HomeMy WebLinkAboutResolutions - 2015.05.06 - 21826MISCELLANEOUS RESOLUTION # 15123 May 6, 2015
BY: General Government Committee ; Christine Long, Chairperson
IN RE: HEALTH AND HUMAN SERVICES - HOMELAND SECURITY DIVISION — STATE OF
MICHIGAN PUBLIC ASSISTANCE GRANT AGREEMENT - OAKLAND COUNTY WATER
RESOURCES COMMISSIONER - ACCEPTANCE
To the Oakland County Board of Commissioners
Chairperson, Ladies and Gentlemen:
WHEREAS the President of the United States declared a disaster for Macomb, Oakland and Wayne
Counties on September 25, 2014, under the authority of the Robert T. Stafford Disaster Relief and
Emergency Assistance Act; and
WHEREAS the disaster declaration is a result of damage resulting from severe storms and flooding
during the period of August 11-13, 2014; and
WHEREAS the Project Application Grant Report breaks down all the expenditures Oakland County
Water Resource Commissioner requested reimbursement for due to storm damage; and
WHEREAS the Project Application Grant Report submitted for a total of $1 ;167,035.44; and
WHEREAS the required 25% match of $291,758.86 is required; and
WHEREAS the grant agreement has been processed through the County Executive Contract Review
Process and the Board of Commissioners Grant Acceptance Procedures.
NOW THEREFORE BE IT RESOLVED that the Oakland County Board of Commissioners authorizes
acceptance of the State of Michigan Public Assistance Grant Agreement in the amount of $875,276.58
from the Michigan Department of State Police, Emergency Management and Homeland Security
Division.
BE IT FURTHER RESOLVED that the Chairperson of the Oakland County Board of Commissioners is
authorized to execute the grant agreement of $875,276.58 and a 25% match of $291,758.86 for a total
of $1,167,035.44 and to approve any grant extensions or changes, within fifteen percent (15%) of the
original award, which are consistent with the original agreement as approved.
BE IT FURTHER RESOLVED that acceptance of this grant does not obligate the County to any future
commitment.
Chairperson, on behalf of the General Government Committee, I move the adoption of the foregoing
resolution.
GENERAL GOVERNMENT COMMITTEE
C ji\\AL
GENERAL GOVERNMENT COMMITTEE
Motion carried unanimously on a roll call vote with Fleming absent.
GRANT REVIEW SIGN OFF — Homeland Security
GRANT NAME: Public Assistance Grant Agreement
FUNDING AGENCY: Michigan State Police Emergency Management and Homeland Security
Division
DEPARTMENT CONTACT PERSON: Sara Stoddard 248 858-5080
STATUS: Grant Acceptance
DATE: April 6, 2015
Pursuant to Misc. Resolution #13180, please be advised the captioned grant materials have completed
internal grant review. Below are the returned comments.
The captioned grant materials and grant acceptance package (which should include the Board of
Commissioners Liaison Committee Resolution, the grant agreement/contract, Finance Committee Fiscal
Note, and this Sign Off email containing grant review comments) may be requested to be place on the
appropriate Board of Commissioners' committee(s) for grant acceptance by Board resolution.
DEPARTMENT REVIEW
Department of Management and Budget:
Approved. — Laurie Van Pelt (4/2/2015)
Department of Human Resources:
HR Approved (No Committee) — Lori Taylor (4/2/2015)
Risk Management and Safety:
Approved by Risk Management. — Robert Erlenbeck (4/2/2015)
Corporation Counsel:
Approved by Corporation Counsel as no legal issues identified. I would note that my calculation of 75%
is $875,276.55 with the 25% County match of $291,758.90.— Stephen Rideout (4/3/2015)
From VanPelt, Laurie
To: West, Catherine A; 5 econtine. Julie L.; Taylor, Lori; Davis. Patricia G
Cc: Stoddard, Sara D; Quisenberrv. Theodore it illigro.,_Ga4i.A; pisacreta, Antonio S
Subject: RE: GRANT REVIEW: Health & Human Services- Homeland Security Division: State of Michigan Public Assistance
Grant Agreement - Oakland County Water Resources Commissioner - Acceptance
Date: Thursday, April 02, 2015 5:01:56 PM
Approved.
From West, Catherine [rnailto:westcaf&oakgov.corn]
Sent: Wednesday, April 01, 2015 4:53 PM
To: Secontine, Julie L; Van Pelt, Laurie M; Taylor, Lori; Davis, Patricia G
Cc: Stoddard, Sara D; Quisenberry, Theodore H; Nigro, Gary A; Pisacreta, Antonio S
Subject: GRANT REVIEW: Health & Human Services- Homeland Security Division: State of Michigan
Public Assistance Grant Agreement - Oakland County Water Resources Commissioner - Acceptance
GRANT REVIEW FORM
TO: REVIEW DEPARTMENTS — Laurie Van Pelt — Karen Jones Secontine — Pat Davis
RE: GRANT CONTRACT REVIEW RESPONSE — Health & Human Services, Homeland Security
Division
State of Michigan Public Assistance Grant Agreement - Oakland County Water Resources
Commissioner
Michigan State Police Emergency Management and Homeland Security Division
Attached to this email please find the grant document(s) to be reviewed. Please provide your
review stating your APPROVAL, APPROVAL WITH MODIFICATION, or DISAPPROVAL, with
supporting comments, via reply (to all) of this email.
