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CM-11-01-022ROUND ROCK, TEXAS PURPOSE. PASSION. PROSPERITY. Item Caption: Approval Date: Department: City Manager Approval Summary Sheet Application for FY2011 Emergency Management Performance Grant (EMPG) January 21, 2011 Police Department Project Manager: Brad Bradford Item Summary: Annual application for salary off -set. Strategic Plan Relevance: 30.0 Public Safety & Security; 31.0 Emergency Management Cost: $35,692 Source of Funds: Outside Resources: FEMA/DHS REV. 6/10/10 FISCAL YEAR 2011 EMERGENCY MANAGEMENT PERFORMANCE GRANT APPLICATION 1. APPLICANT NAME (Jurisdiction): City of Round Rock 2. COUNTY: Williamson 1 3. DISASTER DISTRICT: 6B 4. EMPG STATUS: 0 Current EMPG Program participant 0 New EMPG Program applicant 5. PROGRAM PARTICIPANTS: (List all jurisdictions that ate 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 Identify any jurisdictions that have joined or withdrawn from your program in the last year) n/a 6.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 2011 Emergency Management Performance Grant (EMPG)Guide for information on completing these forms) ►Z� Designation of Grant Officials (TDEM-17B) ►�� Statement of Work & Cumulative Progress Report (IDEM -17A) - This form be shall signed by the EMC ... for Federal Assistance (IDEM -67) -The Authorized Official shall sign this form ' EMPG Staffing Pattem (TDEM-66) - The Authorized Official shall sign this form EMPG Staff Job Description (TDEM-68) - A current job description is required for each staff member listed in the FY 2011 EMPG Staffing Pattern (TDEM-66) 0 FEMA Form 20-16 Summary Sheet for Assurances & Certifications Shall - be signed by an Authorized Official Attached: .. FEMA Form 20-16A, Assurances — Non -Construction Programs 0 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 1 a Direct Deposit Authorization (form 74-146) or Application for Payee ID Number (form AP -152) - The Grant Financial Officer shall sign this form 0 Travel Policy Certification (TDEM-69) - The Grant Financial Officer shall sign this form 7. 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 am listed above. The unde r ned agree to exert their best efforts to accomplish all activities listed in the Statement of Work & Cumulative ii � iViii approved by the Texas Division of Emergency iManagement. ILVII 1-21-1, Auth • • 4Official Date ergency Management Cooi Date Orrin=•nature On 'bat Si•natu►e 8. APPROVAL: The attached Fiscal Year 2011 Statement of Work & Cumulative Progress Report is approved —0 Assistant Director/Chief Date ❑ State Coordinator for Preparedness and Operations TDEM-17 11/10 Mail completed forams and application materials to: e y tot -OL -d22 EMPG Program Administrator Preparedness Section Texas Division of Emergency Management Texas Department of Public Safety PO Box 4087 Austin, TX 78773-0223 age 1 of 1 FISCAL YEAR 2011 DESIGNATION OF EMPG GRANT OFFICIALS APPLICANT NAME (Jurisdiction): City of Round Rock E ERGENCY MANAGEMENT COORDINATOR* NAME Mr. ❑ Ms. Thomas L. Bradford, III Official Mailing Address 2701 N. Mays Round Rock, Texas 78665 Daytime Phone Number (512) 341-3106 Fax Number (512) 218-3267 E-mail Address NAME bbradfordpround ANT FINAN "[I -rock.tx. us O. I FILER (CANNOT BE. EMC) El Mr. ® Ms. Stacie Carter Title Official Mailing Address Accounting Manager 221 East Main St. Round Rock, Texas 78664 Daytime Phone Number (512) 218-3295 Fax Number (512) 218-5442 E-mail Add NAME Title ress scarter round-rock.tx.us AUTHORIZED OFFICIAL(MAYOR, COUNTY JUDGE CITY MANAGER) ❑ Mr. ® Ms. Cindy Demers Official Mailing Address Acting City Manager 221 East Main St. Round Rock, Texas 78664 Daytime Phone Number (512) 218-5410 Fax Number (512) 218-7097 E-mail Address TDEM-17B 11/10 cdemers(c�round-rock.tx.us Page 1 of 1 J FISCAL YEAR 2011 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 12/30/2010 Progress Report #1 Progress Report #2 TASK 1 -WORK PLAN & SEMIANNUAL PROGRESS REPORT Work Plan 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 • Progress Report #1 ■ ■ This Progress Report # 1 is being submitted to the TDEM Preparedness Section First & Second Quarter Financial Reports have been submitted to TDEM Support Services ■ Progress Report #2 • • This Progress Report # 2 is being submitted to the TDEM Preparedness Section Third & Fourth Quarter Financial Reports have been submitted to TDEM Support Services TASK 2 -LEGAL AUTHORITIES FOR EMERGENCY MANAGEMENT PROGRAM ►5 Work Plan Our management @ - ►� • jurisdiction Our NIMSCAST Our TRRN Our legal Our jurisdiction ■ • ■ • will maintain current legal documents establishing our emergency program account is 100% compliant with all objectives and metrics registration completed and resources entered documents are current & on file with TDEM; no additional action is required will prepare or update & submit to TDEM: Commissioner's Court Order # City Ordinance(s) for: Updated Joint Resolution dated: NIMS Adoption dated: ■ October March Progress Report #1 1 — 31 • • • • Our Our Our legal Our jurisdiction NIMSCAST TRRN • ■ • • account is 100% compliant with all objectives and metrics registration completed and resources entered documents are current & on file with TDEM, no additional action is required completed & submitted to TDEM: Commissioner's Court Order # City Ordinance(s) for: Updated Joint Resolution dated: NIMS Adoption dated: • Progress Report #2 April 1- September 30 • • • IN Our Our Our legal Our jurisdiction NIMSCAST TRRN ■ ■ • • account is 100% compliant with all objectives and metrics registration completed and resources entered documents are current & on file with TDEM, no additional action is required completed & submitted to TDEM: Commissioner's Court Order # City Ordinance(s) for: Updated Joint Resolution dated: NIMS Adoption dated: TDEM-17A 11/10 Mail completed form to: EMPG Program Administrator Preparedness Section Texas Division of Emergency Management Texas Department of Public Safety P 0 Box 4087 Austin, TX 78773-0223 Page 1 of 6 TASK 3—PUBLIC EDUCATION/INFORMATION ❑ Option 1: Our jurisdiction will conduct 30 hours of hazard awareness activities for Z Work Plan L local citizens OR 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 continue 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 continue to expand citizen registration in the Regional Emergency Notification System's (extra-911) Database, allowing citizens and businesses to provide their emergency contact information (cell phone; VOIP) for use should emergency arise in home or business while away. We will publish and distribute brochures for "National Night Out." We will participate in our second annual "FEMA Ready Express" preparedness program at Dell Diamond. We will continue to provide other public education opportunities, including National Weather Service's "Skywarn" program. We will participate in local and regional CTCCC efforts. • October March Progress Report #1 1 — 31 IN Our jurisdiction completed the following hazard awareness or public education/information activities: ■ April September Progress Report #2 1 — 30 ■ Our jurisdiction completed the following hazard awareness or public education/information activities: TASK 4—EMERGENCY MANAGEMENT PLANNING DOCUMENTS ' Work Plan 1 ►5 .. NOTE: updated Our jurisdiction and Our We NIMS emergency will • Annexes: •N ■ Plans this develop, Basic Other year. compliance ■O & documents: annexes reviewed management Plan ■A ■P All update, Plans ■Q our B dated or ■C and emergency plan change R prior Annexes ■D IS to and these ■E ■T September management all must annexes planning ■U F be •G ■V 30, NIMS plan are documents: 2005, current H compliant. & annexes ■l must and ■J be revised NIMS •K for currency compliant ■L or ■M • October March Progress Report #1 1 — 31 • • • Our jurisdiction and Our We NIMS emergency updated • Annexes: •N • Basic Other compliance ■O reviewed by Plan documents: management revision •A ■P •B ■Q our or ■C change •R emergency plan ■D ■S and these •E all ■T management annexes planning •F ■U •G ■V are documents: plan current ■H & ■I annexes and ■J for NIMS ■K currency compliant ■L ■M ■ April September Progress Report #2 1 — 30 • • ■ Our jurisdiction and Our We updated NIMS emergency II Annexes: ■N■O■P■Q■R■S ■ compliance by Plan Other documents: reviewed management revision •A our or •B change ■C emergency plan ■D and these ■E IIT management all planning annexes ■F ■U■V •G plan are documents: •H current & ■I annexes and ■J for NIMS •K currency compliant •L ■M IDEM-17A 11/10 Page 2 of 6 11/10 age 3 of 6 TASK 5—EXERCISE PARTICIPATION & SCHEDULE .Our =Our Work Pian required three-year exercise schedule is Iisted.below jurisdiction will conduct & report participation -lira tabletop exercise and afunact onal or full-scale exercise this fiscal year or obtain exercise credit for actual events for these exercises • Our required exercise schedule includes make up exercises from FY NOTE: A Full -Scale exercise must be conducted every three (3) years. REQUIRED EXERCISE SCHEDULE Period Exercise Type Exercise Scenario* Quarter of Year Fiscal Year 2011 Tabletop NH •TH • NS • TR ■ HM e 1 • 2 • 3 • 4 (October 1, 2010 - Functional ■ NH ■TH • NS ■ TR HM • 1 • 2 • 3 0 4 September 30, 2011) Full -Scale ■ NH ■TH ■ NS 'rl TR • HM J1 ■ 2 ❑ 3 ■ 4 Fiscal Year 2012 ►I Tabletop • NH riTH • NS • TR • HM • 1 0 2 1113•4 (October 1, 2011 - • Functional ■ NH ■TH • NS • TR ■ HM ■ 1 ■ 2 ■ 3 ■ 4 September 30, 2012) Full -Scale ■ NH ■TH ■ NS .1 TR • HM 0 1 ■ 2 ■ 3 0 4 Fiscal Year 2013 =� Tabletop ■ NH •TH • NS • TR ■ HM ■ 1 • 2 0 3 ■ 4 (Octo9ber 1, 2012 – ■ Functional ■ NH ■TH • NS • TR • HM • 1 ■ 2 • 3 • 4 September30, 2013) Full -Scale ■ NH •TH ■ NS TR • HM o 1 ■ 2 ■ 3 ■ 4 Our last Full -Scale exercise *Scenarios: was conducted on (date): 11/03/10 Scenario*: TR NH=Natural Hazard, TH=Technological Hazard, NS=National Security, TR=Terrorism, HM=Public Health or Medical We conducted the following exercises and provided documentation to TDEM: Exercise Date # of Participants # of Jurisdictions • ■ ■ Tabletop Functional Full -Scale • October Progress Report #1 1 – • • III Tabletop Functional Full -Scale March 31 • • ■ Tabletop Functional Full -Scale ■ IN Our jurisdiction completed NO Our jurisdiction requested functional on and our request • exercise and or full-scale is pending did 1 not request credit for an actual event exercise credit for an actual event was approved documentation and of approval is attached We conducted the following exercises and provided documentation to TDEM: Exercise Date # of Participants # of Jurisdictions ■ • • Tabletop Functional Full -Scale • April Progress Report #2 1 – • IN ■ Tabletop Functional Full -Scale September 30 ■ • ■ Tabletop Functional Full -Scale ■ • Our jurisdiction completed Our jurisdiction requested functional on and our request NO • exercise and or full-scale is pending did ■ not request credit for an actual event exercise credi for an actual event was approved documentation and of approval is attached TDEM-17A 11/10 age 3 of 6 11/10 age 4 of 6 TASK 6 -TRAINING FOR EMERGENCY MANAGEMENT PERSONNEL d adEMPG-fundeemergency management personnel will participate in the following -training during FY 2010: Position/Name Course Name or Number Thomas L. Bradford, EMC G-358 — Evac & Re -Entry G-197 — Emergency Planning & Special Needs G-628 — Infrastructure Damage Assessment MGT -319 — BT: Mass Prophylaxis Prep & Ping Ken Evans (TBD) 1 Work Plan Emergency management personnel completed the following training and documentation is attached: Position/Name Course Name or Number Date Completed • 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 age 4 of 6 11/10 age5o TASK 7—EMERGENCY MANAGEMENT TRAINING FOR OTHER PERSONNEL r2 Work Plan Our jurisdictionwillconductor arrange emergency management related training for elected officials; other Iocatofficials, & supportagencies. 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 continue to participate in various 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 UASI; BioWatch BAC/PSS; WCLTRC, CTCCC. ►� 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 age5o APPLICANT NAME: City of Round Rock TDEM-17A 11/10 REMARKS (Use an Additional Sheet if Necessary) Page 6 of 6 FISCAL YEAR 2011 APPLICATION FOR FEDERAL ASSISTANCE (Instructions on Reverse) NAME OF PROGRAM/ ASSISTANCE: EMERGENCY MANAGEMENT PERFORMANCE GRANT (EMPG) 3. FEDERAL FISCAL YEAR: FY 2011 6. APPLICANT INFORMATION 1. CFDA NUMBER: 97.042 2. APPLICANT STATUS: New Applicant 0 Renewal 4. START DATE: OCTOBER 1, 2010 5. END DATE: SEPTEMBER 30, 2011 a. Legal Name of Applicant Organization (as it appears on the EMPG Application (TDEM-17): City