CM-13-01-025ROUND ROCK, TEXAS
PURPOSE. PASSION PROSPERITY.
Item Caption:
Cm- QVED
JAN 242013
City Manager Approval Form
Fiscal Year 2013 Emergency Management Performance Grant Application
Approval Date: January 25, 2013
Department Name: Fire Department
Project Manager: Brad Bradford
Assigned Attorney:
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 Emergency Planning Officer..
$43,182 is the expected grant funding. Remaining amount is budgeted in the General Fund.
No. of Originals Submitted: 1
Project Name: Local Emergency Management Performance Grant (EMPG)
Cost: Funds are budgeted for the 2 positions. Grant, if awarded, will partially offset expense.
Source of Funds: General Fund
Source of Funds (if applicable): Select Source Fund
Account Number: 4623-100-00000
Finance Director Approval: Date:
Department Director Approval: David Coatney Date: 1/17/2013
**Electronic signature by the Director is acceptable. Please only submit ONE approval form per item. **
CIP 0 0 Budget
CI El
N/A OK N/A OK
Purchasing
111
Accounting 0
N/A OK 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 2 of 3
Grant Application/Proposal Review Checklist (GAPR)
E Grants Coordinator
Laurie Born
g 671-2876
Department Name: Fire
Dept. Contact Person:
Dept. Contact Phone #:
Charles Meserole
671-2779
PiThis grant requires cost sharing.
Amount: $ 43,182 Source: General Fund
MTh's grant requires a public hearing.
Hearing required on/before:
Ci,pyGrant Co• . ma•—: e Iv
Last Updated: 12/13/2012
Due to CC/CM: 1/2/2013
In what measurable way does this project improve core services?
Leverages funds available by offsetting one-half the salary of the
Emergency Planning Officer, and a small portion of the EMC's
salary.
How does this project align with the City's strategic priorities?
Top Priority: Assuring the safety of citizens
NOFA online ft: htIp:llwww.bcdps.state.tx.us/demlCounciIsCommiaeesIEMPGfindex.htm
Yes No
E
El
Is this project necessary to maintain ISO ratings or accreditation?
Was this project included in last year's Operating Budget?
n If the grant is not awarded, will the project or 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, Fire and Emergency Operations
This project will require subcontracts) 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, Fire and Emergency Operations
This project will require subcontracts) 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
%
# of
months
Salary
Benefits
Total
Emer. MgmL Coord.
15
100
12
$ 7,004
$ 32,004
$ 116,057
Enver. Planning Officer
n/a
100
9
$ 4,263
$ 15,541
$ 52,650
$
TOTAL
Q This project will require additional training not funded by the grant.
E This project requires special licensing/certifications.
This project requires travel not funded by the grant.
Identify the source and amount:
$ 167,449
Discuss:
If funded, this grant will require reporting to:
Agency Name
Milestone
Reports Due
Financial
Reports Due
Reporting System
Name
TDEM
Quarterly
Semi -Annually
Discuss: All EMPG-funded personnel must complete Professional Development Series courses and NIMS training.
Discuss:
Questions Sypecific ta'Equipmnent: Attaach a�cet y of tate eguipment speciftcat ons and
This project will require new equipment not funded by the grant.
riA -IR -col-fax
Discuss:
ric
REVISED 1/172013
Grant Application/Proposal Review Checklist (GAPR)
M This project will require additional training not funded by the grant. Discuss:
170 This project requires special licensing/certifications. Discuss:
El This project will incur expenses for maintenance/operation/testing. Discuss:
Identify the source and amount:
El This equipment is necessary to maintain ISO rating or accreditation. Discuss:
[=I The grant is supplying equipment rather than funding. Discuss:
0 This equipment will require an extended warranty or service agreement. Discuss:
Q The life -cycle for this equipment is less than 3 years. Discuss:
n 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:
2 Name:
3 Name:
Miranda West:
Chris Childs:
Laurie Born:.'
Elaine Wilson
Salaries included in. FY 13
development.
Contact:
Contact:
Contact:
Website URL:
www.
WWW.
www.