Time Frame for Returned Comments: April 9, 2015
GRANT INFORMATION
Date: April 1, 2015
Operating Department: Health & Human Services, Homeland Security Division
Department Contact: Sara Stoddard
Contact Phone: 248 858-5080
Document Identification Number: FEMA-4195-DR-MI / 125-WZPI-00
REVIEW STATUS: Agreement - Resolution required
Funding Period: 9/25/14 through 3/25/16
New Facility/Additional Office Space Needs: None
IT Resources (New Computer Hardware / Software Needs or Purchases): None
RICK SNYDER
GOVERNOR
STATE OF MICHIGAN
DEPARTMENT OF STATE POLICE
LANSING
COL. KRISTE KISSEY ETLIE
DIRECTOR
March 13, 2015
Mr. Gary Nigro
Assistant Chief Engineer
Oakland County Water Resources Commissioner
One Public Works Drive, Building 96 West
Waterford, Michigan 48328-1907
Dear Mr. Nigro:
Enclosed is the FEMA-4195-DR-MI Grant Agreement package for Oakland County Water Resources
Commissioner. Please return the required grant documentation listed on the enclosed Subgrantee Checklist to
our office at the following address:
Attention: Ms. June Martin
Emergency Management and Homeland Security Division
Michigan Department of State Police
4000 Collins Road
Lansing, Michigan 48910
Also enclosed is a copy of the Oakland County Water Resources Commissioner projects that have been
approved to date by the
Federal Emergency Management Agency (FEMA) under disaster FEMA-4195-DR-MI, declared September 25,
2014. Disaster recovery work for which federal funds have been approved is subject to completion by these
deadlines:
Emergency Work (Categories A & B) March 25, 2015
Permanent Work (All Other Categories) March 25, 2016
Reimbursement and close-out procedures are detailed in Section VII of the enclosed grant agreement.
This grant agreement and all required attachments must be completed, signed, and returned no later than
May 12, 2015, If this requirement is not met.this grant agreement will be invalid after May 12, 2015, unless a
prior written exception is provided by the Michigan State Police, Emergency Management and Homeland Security
Division.
Please retain this correspondence for documentation of completion dates and eligible project costs.
If there are any questions regarding your disaster projects, please contact Ms. Sandy Long at (517) 333-4286
or LongS7@michigan.gov .
Sincerely,
Anthony P. Katarsky, Assistant Commander
Governor's Authorized Representative
Emergency Management and Homeland Security Division
Enclosures (10)
cc: Lt. Mark Martinez
EMERGENCY MANAGEMENT AND HOMELAND SECURITY DIVISION • 4000 COLLINS ROAD • LANSING, MICHIGAN 48910
www.mlehigart.gov/msp • (517) 336-6198
State of Michigan
Public Assistance Grant Agreement
FEMA-4195-DR-MI
CFDA Number: 97.036
This Public Assistance Grant Agreement is hereby entered into between the Michigan Department of State Police,
Emergency Management and Homeland Security Division (hereinafter called the Grantee), and
Oakland County Water Resources Commissioner
(hereinafter called the Subgrantee)
Public Assistance ID Number 125-WZPI-00
I. Purpose
The purpose of this grant agreement is to provide supplementary financial assistance for disaster relief in eligible
areas within the state including funds for emergency and permanent work. Eligible costs are per Federal
Emergency Management Agency (FEMA) guidance.
II. Statutory Authority
The President of the United States declared a disaster for Macomb, Oakland, and Wayne Counties in Michigan on
September 25, 2014, under the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act,
42 U.S.C.§§ 5121-5207 (Stafford Act), in accordance with 44 CFR § 206.44. This disaster declaration is a result of
damage resulting from severe storms and flooding during the period of August 11-13, 2014.
