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CM-12-01-004Item Caption: CM' RECEIVED JAN 04 202 City Manager Approval Form Fiscal Year 2012 Emergency Management Performance Grant Application Approval Date: January 6, 2012 Department Name: Administration Department Project Manager: Brad Bradford Assigned Attorney: J Kay Gavle Item Summary: The Emergency Management Performance Grant (EMPG) supports local comprehensive emergency management programs by off -setting the salaries of EMPG staff. This program is administered by the Texas Division of Emergency Management and requests for funding must be submitted annually. Participation will partially fund salaries for the Emergency Management Coordinator and the Assistant Emergency Management Coordinator. $41,800 is the expected grant funding (same as last year's award). Remaining amount is budgeted in the General Fund. No. of Originals Submitted: 1 Project Name: Cost: Source of Funds: Local Emergency Management Performance Grant Funds are already budgeted for the 2 positions. Grant, if awarded, will partially offset expense. General Fund Source of Funds (if applicable): Select Source Fund Account Number: 4623-100-00000 r4.. Finance Director Approval: Cheryl Delaney Department Date: 1/3/ 2 Director Approval: Dateer **Electronic signature by the Director is acceptable. Please only submit ONE approval form per item. ** CIP E Budget N/A OK N/A OK Purchasing 111 N/A OK Accounting N/A OK ITEMS WILL NOT BE PLACED ON THE COUNCIL OR CM AGENDA W/OUT PRIOR FINANCE AND/OR LEGAL APPROVAL REV. 6/20/11 Page 1 of 5 GRANT APPLICATION/PROPOSAL REVIEW FORM 2010 Grants Coordinator Laurie Bom 671-2876 Submit completed form for all City Manager and City Council approvals. Required to: a) submit a grant application b) accept a grant c) renew a grant d) change the budgeted amount of a grant Department Name: Admin Dept. Contact Person: Brad Bradford/Sherrill Voll Dept Directors Signature: Departmental Goal #: Strategic Plan -Priority Goal #: Top Priority: Provide a safe environment...and remain prepared for natural and manmade disasters Requested City Council or City Manager Approval Date: Brief project description For Finance Use ONLY FY11-12 Deadline for GAPR Review. 12121/2011 Tag #: 1 Original Documents Received: 1 12/19/2011 Grant Title & CFDA #: EMPG CFDA #97.042 Funding Agency/Department: FEMAIDHSITDEM Program Name: Grant Term Dates: Est. Award Amount: Local Emergency Management Performance Grant 10/01/11 Through 09/30/12 $41,800 The CORR is a: Recipient ©' Sub -Recipient 01/06/12 Grant Application Deadline: 01/16/12 Emergency Management Performance Grant (EMPG) to support local comprehensive emergency management programs, specifically EMPG personnel. This program is administered by the Texas Division of Emergency Management. Participation will partially fund salaries for the Emergency Management Coordinator and Assistant Emergency Management Coordinator. The Police Department administers the grant. This is an aoolication renewal. Finance Information Is this a new program? BUDGET SUMMARY Yes 11 No Fiscal Year FY11-12 FY12-13 FY13.14 Total Grant Amount $ 41,800 $ 41,800 Required Match* $ Staff Time $ Operational Expenses $ 174,271 $ 174,271 TOTAL Costs $ 216,071 $ - $ • $ 216,071 * Source of Required Matching S: Payroll - General Fund. Grant offsets the salary budgeted for Brad Bradford and Ken Evans. Total salary + benefits s $216,071 If yes, complete a New Program Worksheet (see Tab 2) Proposed Grant -Funded FTEs: N/A Performance Measures: (list three) 1 Submit an EMPG Application, two Progress Reports, and quarterly Financial Reports 2 Conduct hazard awareness activities for local citizens 3 Conduct Natural Hazard, Terroism, and Public Health or Medical exercises TITLE COST/YEAR Emergency Mgmt. Coord. $ 20,900 Asst Emer. Mgmt Coord. $ 20,900 TOTAL: $ 41,800 GRANT -FUNDED MULTI-YEAR TOTAL: RECURRING COSTS: 216,071 Advanced Funds Reimbursable Funds Yes, this is an in-kind' service agreement. El If yes, have the departments providing services been contacted? This is a: (choose application type) Formula Allocation This is an ILA or MOU with: (names of collaborators) REVISED 1229/2011 Identify performance measurements that will show how this new program will provide an improvement or benefit to your department, citizens or other departments. Indicate measurement WITH and WITHOUT the new program resources included. Performance Measurement Proposed Proposed Actual EST Without With 2011-12 2011-12 New Pr • • ra New P ram New Program Worksheet General Fund Library Please indicate if this a new program or if it will support an established program: E:INew Program �Additions/Changes to Existing Program Total New Program Costs New Program Worksheet General Fund 20000 Library Total Contractual Services $ 0 $ 0 $ 0 $ 0 Total Materials and Supplies $ 0 $ 0 0 Total Other Expenses Total Capital Outlay Total New Program Costs Program Change Worksheet Depaftnent Division 0 Program General Fund Wa A Fiscal Year Implemented Priority 0 2011-2012 This is the annual distribution of EMPG funds to each State by the Department of Homeland Serxxity. Historically, the City has applied the funds toward the salaries of the Emergency Management Coordinator and the Assistant Emergency Management Coordinator. The total Salary + Benefits for these two positions in FY12 is $233,693. The City will be reimbursed an est. $41,800 of that amount. 1. Submit an EMPG Application, two Progresss Reports, and quarterly Financial Reports 2. Conduct hazard awareness activities for local citizens. 