COMMENTS/APPROVALS
Budget, revenues added as budget revision review item, will review budgeted amount during FY 14 budget
No issues
Standard renewal of the EMPG. Provides salary off -set for Dorothy Miller beginning January 2013 pay period (9 months). Balance of grant funds
offset Brad Bradford's salary.
4623-100-00000 Revenues. Expenditures are in Salaries. CFDA # 97.042. Project Code will be 97042_13.
REVISED 1/172013
FISCAL YEAR 2013
EMERGENCY MANAGEMENT PERFORMANCE GRANT APPLICATION
1. APPLICANT NAME (Jurisdiction): City of Round Rock
2. COUNTY: Williamson
3. DISASTER DISTRICT: 6B
Program applicant
4. EMPG STATUS: L Current EMPG Program participant ❑ New EMPG
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 2013
Grant (EMPG) Guide for information on completing these forms.)
Emergency Management Performance
form shall be signed by the EMC
this form
shall sign this form
required for each staff member listed in the
be signed by an Authorized Official
Suspension, & Other Responsibility
Authorized Official required only if the
Number (form AP -152) - The Grant
sign this form
// Designation of Grant Officials (TDEM-17B)
/C/ Statement of Work & Cumulative Progress Report (TDEM-17A) - This
@ EMPG Staffing Pattern (IDEM -66) - The Authorized Official shall sign
0 Application for Federal Assistance (TDEM-67) -The Authorized Official
L EMPG Staff Job Description (TDEM-68) - A current job description is
FY 2013 EMPG Staffing Pattem (TDEM-66)
FEMA Form 20-16 Summary Sheet for Assurances & Certifications - Shall
Attached:
A FEMA Form 20-16A, Assurances — Non -Construction Programs
./ FEMA Form 20-16C, Certifications Regarding Lobbying, Debarment,
Matters; and Drug -Free Workplace Requirements
❑ FEMA Form SF LLL, Disclosure of Lobbying Activities - Signed by the
applicant performs lobbying to influence federal actions
@ Direct Deposit Authorization (form 74-146) or Application for Payee ID
Financial Officer shall sign this form
Travel Policy Certification (TDEM-69) - The Grant Financial Officer shall
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 are listed above. The
undersigned agree to exert their best efforts to accomplish all activities listed in the Statement of Work & Cumulative Progress
Report • • • • ed boi.yy exas Division of Emergency Management.
Authorized Official late mergency Management Coordinator Date
(Original Signature) (Original Signature)
Printed Name: Printed Name:
Steve Norwood Thomas L. Bradford
TDEM-17
10/12
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
Page 1 of 1
FISCAL YEAR 2013
DESIGNATION OF EMPG GRANT OFFICIALS
APPLICANT NAME: City of Round Rock
EMERGENCY MANAGEMENT COORDINATOR*
NAME
1 Mr. ❑ Ms. Thomas L. Bradford, III
Official Mailing Address
Please include mail
stop code
2701 N. Mays
Round Rock, TX 78665-2412
Daytime Phone Number
(512) 341-3106
Fax Number
(512) 218-6681
E-mail Address
bbradford(a).roundrocktexas.aov
GRANT
FINANCIAL OFFICER (CANNOT BE EMC)
NAME
❑ Mr. 11 Ms. Sheri Crone
Title
Accounting Supervisor
Official Mailing Address
Please include mail
stop code.
221 East Main St.
Round Rock, TX 78664-5271
Daytime Phone Number
(512) 218-5443
Fax Number
(512) 218-5442
E-mail Address
scroneAroundrocktexas.aov
AUTHORIZED OFFICIAL (MAYOR, COUNTY JUDGE, CITY MANAGER)
NAME
1 Mr. ❑ Ms. Steve Norwood
Title
City Manager
Official Mailing Address
Please imclude mail
stop code.