The Subgrantee agrees to comply with all program requirements in accordance with FEMA guidance. The
Subgrantee also agrees to comply with regulations, including, but not limited to the following, as applicable:
A. Administrative Requirements
• 1. 44 CFR, Part 13, Uniform Administrative Requirements for Grants and Cooperative Agreements to
State and Local Governments (OMB Circular A-102)
2. 2 CFR, Part 215, Uniform Administrative Requirements for Grants and Agreements with Institutions of
Higher Education, Hospitals, and Other Non-Profit Organizations (OMB Circular A-110)
3. 44 CFR, Part 10, Environmental Considerations
B. Cost Principles
1. 2 CFR, Part 225, Cost Principles for State, Local, and Indian Tribal Governments (OMB Circular A-87)
2. 2 CFR, Part 220, Cost Principles for Educational Institutions (OMB Circular A-21)
3. 2 CFR, Part 230, Cost Principles for Non-Profit Organizations (OMB Circular A-122)
4. 48 CFR, Part 31 Federal Acquisition Regulations (FAR), Contract Cost Principles and Procedures
C. Audit Requirements and Other Assessments
1. OMB Circular A-133, Audits of States, Local Governments, and Non-Profit Organizations located at
http://wvvw.whitehouse.gov/omb/circulars_clefault
2. Public Law 107-300, Improper Payments Information Act (IPIA) of 2002 located at
http://wvvw,doLgov/ocfoirnedia/regs/IPIA.pdf
Code of Federal Regulations (CFR) documents are located online at http://www.ecfr.gov ,
III. Award Amount and Restrictions
FEMA will determine eligibility for the program and the grant amounts. Federal assistance will be made available,
within the limits of funds available from Congressional appropriations for such purposes, in accordance with the
Stafford Act, Executive Orders 12148, as amended, and 12673, and applicable regulations found in Title 44 of the
Code of Federal Regulations (CFR), and applicable policy and guidance. Federal funds provided under the
Stafford Act for Public Assistance will be limited to 75% of total eligible costs in the designated area. The federal share is 75% of the costs and the Subgrantee is responsible for providing the remaining 25% matching funds.
FEMA-4195-DR-M I
Oakland County Water Resources Commissioner
Page 2 of 8
Reimbursement amounts will be based on approved FEMA Project Worksheets (PW), Payment will not be made
until the Grantee receives all required documentation described in paragraph IV (B) of this grant agreement.
The Subgrantee shall comply with all applicable state and local ordinances, laws, regulations, and building codes
and standards. Prior to the start of any construction activity, the Subgrantee shall obtain all applicable federal,
state, and local permits and clearances, and comply with all regulations including FEMA compliance with the
National Environmental Policy Act, the National Historic Preservation Act, the Endangered Species Act, and all
other environmental laws and executive orders. Any activities that have been initiated without the necessary
Environmental and Historic Preservation (EHP) review and approval will result in a non-compliance finding
andmili not be eligible for federal funding.
Disaster recovery work, for which federal funds have been approved, is subject to completion by these deadlines:
Emergency Work (Categories A & B) March 25, 2015
Permanent Work (All Other Categories) March 25, 2016
All time frames are set by regulation; however, if extenuating circumstances or unusual project conditions exist, a
time extension may be requested through the Grantee.
IV. Responsibilities of the Subgrantee
A. Grant funds must supplement, not supplant, state or local funds. Federal funds must be used to
supplement existing funds, not replace (supplant) funds that have been appropriated for the same
purpose. Potential supplanting will be carefully reviewed in subsequent monitoring reviews and audits.
The Subgrantee may be required to supply documentation certifying that it did not reduce non-federal
funds because of receiving federal funds. Federal funds cannot be used to replace a reduction in non-
federal funds or solve budget shortfalls in general fund programs.
B. In addition to this grant agreement, the Subgrantee shall complete, sign, and submit to the Grantee the
following documents, which are incorporated by reference into this grant agreement:
1. Standard Assurances
2. Certifications Regarding Lobbying; Debarment, Suspension and Other Responsibility Matters; and
Drug-Free Workplace Requirements
3. State of Michigan Audit Certification (EMD-053)
4. Request for Taxpayer Identification Number and Certification (W-9)
5. Project Completion and Certification Report (P4), certifying project expenditures and completion within
the grant period
6. Other documents that may be required by federal or state officials
7. Permits or Waivers. (For those project worksheets, including work that requires MDEQ review, we will
need either the MDEQ permit that was issued or a written statement or email (waiver) from your
region's MDEQ representative to document the crossing/site does not require a permit. This will be
required prior to the release of FEMA payments to your agency.)
C. Comply with the requirements of the Stafford Act and all FEMA Public Assistance policies.
D. Comply with applicable financial and administrative requirements set forth in the current edition of 44 CFR,
Part 13, including, but not limited to, the following provisions:
1. Account for receipts and expenditures, maintain adequate financial records, and refund expenditures
disallowed by federal or state audit.
2. Retain all financial records, statistical records, supporting documents, and other pertinent materials for
at least three years after the grant is closed by the awarding federal agency for purposes of federal
and/or state examination and audit.
3. Perform the required financial and compliance audits in accordance with the Single Audit Act of 1984,
as amended in 1996, and Office of Management and Budget (OMB) Circular A-133, Audits of States,
Local Governments, and Non-Profit Organizations, as further described in 44 CFR, Part 13.
FEMA-4195-DR-M1
Oakland County Water Resources Commissioner
Page 3 of 8
E. Cooperate with the federal government in seeking recovery of funds that are expended in alleviating the
damages and suffering caused by this disaster against any party or parties whose intentional acts or
omissions caused or contributed to the damage or hardship for which federal assistance is provided
pursuant to the Presidential declaration of this disaster.
