 ...f, s c ion 2225.g,all recipients must
ensure that all conference, meeting, convention, or training space funded in whole or in part with federal funds complies
DHS-FEMA-EMPG-FY 17 Page 30 of 35 City of Kent EMD, El8-099
with the fire prevention and control guidelines of the Federal Fire Prevention and Control Act of 1974, as amended, 15
U.S G. sA9WQn MM
Article XVIII-Fly America Act of 1974
All recipients must comply with Preference for U.S. Flag Air Carriers(air careers holding certificates under 4. Vction
41102)for international air transportation of people and property to the extent that such service is available, in accordance
with the International Air Transportation Fair Competitive Practices Act of 1974(49 U-S C..sectiq.n 4011 8)and the
interpretative guidelines issued by the Comptroller General of the United States in the March 31, 1981 gmendment to
Comptroller General Decision B-138942.
Article XIX-Best Practices for Collection and Use of Personally Identifiable Information(Pill
DHS defines personally identifiable information(PII) as any information that permits the identity of an individual to be directly
or indirectly inferred, including any information that is linked or linkable to that individual. All recipients who collect PII are
required to have a publically-available privacy policy that describes standards on the usage and maintenance of PII they
collect. Recipients may also find the DHS Privacy Impact Assessments riv,a r and Privacy tour [ata.as useful
resources respectively.
Article XX-Americans with Disabilities Act of 1990
All recipients must comply with the requirements of Titles I, II,and III of the Americans with Disabilities Act,which prohibits
recipients from discriminating on the basis of disability in the operation of public entities, public and private transportation
systems, places of public accommodation, and certain testing entities. (A2 U S G sectlans 1 1p1-122131.
Article XXI-Age Discrimination Act of 1975
All recipients must comply with the requirements of the Age Discrimination Act of 1975(TtltWe 42 i.!S Gcrda sactioo 61 1 t
se -),which prohibits discrimination on the basis of age in any program or activity receiving federal financial assistance.
Article XXII-Activities Conducted Abroad
All recipients must ensure that project activities carried on outside the United States are coordinated as necessary with
appropriate government authorities and that appropriate licenses, permits, or approvals are obtained.
Article XXIII-Acknowledgment of Federal Funding from DHS
All recipients must acknowledge their use of federal funding when issuing statements, press releases, requests for proposals,
bid invitations, and other documents describing projects or programs funded in whole or in part with federal funds.
Article XXN-Federal Leadership on Reducing Text Messaging while Driving
All recipients are encouraged to adopt and enforce policies that ban text messaging while driving as described in
13513, including conducting initiatives described in Section 3(a)of the Order when on official government business or when
performing any work for or on behalf of the federal government.
Article XXV-Federal Debt Status
All recipients are required to be non-delinquent in their repayment of any federal debt. Examples of relevant debt include
delinquent payroll and other taxes, audit disallowances, and benefit overpayments. (See Q Q Circular A-129.)
Article XXVI-False Claims Act and Program Fraud Civil Remedies
All recipients must comply with the requirements of al U.a,.C.._senfron 3729-3733 which prohibits the submission of false or
fraudulent claims for payment to the federal government (See.31 U S C s%gmn 3801_3812.which details the administrative
remedies for false claims and statements made.)
Article XXVII-Energy Policy and Conservation Act
All recipients must comply with the requirements of section 82Q1,which contain policies relating to energy efficiency
that are defined in the state energy conservation plan issued in compliance with this Act
Article XXVIII-Education Amendments of 1972(Equal Opportunity in Education Act)-Title IX
DHS-FEMA-EMPG-FY 17 Page 31 of 35 City of Kent EMD, El8-099
All recipients must comply with the requirements of Title IX of the Education Amendments of 1972 f20 t1,5,G, section 1681
et sea.),which provide that no person in the United States will, on the basis of sex, be excluded from participation in, be
denied the benefits of,or be subjected to discrimination under any educational program or activity receiving federal financial
assistance. DHS implementing regulations are codified at Q .F R. Part 17 and 44 C..F.R. Part,12
Article XXIX-Duplication of Benefits
Any cost allocable to a particular federal financial assistance award provided for in C,F.R B:,'act 20p Subpart F may not
be charged to other federal financial assistance awards to overcome fund deficiencies,to avoid restrictions imposed by
federal statutes, regulations, or federal financial assistance award terms and conditions, or for other reasons_ However, these
prohibitions would not preclude recipients from shifting costs that are allowable under two or more awards in accordance with
existing federal statutes, regulations, or the federal financial assistance award terms and conditions_
Article XXX-Drug-Free Workplace Regulations
All recipients must comply with the Drug-Free Workplace Act of 1988(41 U.S.C. section 8101 et seq.,),which requires all
organizations receiving grants from any federal agency agree to maintain a drug-free workplace.You as the recipient must
comply with drug-free workplace requirements in Subpart 8(or Subpart C, if the recipient is an individual)of 2 CFR part 3001,
which adopts the Government-wide implementation(2 CFR part 182)of sec. 5152-5158 of the Drug-Free Workplace Act of
1988(Pub L 100-690,Title V,Subtitle D.41 U.S.C. 8101-8107).
Article XXXI-Debarment and Suspension
All recipients are subject to the non-procurement debarment and suspension regulations implementing Executive Orders
(E.O.) 12549 and 12689 and 2 G, ,Y2_w�,cr .These regulations restrict federal financial assistance awards, subawards,
and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in
federal assistance programs or activities.
Article XXXII-Copyright
All recipients must affix the applicable copyright notices of SpSt9pL4Q19L 402 and an acknowledgement of U.S.
Government sponsorship(including the award number)to any work first produced under federal financial assistance awards.
Article XXXIII-Civil Rights Act of 1968
All recipients must comply with Title Vlll ogre Okvil Rghts Act of 1968 which prohibits recipients from discriminating in the
sale, rental, financing, and advertising of dwellings, or in the provision of services in connection therewith, on the basis of
race, color, national origin, religion, disability, familial status, and sex(d' ..tp,,,,,. ,,.§_qgoE, C1p6).,8g;.q,}, as implemented by the
Department of Housing and Urban Development at� .Pa4t 100 The prohibition on disability discrimination includes the
requirement that new multifamily housing with four or more dwelling units-i e.,the public and common use areas and individual
apartment units(all units in buildings with elevators and ground-floor units in buildings without elevators)-be designed and
constructed with certain accessible features. (See 24 c E R sgghlr n Inn 2Q1 }
Article XXXIV-Civil Rights Act of 1964.Title VI
All recipients must comply with the requirements of Title VI of the Civil Rights Act of 1964(42 U,S.C.spSJipn 2000d et sen),
which provides that no person in the United States will, on the grounds of race, color, or national origin, be excluded from
participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal
financial assistance. DHS implementing regulations for the Act are found at 6 C ER Part 21 and 44 CFR Rod 7
Article XXXV-DHS Specific Acknowledgements and Assurances
All recipients,subrecipients,successors, transferees,and assignees must acknowledge and agree to comply with applicable
provisions governing DHS access to records,accounts, documents, information,facilities, and staff.
1. Recipients must cooperate with any compliance reviews or compliance investigations conducted by DHS.
2. Recipients must give DHS access to, and the right to examine and copy, records, accounts, and other documents and
sources of information related to the federal financial assistance award and permit access to facilities, personnel,and other
individuals and information as may be necessary, as required by DHS regulations and other applicable laws or program
guidance.
DHS-FEMA-EMPG-FY 17 Page 32 of 35 City of Kent EMD, E18-099
3,, Recipients must submit timely, complete, and accurate reports to the appropriate DHS officials and maintain appropriate
backup documentation to support the reports.
4. Recipients must comply with all other special reporting,data collection,and evaluation requirements, as prescribed by law
or detailed in program guidance..
