FEMA - City Representative MVM
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MEMORANDUM
August 31, 2004
TO:
The Honorable Mayor and City Council Members
FROM:
Michael C. Van Milligen, City Manager
SUBJECT: Designation of City Representative for FEMA Assistance
Finance Director Ken TeKippe is recommending City Council approval to designate the
City Manager as the City of Dubuque's authorized representative for signing and filing
documents with the Iowa Homeland Security and Emergency Management Division for
the purpose of obtaining Federal/State financial assistance under the Disaster Relief
Act. This request is due to the severe storms and flooding that began on May 21, 2004.
This designation is required in order for the City to begin receiving FEMA/State disaster
assistance.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
I I / 'Il
°tJ I/¿~~,.} rL----.
Mich el C. Van Milligen
MCVM/jh
Attachment
cc: Barry Lindahl, Corporation Counsel
Cindy Steinhauser, Assistant City Manager
Ken TeKippe, Finance Director
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CITY OF DUBUQUE, IOWA
MEMORANDUM
TO:
Michael C. Van Milligen, City Manager
FROM:
Ken TeKippe, Finance Director
(r:L
ÚR'~
SUBJECT: Designation of City Representative for FEMA Assistance
DATE:
August19,2004
INTRODUCTION
The purpose of this memorandum is to submit a resolution designating you as the City
of Dubuque's authorized representative for signing and filing documents with the Iowa
Homeland Security and Emergency Management Division for the purpose of obtaining
Federal/State financial assistance under the Disaster Relief Act (PL 93-288, as
amended) or otherwise available from the President's Disaster Relief Fund and the
Code of Iowa, Chapter 29C. This request is due to the severe storms and flooding that
began on May 21, 2004. I will also serve as designated representative who may
provide information in these matters.
A resolution approving this designation is required in order for the City to begin
receiving FEMA /State disaster assistance.
DISCUSSION
The City is required to submit the attached forms and a copy of a resolution passed by
City Council designating the City's authorized representative before disaster funds will
be released for public assistance. This process and recommended course of action are
similar to that followed in June 2002 after the storms and floodingand after the
Mississippi flooding in July of 2001
ACTION STEP
The action step is for City Council to adopt the attached resolution designating you as
the City of Dubuque's authorized representative.
KT/jg
Enclosures
cc: Barry Lindahl, Corporation Counsel
Cindy Steinhauser, Assistant City Manager
Dawn Lang, Budget Director
RESOLUTION NO. 335-04
RESOLUTION DESIGNATING THE CITY MANAGER AS THE CITY OF DUBUQUE'S
AUTHORIZED REPRESENTATIVE FOR SIGNING AND FILING DOCUMENTS TO
OBTAIN FEDERAL/STATE FINANCE ASSISSTANCE UNDER THE DISASTER
RELIEF ACT
Whereas, the City of Dubuque received a Presidential Declaration as a disaster
area as the result of severe storms and flooding beginning May 21, 2004; and,
Whereas, the State of Iowa requires the City of Dubuque to designate a
representative for purpose of obtaining Federal/State finance assistance under the
Disaster Relief Act (PL 93-288, as amended) or otherwise available from the President's
Disaster Relief Fund and the Code of Iowa, Chapter 29C.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY
OF DUBUQUE, IOWA:
Section 1. That the City Manager is hereby designated to be the City of
Dubuque's Authorized Representative for the purpose of obtaining Federal/State
finance assistance under the Disaster Relief Act or otherwise available from the
President's Disaster Relief Fund and Iowa Code Chapter 29C. The Finance Director is
authorized and directed to provide information in these matters.
Passed, approved and adopted this 7th day of September, 2004.
Terrance M. Duggan, Mayor
Attest:
Jeanne F. Schneider, City Clerk
STATE OF IOWA
DESIGNATION OF APPLICANT'S AUTHORIZED REPRESENTATIVE
The person here named is Authorized to Represent
City of Dubuque
(Applicant Name)
Name Michael C. Van Milligen SignaWe)
Jobnle' City Manager O'ganiza'ion, City of Dubuque, Iowa
Add..ss' 50 West 13th Street P. O. Box#,
City Dubuque State, Iowa Postal Code 52001-4864
Business Phone #. (563)589-4110 Fax#, (563) 589-4149 Home Phone #, (563) 556-7388
Cellular Phone #, NA E-Mail, ctymgr@cityofdubuque.org
The person named above can sign and file documents with Iowa Homeland Security and Emergency Management Division
for the purpose of obtaining Federal & State assistance under the Disaster Relief Act (PL 93-288, as amended) or otherwise
available from the President's Disaster Reiief Fund and the Code of Iowa, Chapter 29C. A new designation form must be
submitted if the authorized representative for the above named appiicant is changed.