of Round Rock, Texas c. Mailing Address: City Hall 221 East Main St. Round Rock, Texas 78664 b. Name & Telephone Number of Emergency Management Coordinator: Thomas L. Bradford, III, 512-341-3106 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) b. Travel Expenses (from line 19 form TDEM-66) c. Other Expenses (from section 11 on reverse) d. Total Expenses (A + B + C) e. Federal Share (D x .50) 155,971 0 0 155,971 77,986 9. CERTIFICATION: I certify that to the best of my knowledge and belief this application and its attachments are true and correct. a. Typed Name of Authorized Official: b. Title of Authorized Official: c. Original Signature of Authorized Official: d. Date Signed: TDEM-67 11/10 Cindy Demers Ac .410 1-2.1-1 l 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 governing 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 Governments (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 11/10 Page2of2 FISCAL YEAR 2011 EMPG STAFFING PATTERN 1. APPLICANT NAME (as it appears on EMPG Application): City of Round Rock, Texas 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 Salary & Benefits (4+5) 7. % Work in EM Duties 8. Salary & Benefits for EM (6x7) 9. Est. EM Travel Costs Name: THOMAS L. BRADFORD, 111 81,994 21,616 103,610 100% 103,610 0.00 Position: EMERGENCY MANAGEMENT COORDINATOR Name: KEN EVANS 82,867 21,855 104,722 50% 52,361 0.00 Position: ASSISTANT EMERGENCY MANAGEMENT COORDINATOR Name: Position: Name: Position: Name: Position: Name: Position: A. SUBTOTAL 164,861 43,471 208,332 155,971 0.00 10. PART-TIME EMPLOYEES 11. % of Full Time 12. Gross Annual Salary 13. Gross Annual Benefits 14. Gross Salary & Benefits (12+13) 15. % Work in EM Duties 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. 155,971 19. 0.00 CERTIFICATION: 1 certify that no individual list_d ab. n elected office. Signature of Authorized Official: 4111/A \., 'A dor Date Signed: 1 -2A -It rnGee�A tiNDI' � ERS,CPA -AC`C I*R. 1Nd �j('� M1ac11) 11/10 Page 1 of 1 JurisdictionNtame EMPG STAFF JOB DESCRIPTION Staff Member Name Position Title City of Round Rock Thomas L. (Brad) Bradford, III Description Prepared By Date Prepared Emergency Management Coordinator Thomas Bradford 12.30.10 JOB DESCRIPTION 0 Current Job Description Attached ® 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 11/09 Retain a copy of this description for future use. Jurisdiction=Name EMPG STAFF JOB DESCRIPTION Staff Member Name Position Title City °found Rock Ken Evans Description Prepared By Date Prepared Assistant Emergency Management Coordinator Thomas Bradford 12.30.10 JOB DESCRIPTION ❑ Current Job Description Attached ® 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 UASI, HSTF, CBRNE Strike Team, CAIMT, CTIMT, RRTF/IMT. Serves as emergency management coordinator for the Police Department to meet accreditation guidelines. ORGANIZATIONAL RELATIONSHIPS 1. Organization Relationship: Reports to Captain Alain Babin 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 11/09 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 2011 CA FOR (Name of Recipient) City of Round Rock, Texas O.M.B. No. 1660-0025 Expires July 31, 2007 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 I FEMA Form 20-16A, Assurances-Nonconstruction Programs Part II FEMA Form 20-16B, Assurances -Construction Programs Part III FEMA Form 20-16C, Certification Regarding Lobbying; 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�N�Y bEmERs, CPA- AtriN6 ar m A6E.R Typed Name of Authorized Representative Title Sign ture •f Authorized Representative Date Signed 1-21-11 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 CERTIFICATIONS REGARDING LOBBYING; DEBARMENT SUSPENSION AND OTHERRESPONSIBILITY MATTERS;_ t DRUG-FREE WORK•j REQUIREMENTS O.M.B. No. 1660-0025 Expires July 31, 200T 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 included in the award documents for all subawards at all tiers (including subgrants, contracts under grants and cooperative agreements, and subcontracts) and that all subrecipients shall certify and disclose accordingly. la Standard Form -LLL "Disclosure of Lobbying Activities" attached (This form 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 excluded 