3. Conduct Natural Hazard, Terroism, and Public Health or Medical exercises. Identify performance measurements that will show how this new program will provide an improvement or benefit to your department, citizens or other departments. Indicate measurement WITH and WITHOUT the program changes. Performance Measuremer* Actual 2010 Proposed Without est. 2011 canoe Proposed With Total Number of Temp Positions that will be filled by 11 Total Program Costs 'Savirigs Program Change Worksheet General Fund 0 Division R Program $ 0 $ 0 $ 0 Total Contractual Services $ 0 $ 0 $ 0 $ 0 Total Materials and Supplies Fiscal Year knplemented Prbrity / 0 $ 0 $ $ $ 0 $ $ 0 $ CITY OF ROUND ROCK New Program Job Description Please complete the yellow highlighted areas. Be as detailed as possible. JOB TITLE DEPARTMENT PAY GRADE FLSA STATUS ORGANIZATIONAL RELATIONSHIPS Reports to: Directs: SUMMARY OF POSITION: EXAMPLES OF DUTIES: 1 2 3 QUALIFICATIONS (Knowledge, Skill, Abilities) Knowledge of Skills: Ability to: Experience and Training Certificates and Licenses Required Possession of, or the ability to obtain, a valid Texas Driver's License. DISCLAIMER The above information on this description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job. City of Round Rock Capital Outlay States Opo m Page 2 of 3 Grant Application/Proposal Review Checklist (GAPR) Grants Coordinator Laurie Bom 671-2876 Department Name: Admin Dept. Contact Person: Brad Bradford/Sherrill Voll Dept. Contact Phone #: 341-3106 is grant requires cost sharing. Amount: $ 20,900 Source: General Fund This grant requires a public hearing. Hearing required on/before: Grant Coordinator Use Only Last Updated: 12/20/2011 Due to CC/CM: 1/6/2012 In what measurable way does this project improve core services? Leverages funds available to provide Emergency Management by off -setting salary of the Emergency Mgmt. Coord. And Asst. Emer. Mamt. Coord. How does this project align with the City's strategic priorities? Top Priority: Assuring the safety of citizens NOFA online @: 13 Yes No Is this project necessary to maintain ISO ratings or accreditation? Was this project included in last year's Operating Budget? If the grant is not awarded, will the projector service be provided? If yes, how? Budgeted salaries for two staff positions. This grant is part of a larger project with multiple sources of funding. Discuss: This project requires collaboration between multiple Departments. Discuss: Requires coordination between PD and Emergency Operations This project will require subcontract(s) or consultant(s). Discuss: If this is something other than a one-time purchase, or one -day project, identify each staff person needed to accomplish the program objectives and the percent of time per month needed for each (include accounting staff): Title Pay Grade The Department will request funding from the General Fund to continue the program when grant funding ends. Est. $/Year This project is considered a baseline program that must be continued with or without grant funding. Est. $/Year This is a pilot or demonstration program. There may be a need for a follow-up grant or supplemental funding from the General Fund for the follow-up program. Est. $/Year This project requires collaboration between multiple Departments. Discuss: Requires coordination between PD and Emergency Operations This project will require subcontract(s) or consultant(s). Discuss: If this is something other than a one-time purchase, or one -day project, identify each staff person needed to accomplish the program objectives and the percent of time per month needed for each (include accounting staff): Title Pay Grade % d of months Salary Benefits Total EmrgMgt Coord 12 $ 6,834 $ 1,797 $ 103,559 Asst Emrg Mgt Coord 12 $ 7,438 $ 1,938 $ 112,512 $ - TOTAL $ 216,071 If funded, this grant will require reporting to: Agency Name Milestone Reports Due Financial Reports Due Reporting System Name TDEM Quarterly Semi -Annually ® This project will require additional training not funded by the grant. Discuss: ®This project requires special licensing/certifications. Discuss: ®This project requires travel not funded by the grant. Discuss: Identify the source and amount ® This project will require new equipment not funded by the grant. Discuss: REVISED 12292011 Grant Application/Proposal Review Checklist (GAPR) This project will require additional training not funded by the grant. Discuss: QThis project requires special licensing/certifications. Discuss: ® This project will incur expenses for maintenance/operation/testing. Discuss: Identify the source and amount: 1:1 This equipment is necessary to maintain ISO rating or accreditation. Discuss: The grant is supplying equipment rather than funding. Discuss: This equipment will require an extended warranty or service agreement. Discuss: ® The life -cycle for this equipment is less than 3 years. Discuss: ® The funder has an ownership interest in the equipment. Discuss: Does the Department already own this equipment or similar equipment? If so, describe the need for new/additional equipment: Identify the vendor(s) that provided pricing for the equipment: 1 Name: Contact: 2 Name: Contact: 3 Name: Contact: Website URL: www. www. www. REVISED 12/292011 FISCAL YEAR 2012 EMERGENCY MANAGEMENT PERFORMANCE GRANT APPLICATION 1. APPLICANT NAME (Jurisdiction): City of Round Rock 2. COUNTY: Williamson 1 3. DISASTER DISTRICT: 6B 4. EMPG STATUS: 11 Current EMPG Program participant ❑ New EMPG Program applicant 5. PROGRAM PARTICIPANTS: (List all jurisdictions that are participants in your emergency management program. Identify any jurisdictions that have joined or withdrawn from your program in the last year) n/a 6. CHECKLIST OF APPLICATION ATTACHMENTS: (See the FY 2012 Emergency Management Performance Grant (EMPG)Guide for information on completing these forms) ►.4 Designation of Grant Officials (TDEM-17B) Statement of Work & Cumulative Progress Report (TDEM-17A) - This form shall be signed by the EMC ►/ Application for Federal Assistance (TDEM-67) -The Authorized Official shall sign this form 11 EMPG Staffing Pattern (TDEM-66) - The Authorized Official shall sign this form 1 EMPG Staff Job Description (IDEM -68) - A current job description is required for each staff member listed in the FY 2011 EMPG Staffing Pattern (TDEM-66) 4 FEMA Form 20-16 Summary Sheet for Assurances & Certifications - Shall be signed by an Authorized Official Attached: ►�4 FEMA Form 20-16A, Assurances — Non -Construction Programs ►4 FEMA Form 20-16C, Certifications Regarding Lobbying, Debarment, Suspension, & Other Responsibility Matters; and Drug -Free Workplace Requirements ❑ FEMA Form SF LLL, Disclosure of Lobbying Activities - Signed by the Authorized Official required only if the applicant performs lobbying to influence federal actions 0 Direct Deposit Authorization (form 74-146) or Application for Payee ID Number (form AP -152) - The Grant Financial Officer shall sign this form /4 Travel Policy Certification (TDEM-69) - The Grant Financial Officer shall sign this form T. CERTIFICATION: This Application, together with the approved EMPG Statement of Work & Cumulative Progress Report (TDEM-17A), constitutes the annual work plan for the emergency management program whose participants are listed above. The undersigned agree to exert their best efforts to accomplish all activities listed in the Statement of Work & Cumulative • • • Report = • • • - = • by the -xas Divisi of E ergency Management. y%���I� ,.,,� /.2— )1 IZ 1-1- t t Authorized Official Date Emergency Management Coordinator Date Ori• final Si . nature Or}i• incl S'• nature i v!. 8. APPROVAL: The attached Fiscal Year 2012 Statement of Work & Cumulative Progress Report is approved fl Assistant Director/Chief Date ❑ State Coordinator for Preparedness and Operations TDEM-17 12/11 Mail completed forms and application materials to: Grant Coordinator Office of Management and Budget Texas Division of Emergency Management Texas Department of Public Safety PO Box 4087 Austin, TX 78773-0223 age 1 0 FISCAL YEAR 2012 DESIGNATION OF EMPG GRANT OFFICIALS APPLICANT NAME Jurisdiction NAME : Ci of Round Rock @ Mr. ■ Ms. Thomas L. Bradford, III Official Mailing Address 2701 N. Mays Round Rock, TX 78665 Da ime Phone Number 512 341-3106 Fax Number (512) 218-3267 E-mail Address NAME bbradford •►round-rock.tx.us ■ Mr. Ms. Stacie Carter Title Accountin ! Mana ! er Official Mailing Address 221 East Main St. Round Rock, TX 78664 Da ime Phone Number 512 218-3295 Fax Number (512) 218-5442 E-mail Address NAME scarter •►round-rock.tx.us 1 Mr. ■ Ms. Steve Norwood Title Ci Mana . er Official Mailing Address 221 East Main St. Round Rock, TX 78664 Da ime Phone Number 512 218-5410 Fax Number (512) 218-7097 E-mail Address snorwood •►round-rock.tx.us TDEM-17B 12/11 Page 1 of 1 FISCAL YEAR 2012 EMPG STATEMENT OF WORK & CUMULATIVE PROGRESS REPORT APPLICANT NAME (Jurisdiction): City of Round Rock Document Submitted By Date TDEM Review By Date Statement of Work Thomas L. Bradford 12.28.11 Progress Report #1 Progress Report #2 TASK 1 -WORK PLAN & SEMIANNUAL PROGRESS REPORT Our jurisdiction will submit an EMPG Application, two Progress Reports, two Staffing Commitment Certifications, and four Quarterly Financial Reports Our jurisdiction has appointed a NIMSCAST point of contact, established a NIMSCAST account, and is 100% compliant with FY 2009 NIMSCAST objectives and metrics 0 Work Plan • This Progress Report # 1 is being submitted to the TDEM Preparedness Section & Second Quarter Financial Reports have been submitted to TDEM Support • Progress Report #1 • First Services ■ This Progress Report # 2 is being submitted to the TDEM Preparedness Section & Fourth Quarter Financial Reports have been submitted to TDEM Support • Progress Report #2 ■ Third Services TASK 2 -LEGAL AUTHORITIES FOR EMERGENCY MANAGEMENT PROGRAM Our jurisdiction management will maintain current program NIMSCAST account is TRRN registration completed legal documents are current jurisdiction will prepare legal documents establishing our emergency 100% compliant with all objectives and metrics and resources entered & on file with TDEM; no additional action is required or update & submit to TDEM: Court Order # for. dated: L Our - Our 0 Our 0 Work Plan ■ Our ■ Commissioner's • City Ordinance(s) • Updated Joint Resolution • NIMS Adoption dated: ■ Our NIMSCAST account is TRRN registration completed legal documents are current jurisdiction completed 100% compliant with all objectives and metrics and resources entered & on file with TDEM, no additional action is required & submitted to TDEM: Order # for: dated: ■ Our ■ Our • Progress Report #1 ■ Our October 1 — March 31 111 Commissioner's Court II City Ordinance(s) • Updated Joint Resolution ■ NIMS Adoption dated: • Our NIMSCAST account is TRRN registration completed legal documents are current jurisdiction completed 100% compliant with all objectives and metrics and resources entered & on file with TDEM, no additional action is required & submitted to TDEM: Order # for: dated: • Our II Our • Progress Report #2 ■ Our April 1- September 30 • Commissioner's Court ■ City Ordinance(s) ■ Updated Joint Resolution • NIMS Adoption dated: TDEM-17A 12/11 Mail completed form to: age Grant Coordinator Office of Management and Budget Texas Division of Emergency Management Texas Department of Public Safety P 0 Box 4087 Austin, TX 78773-0223 TASK 3 -PUBLIC EDUCATION/INFORMATION • Option 1: Our jurisdiction will conduct 30 hours of hazard awareness activities for local citizens -OR A COMBINATION OF - Option 2: Our jurisdiction will prepare & distribute public education/information materials to a substantial portion of the community. In the space below, describe the materials to be distributed: We will provide local "Public Emergency Contact" registration program, allowing citizens and businesses to provide emergency contact information for use should an emergency arise in home/business while away. We will expand citizen registration of cell phone and VOIP in the Emergency Notification System Database, allowing citizens and businesses to provide their emergency contact information for use should emergency arise in home or business. We will publish and distribute materials for "National Night Out" We will provide other public education opportunities, including National Weather Service's "Skywam" program. We will participate in local and regional CTCCC efforts. We will continue development effort to provide a web -based Special Need Assistance Program (SNAP) program for the community. "`You may provide a combination of both options. 