F. Quarterly Progress Reports on all large projects (over $120,000) are also required and should be
submitted to the Michigan State Police, Emergency Management and Homeland Security Division each
calendar quarter. Deadlines for quarterly report submissions are: January 15, April 15, and July 15, and
October 15.
G. Permit FEMA access and rights to examine and copy records, accounts, other documents, and other
sources of information related to the grant; and permit access to facilities, personnel, and other individuals
and information as may be necessary, as required by FEMA regulations, by other applicable laws, or by
program guidance.
H. The Appeals process is the opportunity for Subgrantee to request reconsideration of decisions regarding
the provision of assistance. The Su bgrantee must file an appeal with the Grantee within 60 days of receipt
of notice of the action or decision being appealed. However, an appeal for a significant net small project
overrun must be filed within 60 days of completion of the Sitgrantee's last small project.
Integrate individuals with disabilities into emergency planning in compliance with Executive Order 13347
and the Rehabilitation Act of 1973.
J. Complete federally-mandated reporting requirements, including, but not limited to, requirements related to
the Federal Funding Accountability and Transparency Act of 2006 (FFATA) (Public Law 109-282), as
amended by Section 6202(a) of the Government Funding Transparency Act of 2008 (Public Law 110-262).
V. Responsibilities of the Grantee
The Grantee, in accordance with the general purposes and objectives of this grant agreement, will;
A. Administer the Public Assistance Grant Program.
B. Provide to the Subgrantee a copy of all required documents, including approved Project Worksheets.
C. Reimburse the Subgrantee in accordance with this agreement for the federal share of allowable
expenditures based upon the signed Project Completion and Certification Report (P4),
VI. Reporting Procedures
Submit quarterly progress reports to the MSP/EMHSD on the status of all large projects. Quarterly progress
reports are required whether or not expenditures are incurred.
Failure by the Subgrantee to fulfill quarterly reporting requirements as required by the grant may result in the
suspension of grant activities until reports are received.
Reporting periods and due dates for each year are as follows:
January 1 through March 31; Due April 15
April 1 through June 30; Due July 15
July 1 through September 30; Due October 15
October 1 through December 31; Due January 15
FEMA-4195-DR-M1
Oakland County Water Resources Commissioner
Page 4 of 8
Quarterly progress reports are to be submitted by the 15th of the month following the end of each quarter.
Quarterly progress reports should be mailed to: Attention: Ms. Sandy Long, Michigan State Police,
Emergency Management and Homeland Security Division, 4000 Collins Road, Lansing MI 48910, unless
the Subgrantee is otherwise notified by the Grantee.
VII. Payment Procedures
Reimbursement amounts will be based on approved FEMA Project Worksheets (PW). Payment will not be made
until the Grantee receives all required documentation described in paragraph IV (B) of this grant agreement.
The maximum amount that can be reimbursed by FEMA is 75 percent of the total eligible costs detailed in the
enclosed Project Completion and Certification Report (P4). The P4 report is a listing of all approved Project
Worksheets (PWs) indicating the approved amount and percentage of work completed at the time of the initial
inspection.
Payment for Small Proiects (under $120,000) - The 76 percent federal share of the total eligible project estimate
will be made as a final payment after the Subgrantee has returned the required forms and documentation as listed
in the Project Close-out Procedures section below.
Payment for Lame Protects (over $120,000) - For projects that are 100 percent complete at project formulation, the
75 percent federal share of the total eligible project estimate will be made as a final payment after the Subgrantee
has returned the required forms and documentation as listed in the Project Close-out Procedures section below.
For large projects that are at least 50 percent complete, the federal share to be reimbursed will be based on actual
expenditures by the date of reimbursement submission, as verified by the Michigan State Police, Emergency
Management and Homeland Security Division. Approved funding will be processed for payment after the
Subgrantee has returned the required forms and documentation listed in the Project Close-out Procedures section
below. The Subgrantee will also need to submit a written request for payment, all required quarterly progress
reports, and documentation that 60 percent or more of the estimated project costs have been expended. The
remainder of the federal share will be reimbursed upon completion and resubmission of a current Project
Completion and Certification Report (P4) certifying the claimed final project costs, in addition to supplying a listing
and detail of all cost documentation. The state will perform a subsequent review to verify actual costs and work
completed.
Project Close-Out Procedures:
A. Make a copy of the attached P4 form and retain it at your work site.
B. If each project is less than $120,000, please complete and sign the P4 form when all projects are
completed and return to the MSP/EMHSD.
C. The MSP/EMI-ISD will schedule further field review and final inspections as necessary. When final
inspections are completed, the balance of eligible funds will be reimbursed.