Others that may provide information in these matters are:
Chief Financial Officer'
Name Kenneth J. TeKippe Job Title Finance Director
CFO Organization, City of Dubuque, Iowa
Add..ss. 50 West 13th Street P. O. Bnx#,
City. Dubuque State, Iowa Postal Code52001-4864
Business Pho", # (563) 589-4133 Fox#' (563) 589-0890 Home Phone #, (563) 588-4027
Cellular Phone #. NA E-Mail, ktekippe@cityofdubuque.org
CERTIFICATION
I Jeanne Schneider , duly appointed City Clerk nf
(Name) (Jab Title)
The City of Dubuque, Iowa do he..by certiIY !hat !he precediog is true and correct
(EnÜtyName)
copy ofa resolution appmved and passed by The Dubuque City Council
upon the date of September 7, 2004 FEMA DR - 1518 -IA
(Dale) (Dlsasl" #)
(Signal"") (Dale)
jschneid@cityofdubuque.org (563) 589-4121
(E-Mail Add",s) (A"a Cade / reiephane Numb,,)
.. .
STATE OF IOWA
APPLICATION FOR FEDERAL I STATE ASSISTANCE
FEMA DISASTER # I SUBMITTAL DATE I APPLICANT LEGAL NAME
1518 9/7/2004 City of Dubuque, Iowa
STREET ADDRESS
50 West 13th Street
CITY ¡STATE POSTAL CODE I COUNTY
Dubuque IA 52001-4864 Dubuque
MAILING ADDRESS (if differenl from streel add..ss)
CITY ¡STATE fOSTAl CODE
NAME OF PRIMARY CONTACT JOB TITLE OF PRIMARY CONTACT
Michael C. Van Milligen City Manager
(AREA CODE) TELEPHONE # I (AREA CODE) FACSIMILE # E-MAil ADDRESS
(563) 589-4110 (563) 589-4149 ctymgr@cityofdubuque.org
ORGANIZATION TYPE (check one)
0 State Agency EJ City 0 Special District
0 County 0 Township 0 Private Non-Profit
FEDERAL TAX ID# I FISCAL YEAR (FY) START DATE
42-600459 MONTH, July DAY; 1
APPLICANT INFORMATION
CERTIFICATION
I do hereby certify that, to the best of my knowledge and belief, the information on this application is true and
accurate, and that this application will comply with project administration requirements.
Michael C. Van Milligen City Manager
Name of Designaled Aulhorized Representative Job Title ot Designated Authorized Rep,esentative
(563) 589-4110 (563) 589-4149
(Area Code) 'Telephone Number (Area Code) / Facsimile Number
September 7, 2004
Signature of Designated Aulhorized Represenlative Date
STATE OF IOWA
APPLICANT'S ASSURANCES AND CERTIFICATIONS
NOTE, Certain af th"e assu,ances and certificatlans may nol be applicable to this project 0' p'ogram. If you have questions, please contact !he
Awa"Hng Agency. Certain Fede",' assistance Awa""ng Agendes may "quire applicants 10 cert">, to additional assu,ances not induded in
this document Appl;cants ,.,1 be inst,ucted by the Awa"'ing Agen d additional assu"nces a" "qui'ed.
AS THE DULY DESIGNATED AUTHORIZED REPRESENTATIVE FOR THIS APPLICANT, I DO HEREBY AGREE IN THEIR NAME AND
ON THEIR BEHALF TO ALL OF THE FOLLOWING TERMS AND CONDITIONS OF THIS GRANT.
I HOLD HARMLESS AGREEMENT
Pu,.uanl to §403 and §407 ofthe Robert T. Siaffa'" Dlsast., Relief
and Eme",ency Assistance Act (PL 93-2a6, as amended), 42 U.S.C.