5. If, during the past three years, recipients have been accused of discrimination on the grounds of race, color, national origin
(including limited English proficiency(LEP)), sex, age,disability, religion, or familial status, recipients must provide a list of all
such proceedings, pending or completed, including outcome and copies of settlement agreements to the DHS FAO and the
�? .R.S.. lfl oC C;i'1f1 F i hTe ggSi civil.(,i(7er�jf,! (CRCL)by e-mail at rra ,1Y;}y rgy,or by mail at U,S. Department of Homeland
Security Office for Civil Rights and Civil Liberties Building 410, Mail Stop#0190 Washington, D.C. 20528,
6. In the event courts or administrative agencies make a finding of discrimination on grounds of race, color, national origin
(including LEP), sex, age, disability, religion,or familial status against the recipient, or recipients settle a case or matter
alleging such discrimination, recipients must forward a copy of the complaint and findings to the DHS FAO and the CRCL
office by e-mail or mail at the addresses listed above.
The United States has the right to seekjudicial enforcement of these obligations.
Article XXXVI-Assurances,Administrative Requirements,Cost Principles,and Audit Requirements
DHS financial assistance recipients must complete either the OMB Standard Form 424B Assurances.-Non-Canstnu Lion
Programs.oc UME3 andard Form 4?4fDA,adtanc, s Gonstrucl'jonPro ram,as aoDlicrpble. Certain assurances in these
documents may not be applicable to your program, and the DHS financial assistance office may require applicants to certify
additional assurances.Applicants are required to fill out the assurances applicable to their program as instructed by the
awarding agency, Please contact the financial assistance office I you have any questions.
DHS financial assistance recipients are required to follow the applicable provisions of the Uniform Administrative
Requirements, Cost Principles,and Audit Requirements for Federal Awards located at 2 C.F.R. Pig 200, and adopted by
DHS at 2(,F R Pa0Z,
Article XXXVII-National Environmental Policy Act
All recipients must comply with the requirements of the NAfignal IErTv ronrnecitp Rplicy Art(NEPA)and the Council on
Environmental Quality(CEQ) Regulations for Implementing the Procedural Provisions of NEPA,which requires recipients to
use all practicable means within their authority, and consistent with other essential considerations of national policy,to create
and maintain conditions under which people and nature can exist in productive harmony and fulfill the social,economic, and
other needs of present and future generations of Americans.
Article XXXVIII-Nondiscrimination in Matters Pertaining to Faith-Based Organizations
It is DHS policy to ensure the equal treatment of faith-based organizations in social service programs administered or
supported by DHS or its component agencies, enabling those organizations to participate in providing important social
services to beneficiaries.All recipients must comply with the equal treatment policies and requirements contained in 6 C.F_R,.
Part 19 and other applicable statues, regulations, and guidance governing the participations of faith-based organizations in
individual DHS programs.
Article XXXIX-Acceptance of Post Award Changes
In the event FEMA determines that changes are necessary to the award document after an award has been made, including
changes to period of performance or terms and conditions, recipients will be notified of the changes in writing.Once
notification has been made, any subsequent request for funds will indicate recipient acceptance of the changes to the award.
Please call the FEMAIGMD Call Center at(866)927-5646 or via e-mail to ASK:Q9Dj dhS9py if you have any questions.
Article XL-Prior Approval for Modification of Approved Budget
Before making any change to the DHSIFEMA approved budget for this award,you must request prior written approval from
DHSIFEMA where required by 2 C,F,R. Section 200.308.. For awards with an approved budget greater than$150,000,you
may not transfer funds among direct cost categories, programs,functions,or activities without prior written approval from
DHSIFEMA where the cumulative amount of such transfers exceeds or is expected to exceed ten percent(10%)of the total
budget DHSIFEMA last approved. You must report any deviations from your DHSIFEMA approved budget in the first Federal
Financial Report(SF-425)you submit following any budget deviation, regardless of whether the budget deviation requires
prior written approval,
DHS-FEMA-EMPG-FY 17 Page 33 of 35 City of Kent EMD, E18-099
Article Xi-Disposition of Equipment Acquired Under the Federal Award
When original or replacement equipment acquired under this award by the recipient or its sub-recipients is no longer needed
for the original project or program or for other activities currently or previously supported by DHS/FEMA,you must request
instructions from DHS/FEMA to make proper disposition of the equipment pursuant to 2 C F R. Section 200,313.
Article XLII-Buy American and Hire American
All recipients are required to comply with any applicable provisions of the Buy American Act(41 U.S.C. Sections 8301
through 8305), and any other applicable statutes, regulations, or rules that require,or provide a preference for,the purchase
or acquisition of goods, products, or materials produced in the United States,
BUDGET COST CATEGORIES
Personnel $2,299,139.00
Fringe Benefits $851,982 00
Travel $115,283.00
Equipment $0.00
Supplies $238,705,00
Contractual $10,757,302.00
Construction $0,00
Indirect Charges $350,837.00
Other $0.00
DHS-FEMA-EMPG-FY 17 Page 34 of 35 City of Kent I E18-099
QbBgatlng Dorwnmttor Award/Ammdmmt .
Is.AOREEMINTNO. 2,AMENDMENT NO. 3. 4.TYPE OF ACTION 5.CONTROLNO.
EMS-2017.EP-00004-SO1 "' RECIPIENT AWARD FY2017R10EMPG
NO.
9160010950
6.RECIPIENT NAME AND 7.ISSUING FEMA OFFICE AND S.PAYMENT OFFICE AND ADDRESS
ADDRESS ADDRESS Financial Services Branch
Washington Mitary Graut Operations 500 C Street,S.W.,Room 723
Department 245 Murray Lane-Building 410,SW Washington DC,20472
Building 20 Washington DC,20528.7000
Camp Murray,WA,98430- POC:866-927-5646
5122
9.NAME OF RECIPIENT PHONE NO, 10,NAME OF FEMA PROTECT COORDINATOR
PROJECT OFFICER Central Scheduling mdInformationDesk
Tirzah Kincheloe Phone:800.368-6498
Email:Askcsid@dhs.gov
11.EFFECTIVE DATE OF 12. 13.ASSISTANCE ARRANGEMENT 14.PERFORMANCE PERIOD
THISACTION METHOD Cost Reimbursement From: To:
10/01/2016 OF 10/012016 09/302018
PAYMENT
PARS Budget Period
10/012016 09/30/2018
15.DESCRIPTION OF ACTION
a.(Indicate finding data for awards or financial changes)
PROGRAM CFDA NO, ACCOUNTINGDATA PRIOR AMOUNT CURRENT COMULATIVENON-
NAME (ACCSCODE) TOTAL AWARDED TOTAL FEDERAL COMMITMENT
ACRONYM XXXX-XXX-XXXXXX- AWARD THIS AWARD
XXXXX-XXXX-XXXX-X ACTION
+OR(-)
Emergency 97.042 2017-1`A-DIII-R107. $0.00 $7,306,624.00 37,306,624.00 See Totals
Management 4101-D
Performance
Grants
TOTALS $0.00 57306,624.00 $7^,624.00 57.306,624M
b.To describe changes other than funding data or financial changes,attach schedule and check here.
WA
16 a FOR NON-DISASTER PROGRAMS:RECIPIENT IS REQUIRED TO SIGN AND RETURN THREE(3)COPIES OF THIS
DOCUMENT TO FEMA(See Block 7 for address)
Emergency Managemcut Performance Grants recipients are not required to sign and return copies of this document However,recipients
should print and keep a copy of this document for their records.
16b.FOR DISASTER PROGRAMS:RECIPIENT IS NOT REQUIRED TO SIGN
This assistance is subjectto terms and conditions attached to this award notice or by incorporated reference inprogram legislation cited
above.