D. Perform the required financial and compliance audits in accordance with the Single Audit Act of 1984, as
amended in 1996 and OMB Circular A-133, as revised. All documentation must be retained for at least
three years after the grant is closed by the awarding federal agency for purposes of federal and/or state
examination and audit. If an audit is required, submit a copy of the annual audit report to: Michigan
Department of State Police, Grants and Community Services Division, 333 South Grand Avenue, Lansing,
Michigan 48909. For federal audit purposes, the CFDA number of the grant Is 97,036 and is titled
Public Assistance Grants. The award is passed through the MSP/EMHSD from FEMA. The disaster
award number is FEMA-4195-DR-Mi.
E. If claiming Direct Administrative Costs as part of the Project Worksheet (PW), actual cost documentation
must be provided; I.e., cost of compiling damages and cost information, maintaining financial and project
records, monitoring project, preparing reimbursement requests and quarterly progress reports.
FEMA-4196-DR-M1
Oakland County Water Resources Commissioner
Page 5 of
VIII. Employment Matters
The Subgrantee shall comply with Title VI of the Civil Rights Act of 1964, as amended; Title Vill of the Civil Rights
Act of 1968; Title IX of the Education Amendments of 1972 (Equal Opportunity in Education Act); the Age
Discrimination Act of 1975; Titles 1,11 and 111 of the Americans with Disabilities Act of 1990; the Elliott-Larsen Civil
Rights Act, 1976 PA 453, as amended, MCL 37.2101 at seq.; the Persons with Disabilities Civil Rights Act, 1976
PA 220, as amended, MCL 37.1101 et seq., and all other federal, state and local fair employment practices and
equal opportunity laws and covenants. The Subgrantee shall not discriminate against any employee or applicant
for employment, to be employed in the performance of this grant agreement, with respect to his or her hire, tenure,
terms, conditions, or privileges of employment; or any matter directly or indirectly related to employment because
of his or her race, religion, color, national origin, age, sex, height, weight, marital status, limited English proficiency,
or handicap that is unrelated to the individual's ability to perform the duties of a particular job or position. The
Subgrantee agrees to include in every subcontract entered into for the performance of this grant agreement this
covenant not to discriminate in employment. A breach of this covenant is a material breach of the grant
agreement.
The Subgrantee shall ensure that no subcontractor, manufacturer, or supplier of the Subgrantee for approved
projects related to this grant agreement appears on the Federal Excluded Parties List System located at
http://vmv.sarn.gov.
The Subgrantee shall comply with regulation 2 CFR Part 17, Subpart F relating to maintenance of a Drug-Free
Workplace (see related certification form contained in this grant agreement package).
The Subgrantee shall comply with regulation 44 CFR Part 18 relating to New Restrictions on Lobbying (see related
certification form contained in this grant agreement package).
IX. Construction Requirements
The Subgrantee shall comply with all applicable state and local ordinances, laws, regulations, and building codes
and standards. Prior to the start of any construction activity, the Subgrantee shall obtain all applicable federal,
state, and local permits and clearances, and comply with all regulations including FE1V1A compliance with the
National Environmental Policy Act, the National Historic Preservation Act, the Endangered Species Act and all
other environmental laws and executive orders. Any activities that have been initiated without the necessary
EHP review and approval will result in a non-compliance finding and will not be eligible for federal funding.
The Subgrantee shall ensure that any work done under this grant complies with the barrier free design
requirements of 1966 PA 1, as amended, MCL 125.1351 at seq. (Utilization of Public Facilities by Physically
Limited Act).
The Davis-Bacon Act requires federal agencies to pay workers under contract to them the "prevailing wage" based
on the local union wage scale defined by the U.S. Department of Labor. Generally, the provisions of the Davis-
Bacon Act do not apply to state or local contracts for work completed using public assistance funds under the
Stafford Act. However, the provisions may apply to contracts let by other federal agencies, such as the U.S. Army
Corps of Engineers. If a state or local government incorporates prevailing wage rates of the U.S. Department of
Labor as part of its normal practice for all contracts, regardless of funding source, then those rates would be
eligible.
X. Insurance
In compliance with P.L. 103-325, Title V National Flood Insurance Reform Act of 1973, section 582 requires that
any person who receives federal assistance for the repair, replacement, or restoration for damage to any personal,
residential, or commercial property, at any time, must maintain flood insurance if the property is located in a
Special Flood Hazard Area.
FEMA-4195-DR-M I
Oakland County Water Resources Commissioner
Page 6 of 8
XL Limitation of Liability
The Grantee and the Subgrantee to this grant agreement agree that each must seek its own legal representative
and bear its own costs, including judgments, in any litigation that may arise from performance of this contract. It is
specifically understood and agreed that neither party will indemnify the other party in such litigation.
This is not to be construed as a waiver of governmental immunity for either party.
XII. Third Parties
This grant agreement is not intended to make any person or entity, not a party to this grant agreement, a third
party beneficiary hereof or to confer on a third party any rights or obligations enforceable in their favor.