221 East Main St.
Round Rock, TX 78664-5271
Daytime Phone Number
(512) 218-5410
Fax Number
(512) 218-7097
E-mail Address
snorwood( roundrocktexas.aov
11/12
Page 1 of 1
SFISCAL YEAR 2013
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
12.21.12
Progress Report #1
Progress Report #2
TASK 1 -WORK PLAN & SEMIANNUAL PROGRESS REPORT
Our jurisdiction will submit an EMPG Application, two Progress Reports, 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
J 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:
Order #
for:
dated:
t.� Our
0 Our
0 Our
J Work Plan
• Our
• Commissioner's Court
■ 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
MICommissioner's Court
■ 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 #
dated:
• Our
MIOur
• Progress Report #2
• Our
April 1-
September 30
• Commissioner's Court
• City Ordinance(s) for:
• Updated Joint Resolution
• NIMS Adoption dated:
TDEM-17A
11/2012
Mail completed form to:
Page 1 of 6
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
lil
kl
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
0
Work Plan
the materials to be distributed: We will continue citizen registration of cell phone
and VOIP in the Emergency Notification System Databases, 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" and during open houses. Other public education opportunities will include
NWS Skywarn/Storm Spotter program. We will participate in local and regional
CTCCC efforts. We will continue publication of our emergency management website
and effort to provide a web-based special need assistance program.
**You may provide a combination of both options.
■ Progress Report #1
October 1 —
March 31
•
•
Our jurisdiction completed the following hazard awareness and/or public
education/information activities:
No Task 3 progress was made this report period.
■
April
September
Progress Report #2
1 —
30
• Our jurisdiction completed the following hazard awareness and/or public
educationfinformation activities:
• No Task 3 progress was made this report period.
TASK 4-EMERGENCY MANAGEMENT PLANNING DOCUMENTS
0
Work Plan
0 Our jurisdiction
and
i2 Our
• We
NOTE:
this year.
NIMS
emergency
will
•
Annexes:
•N
■
Plans
develop,
Basic
Other
All
compliance
■O
&
Plans
documents:
annexes
reviewed
management
Plan
■A
■P
update,
and
•B
•Q
Annexes
our
dated
or
■C
emergency
plan
change
■R
prior
•D
must
and
these
■S
to
■E
September
be
management
all
•T
NIMS
annexes
planning
•F
■U
•G
30,
compliant.
are
documents:
■V
2008
plan
•H
current
must
&
•I
annexes
and
■J
be
revised
NIMS
•K
for
currency
compliant
■L
or
updated
•M
■
October
March
Progress Report #1
1 —
31
• Our jurisdiction
and
■ Our
• We updated
NIMS
emergency
■
Annexes:
•N
■Other
Basic
compliance
10
by
Plan
documents:
reviewed
management
revision
■A
■P
•B
•Q
our
or
change
■C
emergency
plan
•R
•D
and
these
■S
■E
management
all
planning
IT
annexes
•F
■U
•G
are
documents:
■V
plan
■H
current
&
■I
annexes
and
■J
NIMS
■K
for
currency
compliant
■L
■M
■
April
September
Progress Report #2
1 —
30
■ Our jurisdiction
and
IllOur emergency
• We updated
NIMS
•
Annexes:
•N
•
Basic
Other
compliance
■O
by
Plan
documents:
reviewed
management
revision
■A
■P
■B
•Q
our
or
change
■C
emergency
plan
DD
•R
•S
and
these
■E
all
IT
management
annexes
planning
■F
■U
■G
documents:
•V
plan
are
■H
& annexes
current and
■I ■J
NIMS
■K
for
currency
compliant
■L
UM
TDEM-17A
11/2012
Page 2 of 6
TASK 5— TEP, NOTIFICATION AND EXERCISE PARTICIPATION
Training and Exercise Plan
Each jurisdiction must develop and submit a multi-year Training and Exercise Plan
(TEP), not less than three years, to the TDEM Exercise Unit @
TDEM.EXERCISES o(7.dps.texas.gov .
0
Work Plan
Each jurisdiction must submit the Pre -Exercise Notification Form to the TDEM Exercise
Unit not less than 45 days prior to a planned exercise event.
Each jurisdiction must submit an After Action Report (AAR) and Improvement Plan (IP)
for a minimum of two (2) discussion -based exercises and one (1) operations -based
exercise. All AARs/LPs all exercise activities to the TDEM Exercise unit not more than
45 days after the conclusion of the exercise.
.Real world events are currently allowed.