0 Work Plan • Our jurisdiction completed the following hazard awareness and/or public education/information activities: • Progress Report #1 October 1 — March 31 • Our jurisdiction completed the following hazard awareness and/or public education/information activities: • Progress Report #2 April 1 — September 30 TASK 4 -EMERGENCY MANAGEMENT PLANNING DOCUMENTS 0 Our jurisdiction reviewed our emergency management plan & annexes for currency and NIMS compliance 0 Our emergency management plan and all annexes are current and NIMS compliant 0 We will develop, update, or change these planning documents: • Basic Plan 0 Work Plan Annexes: ►ZEA ■ B ..1C OD E IMF ►Z� G ■ H ►C1 I ..1J 4 K NI_ 0M ON O ■P 0Q •R OS OT NU OV • Other documents: NOTE: Plans & annexes dated prior to September 30, 2005, must be revised or updated this year. All Plans and Annexes must be NIMS compliant • Our jurisdiction reviewed our emergency management plan & annexes for currency and NIMS compliance • Our emergency management plan and all annexes are current and NIMS compliant • Progress Report #1 • We updated by revision or change these planning documents: October 1 — March 31 • Basic Plan Annexes: ■A ■B ■C ■D ■E ■F •G •H ■I ■J •K •L ■M ■N■O■P■Q■R■S■T■U■V • Other documents: ■ Our jurisdiction reviewed our emergency management plan & annexes for currency and NIMS compliance • Our emergency management plan and all annexes are current and NIMS compliant • Progress Report #2 • We updated by revision or change these planning documents: April 1 — September 30 • Basic Plan Annexes: ■ A ■ B MID ■ D ■ E ■ F ■ G ■ H ■ I ■ J ■ K ■ L ISM •N ■O ■P ■Q ■R ■S •T ■U ■V • Other documents: IDEM -17A 11/10 Page 2 of 6 TASK 5—EXERCISE PARTICIPATION & SCHEDULE ❑ Work Plan Submit the jurisdiction's TEP no later than 60 days after the conduct of the TEP Workshop, or with the EMPG application package/work plan 1. Each jurisdiction receiving EMPG funding must: a. Conduct two (2) discussion -based exercises and one (1) operations -based exercise demonstrating a progressive exercise program. A full-scale exercise must be conducted and evaluated at least every three years. Actual incident response is NOT eligible for substitute exercise credit. Exercise program must he consistent with the principles outlined in the Homeland Security Exercise and Evaluation Program (HSEEP). b. Develop and submit a multi-year Training and Exercise Plan (TEP), not less than three years, to the TDEM Exercise unit. 2. Each individual funded through the EMPG program must actively participate in a minimum of three exercises within the performance period TDEM-17A 11/10 Page 3 of 6 TASK 6 -TRAINING FOR EMERGENCY MANAGEMENT PERSONNEL ALL EMPG-funded emergency management personnel will participate in the following training during FY 2012: Position/Name Course Name or Number Thomas L. Bradford, EMC E-388 — Advanced Public Information Officer G-629 — Infrastructure Damage Assessment G-628 — Evacuation & Re -Entry G-197 — Emergency Planning & Special Needs Ken Evans TBD 0 Work Plan Emergency management personnel completed the following training and documentation is attached: Position/Name Course Name or Number Date Completed Thomas L. Bradford, EMC E-388 — Advanced PIO 12/08/11 • Progress Report #1 October 1 — March 31 Emergency management personnel completed the following training and documentation is attached: Position/Name Course Name or Number Date Completed • Progress Report #2 April 1 — September 30 TDEM-17A 11/10 TASK 7 -EMERGENCY MANAGEMENT TRAINING FOR OTHER PERSONNEL Our jurisdiction will conduct or arrange emergency management related training for elected officials, other local officials, & support agencies. 0 Work Plan The following formal training courses were taught or contracted: Date Course Title 1 Class Description 1 # Trained • Progress Report #1 October 1 — March 31 The following formal training courses were taught or contracted: Date Course Title 1 Class Description 1 # Trained ■ Progress Report #2 April 1 — September 30 TASK 8 -EMERGENCY MANAGEMENT ORGANIZATIONAL DEVELOPMENT Our jurisdiction will participate in the following emergency management organizational development activities, including CAPCOG Regional Homeland Security Task Force; Texas Homeland Security Conference; WCEPG/LEPC; CTPG; CTCTTF; CTSSC; FBI InfraGard; CASHP; CAIMT; CTIMT; RRTF/IMT; Austin -Round Rock Urban Area Activities; BioWatch BAC/PSS; WCLTRC, CTCCC. 0 Work Plan Our jurisdiction completed the following staff development activities: ■ Progress Report #1 October 1 — March 31 Our jurisdiction completed the following staff development activities: • Progress Report #2 April 1 — September 30 TDEM-17A 11/10 age b0 APPLICANT NAME: REMARKS (Use an Additional Sheet if Necessary) TDEM-17A 11/10 Page 6 of 6 FISCAL YEAR 2012 APPLICATION FOR FEDERAL ASSISTANCE (Instructions on Reverse) NAME OF PROGRAM/ ASSISTANCE: EMERGENCY MANAGEMENT PERFORMANCE GRANT (EMPG) 1 • CFDA NUMBER: 97.042 2. APPLICANT New Applicant Renewal STATUS: ❑ 4 3. FEDERAL FISCAL YEAR: FY 2012 4. START DATE: OCTOBER 1, 2011 5. END DATE: SEPTEMBER 30, 2012 6. APPLICANT INFORMATION a. Legal Name of Applicant Organization (as it appears on the EMPG Application (TDEM-17): City of Round Rock, Texas b. Name & Telephone Number of Emergency Management Coordinator: Thomas L. Bradford, III 512-341-3106 c. Mailing Address: City Hall 221 Eat Main St. Round Rock, Texas 78664 Employer Identification Number/Tax ID# 74-6017485 d. Physical Address (if different from Mailing Address): Round Rock Police Department 2701 N. Mays Round Rock, Texas 78665 7. EMPG PERSONNEL SUMMARY (include only those staff that will be paid with EMPG funds): a. Number of EMPG Staff & Percentage of Time Worked in Emergency Management Duties: # Staff Percent # Staff Percent # Staff Percent 1) Full Time: 1 100% 1 50% 2) Part Time b. Total Number of EMPG-Funded Personnel 8. ESTIMATED EXPENSES: a. Salary & Benefits (from line 18, form TDEM-66) 159,814.71 b. Travel Expenses (from line 19 form TDEM-66) c. Other Expenses (from section 11 on reverse) d. Total Expenses (A + B + C) 159,814.71 e. Federal Share (D x .50) 79,907.35 9. CERTIFICATION: I certify that to the best of my knowledge and belief this applicati n and its attachments are tru and correct. a. Typed Name of Authorized Official: Steve Norwood b. Title of Authorized Official: City Manager c. Original Signature of Authorized Official: d. Date Signed: / �'%6 z-- TDEM-67 12/11 Page 1 of 2 INSTRUCTIONS 1. Except as indicated below, entries are self-explanatory. 2. Item 7A: Enter the legal name of your jurisdiction. Your entry should match the Applicant Name used on the EMPG Program Application (TDEM-17). 