X111. Grant Agreement Period
The effective date of this grant agreement is September 25, 2014; and is in full force and effect from September
25, 2014 until the completion of approved FEMA projects per guidelines stipulated in Section III (Award Amount
and Restrictions). This grant agreement package consists of two identical grant agreements, simultaneously
executed; each is considered an original having identical legal effect. This grant agreement may be terminated by
either party by giving thirty (30) days written notice to the other party stating reasons for termination and the
effective date, or upon the failure of either party to carry out the terms of the grant agreement. Upon any such
termination, the Subgrantee agrees to return to the Grantee any funds not authorized for use, and the Grantee
shall have no further obligation to reimburse the Subgrantee.
XIV. Entire Grant Agreement
This grant agreement is governed by the laws of the State of Michigan and supersedes all prior agreements,
documents, and representations between the Grantee and the Subgrantee, whether expressed, implied, or oral.
This grant agreement constitutes the entire agreement between the parties and may not be amended except by
written instrument executed by both parties prior to the grant end date. No party to this grant agreement may
assign this grant agreement or any of his/her/its rights, interest, or obligations hereunder without the prior consent
of the other party. The Subgrantee agrees to inform the Grantee in writing immediately of any proposed changes
of dates, budget, or services indicated in this grant agreement, as well as changes of address or personnel
affecting this grant agreement. Changes in dates, budget, or services are subject to prior written approval of the
Grantee. If any provision of this grant agreement shall be deemed void or unenforceable, the remainder of the
grant agreement shall remain valid.
The Grantee may suspend or terminate grant funding to the Subgrantee, in whole or in part, or other measures
may be imposed for any of the following reasons:
A. Failure to comply with the requirements or statutory objectives of federal or state law.
B. Failure to make satisfactory progress toward the goals or objectives set forth in the subgrant application.
C. Failure to follow grant agreement requirements or special conditions,
D. Proposal or implementation of substantial plan changes to the extent that, if originally submitted, the
project would not have been approved for funding.
E. Failure to submit required reports.
F. Filing of a false certification in the application or other report or document.
Before taking action, the Grantee will provide the Subgrantee reasonable notice of intent to impose corrective
measures and will make every effort to resolve the problem informally.
FEMA-4195-DR-MI
Oakland County Water Resources Commissioner
Page 7 of 8
XV. Business Integrity Clause
The Grantee may immediately cancel the grant without further liability to the Grantee or its employees if the
Subgrantee, an officer of the Subgrantee, or an owner of a 25% or greater share of the Subgrantee is convicted of
a criminal offense incident to the application for or performance of a state, public, or private grant or subcontract;
or convicted of a criminal offense, including, but not limited to any of the following: embezzlement, theft, forgery,
bribery, falsification or destruction of records, receiving stoIen property, attempting to influence a public employee
to breach the ethical conduct standards for State of Michigan employees; convicted under state or federal antitrust
statutes; or convicted of any other criminal offense which, in the sole discretion of the Grantee, reflects on the
Subgranteers business integrity.
XVI. Freedom of information Act (FOIA)
Much of the information submitted in the course of applying for funding under this program, or provided in the
course of grant management activities, may be considered law enforcement-sensitive or otherwise critical to
national security interests. This may include threat, risk, and needs assessment information; and discussions of
demographics, transportation, public works, and industrial and public health infrastructures. Therefore, each
Subgrantee agency Freedom of Information Officer will need to determine what information is to be withheld on a
case-by-case basis. The Subgrantee should be familiar with the regulations governing Protected Critical
Infrastructure Information (6 CFR Part 29) and Sensitive Security Information (49 CFR Part 1620), as these
designations may provide additional protection to certain classes of homeland security information.
3/13/2015
Date
o
FEMA-4195-DR-Ml
Oakland County Water Resources Commissioner
Page 8 of 8
XVII. Official Certification
For the Subgrantee
The individual or officer signing this grant agreement certifies by his or her signature that he or she is authorized to
sign this grant agreement on behalf of the organization he or she represents. The Subgrantee agrees to complete
all requirements specified in this grant agreement.
Subgrantee Name Subgrantee's DUNS Number
Printed Name Title
Signature Date
For the Grantee (Michigan State Police, Emergency Management and Homeland Security Division)
Anthony Katarsky Governor's Authorized Representative
Printed Name Title
PA-05411-4195-PW-00141(0)
• Facility Number:
Facility Hanle:
Location:
Capture Date: 03/09/201520:10
:Scope of Work:
• tleelirli . .
• Applicant in: 125-LL.7et.00 •
Bundle m: PA-05411-4195-State.0021(20)
Federal Emergency Management Agency ..
%Project Application Grant Report (P.2) '
• r Disaster: FE.MA-4195-011-Mr
. ..... .
Applicant: OAKLAND COUNTY WATER RESOURCES CDOBSIoNER .. . . . ..
' Cost Share •• :".',Projected Completion pate '• .: '.' ' . '' 1 " 1. ', . ,:', ' Approved PW Amount ($)
N 1 l 03-25-2016 ' 167035 , 44
, .