NOTE: A Full -Scale exercise must be conducted every three (3) years.
REQUIRED EXERCISE SCHEDULE
Performance
Period
Exercise Type
Exercise Name & Exercise Date
Quarter of Year
0
Discussion Based
Wildland Fire VTTX Feb 20, 2013
• 1 0 2 ■ 3 ■ 4
Fiscal Year 2013
aDiscussion
Based
Flood in City VTTX March 13, 2013
III1 02 ❑ 3 ■ 4
(October 1, 2012 -
L
Operational Based
Disorientation Drill October 17, 2012
0 1 • 2 ❑ 3 • 4
September 30, 2013)
•
Real World Event
❑ 1 ■ 2 0 3 ■ 4
0
Full Scale
Urban Shield Dec 1&2, 2012
0 1 ■ 2 0 3 ■ 4
Our last Full -Scale exercise
was conducted on (date): Dec 1&2, 2012
•
October
March
Progress Report #1
1 —
31
We conducted the following exercises and provided documentation to TDEM:
Name of Submitter: Date submitted:
Exercise Type
Exercise Name 1 Exercise Date 1 EMPG Funded Y/N
•
■Discussion
•
•
•
Discussion
Operation
Real World
Event
Full Scale
•
event
■
Our jurisdiction completed NO exercise and did not request credit for an real world
Exercise approved documentation attached
IIProgress Report #2
April 1 —
September 30
We
Name
conducted the following exercises and provided documentation to TDEM:
of Submitter: Date Submitted
Exercise
Type
Exercise Name 1 Exercise Date 1 EMPG Funded YIN
•
■
■
■
•
Discussion
Discussion
Operation
Real World
Event
Fullll Scale Scale
•
event
•
Our jurisdiction completed NO exercise and did not request credit for an real world
Exercise approved documentation attached
TDEM-17A
11/2012
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 2013:
Position & Name Course Name or Number
Bradford, Thomas L., EMC CAPTAP
MGT -310 TRA; and MGT -315 ETRA
IS -100 ICS; and IS -200 ICS
G-710 Mitigation PIng/Revised
G-270 Recovery from Dist/Local Government
G-197 Emrg Ping & Special Needs
G-358 Evacuation & Re -Entry
Miller, Dorothy, EPO IS -230A Principles of EM
IS -235A Emrg Ping
G-270 Recovery from Dist/Local Government
IS -242A Effective Communication
IS -244A Managing Volunteers
E-948 Situational Awareness & Common Operating Picture
0 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
• No training took place this report period.
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
■ No training took place this progress report period.
TDEM-17A
11/2012
Page 4 of 6
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.
►5 Work Plan
The following
formal training courses were taught or contracted:
Date
Course Title 1 Class Description 1 # Trained
took place this progress report period.
■ Progress Report #1
October 1 —
March 31
• No training
The following formal training courses were taught or contracted:
Date
Course Title 1 Class Description 1 # Trained
took place this progress report period.
• Progress Report #2
April 1 —
September 30
■ No training
TASK 8 -EMERGENCY MANAGEMENT ORGANIZATIONAL DEVELOPMENT
Our jurisdiction will participate in the following emergency management organizational
development activities: CAPCOG Regional Homeland Security Task Force; CAPCOG
Regional Preparedness Committee; CAPCOG Exercise SubCommittee; Texas Homeland
Security Conference; WCEPG/LEPC; CTPG; CTCTTF; CTSSC; FBI InfraGard; FBI
InfraGard Board; CASHP; CAIMT/CTIMT; Austin -Round Rock UA; BioWatch BAC/PSS;
WCLTRC; CTCCC; WCC T&EPW Workshop; NWS Storm Ready Program; WILDCATS;
UA CIP Program Core Working Group.