5170(b) and 5173, this applican' ag.." to indemnify, hold harmless, and
defend Ihe United Slates of America and Ihe Slate of Iowa, as well as
Ihei, agents and employees, for any claims arising f,"m Ihe 'emoval of
debris ar w'eckage fram this disaster. This applicent ag"" Ihat debris
..moval f,"m public and private property,.11 not occu, until the land-
own., p,"vides an uncondlianal authorizaHon fo, the "moval of debris.
II CERTIFICATION REGARDING LOBBYING
As required by the "gulaHans impiemenHng the New Restrictions on
Lobbying (44 CFR §16), Ihis applicant herebycertiHes Ihat, 10 the best
of Ihel, knowledge and belief'
A. No Fede,,' app,"priated funds have been or will be paid, by 0' on
behad of Ihis applicenl, 10 any pe"on for influencing 0' attempting
la influence an officer ar employee of any agency, a Member of
Cang"ss, an afficer 0' employee of Congress, 0' an employee of
a Member of Cong"ss, in connection wrih Ihe awa"'ing of any
Federal conl,act, the making of any Fede",' g",nt, the ma~ng of
any Fed.,al loan, the enlering inlo af any coope'ative agreement,
0' Ihe extension, continuation, "newal, amendmenl, or modlHcatlon
of any Fede",' cont",ct, g,anl, loan, or cooperaHve agreement
B. If any funds othe, Ihan Federal appropriated funds have been 0'
"" be paid la any pe,.on fo, influendng 0' attempting to influence
an officer or employee of any agency, a Membe, of Congress, an
officer ar employee of Congress, 0' an employee of a Membe, of
Congress in connection ,.;Ih Ihis Fede'al conI_, g,ant, loan, 0'
coope"Hve ag..ement, this applicanl shall complele and sutimit
Standa'" Fo"" . LLL, "Disdosu.. Fo'm 10 Report Lobbying", in
acco<dance with it's instructions.
C. This appl;cant shall ,equi.. that Ihe language of Ihls certification
be I,duded in Ihe awa'" documents fo, all sub-awards al all He,.
(Ind,dlng sub-cont,acls, sub-g,anls, and cont",cts und., g,anls,
loans, and cooperaHve ag,eemenls) and Ihal all sub-"ciplenls
shall certdy and disdose aceo"'ingly.
This certif..Hon is a material ,ep,esentation of fact upo, which reliance
is placed wheo this t"",action Is made or ent.,ed inlo. Submisslan of
Ihis certlficetion is a p.."qulsite 10 ma~ng or entering Inlo Ihls trans-
action, Imposed by §1352, title 31, U.S. Code. Any pe,.o, whofailsto
file the "q,i"d certification shall be subject to a dvil pe,ally of nolless
Ihan $10,000, and not mare Ihan $100,000, fo, each failu,e.
III DEBARRMENT, SUSPENSION, & OTHER RESPONSIBILITY MATTERS
As requi"" by Executive 0,derN12549, Debamnent and Suspension, and
implemenled by 44 CFR Part 67, fm p,"spectlve partidpants in primary
covered t"",actions, as defined in 44 CFR Part 17, §17.510.A.
This applicant he"by certifies Ihal it and II's principals.
A Me not p"sent~ debaned, suspended, p,"posed fo, debanment,
dedared ineligible, sentenœc! to a de,ial of Fede,al benefils by a
Stale of Federal court. 0' volunlarily excluded f,om covered
t,asactlons by any Fede'al department 0' agency.
B. Have '01 within a Ih,ee-yea, period p"cedlng this applicaHan been
convicted of 0< had a civilian judgemenl ,ende..d againsl them for
commission of f,aud or a criminal offense In co,necHo, ,.;Ih
obleining, attempHng 10 obtain, 0' perto,m a public (Fed.,al, Stale,
0' local) I,ansaction 0' conl"'ct unde, a public t",nsactlon: violation
of Fede",' 0' Slate antll,"sl stalules or commission of
embezzlemenl, Iheft, fo'gery, bribery, falsmcatlon or dest,uctian of
,eco,ds, making false statemeols, 0' 'eceiving slolen p'"perty
C. A,enolpresenllyi,dlcledfo',orolhe<wisecriminallyo,civilly
chsoged by a govemmental e,tlty (Federal, Siale, or local), with
commission of any of Ihe offenses enume,aled In the p,ecedlng
paragraph of Ihls certlficatlo,
PAGE 1 OF 2
D Have nol wrihln a th..e-yea, period poeceding Ihis application had
one or more public t,ansactions (Fede",', State, 0' local) te""inated
for cause m default
Whe" the applicant is unable 10 cert">, to any of Ihe statements In this
certification, they shall attach an explanation 10 fhis application.