17.RECIPIENT SIGNATORY OFFICIAL(Name and Title) DATE
Sierra Wardell,Preparedness Grants Section Program Manager Fri Aug 25 19:%14 GMT
2017
18.TEMA SIGNATORY OFFICIAL(Name and Title) DATE
Mon Aug 21 19:57:05 UNIT
t 2017
IC MBERLY ERIN PENFOLD,Assistance Officer
DHS-FEMA-EMPG-FY 17 Page 35 of 35 City of Kent EMD, E18-099
2 CFR Part 200 Subpart F Audit Certification Form
Audits of States, Local Governments, Indian Tribes, and Non-Profit Organizations
Contact Information
Subreciplent Name(Agency, Local Government, or Organization): City of Kent, WA
Authorized Chief Financial Officer(central accounting office) Aaron BeMiller
......--
Address: 220 Fourth Avenue South Kent, WA 98032
_—
Email abemiller@kentwa.gov Phone# 253 856-5260
Purpose: As a pass-through entity of federal grant funds,the Washington Military Department/Emergency Management Division(Department)
is required by 2 CFR Part 200 Subpart F to monitor activities of subrecipients to ensure federal awards are used for authorized purposes and
verify that subrecipients expending $750,000 or more in federal awards during their fiscal year have met the 2 CFR Part 200 Subpart F Audit
Requirements. Your entity is a subrecipient subject to such monitoring by MIUEMD because it is a non-federal entity that expends federal grant
funds received from the Department as a pas ;?art 200 Subpart F should be consulted
when completing this form,
Directions: As required by 2 GFR Park 20D° �� �i i '��� tr'���%i �u10.�rG+��i �;��`;deral awards in a fiscal year shall have
a single or pmgram�specffic audit cond+sn4ed f "�/�/� �%ji` �� -ri%����i /%��� ����%%iiments, you must complete Section A of
i rii l /�/ / io o i it
this Farm. If your entity is subject to thkse re �� �i�"�`��{�,��yr6 �� %
and return this form with your grant agreeml��i rj%f%i, i ��j� ��/%�j��J�/%�j/� ��� ment is closed. Failure Failu euto return dthis
f�/ ///� /lli / rri
completed Audit Certification Form may result������,i �4,�.1/ ��� i piiri � // i ,r Federal awards or disallowance of costs,
and suspension or termination of federal
SECTION A: Entities NOfiSYlP3Pect
Our entity is not subject to the requirements
❑ We did not expend $750,000 or more
❑ We are a for-profit agency.
❑ We are exempt for other reasons
However, by signing below, I agree that we %����' /i��l�� '� % � ��������`
which we participate, that we are re wired tc ��� � �� ���% �� %%��%��i��%�w���%��� �; ations governing the programs) in
agencies and their designees, and that WM � � �j� ���j�%%� %7�� �����i%ss to such records by federal and state
/ / / � �i�////,/ %�,/ 31 information and/or documentation to
ensure proper stewardship of federal funds
S= TIQii a$n i "es tha A E subiect to the auglif(IggWrements of 2 CFR Parl Subpart F
Gom lets the information below and chekapriake box) —
❑ We completed our last 2 CFR Part 200 Subpart F Audit on[enter date] for Fiscal Year ending[enter date] . There
were no findings related to federal awards from WMD/EMD. No follow-up action is required by WMD/EMD as the pass-through entity..
A complete copy of the audit report,which includes exceptions, corrective action plan and management response, is
either provided electronically to contracts.officeQmil.wa.aov or provide the state auditor report number
❑ We completed our last 2 CFR Part 200 Subpart F Audit on[enter date] for Fiscal Year ending [enter date] There
were findings related to federal awards.
A complete copy of the audit report,which includes exceptions, corrective action plan and management response,is either
provided electronically to contracts,offica mJI.wa. ov,or provide the state auditor report number:
❑ Our completed 2 CFR Part 200 Subpart F Audit will be available on [enter date]for Fiscal Year ending
[enter date]. We will provide electronic copy of the audit report to contra cts,offioe( imtDiva.eov at that time or
provide the state auditorlqport number:
I hereby certify that I am an individual authorized by the above identified entity to complete this form. Further, I certify that the
above information is true and correct and all relevant material findings contained in audit report/statement have been disclosed.
Additionally, I understand this Form is to be submitted every fiscal year for which this entity is a subrecipient of federal award
funds from the Department until the grant agreement is closed.
Signature of Authorized Chief Financial Officer. Date:
Print Name &Title. Aaron BeMiller - Finance Director
"MD Form 1009-13.8119/2013,Updated 9l9(215
Washington Military Department Contract Number:
Debarment, Suspension, Ineligibility or Voluntary Exclusion Certification Form
NAME Doing business as(DBA)
John Madson Kent- Emergency Management
ADDRESS Applicable Procurement WA uniform Business Federal Employer Tax
24611 116th Ave SE or Solicitation#,if any: Identifier(UBI) Identification#.
i
Kent, WA 98030 170-000-002 91-6001254
This certification is submitted as part of a request to contract.
Instructions For Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower
Tier Covered Transactions
--
READ CAREFULLY BEFORE SIGNING THE CERTIFICATION Federal regulations require contractors and bidders to sign and
abide by the terms of this certification, without modification in order to participate in certain transactions directly or
indirectly involving federal funds
..... .._.......�. ..... . m m .._
1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out
below.
2. The certification in this clause is a material representation of fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an
erroneous certification, in addition to other remedies available to the Federal Government the department or agency
with which this transaction originated may pursue available remedies, including suspension and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice to the department, institution or office to
which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was
erroneous when submitted or had become erroneous by reason of changed circumstances.
4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transac' n, participant, person,
primary covered transaction, principal, proposal ru q t���' j se, have the meaning
set out in the Definitions and Coverage sec' You may contact the
person to which this proposal is submitted f II
5. The prospective lower tier participant ag uuuupmVVVVI 111 ii """" IIIIIIIIIII proposed P P p P ^^^^^ '^ a ro osed covered
transaction be entered into, it shall not kno with a person who is
proposed for debarment under the applicabl r voluntarily excluded
from participation in this covered transact ency with which this
transaction originated.
6. The prospective lower tier participant furthe lude this clause titled
"Certification Regarding Debarment, Sus ower Tier Covered
Transaction," without modification, in all low or lower tier covered
transactions.
7. A participant in a covered transaction may rel a lower tier covered
transaction that it is not proposed for debaim ligible, or voluntarily
excluded from covered transactions, unless it pant may decide the
method and frequency by which it determines but is not required
to, check the List of Parties Excluded from Fe
8. Nothing contained in the foregoing shall be records in order to
render in good faith the certification required a participant is not
required to exceed that which is normally posy business activity.
9. Except for transactions authorized under pars ese instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under applicable
CFR, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other
remedies available to the Federal Government, the department or agency with which this transaction originated may
pursue available remedies, including suspension and/or debarment.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier
Covered Transactions
The prospective lower tier participant certifies, by submission of this proposal or contract, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any Federal department or agency. Where the prospective lower tier
participant is unable to certify to any of the statements in this certification, such prospective participant shall
attach an explanation to this form.
Bidder or Contractor Signature: Date:
Print Name and Title: John Madson - Division Chief
Washington Military Department Contract Number:
FEDERAL DEBARMENT, SUSPENSION
INELIGIBILITY and VOLUNTARY EXCLUSION
(FREQUENTLY ASKED QUESTIONS)
What is"Debarment, Suspension, Ineligibility. and Voluntary Exclusion"?
These terms refer to the status of a person or company that cannot contract with or receive grants from a federal agency.
In order to be debarred, suspended, ineligible, or voluntarily excluded, you must have:
• had a contract or grant with a federal agency, and
• gone through some process where the federal agency notified or attempted to notify you that you could not contract
with the federal agency.