3. Item 8A: Indicate the number of full-time employees who work specific percentages of time in emergency management duties. Example: 1 staff © 100 percent, 2 staff @ 50 percent. Also indicate the number of part- time employees. Include only staff members whose salary and benefits will be supported by EMPG funding. The data in this section should agree with the information included on the EMPG Staffing Pattern (TDEM-66). 4. Item 10 A, B, & C. This form must be signed by an Authorized Official, who is a person authorized by the goveming body of the jurisdiction to apply for grants and accept grants and execute agreement and contracts on behalf of the jurisdiction. Authorized Officials are County Judges, Mayors, and many City Managers — not Emergency Management Coordinators. 11. OTHER ALLOWABLE EXPENSES: Describe the other allowable expenses of your emergency management program that you are requesting be supported by EMPG funding and provide an estimate of the amount of those expenses. These costs must comply with 2 CFR, Part 225, Cost Principles for State. Local, and Indian Tribe Govemments (OMB Circular A-87). Salaries and expenses for elected officials are not allowed. Any proposed expenditure in the amount of $5,000.00 or more must be listed in this section. Continue on a separate sheet if necessary. Transfer the Total calculated below to line 9c on the front of this form. To determine if an expense is allowable under the EMPG program, refer to the DHS Authorized Equipment List (AEL) available on the Responder Knowledge Base at https://www.rkb.us/contentdetail.cfm?content id=210237&GetAELSELCats=1. You must be a registered user to access this listing. Specific Description of Expense (Descriptions must be specific — do not use broad or general categories, such as operating or administrative expenses) Estimated Amount Total TDEM-67 12/11 Page 2 of 2 FISCAL YEAR 2012 EMPG STAFFING PATTERN 1. APPLICANT NAME (as it appears on EMPG Application): City of Round Rock 2. COUNTY: Williamson 3. FULL-TIME EMPLOYEES (including those who work all or only a portion of their time in emergency management duties) 4. Gross Annual Salary 5. Gross Annual Benefits 6. Gross 7.% Salary & Work in Benefits EM (4+5) Duties 8. Salary & Benefits for EM (6x7) 9. Est. EM Travel Costs Name: Thomas L. Bradford,111 Position: EMC 81,993.60 21,564.98 103,558.58 100% 103,558.58 Name: Ken Evans Position: AEMC 89,252.80 23,259.47 112,512.27 50% 56,256.13 Name: Position: Name: Position: Name: Position: Name: Position: 10. PART-TIME EMPLOYEES A. SUBTOTAL 11. % of Full Time 12. Gross Annual Salary 13. Gross Annual Benefits 14. Gross 15.% Salary & Work in Benefits EM (12+13) Duties 159,814.71 16. Salary & Benefits For EM (14x15) 17. Est. EM Travel Costs Name: Position: Name: Position: Name: Position: Name: Position: Name: Position: Name: Position: B. SUBTOTAL TOTAL Add Subtotals in A & B above 18. 159,814.71 19. CERTIFICATION: 1 certify that no individual listed above h • ds an elected office. Signature of Authorized Official: Date Signed: TDEM-66 12/11 0/ 0 EV; 2— Page 1 of 1 EMPG STAFF JOB DESCRIPTION Jurisdiction Name City of Round Rock Staff Member Name Thomas L. (Brad) Bradford, III Position Title Emergency Management Coordinator Description Prepared By Thomas Bradford Date Prepared 12.28.11 ❑ Current Job JOB DESCRIPTION Description Attached .1 See Below A. Provide a general description of the duties performed by this staff member. SUMMARY OF POSITION: The City of Round Rock Emergency Management Coordinator (EMC) is responsible for planning, organizing and directing activities for the City's Emergency Management Plan, including: Develop, review and update emergency operation plan to prepare for potential emergency or disaster situations. Coordinate staffing for the EOC with designated department personnel, and coordinates EOC activities. Prepare and submit program funding documents and coordinate grant proposal activities related to emergency preparedness. Develop, coordinate and lead emergency management training, coordinate and evaluate emergency operations drills and actual disasters; make recommendations to improve operations and/or response. Advise departments on their emergency plans and coordinate interdepartmental activities. Communicate emergency operations plans to appropriate local groups to coordinate response planning with City operations. Evaluate EOC operations during and after emergency operations exercises and/or emergencies and actual disasters; make recommendations to City Manager and appropriate departments. ORGANIZATIONAL RELATIONSHIPS: 1. Reports to City Manager on emergency responsibilities. 2. Advises Mayor, City Council and City Manager on emergency management matters. B. If this staff member performs both emergency management duties and other duties, identify the specific emergency management duties performed. TDEM-68 12/11 Retain a copy of this description for future use. EMPG STAFF JOB DESCRIPTION Jurisdiction Name City of Round Rock Staff Member Name Ken Evans Position Title Assistant Emergency Management Coordinator Description Prepared By Thomas Bradford Date Prepared 12.28.11 ❑ Current Job JOB DESCRIPTION Description Attached /1 See Below A. Provide a general description of the duties performed by this staff member. SUMMARY OF POSITION The City of Round Rock Assistant Emergency Management Coordinator (AEMC) assists the EMC and participates in regional committees, including within Austin -Round Rock Urban Area, HSTF, CBRNE Strike Team, CAIMT, CTIMT, RRTF/IMT. Serves as emergency management coordinator for the Police Department in meeting accreditation guidelines. ORGANIZATIONAL RELATIONSHIPS 1. Reports to Assistant Chief on Lieutenant's responsibilities. B. If this staff member performs both emergency management duties and other duties, identify the specific emergency management duties performed. Provide guidance and support to City Staff and Elected Officials on matters involving Emergency Management. Provide coordination of development and revisions of planning documents. Develop and submit financial documents and work plans as required. Provide information to citizens regarding Emergency Management. 