IV ASSURANCES - CONSTRUCTION PROGRAMS
This applicant does he"by cert">' Ihat ft,
A Has the legal aulhority 10 apply fo, Fede",1 as~stance, and the
inslitutional, managerial, and finandal capabifty (inctuding funds
suffidenl to pay Ihe non-Fade"" share at project costs) 10 ensu"
prop" planni'g, management, and completion of Ihe project
described in this appl;catlon.
B. Will give the Awaldlng Agency, Ihe CompUolI.,oflhe United
States, and if appropriate the State, th_h any authorized ..p-
lesentatlve, access to and the right to examine all ..co"'s, books
pape,., or documents "Iated 10 !he assistance, and ,.;n establish
a p,"pe, accounting syslem in acco"'ance wrih geoo",lly accepted
aceountlng slandards, 0' agency directives.
C. Will not dispose of, mod">, Ihe use of, m change Ihe leons at Ihe
real property tftle, 0' olh., interest in !he sfte and fadlfties wihout
pe""ission and instructions from Ihe Awa"'ing Agency. .... oeco'"
Ihe Fede",1 Int.,est in the Iitle at ..al property in acco"'ance wrih
Awa"'ing Agency directives, and ,.;n include a covenant in the title
of ,eal property in accordance with Awa"'ing Agency directives,
a,d,.;11 include a covenant in the title at real property acquired In
whole 0' in part wrih Federal assistance funds 10 assu.. non-
discrimination during the useful "e of the project.
D. Will comply with Ihe requi..ments of the assistance Awa"'ing
Agency with ..ga'" 10 Ihe drafting, "view, and approval of
construction plans and specifications.
Will p,"vide and maintain competent, adequate engineering
supervision at Ihe conslruction site to ensu" thai the complete
work comforms with the approved plans and specffications. and
";11 furnish plog..SS "ports and oth., Info""atíon as requi"'" by
Ihe as~stance Awa"'ing Agency. 0' the State.
Will initiate and complete the work within the applicable time f,ame
after "ceipl of approval of the Awa"'ing Agency.
G Will establish safegua"'s to prohibft employees fcom using their
poslions for a pulpOse Ihal constitutes. 0' presenls the appea,ance
of, pe,.onal m organ~atlonal conflict of inle..st 0' personal gain.
H. Will comply ,.;th the Inte,govemmental Pe,.onnel Act of 1970
(42 U.S.C. §4726 - 4763) lelating 10 prescribed standa"'s fOf merit
systems for prog",ms funded unde, one of the nineteen statutes,
0' regulations specified in Append~ A of OPM's Standa"'s for a
Ment System of Personal Administration (5 CFR §900(m.
Will comply wllh Ihe Lead-Based Paint Poisoning P"venlion Act
(42 U.S.C. §4801 et seq.) which prohibits the use of a lead-based
palnl in construction or ..habilftation of ..sidence structu....
Will comply with all Federal slatutes 'elating to non-discrimination.
These Indude, but a.. nollimited 10,
1. TitleVloftheCivilRighlsActof19S4(PL66-352)w!IIch
prohibits discrimination an the basis of race, colo" 0'
national origin.
2. Title IX ofthe Federalion Amendmenls of '972, as amended
(20 U.S.C. §1S81 -1683 and 1665 - 1666) which prohibits
dis-criminatlon on the basis of sex.
§504 ofthe Rehabilitation Act of '973, as amended (U.S.C §794)
which prohibfts discrimination on Ihe ba~s of handicaps.
The Age Discrimination Act of 1975, as amended (42 U.S.C
§6101 - 6107) which prohibits discriminalion on the basis of age.
5. The Drug Abuse Office and T..atment Act of 1972, as
amended (PL 93-255) ,elating 10 non-dlscriminatio, on the
basis of drug abuse.
. ,
STATE OF IOWA
APPLICANT'S ASSURANCES AND CERTIFICATIONS
K.
5. The Compoehensive Aloohol Abuse and Alcohoism
P..vention, T..atment. and Rehabi"ation Act of 1970, as
amanded IPL 91-515) ,,'ating to con""entiali}' of alcohot
and drug abuse patient raoorns.