• Generally, this process occurs where you, the contractor, are not qualified or are not adequately performing under a
contract, or have violated a regulation or law pertaining to the contract.
Why am I required to sign this certification?
You are requesting a contract or grant with the Washington Military Department. Federal law (Executive Order 12549)
requires Washington Military Department ensure that persons or companies that contract with Washington Military
Department are not prohibited from having federal contracts.
What is Executive Order 12549?
Executive Order 12549 refers to Federal Executive Order Number 12549. The executive order was signed by the
President and directed federal agencies to ensure that federal agencies, and any state or other agency receiving federal
funds were not contracting or awarding grants to persons, organizations, or companies who have been excluded from
participating in federal contracts or grants. Federal agencies have codified this requirement in their individual agency
Code of Federal Regulations (CFi
What is the purpose of this certification?
The purpose of the certification is for you to tell Washington Military Department in writing that you have not been
prohibited by federal agencies from entering into a federal contract.
What does the word "proposal" mean when referred to in this certification?
Proposal means a solicited or unsolicited bid, application, request, invitation to consider or similar communication from
you to Washington Military Department.
What or who is a "lower tier participant"?
Lower tier participants means a person or organization that submits a proposal, enters into contracts with, or receives a
grant from Washington Military Department, OR any subcontractor of a contract with Washington Military Department. If
you hire subcontractors, you should require them to sign a certification and keep it with your subcontract.
What is a covered transaction when referred to in this certification?
Covered Transaction means a contract, oral or written agreement, grant, or any other arrangement where you contract
with or receive money from Washington Military Department. Covered Transaction does not include mandatory
entitlements and individual benefits.
Sample Debarment, Suspension, Ineligibility, Voluntary Exclusion Contract Provision
Debarment Certification. The Contractor certifies that the Contractor is not presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participating in this Contract by any
Federal department or agency. If requested by Washington Military Department, the Contractor shall complete
a Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion form. Any such form
completed by the Contractor for this Contract shall be incorporated into this Contract by reference.
FFATA FORM
.
Subrecipient Agency City of Kent - Emergency Manaqement Division
Grant and Year EMPG 2017 Agreement Number. E18-099
.... -- ---- ..... .......m.
by Jennifer Jennifer Keizer EM Specialist 253-856-4342
Ndme Title TrdepP7b�,tr
----- ........ ---...-
_ ............
Date Completed 10/17/19
—77
STEP 1,
y gagreement _ y :d NO YES STOP, no furthe
your
n $25 000v anal sis needed, / GO to Step 2
GO to Step 6
Is our rant less tha
i
In your preceding fiscal year, did your YES NO STOP, no further
organization receive 80% or more of its annual GO to STEP 3 7 analysis needed, GO to
gross revenues from federal funding? V Step 6
In your preceding fiscal year, did your YES NO STOP no further
organization funding?
receive $25 ODO DOD or more in GO to STEP 4 analysis needed GO to
federal fundmg? Step 6
7777
Does the public have access to information about YES STOP, no further NO
the total compensation*of senior executives in analysis needed, GO to STEP 5
your organization? GO to step 6
1'. ,,��„-��,,.'%� //,�i i, "„i ire,/i,,, ,„ „%/';�r /, ,�, ;?.",f'� ,,,�/.,, .,..,m.,..:c/;.;:',t.; , .i�, ,.;../..!d✓,�:!la...:%..:.",.uw.,.,u/ .1, : . ! , !;�-.
Executive #1 Name
Total Compensation amount $
Executive#2 Name:
Total Compensation amount: $
...m_._.
Executive#3 -._.Narr
me
Total Compensation -amount---$-
.........
Executive #4 Name. m Ww
Total Compensation amount: $
Executive#5 Name, -- ---------- -
Total Compensation amount', $
If your organization does not meet these criteria, specifically identify below each criteria that is not met for your
organization For Example "Our organization received less than $25 000"
Signature: Date:
Total compensation refers to:
• Salary and bonuses
• Awards of stock, stock options, and stock appreciation rights
• Other compensation including, but not limited to, severance and termination payments
• Life insurance value paid on behalf of the employee
Additional Resources:
http:l/www.whitehouse rftowYnnnb/open
h tto:J/www.h rsa.g ov/a ra nts-1ffat a.ht m l
http:/Mww,qpo.gov/fdsys/pkq/FR-2010-09-14)pdf/2010-22705,f)dft
http:l/www.grants.gov/
Page 1 of 3
FFATA PROVISIONS AND INSTRUCTIONS
For Compliance With The
Federal Funding Accountability and Transparency Act of 2006 (P.L. 109-282) (FFATA)
The Federal Funding Accountability and Transparency Act (FFATA) was signed on September
26, 2006. The FFATA legislation requires information on federal awards (federal financial
assistance and expenditures) be made available to the public via a single, searchable website.
Federal awards include grants, subgrants, loans, awards, cooperative agreements and other forms
of financial assistance as well as contracts, subcontracts, purchase orders, task orders, and
delivery orders. The legislation does not require inclusion of individual transactions below
$25,000 or credit card transactions before October 1, 2008. However, if an award is initially
below this amount yet later increased, the act is triggered. Due to this variability in compliance
Subrecipients are required by the Military Department to be familiar with the FFATA
requirements and complete this Worksheet for each contract for the State's submission in to the
FFATA portal.
ADDITIONAL PROVISIONS
A. This contract (subaward) is supported by federal funds, requiring compliance with the
Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act)
and Office of Management and Budget Guidance (OMB). Public Law 109-282 as amended
by section 6202(a) of Public Law 1 10-252 (see 31 U.S.C. 6101 note). By entering into this
contract, contractor agrees to provide all applicable reporting information to the Washington
Military Department (WMD) required by FFATA and OMB Guidance.
B. The FFATA requires the OMB to establish a publicly available online database
(USASpending.gov) containing information about entities that are awarded Federal grants,
loans, and contracts. As required by FFATA and OMB Guidance, certain information on the
first-tier subawards related to Federal contracts and grants, and the executive compensation
of awardees, must be made publicly available.
C. For new Federal grants beginning October 1, 2010, if the initial subaward is equal to or
greater than $25,000, reporting of the subaward and executive compensation information is
required. If the initial subaward is below $25,000 but subsequent grant modifications result
in a total subaward equal to or over $25,000, the subaward will be subject to the reporting
requirements as of the date the subaward exceeds $25,000. If the initial subaward equals or
exceeds $25,000 but funding is subsequently de-obligated such that the total award amount
falls below $25,000, the subaward continues to be subject to the reporting requirements of
the Transparency Act and OMB Guidance.
D. As a Federal grant subawardee under this contract, your organization is required by FFATA,
OMB Guidance and this contract to provide the WMD, as the prime grant awardee, all
information required for FFATA compliant reporting by WMD. This includes all applicable
subawardee entity information required by FFATA and OMB Guidance, subawardee DUNS
number, and relevant executive compensation data, as applicable.
1. Data about your organization will be provided to USASpending.gov by the WMD.
System for Award Management (SAM) is a government wide registration system for
organizations that do business with the Federal Government. SAM stores information
about awardees including financial account information for payment purposes and a link
to D&B for maintaining current DUNS information, www.sam.gov. WMD requires SAM
registration and annual renewal by your organization to minimize unnecessary data entry
Page 1 of 2
jand re-entry required by both WMD and your organization. It will also reduce the
potential of inconsistent or inaccurate data entry.
1 2. Your organization must have a Data Universal Numbering System (DUNS) number
obtained from the firm Dun and Bradstreet (D&B) (www.dnb.com). A DUNS number
provides a method to verify data about your organization. D&B is responsible for
maintaining unique identifiers and organizational linkages on behalf of the Federal
Government for organizations receiving Federal assistance.