1. Reports to: Thomas Bradford, EMC, on Emergency Management responsibilities. TDEM-68 12/11 Retain a copy of this description for future use. U.S. DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY SUMMARY SHEET FOR ASSURANCES AND CERTIFICATIONS FOR FY 2012 O.M.B. No. 1660-0025 Expires July 31, 2007 CA FOR (Name of Recipient) City of Round Rock, Texas This summary sheet includes Assurances and Certifications that must be read, signed, and submitted as a part of the Application for Federal Assistance. An applicant must check each item that they are certifying to: Part 1 FEMA Form 20-16A, Assurances-Nonconstruction Programs Part I1 FEMA Form 20-16B, Assurances -Construction Programs Part I11 (_/j FEMA Form 20-16C, Certification Regarding Lobbying; II�� Debarment, Suspension, and Other Responsibility Matters; and Drug -Free Workplace Requirements Part IV SF LLL, Disclosure of Lobbying Activities (If applicable) As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the identified attached assurances and certifications. ,/c Iood Ty . _ . Name of Authorized Representative Signature of Authorized Representative Cit l (VtaYlct Title 412 t0/2— Date Signed NOTE: By signing the certification regarding debarment, suspension, and other responsibility matters for primary covered transaction, the applicant agrees that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by FEMA entering into this transaction. The applicant further agrees by submitting this application that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -Lower Tier Covered Transaction," provided by the FEMA Regional Office entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. (Refer to 44 CFR Part 17.) Paperwork Burden Disclosure Notice Public reporting burden for this form is estimated to average 1.7 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing, reviewing, and maintaining the data needed, and completing and submitting the form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, U.S. Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington DC 20472. You are not required to complete this form unless a valid OMB control number is displayed in the upper corner on this form. Please do not send your completed form to the above address. FEMA Form 20-16, OCT 04 PREVIOUS EDITION OBSOLETE U.S DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY ASSURANCES-NONCONSTRUCTION PROGRAMS O.M.B. No. 1660-0025 Expires July 31, 2007 Paperwork Burden Disclosure Notice Paperwork reporting burden for this form is estimated to average 1.7 hours per response The burden estimate indudes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right comer of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden estimate to: information Collection Management, U. S. Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. NOTE: Do not send your completed form to the above address. NOTE: Certain of these assurances may not be applicable to your project or program. If you have any questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant, I certify that the applicant: 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non -Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. Section 4727-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statues or regulations specified in Appendix A of OPM's Standards for Merit System of Personnel Administration (5 C.F.R. 900, Subpart F). 6. Will comply with all Federal statues relating to nondiscrimination. These indude but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P. L. 88-352) which prohibits discrimination on the basis of race, color, or national origin; (b) Title IV of the Education Amendments of 1972, as amended (20 U.S.C. Sections 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. Section 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. Sections 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970,) P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912, (42 U.S.C. 290-dd-3 and 290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Acts of 1968 (42 U.S.C. Section 3601 et. seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provision in the specific statue(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statue(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Title II and III of the Uniformed Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provides for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or Federally assisted programs. These requirements apply to all interest in real property acquired for project purposes regardless of Federal participation in purchase. 8. Will comply with provisions of Hatch Act (5 U.S.C. Sections 1501-1508 and 7324-7328) which limit the political activities of employees whose principle employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis -Bacon Act (40 U.S.C. Sections 276a to 276a-7) the Copeland Act (40 U.S.C. Section 276c and 18 U.S.C. Sections 874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. Sections 327-333), regarding labor standards for federally assisted construction subagreements. 10. Will comply, if applicable with flood insurance purchase requirements of Section 102a of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988;(e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16) U.S.C. Sections 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176 (c) of the Clear Air Act of 1955, as amended (42 U.S.C. Section et seq.); (g) protection underground sources of drinking water under Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205). 12. Will comply with the wild and Scenic Rivers Act of 1968 (16 U.S.C. Sections 1271 et seq.) related to protecting components of the national wild and scenic rivers systems. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a -et seq.). 14. Will comply with P.L 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead -Based Paint Poising Prevention Act (42 U.S.C. Sections 4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984. 18. WIII comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies goveming this program. 