7. Hie VI/I of the Civ' R~hts Act of 1958, as amended (42
U.S.C. §3501) relating to non-discrimination in the sala,
..n'at, 0' financing of housing.
8. Any oth", non-discriminat",n provisions in the s-"c
statutels) unde, which application fo, Fede,al assmance
~ being made.
9. The ,equi..menfs on any oth.. non-discrimination statufels)
wh"" may ap",y to the application.
WiN com",y, 0' al..ady has complied, with tha requirements of T'les
1/ and III of the Un"orm Relooat",n Assistance and Re" PIOpeny
Acquis"an Pol;c;es Act of 1970 IPL 91-545), wh~h provides fak
and equ"able t..atment of pe"'ons displaced, o'whose p'openy is
acquioed as a resu' 01 Federal and Federal~ assisted programs.
These "'qukemen.. app~ to ail inte",sts in ",al pmpeny pu'Poses
>egarnless of Fedeno! part;c;patinn in puochases.
Wdlcomp~w'h the provisions of the Hatch Act (fi U.S.C. §1501-
1508 and 7324 - 7328) which lim' the po,"ieal activ",es 01
employees whose princi"'e emp",yment activ",es are fundad in
whcte or in part with Federal funds.
Win comp~ w'h the flood insu,ance purehase ..quiremen.. of
§102Ia) of the Flood Oisaste, Protection Act of 1973 (PL 93-234)
wh"" ..qui"'s "'cipients in a special flood hazald area to participate
in the prag,am, and to purehase flood insulance "the total cost of
insu",ble construction and acquis'ion is $5,000 0' mo,".
Wi! comp~ w'h the envilonmenlal standa,ds which may be
p"'scribed pu..uant to the tollow;ng,
1. Instnutlon of the environmental quaii}' contml measures
unde, the National EnvironmentaJ Poticy Act of 1969
IPL 91-190) and Executive Order011514.
2. Nat",nal Environmental Policy Act of 1959, as amended
IPL 91-190) and Executive Ord..011514.
3. Not"~ation of violating facil",es pu"uant to E.O. 011990
4. Evaluat",n of flood haza,ds in flaod plains in accordance
with Executive Order #11988.
5. Assu,ance of project consistency w'h the appmved State
management pmg,am developed ""d.. the Caast.. Zone
Management Act of 1972 (15 U.8.C. §1451 et seq.).
s. Confo,m'y of Fedelal actions to State implement-., Plans
und.. §1764(c) ofthe Clean MAct of 1955, as amended (42
U.S.C. §7401 e' seq.).
7. Pn>tection of und..gmund sou,ces of drinking wat.. under
the Safe Drinking Wate, Act of 1974, as amended IPL 93-523).
8. Pmtection of endangered species under the Endangeled
Species Act of 1S73, as amended IPL 93-205).
"'iI comply with the ""d Scenic Rive.. Act of 19S8 (16 U.S.C. §1271
et s...) ..Iated 10 pmtecting oomponen"", potential oomponents
af tho national wild and scenic rive" system.
Wdl assist the Awerning Agency in assuring compliance with §108
of tho National Hisloric Preservation Act of 1966, as ame_d
(16 U.S.C. §470), Executive Orner 0 11593 (identmcation and p,,-
servation of histaric p,operties), and the Archaeolagieal and
Historic Preservation Act of 1974 116 U.S.C. §469Ia)(1) et seq.).
"'" cause to be pertarmed the required financial and compiance
audils in acco,dance with the Single Audil Act, as amended.
Will comp~ w," all applicable lequilemen" ot all othel Fede<allaws,
Executive Orne", ..gulat",ns, and policies governing this prog,am.
L.
M.
N.
O.
Q.
R.
V CERTIFICATION OF ORUG-FREE WORKPLACE REQUIREMENTS
This certmeation is ,eqUi"'d by the oegulat",ns implemenling the Orug-F...
Woritplace Act of 1968 and 44 CFR §171~. The oeguiations, published in Ihe
May 25, 1990 Federal Regist.., requi'" certffication by sub-grantees, prio, to
award, Ihat they win maintain a drug-f... worit"'ace. The certífication that
follows is a material ,epresentat",n of lact upon which reliance wlíl be placed
when Ihe Agency determines to swam tho grant False certification 01
v",lation af the certification shall be gcounds fOf suspens",n of payments,
suspension Of terminat",n of grants, or government wide suspension or
debaoment (44 CFR Part 17, subpart C, 17.300, and subpart 0, 17.400).