E. The WMD, as the prime awardee, is required by FFATA to report names and total
compensation of the five (5) most highly compensated officers of your organization (as the
subawardee) if:
1. Your organization (the subawardee), in the preceding fiscal year, received 80 percent or
more of its annual gross revenues from Federal awards and $25,000,000 or more in
annual gross revenues from Federal awards; and
2. The public does not have access to this information about the compensation of the senior
executives of your organization through periodic reports filed under section 13(a) or
15(d) of the Securities and Exchange Act of 1934 (15 U.S.C. §§ 78m(a), 78o(d) or
section 6104 of the Internal Revenue Code of 1986.
"Total compensation" for purposes of this requirement generally means the cash and non-
cash value earned by the executive during the past fiscal year and includes salary and bonus;
awards of stock, stock options and stock appreciation rights; and other compensation such as
severance and termination payments, and value of life insurance paid on behalf of the
employee, and as otherwise provided by FFATA and applicable OMB guidance.
F. if(1) in the preceding fiscal year your organization received 80 percent or more of its annual
gross revenues from Federal awards and $25,000,000 or more in annual gross revenues from
Federal awards, and (2) the public does not have access to this information about the
compensation of the senior executives of your organization through periodic reports filed
under section 13(a) or 15(d) of the Securities and Exchange Act of 1934 (15 U.S.C. §§
78m(a), 78o(d) or section 6104 of the Internal Revenue Code of 1986, insert the names and
total compensation for the five most highly compensated officers of your organization as
identified in Step 5 of the FFATA Form.
Page 2 of 2
i
SIGNATURE AUTHORIZATION FORM
WASHINGTON STATE MILITARY DEPARTMENT
Camp Murray, Washington 98430-5122
Please read instructions on reverse side before completing this form.
NAME OF ORGANIZATION DATE SUBMITTED
City of Kent - Emergency Management Division
PROJECT DESCRIPTION CONTRACT NUMBER
Emergency Management Performance Grant E18-099
1 . AUTHORIZING AUTHORITY
SIGNATURE PRINT OR TYPE NAME TITLEFFERM OF OFFICE
Suzette Cooke Mayor
Matthew Morris Fire Chief
v
2. AUTHORIZED TO SIGN CONTRACTS/CONTRACT AMENDMENTS
STATURE PRINT OR TYPE NAME TITLE
Suzette Cooke Mayor
Matthew Morris Fire Chief
3. AUTHORIZED TO SIGN REQUESTS FOR REIMBURSEMENT
SIGNATURE PRINT OR TYPE NAME TITLE
Jennifer Keizer EM Specialist
John Madson EM Manager- Division Chief
11NAC-11V0L11H0MEXARENBI..,.1VVPISIGNAUTH Revised 3/03
INSTRUCTIONS FOR SIGNATURE AUTHORIZATION FORM
This form identifies the persons who have the authority to sign contracts, amendments,
and requests for reimbursement. It is required for the management of your contract with
the Military Department (MD). Please complete all sections. One copy with original
signatures is to be sent to MD with the signed contract, and the other should be kept with
your copy of the contract.
When a request for reimbursement is received, the signature is checked to verify that it
matches the signature on file. The payment can be delayed if the request is
presented without the proper signature. It is important that the signatures in MD's files
are current. Changes in staffing or responsibilities will require a new signature
authorization form.
1. Authorizing Authority. Generally, the person(s) signing in this box heads
the governing body of the organization, such as the board chair or mayor. In
some cases, the chief executive officer may have been delegated this
authority.
2. Authorized to Sign Contracts/Contract Amendments. The person(s) with
this authority should sign in this space. Usually, it is the county
commissioner, mayor, executive director, city clerk, etc.
3. Authorized to Sign Requests for Reimbursement. Often the executive
director, city clerk, treasurer, or administrative assistant have this authority.
It is advisable to have more than one person authorized to sign
reimbursement requests. This will help prevent delays in processing a
request if one person is temporarily unavailable.
If you have any questions regarding this form or to request new forms, please call your
MD Program Manager.
Form W.9 Request for Taxpayer Give Form to the
(Rev.December 2014) Identification Number and Certification requester.Do not
Department of Treasury send to the IRS.
Internal Revenue Service
t Name(as shown on your income tax raalumt.Narne Is required on ffia hits;do not leave this line blank,
City of Kent- Emergency Management Division
___...-.Busi, ._ ....... .. .. ......w_..... ...______..... ��
N 2 ness name/disregarded cnttity name If different from above
m
m
a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes'. 4 Exemptions(codes apply only to
GBII
single-member LLC in entitles,not indchduals`;see
❑ Individual/sale proprietor or ❑ C Corporation ❑ S Corporation [:1x Partnership ❑ TrusVestate instructions on page 3).
w e
2 � ❑Limited liability company,Enter the tax classification(C—C corporation,S—S corporation,P=partnership)► Exempt payee code(If any)
`p : Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box In the line above for Exemption from FATCA reporting
y the tax classification of the single-member owner. code(If any)
C .
R ❑Other(see instructions)► (Men 1, iArre "', la Pia u5J
U _._....._'______ .._. ,,.. .. .... .... ...._. _� _._......_... .'......,._
5 Address(number,street,and apt.or suite no,) Requester's name and address(optional)
U
n 24611 116th Ave SE
.....,._ .w__...............
al6 City,state,and ZIP code
m
Kent,WA 98030
7 List account numbers)here(optional)
FEM Taxpayer Identifioation Number(TIN)
Enter your TIN In the appropriate box.The TIN provided must match the name given on line 1 to avoid social security number
backup withholding. For individuals,this Is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,seethe Part I instructions on page 3. For
entities, it is your employer identification number(EIN). If you do not have a number,see Now to get a
TIN on page 3. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identdicatmn number
guidelines on whose number to enter.
9 1 1 6 0 0 1 1 2 5 4
Certification
Under penalties diff perjury, I certify that: --�.m.. �
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S.citizen or other U.S.person(defined below); and
4.The FATCA cartels)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends an your tax return.For real estate transactions, item 2 does not apply. For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA), and
generally, payments other than interest and dividends,you are not required to sign the certification, but you must provide your correct TIN_See the
Instructions on page 3.
Sign Signature of
Here U.S.person Date►
General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. •Form 1099-C(canceled debt)
Future developments,Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
as legislation enacted after we release it)is at www.irs.gowpv9.
Use Farm W-9 only If you are a U,S,person(Including a resident alien),to
Purpose of Form provide your correct TIN.
An individual or entity(Farm W-9 requester)who is required to file an information I/you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2,
which may be your social security number(SSN),Individual taxpayer Identification By signing the filled-out form,you:
number IITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
identification number(EIN),to report on an information return the amount paid to to be issued),
you,or other amount reportable on an information return,Examples of information
returns include,but are not limited to,the following 2.Certify that you are not subject to backup withholding,or
•Form 1099-INT(interest earned or paid) 3,Claim exemption from backup withholding T you are a U.S.exempt payee.IF
•Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of
any partnership Income from a U.S.trade or business Is not subject to the
•Farm 1099-MISC(various types of income,prizes,awards,or grass proceeds) withholding tax on foreign partners'share of effectively connected income,and
•Form 1099-B(stack or mutual fund sales and certain other transactions by 4.Certify that FATCA codes)entered on this form(if any)indicating that you are
brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
•Form 1099-5(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat,No.10231X Farm W-9(Rev. 12-2014)
i Form W-9(Rev.12-2014)
Page 2
Note.If you are a U.S,person and a requester gives you a form ether than Form 3.The IRS tells the requester that you furnished an incorrect TIN,
W-9 to request your TIN,you must use the requester's form if it is substantially 4,'goe IRS teillls you that you are s✓ibjer,t to backup withholding because you did
similar to this Form W-9. notm all our internal and dividends an your tax return(for rep
ortable interest
Definition of a U.S.person.For federal tax purposes,you are considered a US. and dividends pally),or
person If you are 5,You do not certify to the requester that you are riot subject to backup
•An individual who is a U.S,.citizen or U.S,resident alien; whff adding under 4 above(for reportable Intel and dividend accounts opened
•A partnership,corporation,company,or association created or organized in the after 1983 only)„
United States or under the law.of the United States, Certain payees and presents are exempt from backup wi lehiolding.See Exempt
•An estate(other than a foreign estate);or pays&code on page 3 and the separate Instructions for the Requester of Form
•Adomestic trust(as defined In Regulations section 301 7701-7). W-9 for more information.