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
11/2012
Page 5 of 6
APPLICANT NAME:
REMARKS
(Use an Additional Sheet if Necessary)
TDEM-17A
11/2012
Page 6 of 6
FISCAL YEAR 2013
EMPG STAFFING PATTERN
2. COUNTY
Williamson
9. Est EM
Travel Costs
o
o
0
o
o
m
o
o
0
o
o
m
16. Salary &
Benefits for
EM (14x15)
0.00
0.00
0.00
0
0
0
0
0
Le
8. Salary &
Benefits for
EM (6x7)
Oo
N
01
m
rl
41
o o
N
to
O
l0
N
e-1
O
O
00
0
O
to
0
0.00
0
O
O1
V•
cF
t.0
r-1
7. % Work in
EM Duties
0
0
N
0
0
N
12. Gross
Annual Salary
P:4
rr j
1. APPLICANT NAME (as is appears on EMPG application)
City of Round Rock
6. Gross Salary
& Benefits
(4+5)
51,392.00
O
h:
47
o
6.
'-I
1-1
0.00
O
O
O
O
0.00
CR
0
..
E.`2E.`2E2E2E
Z
5. Gross
Annual
Benefits
o
0
iiiN
O
32,004.00
..
ea
N
0
0.
6
CO
Z
E
N
0
a
..
ta
Z
e,{
5:k
SFA
4. Gross
Annual Salary
38,367.00
84,053.00
3. FULL-TIME EMPLOYEES
(including those who work all or only a portion of their time in
emergency management duties)
Name: Dorothy Miller
Position: Emergency Planning Officer
Name: Thomas L. Bradford, III
Position: Emergency Management Coordinator
..
E co
Z
C
0
o
a
Name: 1
C
o
0
a
6
E
Z
E
o
IA
O
a
Name:
C
o
IA
o
a
..
E
Z
E
o
to
0
a
A. SUBTOTAL:
17. Est EM
Travel Costs
16. Salary &
Benefits for
EM (14x15)
0.00
0.00
0.00
0
O
15. % Work in
EM Duties
14. Gross
Salary &
Benefits
(12+13)
0.00
0 0
O O
O 0
0
0
O
13. Gross
Annual
Benefits
12. Gross
Annual Salary
7
LL
w
O
Zig W
N E
N j-
10. PART-TIME EMPLOYEES
..
E.`2E.`2E2E2E
Z
E
N
O
0.
6
Z
E ..
aa CO
N Z
O
a
..
ea
N
0
0.
6
CO
Z
E
N
0
a
..
ta
Z
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Su
0
0
0
0
0
0
0
0
O
C
0
Y
0
0.
Cd
G
R
2
c
0
M
O
a
cd
G
2
C
0
,
O
a
B. SUBTOTAL:
of
N
0
0
0
0
0
N
0
ry
0
N
FISCAL YEAR 2013
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:
❑
@
3. FEDERAL FISCAL YEAR:
FY 2013
4. START DATE:
OCTOBER 1, 2012
5. END DATE:
SEPTEMBER 30, 2013
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 East Main St.
Round Rock, TX 78664
Employer Identification Number/Tax
ID# 74-6017485
d. Physical Address (if different from Mailing Address):
2701 N. Mays
Round Rock, TX 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:
2
100
2) Part Time
b. Total Number of EMPG-Funded Personnel: 2
8. ESTIMATED EXPENSES:
a. Salary & Benefits (from line 18, form TDEM-66)
$168,707
b. Travel Expenses (from line 19 form TDEM-66)
$6,000
c. Other Expenses (from section 11 on reverse)
d. Total Expenses (A + B + C)
$174,707
e. Federal Share (D x .50)
$87,353
Note: If you cannot meet the cash match requirement,
2 of the Local Emergency Management Performance
cash match requirement at the time of application.
check
Grant
the box below and attach a match proposal as specified in Section
Guide. TDEM must review and approve any exceptions made to the
Match Exception Requested
■ Cash
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:
Steve Norwood
b. Title of Authorized Official:
City Manager
c. Original Signature of Authorized Official:
d. Date Signed:
ea 2,,C7/":-
TDEM-67
10/12
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. 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
httos://www.rkb.us/contentdetail.cfm?content id=210237&GetAELSELCats=1. You must be a registered user to
access this listing.
Please reference the appropriate Authorized Equipment List (AEL) for expenses listed below.
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
10/12
Page 2 of 2
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
12.14.12
❑ Current Job
JOB DESCRIPTION
Description Attached 0 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 Fire Chief 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 Retain a copy of this description for future use.