19. It will comply with the minimum wage and maximum hours provisions of the Federal Fair Labor Standards Act (29 U.S.C. 201), as they apply to employees of institutions of higher education, hospitals, and other non-profit organizations. FEMA Form 20-16A, OCT 04 PREVIOUS EDITION OBSOLETE U. S. DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY CERTIFICATIONS REGARDING LOBBYING• DEBARMENT SUSPENSION AND OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS O.M.B. No. 1660-0025 Expires July 31, 2007 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 1.7 hours per response. The burden estimate includes the time for reviewing instructions and searching existing data sources, gathering and maintaining the data needed and completing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right comer of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, U.S. Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0001). NOTE: Do not send your completed form to this address. Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the instructions for certification included in the regulations before completing this form. Signature of this form provides for compliance with certification requirements under 44 CFR Part 18, "New Restrictions on Lobbying" and 28 CFR Part 17, "Govemment-wide Debarment and Suspension (Nonprocurement) and Govemment-wide Requirements for Drug -Free Workplace (Grants),." The certifications shall be treated as a material representation of fact upon which reliance will be placed when the Federal Emergency Management Agency (FEMA) determines to award the transaction, grant, or cooperative agreement. 1. LOBBYING As required by section 1352, Title 31 of the U.S. Code, and implemented at 44 CFR Part 18, for persons entering into a grant or cooperating agreement over $ 100,000, as defined at 44 CFR Part 18, the applicant certifies that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the making of any Federal grant, the entering into of any cooperative agreement, and the extension, continuation , renewal, amendment, or modification of any Federal grant or cooperative agreement. (b) If any other funds than Federal appropriated funds have been paid or will be paid to any other person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or an employee of Congress, or employee of a member of Congress in connection with this Federal Grant or cooperative agreement, the undersigned shall complete and submit Stand Form -LLL, "Disclosure of Lobbying Activities," in accordance with its instructions (c) The undersigned shall require that the language of this certification be induded in the award documents for all subawards at all tiers (induding subgrants, contracts under grants and cooperative agreements, and subcontracts) and that all subrecipients shall certify and disdose accordingly. Standard Form -LLL "Disdosure of Lobbying Activities" attached (This9m must be attached to certification if nonappropriated funds are to be used to influence activities.) 2. DEBARMENT,SUSPENSION, AND OTHER RESPONSIBILITY MATTERS (DIRECT RECIPIENT) As required by Executive Order 12549, Debarment and Suspension, and implemented at 44 CFR Part 67, for prospective participants in primary covered transactions, as defined at 44 CFR Part 17, Section 17.510-A. The applicant certifies that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, sentenced to a denial of Federal benefits by a State or Federal court, or voluntarily exduded from covered transactions by any Federal department or agency; (b) Have not within a three-year period preceding this application been convicted of a or had a civilian judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or perform a public a public (Federal ,State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Are not presently indicted for otherwise criminally or civilly charged by a govemmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification; and (d) Have not within a three-year period preceding this application had one or more public transactions (Federal, State, or local) terminated for cause of default; and B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application. 3. DRUG-FREE WORKPLACE (GRANTEE OTHER THAN INDIVIDUALS) As required by the Drug -Free Workplace Act of 1988, and implemented at 44 CFR Part 17, Subpart F, for grantees, as defined at 44 CFR Part 17.615 and 17.620- A. The applicant certifies that it will continue to provide a drug-free workplace by; (a) Publishing a statement notifying employees that the unlawful manufacture, distributions (b) Establishing an on-going drug free awareness program to inform employees about - (1) The dangers of drug abuse in the workplace; (2) The grantee's policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee to be engaged in the performance of the grant to be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will - (1) Abide by the term of the statement; and (2) Notify the employee in writing of his or her conviction for a violation of a criminal drug statute occurring ion the workplace no later than five calendar days after such convections; (e) Notifying the agency, in writing, with 10 calendar days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, induding position, title, to the applicable FEMA awarding office, i.e., regional office or FEMA office. FEMA Form 20-16C, OCT 04 PREVIOUS EDITION OBSOLETE (f) Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph (d)(2), with respect to any employee who is convicted - (1) Taking appropriate personnel action against such an employee, up to and induding termination, consistent with the requirements of the Rehabilitation act of 1973, as amended; or (2) Requiring such an employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug free workplace through implementation of paragraphs (a),(b),(c),(d),(e) and (f). B. The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: Place of Performance (Street address, City, County, State, Zip code) Check ❑ If there are workplaces on file that are not identified here. Section 17.630 of the regulations provide that a grantee that is a State may elect to make one certification in each Federal fiscal year. A copy of which should be induded with each application for FEMA funding. States and State agencies may elect to use a state wide certification. 