A. The S,b-grantee certmes that' wi" or wlíl continue to provide a
d,ug-free werit",ace by,
,. Publishing a statement notifying employees Ihat the unlawful
manufactule, distribution, dispensing, possess",n, Of use of
a contmiled substance ~ pmhibned in the sub-granfee's
werit",ace and spec;fying the actions that win be taken
againsl employees for viotation of such prohibòtion.
2. Estab1~hing an ongoing drug-f..e awareness pmgram 10
inform employees about-
(a) The dange.. of drug abuse in the we",place.
Ib) The sub-grantee's policy of maintaining a drug-flee werit"'ace.
(c) Any available drug oounseling, rehab...tian, and
employee as~stance pmgrams.
(d) The pena"es Ihat may be imposed upon employees fOf
drug abuse violations occurrtng in lhe wo",place.
3. Making' a requi,ement Ihat each employee to be engaged
in the pertormance of the granf be given a ropy of the
notmcation statement published by the sub-g",ntee.
4. Notifying the employee in the statement that, as a cond",on
of employment und.. the granf, tho employee will-
(a) Abide by Ihe terms of the statement
(b) Notify Ihe employ.. in wrtting of his 0' he, conviction fOf
a violation of a criminal drug statute occurrtng in the worit-
place no 1a1.. than five calenda, days after such conv;ction.
5. Notifying the Awarding Agency in writing within ten caledar
days after receiving such notice fmm an employee Of oth..-
wise receiving actual notice of such conviction.
6. Taking one of the foilowing actions within 30 calendar days
of receiving such notice, with 'espect to any employee who
is so convicted-
la) Taking appropriate pe",onnel action against such an
employee, up to and inctuding termination of employ-
ment, oonsistent w'h the requi",menfs of the
Rehabilitaion Act of 1973, as amended; - Of-
Ib) Requiring the employee to participate satisfactori~ in a
drug atiuse assistance or ..habi,"ation program
approved foe such pUlpOSOS by a Federal, StaJe, Of
local heailh, law enfotcement, 0' olh.. appropriate agency.
7. Making a good fa'h effort to oonlinue '0 maintain a drug-
f,ee woritplace th,ough im"'ementation of ail of the terms
set forth in this certmcation.
Employe.. of convicted employees must provide notice, induding
pos",on "Ie, to every grant officer or other des~nee on whose g,ant
activOy the oonvicted employee was we",ing, unless the Fed..al agency
has des~nated a cent,al point fn, the """'i'" of such .-os. Notíce
shall indude the idenlmcalion numbe~s) of each affected g,ant
The lelms and conditions of this cortmcation app~ to any and all s'es
and locations at which the sub-g,antee we",s or otho<wise canducts
business.
THE SiGNATURE CERTIFICATION OF THiS FORM SHAtt aETREATED AS A MATERIAl. REPRESENTATION OF FACT UPON WHICH RELIANCE
WILL BE PLACED WHEN THE GRANTEE DETERMINES TO AWAREO THE COVERED TRANSACTION, GRANT, OR COOPERATIVE AGREEMENT
Michael C. Van Milligen for the City of Dubuque, Iowa
Applicant Name
1518
OisastelO
Signature of Designated Authocized Representative
September 7, 2004
Date
PAGE 2 OF 2
.. ,
STATE OF IOWA
SUBSTITUTE W 91 VENDOR UPDATE FORM
In order for the State of Iowa to pfocess payment of the amount that is due, and to comply with Internal Revenue Service
. "regulations on reporting such payments, we must receive the information being requested on this form. Failure to provide
this information will result in the withholding of payment. (Please print or type all entries except for signature)
BOX A BOX B
Are you I your business:
Individual
or Sole Pfoprietorship
YES
NO
NO
[I]
[S]
If the answef to both was no, please complete Box B.