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, including 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 including 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 included with each application for FEMA funding. States and State agencies may elect to use a state wide certification. U.S DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY ASSURANCES-NONCONSTRUCTION PROGRAMS 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. O.M.B. No. 1660-0025 Expires July 31, 2007 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 include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P. L. 88-352) which prohibits discrimination on the basis of race, color, or national origin; (b) Title 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. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing 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 >ra',' 74176 rar (Rev.1-0715) VENDOR DIRECT DEPOSIT AUTHORIZATION For Comptroller's use only Under Ch. 559, Govemment Code, you are entitled to review, request, and correct information we have on file about you, with limited exceptions in accordance with Ch. 552, Govemment Code. INSTRUCTIONS • Use only BLUE or BLACK ink. • Alterations must be initialed. TRANSACTION TYPE SECTION 1 • Check all appropriate box(es). • For further instructions, see the back of this form. o New setup ❑ Cancellation ❑ Interagency transfer (Sections 2, 3 & 4) (Sections 2 & 3) (Sections 2, 3 & 4) ❑ Change financial institution 0 Change account number ❑ Change account type (Sections 2, 3 & 4) (Sections 2, 3 & 4) (Sections 2, 3 & 4) PAYEE IDENTIFICATION cv Z 0 Li] to 1. Social Security number or Federal Employers Identification (FED 71 41 6 1 10. Authorized signature 2. Mail code (If not known, will be completed byPayirgState Agency) 1 0 1 0 1 0 0 1 1 1 7 1 4 1 8 1 5 a Name City of Round Rock 4. Business phone number ( 512 ) 218-5400 5. Mailing address 221 E. Main Street 6. City Round Rock 7. State TX 8. ZIP code 78664 AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION M Z U cn to 9. I authorize the Comptroller of Public Accounts to deposit my payments from the state of Texas to my financial institution electronically. I further understand that the Comptroller of Public Accounts will reverse any payments made to my account in error. I also agree to comply with the National Automated Clearing House Association's rules and the Texas Comptroller of Public Accounts' rules for electr is payments at all pmes. 4r(. �_ a 10. Authorized signature 11. Printed name Elaine S. Wilson 12 e Uri/ It FINANCIAL INSTITUTION (Completion by financial institution is r Z O U to 13. Financial institution name Bank of America 27. Printed name 14. City Austin 15. State TX 16. Routing transit number 1 1 1 1 1 1 1 0 1 i 0 1 0 1 0 1 2 1 1 5 1 17. Customer account number 1 0 1 0 1 4 1 7 1 9 1 5 1 8 (Dashes required 1 4 1 6 1 8 1 ■ YES) I I 1 x188.. Type of account 21Checking ■Savings 2 1 11 I I 19. Representative name (Please pont) Kathaleen Ford -Smith 20. Title Sr. Vice President 21. Representative signature (Optional) 22. Phone number ( 512 ) 397-2026 23. Date CANCELLATION BY AGENCY U w (n 24. Reason 25. Date PAYING STATE AGENCY n0 Z Q o w CO 26. Signature 27. Printed name 28. Agency name 29. Agenq number 1 1 1 1 30. Comments 31. Phone number ( 32. Date Note: A vendor can receive email or fax notifications providing one (1) business day advance notice of the payment posting to the vendor's account. The Advance Payment Notification is available to vendors receiving direct deposit payment(s) from the State of Texas. To enroll in this free service, complete the Advance Payment Notification Authorization, Form 74-193, available on the Internet at: htto://www.window.state.tx.us/taxinfo/taxfomis/74-193.odf For additional information or assistance, please contact the Claims Division by: Email: claims.pin@cpa.state.tx.us Phone: 512/936-8138 in Austin or 800/531-5441 Ext. 6-8138 toll free 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. uslfmx/travel/textravel/index. php 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 Stacie Carter, Accounting Manager Original Signature of Grant Financial Officer 4(4 d,i0t, Date Signed 01 / 11 /11 TDEM-69 11/09