10/12
EMPG STAFF JOB DESCRIPTION
TDEM-68 Retain a copy of this description for future use.
10/12
Jurisdiction Name
City of Round Rock
Staff Member Name
Dorothy Miller
Position Title
Emergency Planning Officer
Description Prepared By
Thomas Bradford
Date Prepared
12.14.12
❑ 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: This position assists the City's EMC and participates in regional committees such as Homeland
Security Task Force, Regional Preparedness, Regional Exercise, WILCO Emergency Planning Group and Capital Area IMT (Logs Chief).
Duties performed by this staff member:
• Assist internal emergency management planning process, including ongoing revisions and coordination of City Emergency
Management Plan and Annexes, maintaining Jurisdiction Preparedness Profile of "Advanced" as requirement of funding
sources to include EMPG.
• Assist training and maintenance of City's NIMS compliance.
• Assist emergency management planning and response relationships between City and its partners, including schools,
hospitals, county, region, state, and federal departments and agencies.
• Assist development of Special Needs Assistance Program (SNAP).
• Assist development and maintenance of Critical Infrastructure Protection Program.
• Enhance the promotion of emergency preparedness throughout City and its broader community.
• Maintain MEP certification and assist in emergency preparedness training and management of Homeland Security Exercise
and Evaluation Program (HSEEP) within City and its wider community.
• Assist disaster response and recovery efforts.
• Maintain Emergency Management Webpage; and assist with social media efforts as required.
ORGANIZATIONAL RELATIONSHIPS
Reports to and advises the City's EMC 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 Retain a copy of this description for future use.
10/12
FEDERAL EMERGENCY MANAGEMENT AGENCY
SUMMARY SHEET FOR ASSURANCES AND CERTIFICATIONS
O.M.B. No. 3067.0206
Expires February 26, 2007
FOR
FY 2013
CA FOR (Name ofApplieany
City of Round Rock, Texas
This summary sheet 'ncludes
Application for Fede
An applicant must check
Assurances and Certifications that must be read, signed, and submitted as a part of the
al Assistance.
each item that they are certifying to:
FEMA Form 20-16A, Assurances-Nonconstruction Programs
FEMA Form 20-16B, Assurances -Construction Programs
FEMA Form 20-16C, Certifications Regarding Lobbying;
Debarment, Suspension, and Other Responsibility
Matters; and Drug -Free Workplace Requirements
SF LLL, Disclosure of Lobbying Activities (If applicable)
representative of the applicant, l hereby certify that the applicant will comply with the identified
certifications.
City Manager
Part 1 X
Part 11
Part III X
Part IV X
As the duly authorized
attached assurances and
Steve Norwood
Typed Name
of Authorized Representative Title
....- ......--0,-,-->-- ,,i'/ 2r) ----Z--?
......i_..„ ,-,
Signature of Authorized Representative 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 Once 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. Burden means the time, effort and
financial resources expended by persons to generate, maintain, retain, disclose, or to provide information to us. You may
send comments regarding the burden estimate or any aspect of the form, including suggestions for reducing the burden
to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472,
Paperwork Reduction Project (3067-0206). 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. Please do not send your completed form to the above
address.
FEMA Form 20-16, FEB 01
U.S. DEPARTMENT OF HOMELAND SECURITY
ASSURANCES -NON -CONSTRUCTION PROGRAMS
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 4728-4763) relating to
prescribed standards for merit systems for programs
funded under one of the nineteen statutes or regulations
specified in Appendix A of OPM's Standards for a Merit
System of Personnel Administration) 5 C.F.R. 900,
Subpart F).
6. Will comply with all Federal statutes 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 IX 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 provisions in the specific statute(s)
under which application for Federal assistance is being
made; and (j) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
7. Will comply, or has already complied, with the
requirements of Title II and III of the Uniform
Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (P.L. 91-646) which provide 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 purchases.
8. Will comply with provisions of the Hatch Act (5
U.S.C. Sections 1501-1508 and 7324-7328) which limit
the political activities of employees whose principal
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 102(a) 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.