74-176 (Rev.5-11/11) Vendor Direct Deposit / Advance Payment Notification Authorization This form may be used by vendors or individual recipients - to receive payments from the state of Texas by direct deposit - to change or cancel existing direct deposit infonnation Transaction Type For Comptroller's Use Only For State Agency Use ❑ Advance Payment Notification ❑ international Payments Verification ❑ Interagency Transfer z 0 U w to ❑ New setup (Sections 2, 3, 4 and 5 - Section 6 is optional) ❑ Change financial institution (Sections 2, 3, 4 and 5 - Section 6 is optional) ❑ Change account number (Sections 2, 3, 4 and 5 - Section 6 is optional) ❑ Change account type (Sections 2, 3, 4 and 5 - Section 6 is optional) ❑ Cancellation (Sections 2 and 4 - Sections 7 and 8 for state agency use) Payee Identification N 0 r: o co Social Security Number (SSN) or Employer Identification Number (EIN) IIIIIIIIIIII Mail code (If not known, leave blank) 1 1 i 1 Payee name (BusinessAndividual) Phone number e Mailing address City State ZIP code financial Institution (Completion by financial institution is re to Z 01 UFinancial w to Financial institution nave Authorized signature sign here Printed name Date City ext. Email address 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 t I name State Routing transit number (9 digits) _ I 1 1 1 1 I I I (_ I I Customer account number maximum 17 characters) I 11 till I 1 I 1 1 1 1 I 1 1 I Type of account ■ Checking ■Savings representative name (optional) Title (optional) Financial representative signature (optional) Phone number (optional) ( ) ext. Date (optional) Authorization for Setup, Changes or Cancellation NI- z 0 w I authorize the Texas Comptroller of Public Accounts to deposit my payments from the state of Texas to my financial institution electronically. I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error. I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's rules. (For further information on these rules, please contact your financial institution.) Authorized signature sign here Printed name Date International Payments Verification (required) U) U w rn wll these payments be forwarded to a financial institution outside the United States? ❑ YES 0 NO Authorization for Advance Payment Notification m I authorize the Texas Comptroller of Public Accounts to send an email notification one business day prior to the payment posting to my account. OZ U co Contact name (Please print) Contact phone number ( ) ext. ext. Email address 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 t I name Cancellation by Agency (for state agency use) r - U w 0) Reason Date Authorized Signature (for state agency use 03 z 0 sign Signature here r Date Phone number ( ) ext. Agency number oAgency w N name Comments Please return your completed form to: ' Form 74-176 (BackXRev5-11/11) Instructions for Vendor Direct Deposit / Advance Payment Notification Authorization Under Ch. 559, Govemment Code, you are entitled to review, request and correct information we have on file about you, with limited exception in accordance with Ch. 552, Govemment Code. To request information for review or to request error correction, contact us at (800) 531-5441, ext. 6-6057. Section 1: Select the appropriate transaction type(s). Section 2: Provide the Social Security Number or Employer Identification Number (EIN). Section 3: Completion by financial institution is recommended. Important: Your direct deposit account information may be different from the account information printed on your checks. It is recommended that you contact your financial institution to confirm your direct deposit account information. Note: A prenote test will be sent to your financial institution for the account information entered into the Comptroller's system. The prenote test is for a period of six banking days, and it is sent to your financial institution to verify your account information. If no further action is required by your financial institution, your direct deposit instructions will become effective when the six banking day prenote time frame has expired. Section 4: Must be completed in its entirety, and no alterations to the authorization language will be accepted. Section 5: If you receive state payments by direct deposit which are forwarded from a United States financial institution to a financial institution outside the United States, please contact the Texas Comptroller of Public Accounts at (512) 936-8138 and FAX your form to (512) 475-5424. Section 6: Provide the contact name, phone number and email address to which payment notifications are to be sent. Notifications are sent for direct deposit payments only, and emails are sent one business day prior to the deposit. Submit the completed form to the state agency with which you are conducting business. If the agency is unknown, please call (512) 936-8138 to obtain contact information. For State Agency Use Section 7: Provide reason for cancellation request. Section 8: Must be completed if submitting form to the Comptroller's office for international payment verification, advance payment notification or interagency transfer processing. Indicate requested action using the "For State Agency Use" box located at the top of the form. If an intemational payments verification, advance payment notification or interagency transfer is requested by the agency, select the desired action(s) in the box on the upper right corner of the form and submit the form to the Comptroller's office. State agencies should complete the direct deposit setup or change prior to submitting the form to the Comptroller's office. TRAVEL POLICY CERTIFICATION Jurisdiction Name: City of Round Rock, Texas Check one of the two blocks below This jurisdiction has no qualifying travel regulations. EMPG participants requesting reimbursement for travel expenditures will do so in accordance with State of Texas travel regulations and reimbursement rates as published by the Texas Comptroller of Public Accounts. State travel regulations are available at https://fmx.cpa.state.tx.us/fmx/travelftextravelfindex.rotw OR ❑ This jurisdiction has its own qualifying travel policy, a copy of which is attached. EMPG participants requesting reimbursement for travel expenditures will do so in accordance with that policy. Name of Grant Financial Officer (Printed or Typed) Stacie Carter, Accounting Manager Original Signature of Grant Financial Officer Date Signed TDEM-69 12/11