If you answered yes to either item, please provide your
Social Security number:
AND
Complete the Name and Address Below:
Last Name:
First Name:
MI:
Doing Business As:
Address:
Address:
City:
State:
Postal Code:
Is your business:
Corporation
Partnership
Estate or Trust
Public Service Corp
Government
Other
YES
-1L-
[C]
[P]
[E]
[UJ
[G]
[0]
~
Please explain
Pi ease provide your Federal Employer Identification number:
42-6004596
AND
Complete the Name and Address Below:
Firm:
City of Dubuque, Iowa
Doing Business As:
Address:
50 West 13th Street
Address:
City:
Dubuque
State:
IA
Postal Code:
52001-4864
CERTIFICATION MUST BE SIGNED BY VENDOR
Certification - Under penalties of pe~ury, I certify that:
(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) I 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 withhoiding as a resut of a faiiure to report all interest or dividends, or
(c) the IRS has notified me that I am no longer subject to backup withholding.
Signature:
Date:
September 7, 2004
FOR OFFICE USE ONLY Refer to Procedure 270.450 for more details
From:
Dept.
0 Add
0 Change
(Include vendor code and
changes only)
Contact
0 Delete
Reason:
Added for Purchasing
0 Yes 0 No
, '
f
STATE OF IOWA
PUBLIC ASSISTANCE PROGRAM "CRITICAL DOCUMENTS" INSTRUCTIONS
'. Please find included here the 4 documents referred to by State Public Assistance Program staff as "Critical Documents".
These documents include:
1. Designation of Applicant's Authorized Repfesentative
2. State of Iowa Application for Federal I State Assistance
3. Applicant's Assurances and Certifications
4. State of Iowa Substitute W 9/ Vendor Update Form
Each Applicant approved for Public Assistance Grant funding must submit to Iowa Homeland Security and Emergency
Management Division all of these forms - completed, and signed by the individual designated as the Authorized
Representive for theif jufisdiction. It is recommended that each applicant designate an authorized representative as
soon as possible. In accordance with the State of Iowa Public Assistance Administrative Plan and the
FEMA - State Agreement:
PA YMENTS OF APPROVED GRANT FUNDING CANNOT BE MADE TO AN APPLICANT UNTIL ALL OF THESE
COMPLETED AND SIGNED FORMS ARE ON FILE WITH IOWA HOMELAND SECURITY AND EMERGENCY
MANAGEMENT DIVISION.
Completed and signed forms should be copied for the Applicant's files, and the original document mailed to:
Public Assistance Progfam Administrator
Iowa Homeland Security and Emergency Management Division
Hoover State Office Building - Level A
Des Moines, IA 50319-0113
Please keep in mind the following information when completing these forms:
Desiqnation of Applicant's Authorized Representative: The Applicant may designate anyone of their choosing to
be their authorized representative. However, the person so designated must have signatory authority on behalf of
the applicant, will be the addressee for all official correspondence (including funding warrants), and will be the first
point of contact for audits or other administrative issues while the grant is open & after it is closed. The applicant
should designate this individual in accordance with theif established regulations and procedures for such actions.
The Authorized Representative designation portion of this form (top box) must be completed with all applicable
information. It is essential that the Authorized Representative sign on the signature line in the upper right
corner of this section,
Completing the middle section of the form is optional, and the individual named in this section does not need to be
the "Chief Financial Officer". However, it is beneficial to have an alternate contact for routine inquiries.
The bottom "Certification" box may be completed by any entity official. This is the applicant's certification that the
applicable statutes, policies, and procedures established by the entity for designating an authorized representative
have been adhered to. If the designation is done by resolution, a copy of the resolution may be included with the
submittal of the critical document forms. Please be sure to enter the disaster number in the "Certification" box.
State of Iowa AD plication for Fedefall State Assistance: All required information needs to be entered, especially the
Federal Tax ID number and the Fiscal year start date. The completed form needs to be signed by the Designated
Authorized Representative,
ApDlicant's Assurances and Certifications: In signing this form, the applicant does thereby agree to
to all of the terms and conditions set forth therein. Please read it carefully, and have it signed by the Designated
Authorized Representative.
State of Iowa Substitute W9 I Vedor UDdate Form: For the purpose of this form, the applicant I entity is the
vendor. Public Assistance Program applicants will need to check "no" on the first two lines of Box A, then proceed
to complete Box B. The "Federal Employer Identification Number" is the same thing as the "Federal Tax ID Number"
required on the State Application for Federal State Assistance form. Once all applicable information has been
entered, the form should be signed by the Designated Authorized Representative.
Any questions about these forms may be directed to Pat Hall or Michael Powell, at (515) 281-3231.