Form 20-16A, JUN 94
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. Section 1451 et seq.); (1) conformity
of Federal actions to State (Clean Air) Implementation
Plans under Section 176(c) of the Clean Air Act of 1955,
as amended (42 U.S.C. Section 7401 et seq.); (g) protection
of underground sources of drinking water under the 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. Section 1271 et seq.) related to
protecting components or potential components of
the national wild and scenic rivers system.
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-1 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 Poisoning
Prevention Act (42 U.S.C. Section 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.
Form 20-16A (BACK)
U. S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
CERTIFICATIONS REGARDING LOBBYING• DEBARMENT SUSPENSION AND
OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS
0.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
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.
✓❑ 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;
FEMA Form 20-16C, OCT 04
(c) Are not presently indicted for otherwise criminally or civilly charged by a
governmental 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.
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)
221 East Main Street
Round Rock, TX 78664
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.
)'77,7r 74-176
(Rev.5-12)12)
Direct Deposit Authorization / Advance Payment Notification
This form may be used by vendors, individual recipients or state employees to receive payments from the state of Texas
by direct deposit or to change/cancel existing direct deposit information.
Transaction Type
For Comptroller's Use Only
1 1
Z
0
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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)
o Cancellation (Sections 2 and 4 - Sections 7 and 8 for state agency use)
Payee Identification
c„
z
O
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N
• Texas Identification Number (TIN)
( 1
1 71 4 ,
6 ,
01
1, 71 41 81 5 , 11
Customer account number maximum 17 characters)
4 5 6 8 9 1 3 8 6
I 1 1 1 1 I 1 I I 1
Mail code
(!foot known, leave blank) 1 0 1
01
11
V Employer Identification Number (EIN)
•■ Social Security Number (SSN)`
-
Larne!! Camus
Payee name (Business/Individual/Employee)
City of Round Rock
Senior Vice President
Financial representative signature (optional)
`� "rte I 4..1(2"-1‘11a11
Phone number (optional)
( )
ext.
Phone number
( 512
) 218-5400 ext.
1
1
Mailing address
221 E Main Street
1
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City
Round Rock
Stale
TX
ZIP code
78664
Financial Institution (Completion by financial institution is recommend
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Financial institution name
JPMorgan Chase,N.A.
City
Austin
1 further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's
Slate
TX
Routing transit number (9 digits)
1 1 1 1 1 1 1 0 - 0 0 6
I 1 1 I 1
1 4
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4 5 6 8 9 1 3 8 6
I 1 1 1 1 I 1 I I 1
1
Type of account
Checking
■ Savings
Financial representative name (optional)
-
Larne!! Camus
Title (optional)
Senior Vice President
Financial representative signature (optional)
`� "rte I 4..1(2"-1‘11a11
Phone number (optional)
( )
ext.
Dale (optional)
Authorization for Setup, Changes or Cancellation (required,
"*
z
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.
0
1 further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's
wrules.
(For further information on these rules, please contact your financial institution.)
co
sign Aul d signat
Panted name
Dale
Comments
here '�
Elaine Wilson
12/14/12
International Payments Verification (required)
w
cn
Will these payments be forwarded to a financial institution outside the United States?
If TES," also complete the ACH (Direct Deposit) Payment Destination Confirmation (Fonn 74-227).
❑ YES WINO
Advance Payment Notification Setup for Vendor/Employee Travel
SECTION 6
I request the Texas Comptroller of Public Accounts to send an email notification one business day prior to the payment posting to my account.
Data
Contact nam (Please pont)
t. /3in� C (.1�J. , 1So".
)
Contact phone number //
( 't Z-) 2I$ , stitfiext.
Agency number
Agency name
Comments
Email address.
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Cancellation by Agency (for state agency use)
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Reason
Date
Authorized Signature (for state agency use
SECTION 8 I
Signature
sign
here
Data
Phone number
(
)
ext.
Agency number
Agency name
Comments
Please return your completed form to:
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/travelltextravellindex.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
(Printed or Typed)
Sherri Crone
Original Signature of Grant Financial
Officer
(
Date Signed
(a.- I Z.- l a.
TDEM-69
10/12