Special rules for partnerships.Partnerships that conduct a trade or business in Also see Special rules ferpartnerships above,
fire United States are generally required to pay a withholding tax under section What is FATCA reporting?
1446 on any foreign partners'share of effectively connected taxable income from
such business.Further,in certain cases where a Form W-9 has not been received, The Fannon Account Tux CUr geliance Acn IFAT"City)requires a(Yu cipating foreign
the rules andor section 14+46 require a partnership to presume that a partner is a finar laP Institution a repast all United States account holders that are specified
foreign person,and pay the section 1446 withholding tax.Therefore,If you are a United States persons.Certain payees are exempt fern FAT'CA reporting.See
US,person that is a partner in a partnership conducting a trade or business in the !exemption/mini FA ECA roparlo p code an page 3 and the Insuu4tidns for file
United States,provide Form W-9 to the partnership to establish your U.S,status Requester of Form W-9 for more information.
and avoid section 1446 withholding on your share of partnership Income,
In the cases below,the following person must give Form W-9 to the partnership Updating Your Information
for purposes,of establishing its U.S.status and avoiding withholding on its You must provide updated information to any person to wham you claimed to be
allocable share of net income from the partnership conducting a trade or business tall exempt payee if you are no longer an exempt Slaves and anticipate rKi irayng
in the United States: reportable payments in file future from this person,For Crample,you may need to
•In the case of a disregarded entity with a I owner,the U.S.owner of the provide updated)Information if you ara'a C corporation that elects to be an S
disregarded entity and not the entity, corporation,or If you no longer are tax exempt.In addition,you must furnish a new
• the case a,renter trust with a U.S.grantor t Form W-9 If the name or TIN changes for the account,for example,If the grantor
rantor other U.S.owner,generally, -
thee U.S.grantor ar)Cher U.S.owner of the grantor trust and not the trust;
and at a grantor trust dies
•In the case of a U.S.trust(other than a grantor trust),the U,S.trust(other than a Penalties
grantor trust)and not the beneficiaries of the trust
Padluro to furnish TIN.If you fall to tarnish f your correct TIN to a requester,Cox t you are
Foreign ties person,o you area foreign person or the U.S-branch of a-1 in t thank real reasonable
a penalty of not for each such failure unless your failure Is due to
that Itas elected tom irea1ed or a U.S.person,do not use Form W-oldingdad,use reasonable cause and not to willful neglect.
the oar side t Form an or Form 3233(see Publication 513,Withholding of Tax Civil penalty for false Tnformaj with respect to withholtling.It'you make9
on Nonresident Aliens end Foreign Entities).
falarl e u!t with a teaspoonsteaspoonsbasic that results In no backup wiIhVruPdirrg.
Nonresident often who becomes a resident alien.Ganmrally,only a nonresident you arere subject to a 6441g pti
alien residual may use the terms of a tax treaty to reduce or eliminate U.S.tax on Criminal penalty for falsifying information.Willfully falsifying certifications or
certain types of income.However,most tax treaties contain a provision known as affirmations may subject you to criminal penalties including fines end/or
a"saving clause."Exceptions specified in the saving clause may permit an imprisonment.
exemption from tax to continue for pertain types of income even after the payee
has olhtneise become a U.S.resident alien for tax purposes. Misuse of TINS.If the requester discloses or uses TINS in violation of federal law,
If you are a U.S.resident alien who is relying on an exception contained in the the requester may be subject to civil and criminal penalties.
saving clause of a tax treaty to claim an exemption from U.S.tax on certain types
of income,you must attach a statement to Form W-9that specifies the following Specific Instructions
five terns:.
1-The treaty country.Generally,gtig must be the same treaty under which you Line t
claimed exemption from tax as a nonresident allen. You must enter one of the following on this line;do not leave this line blank.The
2.The treaty article addressing the income,. name should match the name on your tax return.
3.The adds number(or location)in the tax treaty that contains the saving If this Form W-9 is for a joint account,list first,and then circle,the name of the
clause and Its exceptions. person or entity whose number you entered in Part I of Farm W-9.
4.The type and amount of Income that qualifies for the exemption from tax a, Individual.Generally.enter file name shown on your tax aatucrc It Veto have
changed your last name without Iniolming rho Social Secudly Adrinausbatdon(SSA)
5-Sufficient facts to justify the exemption from tax antler me terms of the treaty oY the name change,antart ye+lrftrsl llama„tna Nast name as slxowrn on senor social
article. security card,and your new last name,
Example.Abl is 20 or the td.S China Irgceamw tax apply allows on exemption Note.ITIN applicant:Enter your individual name as It was entered on your Form
Door tax for Scholarship Income repHll try a Chinese student temporenly present W,T application,IIna I a.This should also be the same as the name you entered on
In the hall States.Under U.S.law,this student will become a resident allsn far the Forev 1040/1040yoIC40i you filed with your application.
tax purposes If his or her stay In the Ended Star"Fxt oode 5 calendar years.
However,paragraph 2 at the first Protocol to the U S Cta rto Insets grated April 30, It Sale proprietor or single-member LLC.Enter your individual name as
064)allows the provisions of Artlate 20 he oars dner,to apply even Chet the shown on your 1040l10401ruUm gB,2 on hine t.You may enter your business,trade,
Chinese student becomes a resident alien of the United States.A Chinese student or"doing business as"IDEA)name on line 2,
who qualities for this exception(under paragraph 2 of the first protaaoBi aria]Is c. Partnership,LLC that is not a single-member LLC,C Corporation,or S
fairing on this exception to shim an examptlon from tax rep his or her somArin hip Corporation.Enter the entity's name as shown on the entity's tax return on line 1
tar fellowship occurs world ablaGh to Form W-9 a statement that includes the and any business,trade,or DBA name on line 2,
information described above to support that exemption. d. Other entities.Enter your name as shown on required U.S.federal tax
If you are a nonresident alien or a foreign entity,give the requester the documents on line 1,This name should match the name shown on the charter or
appropriate completed Form W-B or Form 6233, other legal document creating the entity.You may enter any business,trade,or
DBA name on line 2
Backup Withholding e. Disregarded sanity,.For U.S.federal tax purposes,an entity plat Is
What is backup withholding?Persons making certain payments to you must disregarded as so bull Separate frarn as owner is Treated as a"disregarded
tinder oortain conditions withhold and pay to the IRS 25%of such payments.This entity." See Regulations section 301.7701-2(c)(2)(1II).Enter the owner's name on
is called"backup withholding," Payments tflal maybe subject to backup line 1.The name of the entity entered online 1 should never be a disregarded
withholding include Interest,tax-exempt Interest,dividdnd'%broker and barter entity.The name on line 1 should be the name shown on the income tax return on
exchange transactions,rents,royalties,nonemployee pay,payments made in which the income should be reported,For example,if a foreign LLC that is treated
settlement of payment card and third party network transactions,and certain as a disregarded entity for U.S,federal tax purposes has a single owner that is a
payments front fishing boat operators.Real estate transactions are not subject to U,S.person,the U.S.owner's name is required to be provided on line 1,If the
backup withholding. direct owner of the entity is also a disregarded entity,enter the first owner that is
You will not be subject to backup withholding on payments you repave it you not disregarded for federal tax purposes Enter the disregarded area]name on
give the requester Ma correct TIN,make the r line 2 Business naPnadd'13m aortal and! nail If the owner or the disregarding
yt proper certiticagions,and report all entity Is a fouxl n ersom line Owner real cam le appropriate g dm1
your taxable interest and dividends on your tax return. g p p,rta an a rp Xato Form W-{q
Payments you receive will be subject to backup withholding if: instead of a Farm W-9. This is the case even if the foreign person has a US.TIN.