,
!Water Retention Basin
11.400 Ajax Drive, Madison Heights, Mi
• 42.50775, .53.11177
WORK COMPLETED:
Subgrantae utilized an engineering firm pl/adaTrios) to analyze damages and provide estimates for the repair process. The report Is attached to this project
worksheet.
Subgrantee utilized farce account labor, equipment and contractors ta make the repairs to the mechanical, structural and electrical damages as follows;
GWK Main Facility (Screening Room and operation Rooms):
1) Replace rine each hot water , pressure washer,
2) Replace one each cordless combo kit (Includes 1/2 Inch drive impact hammer and reciprocating saw),
3) TemPorarILY plug the line at the broken volute with rubber flange and gasket,
4) Replace rutting steel curtain overhead door and central box,
SCOPE OF WORK (CONTI:
WORK COMPLETED:
5) Secure the elevator car and dewater and clean elevator pit,
61 Replace the motor for the sluicing trough pump,
71 Purchased 7 each.wing nut plugs to temporarily plug the floor drains in the chlorine lank and pump rooms.
1
'',' I GWK Retention Treatment Basin: $978,646.00
'11) Replace 59 each flushing vault panel sub plates and 59 each transforrners (5e23,664.(10) and replace 236 each pneumatic valve actuators and limit switches Parts
I" $292,640.00, Labor- $124,100.00)
. , 2) Repair/Replace pipe support hangers (527,765.00),
I 3) Replace 2 each chlorine line joints ($5,000.00) and replace 2 each flushing nozzles ($1000.00),
. I 4) Load and haul off an estimated 100 cy of contaminated Class II debris to Oaklond Heights Development, Inc, 2359 Brown Road, Auburn Hill, M148326, License
I Number 9306 64,479.00). A copy of the operating license Is attached. This debris Is included as incidental to the repairs.
I A signed Emergency Debris Management Certification Form is Included with this project.
i
i Doeuindre Pump Station: 551,103.00 . 1 1 )Replace .4 each Raton: actuators (4 cache $12,000.00 each - 548,000.00) and replace 4 each actuator disconnects (4 cache $775.0040 each . $3,100.00).
Henry Graham Drain: $12,870.00
1) Manufacture and Install a new 14 ft long 09 ft tall steel pipe hinged security gate at the discharge point of Henry Graham Drain (512,870.03),
Project Notes:
This CEF estimate is completed to evaluate the applicants submitted estimates for costeffectIveness and competitive pricing. Using the documentation submitted by
the applicant the CEF specialist compiled the Part A using:
2015 RS Means Costy.ndis for labor, equivnent and material components.
Local vendor and online supplier catalogs for current compeUtIve pricing on acteators subplates and transformers.
ApplIc n nes vendor subrniued estimates far specialized immediate replacement of broken volute and pump.
Applicant's vendor submitted estimate for specialized repair of 2 submerale pumps,
Applicant submitted vendor proposal for specialized service to remove and replace existing damaged valve actuators.
The applicant did not submit an itemized estimate for the replacement of 'sub plates' in the flushing valve vaults
therefore an allowance wax .Acided for the replacement of connectors and the refurbishment of existing panel bearderendosures.
Sulograntee IS requesting mitigation to Install backflew devices in 59 vaults. A Hazard Mitigation Proposal is included with this project worksheet.
The Sub-Grantee is requesting Direct Administrative Costs that are directly chargeable to this specific project. Associated eligible work is related to administration of
, the Sub...Grantee Application only and in accordance with 44 CPR 13.22. These costs are treated consistently and uniformly as direct cost In all federal awards and
I other Sub-Grantee activities and are net Included In any approved indirect castrates,
144 CRF 513.36 Procurement. (1:11 Procurement standards, Di) Grantees and subgrantees will use their own procurement precedures which reflect applicable State and
local laws and regulations, provided that the procurements conform to applicable Federal law and the standards Identified In section 13.36.
1
' As described In 44 CFR 13.42 (2)(b), 3(c), Sub•Grantee must maintain all work related records fern period of three (3) years from Sub-Grantee closure (final
j payment). All records relative to this Sub-Grantee Application are subject LO examination and audit by the State, FEMA and the Comptroller General of the United
I States and must reflect work related to disaster specific tO313 ,
Contracting Procedures:
• As per Subgrantee:
• Oakland County has many blanket contracts that we utilize for as-needed and emergency services. These contracts are publically bid through our Purchasing
Department and are usually a performance based bid considering things such as work experience, responsiveness, references as well as Saber and equipment rates.
In the case with the 59 flooded valve +mutts and the su Osequen tetectrical damage, we utiled Motor City Electric who we have a current contract with for
Instrumentation and control services, The controls Nitta facility are unique and Motor City has extensive experience and knovAedge of this system. In 2009, there
was some damage to 3 of the 59 valve vaults and the electrical sub•plates required replacing, same as we are currently doing. Motor City was the contractorwho
; performed the replacement work at a cost of approximately $13,000 per valve vault which ts what we had originally estimated for the recent damages. However, It
was discovered that all of the equipment is currently outdated and no longer available, Motor City proposed to replace the damaged components with newer
technology at a cost of approximately $9,000 per valve vault which is what we approved them to do. This is significantly less money than we originally estimated.