1 You do not furnish your TIN to the requester,
2.You do not certify your TIN when required(seethe Part II instructions on page
3 for estate),
Form W-9(Rev-12-2014) Page 3
Line 2 'However,the following payments made to a corporation and reportable on Form
It you have a business name,trade name,DBA name,m disregarded entity name, 1099-MISC are not exempt from backup withholding:medical and health care
you may enter it on line 2. payments,attorneys'fees,gross proceeds paid to an attorney reportable under
section 6045(n and payments for services paid by a federal executive agency,
Line 3 Exemption from FATCA reporting code.The following codes identify payees
Check the appropriate box in line 3 for the U S.federal tax classification of the that are exempt from reporting under FATCA.These codes apply to persons
person whose name is entered on line 1.Check only one box in line 3. submitting this form for accounts maintained outside of the United States by
Limited Liability Company(LLC).If the name on line 1 is an LLC treated as a certain foreign financial institutions.Therefore,if you are only submitting this form
for an account you hold in the United States,you may leave this field blank
partnership for U.S.federal tax purposes,check the"Limited Liability Company" Consult with the person requesting this form if you are uncertain if the financial
box and enter"P"in the space provided.If the LLC has filed Form 8832 or 2553 to institution is subject to these requirements.A requester may indicate that a cede is
be taxed as a corporation,check the"Limited Liability Company"box and in the not required by providing you with a Form W-9 with"Not Applicable"(or any
space provided enter"C"for C corporation p por"S"for S corporation If it is a
P
single-member LLC that is a disregarded entity,do not check the"Limited Liability similar Indication)written or printed on the line far a FATCA exemption code,
Company"box;Instead check the first box In line 3"Individual/sole proprietor or A—An organization exempt from tax under section 501(a)or any Individual
single-member LLC," retirement plan as defined in section 7701(a)(37)
Line 4, Exemptions B—The United States or any of its agencies or Instrumentalities
If you are exempt from backup withholding and/or FATCA reporting,enter in the C—A state,the District of Columbia,a U,S.commonwealth or possession,or
appropriate space in line 4 any consist that may apply to you. any of their political subdivisions or instrumentalities
Exempt payee code. D—A corporation the stock of which is regularly traded on one or more
established securities markets,as described in Regulations section
• Generally,Individuals(including sole proprietors)are not exempt from backup 1.1472-1(c)(1)(i)
withholding E—A corporation that is a member of the same expanded affiliated group as a
• Except as provided below,corporations are exempt from backup withholding corporation described In Regulations section 1.1472-1(c)(1)(i)
for certain payments,including interest and dividends„
F—A dealer in securities,commodities,or derivative financial instruments
• Corporations are not exempt from backup withholding for payments made In (Including notional principal contracts,futures,forwards,and options)that is
settlement of payment card or third party network transactions, registered as such under the laws of the United States or any stale
• Corporations are not exempt from backup withholding with respect to attorneys' G—A real estate investment trust
fees or gross proceeds paid to attorneys,and corporations that provide medical or H—A regulated investment company as defined in section 851 or an entity
health care services are not exempt with respect to payments reportable on Form 1099-MISC. registered at all times during the tax year under the Investment Company Act of
1940
The following codes identify payees that are exempt from backup withholding, I—A common trust fund as defined In section 584(a)
Enter the appropriate code In the space in line 4.
1—An organization exempt from tax under section 501(a),any IRA,or a d—A bank as defined In section 581
custodial account under section 403(b)(7)if the account satisfies the requirements K—A broker
of section 401(f)(2) L—A trust exempt from tax under section 664 or described In section 4947(a)(1)
2—The United States or any of its agencies or Instrumentalities M—A tax exempt trust under a section 403(b)plan or section 457(g)plan
3—A state,the District of Columbia,a U.S.commonwealth or possession,or Note.You may wish to consult with the financial institution requesting this form to
any of their political subdivisions or instrumentalities determine whether the FATCA code and/or exempt payee code should be
4—A foreign government or any of its political subdivisions,agencies,or completed,
instrumentalities
5—A corporation Line 5
6—A dealer In securities or commodities required to register in the United Enter your address(number,street,and apartment or suite number),This is where
States,the District of Columbia,or a U.S.commonwealth or possession the requester of this Form W-9 will mall your information returns,
7—A futures commission merchant registered with the Commodity Futures Line 6
Trading Commission Enter your city,state,and ZIP code.
8—A real estate investment trust
9—An entity registered at all times during the tax year underthe Investment Part 1.Taxpayer Identification Number(TIN)
Company Act of 1940 Enter your TIN in the appropriate box.If you are a resident alien and you do not
10—A common trust fund operated by a bank under section 584(a) have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer
11—A financial institution identification number(ITIN).Enter it in the social security number box.If you do not
have an ITIN,see Haw to get a TIN below.
12—A middleman known in The investment community as a nominee or If you are a sole proprietor and you have an EIN,you may enter either your SSN
custodian - or EIN,However,the IRS prefers that you use your SSN.
13—A trust exempt from tax under section 664 or described in section 4947 If you are a single-member LLC that is disregarded as an entity separate from its
The following chart shows types of payments that may be exempt from backup owner(see Limited Liability Company(LLC)on this page),enter the owner's SSN
withholding_The chart applies to the exempt payees listed above,1 through 13, (or EIN,if the owner has one).Do not enter the disregarded entity's EIN.If the LLC
_, is classified as a corporation or partnership,enter the entity's EIN.
IF the payment is for.,, THEN the payment is exempt for... Note.See the chart on page 4 for further clarification of name and TIN
combinations.
Interest and dividend payments All exempt payees except _..._._ w How to get a TIN.If you do not have a TIN,apply for one immediately,To apply
for 7 for an SSN,get Farm SS-5,Application for a Social Security Card,from your local
........ .........____...___.._.._...___..........,.. SSA office or get this form online at wwwssa.gov.You may also get this form by
Broker transactions Exempt payees 1 through 4 and 6 calling 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer
through 11 and all C corporations.S Identification Number,to apply for an ITIN,or Form SS-4,Application for Employer
corporations must not enter an exempt Identification Number,to apply for an EIN,You can apply for an EIN online by
payee code because they are exempt accessing the IRS websee at www.ro,gowbusinesses and clicking on Employer
only for sales of noncovered securities Identification Number(EIN)under Starting a Business,You can get Forms W-7 and
acquired prier to 2012, SS-4 from the IRS by visiting IRS over or by calling 1-300-TAX-FORM
------. ------------- (1-800-829-3676),
Barter exchange transactions and Exempt payees 1 through 4 If you are asked to complete Form W-9 but de not have a TIN,apply for a TIN
patronage dividends and write"Applied Far"in the space for the TIN,sign and date the farm,and give it
""""------ to the requester For interest and dividend payments,and certain payments made
Payments over S(500 required to be r Generally exempt payees with respect to readily tradable instruments,generally you will have 60 days to get
reported and direct sales ra✓F,r$S,Ob0 1 through 5- a TIN and give it to the requester before you are subject to backup withholding on
......................... payments The 60-day rule does not apply to other types of payments.You will be
Payments made in settlement of Exempt payees 1 through 4 subject to backup withholding on all such payments until you provide your TIN to
payment card or third party network the requester.
transactions Nate.Entering"Applied For'means that you have already applied for a TIN or that
See Form 1099-MISC,Miscellaneous Income,and its instructions. you intend to apply for one soon.
Caution:Adisregarded U.S.entity that has a foreign owner must use the
appropriate Form W-8.
Form W-9(Rev_12-2014) Page 4
Part 1l. Certification You must show your individualname and you may also enter your business orDBA name on
To establish to the withholding agent that you are a U,S person or resident alien, the'Business neme/did egarded entity name line You may use either your SSN or EIN(if you
have oriel but the IRS encourages you to use your SSN.
sign Form W-9„You may be requested to sign by the withholding agent even It °List first and circle the name of the trust,estate,or pension trust. Do not furnish the TIN of me
items 1,4,or 5 belusv Indicate other^rvise-
personal representative or trustee unless the legal entity Itself is not designated In the account
For a joint account,only the person whose TIN is shown In Part I tifirl GId sign tltleJ Also see also
mur rotes id partnerships on page 2.
(when required). n the case of a disregarded entity,the person lien Kifgd on line l 'Note.Grantor also must provide a Form W-9 to trustee of trust-
must sign.Exempt payees,see Exempt payee code earlier. Note.If no name Is circled when more than one name Is listed,the number will be
Signature requirements.Complete the certification as indicated in items 1 considered to be that of the first name listed
through 5 below.
1.Interest,dividend,and barter exchange accounts opened before 1984 Secure Your Tax Records from Identity Theft
and broker accounts considered active during 1983,You must give your Identity theft occurs when someone mans your personal information such as your
corset TIN,but you do not have to sign the dratilicallon- name„SSN,or other dshodying in aminnerm,without your Permission,to cement
2.Interest,dividend,broker,and barter exchange accounts opened after feud or other crimes.An identity chief may use your SSN to get a job or may file a
1983 and broker accounts considered inactive during 1983 You trust sign the tAs return using your SSN to receive a refund,.
cartiflostierl at backup withholding eesl apply.II you are subject to backup To reduce your risk:
wllhholfung acid your are marery pmvidilrug your correct TIN to the legal you
must cross out item 2 in the certification before signing the form,. •Protect your SSN,
3.Real estate transactions.ions.You must sign the ceditication.You may cross out •Ensure your employer is protecting your SSN,and
item 2 of the certification, •Be careful when choosing a tax preparers
4.Other paternoster.You tames give peter suspect'I"IN,but you do not have to sign If your tax records are affected by identity theft and you receive a notice from
the certification scheme you have river notldled treat you Peters previously given an the IRS,respond right away to the name and phone number printed on the IRS
Incorrect Hid."Other payments'"Include payments nrade I the course of the notice or letter.
requester's trade or business for rents,royalties,goods(other than bills for If ycmr lax records are riot chiral affected by rdelttity put but you ill you
merchandise),medical and hearth care services(including payments to are at risk duo to a Got tar stolen Verde of earlier,questionable creditcard& p 490 f activity
corporations),a? t c to a nd third arty for network
transactions,
payments made In or Form
14 report,ocmact rho IRS Ydnnllly'Fhxll&1nt11ne at 1 8gL1-fl0&g4'gGl nr subunit
certain
nl payments atr.card and third party fishermen,
transactions,payments to Form 14039.
certain fishing boat crew members and fishermen,and grass proceeds paid to For more information,see Publication 4535,IdentityTheft Prevention and Victim
attorneys(including payments to corporations). Assistance..
5.Mortgage interest paid by you,acquisition or abandonment of secured eft who are experiencing economic harm or a system
Victims of identity theft property,cancellation of debt,qualified tuition program payments(under
section 529),IRA,Coverdell ESA,Archer VISA or HSA contributions or problem,or are seeking help in resolving tax problems that have not been resolved
distributions,and pension distributions.You must give your correct TIN,but you through normal channels,may be eligible for Taxpayer Advocate Service F AS)
do not have to sign the certification, assistance-You can reach TAS by selling the TAS toll frets case Intake line at
1-877-777-4778 or TTY/TDD 1-800-829-4059,
What Name and Number To Give the Requester Protect yourselffrom suspicious smalls orphaning schemes, Pbsiall is the
brashpn and use of email and wkrbsdes designed to re lc iestit9nt3te besides.
For this type of account: Give name and SSN of: emttHs and wabsiias.The all common,not is sending an Rush to a user faskety
_. .individual sass ...., ...., r p Inmate ranter rise If„la feu rig Ca lace an n6tlibll:IhdYl lag p 1 If>,n atdenM1pC to�SCanr Kha Lfear
1 Individual The actual Into surrenderingprivate Information that will be loved lot identity theft
2.Two or more lndlmduals feint The actual owner of the account or, The IRS does not initiate contacts with taxpayers via emails.Also,the IRS does
account) if combined funds, firs[ not request personal detailed Information through email or ask taxpayers for the
individual on the account' PIN numbers,passwords,or similar secret access information for their credit card,
3,Custodian account of a minor The minor' bank,or other financial accounts.
(Uniform Gift to Minors Act) If you receive an unsolicited email claiming to be from the IRS,forward this
4,a.The usual revocable savings The grantor-trustee' message to phishingrsirs.gov.You may also report misuse of the IRS name,logo,
trust(grantor is also trustee) or other IRS property to the Treasury Inspector General for Tax Administration
IN,So-called trust account that is The [ROTA)at 1-800-366-4484.You can introvert suspicious enrolls to the Federal
not a legal or valid trust under actual owner' Trade Commission at:Spamisucmiam,or contact them at www.ftc.gov/idrheft or
state law 1-877-IDTHEFT(1-877-438-4338),.
5.Sole proprietorship or disregarded The owner' Visit IRS,gov to learn more about identity theft and haw to reduce you(risk.
entity awned by an individual
6.Grantor trust filing under Optional The grantor' Privacy Act Notice
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(I) Section 6109 of the Internal Revel f,ode requires you to provide,your correct
(A)) TIN to persons(including kvderal agendra p who are required to file Information
For this ty pe account Give name and of: returns with the IRS to report interest,dividends,or certain other income paid to
_......._ .-----..... EIN you,mortgage interest you paid;the acquisition or abandonment of secured
. .____ .....�.._................._.
%,t)isreyarded entity not owned by an
L__ _The owner property;the cancellation o/debt;or contributions you made to an IAA,Archer
Individual VISA,or HSA,The person collecting this form uses the Information on the form to
6,A valid trust,estate,or pension trust Legal entity' file information returns with the IRS,reporting the above Information.Routine uses
of this Information Include giving It to the Department of Justice forded and
9.Corporation or LLC electing The corporation criminal litigation and to clues,states,the District of Columbia,end US,
corporate status on Form 8832 or commonwealths and possessions for use in administering their laws.The
Form 2553 information also may be disclosed to other countries under a treaty,to federal and
10.Association,club,religieus, The organization state agencies to enforce civil and criminal laws,or to federal law enforcement and
charitable,educational,or other tax- intelligence agencies to combat terrorism,You must provide your TIN whether or
exempt organization not you are retained He file a tar',return.Under gaction 3406,payers ntust Generally
11.Partnership or multi-member LLC The partnership withhold a percentage of taxable interest,dividend,and certain other payments to
a payee who does riot give a TIN tie the payer.Certain penalties may also apply for
12.A broker or registered nominee The broker or nominee providing false or fraudulent infonmahor'r.
13,Account with the Department of The public entity
Agriculture In the name of a public
entity(such as a state or local
government,school district,or
prison)that receives agricultural
program payments
14.Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2(see
Rrigulations section 1.871-4(b)(2)(i)
(art)
'List first and circle the name of the person whose number you turret If only one person on a
joint account has an SSN,that persona number must be furnished.
2 Circle the minor's name and furnish the minor's SSN-
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