IIn the weeks that followed, it was discovered that all of the limit switches and valve actuators in these valve vaults were also destroyed. We did not have a current
letLindtrarct for these components, to We pet them out for bids, Corrosion Fluid Products Is the local representative km these components and was subsequently the only
1
The WOC has recently gone out for bids to procure several contracts for mechanical and plumbing contractors to perform additional as -needed services. Ooroffice
awarded 3 separate contracts for these services and these contracts are now In place. For all of the remaining work yet ta be completed, I intend to have these three
i contractors provide quotes to competitively bid against each other. '
! Cat
1 F
GWK RetentionTreatrnent Basin:
4) Utilized force account labor, equipment and materials (water) to Rush the 2.1 mile basin three times to remove contaminated debris from the concrete yaks and
fioor into the collection trough. This process is normally accomplished with one Rushing after an event. Utilized force account labor and equipment to remove an
estimated 30 cy of contaminated debris from the collection bough to a 30 ey rolleaff container and an estimated 100 cy of contaminated debris to the drying pad for
a total el 130 cy of debris. The 30 cy roll-off centateerwas delivered, picked up and dumped by Waste Management Systems at a local licensed landfill. This debris it
included en lorhienral to the repairs.
WORI(TO BE COMPLETED: 11,21,1,938,70 Estimates provided by the Subgrantee.
Damage Inspection and repalrestimates by Wade Trim Associates: 540,000.00
GWK Main Facility (Screening Room and Operation Rooms): (132,220.70
3) Replace the broken volute ($12,557.00) and repair/rebuild the volute pump ($3,742.76).
8) Replace 2 each exhaust fan motors ($10,000.00 each x 2 each 520,000,00) and replace 2 each exhaust fan disconnect breakers ($70100 each 02 each
51,400.00).
91 Replace pull box, miscellaneous conoded/damaged disconnect breakers, grounding bar, box cover gaskets and redo Splices, cleanout boxes and apply lube/rust
inhibitor to 15 pull boxes (51 ,901.00).
101 Remove and replace (4 man-hours x 546.16/hr average wage including fringe = 5104.64)2 eactisubmersible pumps (2 each 1155 model KRT F 150.401/406X x
$46,218.15 each - 592,436.30).
1 PW .
Amount • I . Eligible ($) ' '•
Federal Share ($) •
,
PWs ($) • itthgrardee Admin Exp. ($
. . . '• ... Total ($) . 1,167,035,44r 0.901 1,167,035.0: ' I . .
,. 1375,276.511L... 0.00 ! S75,276.58 ' .i 1
PA.05.
MI-
4195.
Pw-
00141
Total for I Ms: $1,167,035.44
Subgrantee Admin.; $0.00
Grand Total: $1,161,035.44
PA-05.
0.41-4192- 51,167,035.44 N F State-0021
(20)
03.25.
2016
Page 1 of 2
Generated Date: 03/10/2015 13:38
Federal Entergeney,Monagement Agency
Project Completion and Certification Report (P.4)
Disaster: FEMA-4195-DR-1',II
Applicant TIPS ID: 125-UIZPI-00 Applieont/Subdivlsion Name: OAKLAND COUNTY WATER RESOURCES COMMISSIONER_
pwo Amendment ApprovedCo R sha5rke undle Dor_ je.y3 1,1
Protected ,..,
Cowin", Elie Amount as Dale
Actual Dote.
Completed
Amt. Clnitned bY
.ApnLcuit Commento
5 $1,167,035.44
https://isOUrCe.fema.gov/emmideornmon/view/p4Report.jsp7printatti=print&app_ids='125.,, 3/10/2015
PA-05-MI-4195-P*00141(0) :•.,' p .:; J..:•....:'!,,;,:,..,;::!.., • . -•'•:,.',.,• . • '•:,:1',-%'....;... • •.:L' ' ' ' • .. 'I',.:. i., 1. ,.1, :. .' n••._‘ , ''•n•n ..- ; . , ::',r ' • "- ' " ..'. :),.. . • ' • . ' • ..-.:1, % .,',:, . •n•' i ...r ; 1 -, :.'. Applicant Name: Application Title: OASLAWO COUNTY WATER RESOURCES cOMMISSIONER UJ2PI61 Retention Trealment Basin
Period of Performance Start: • . Period of Performance End: : 39-25-2014 03-25-2016
Subgrant Application - Entire Application
Application Title: u..i.zpio: Retention Treatment Bo&
Application Number: PA-65. MI4105•PW•061-11(0)
Application Type: SubwrintAppfcAllen (PA
.•Preparerinforrnatton
Prefix
Mr.
First Name • • DONALD
Middle initial
Last Name , CHASTAIN
Title
Agency/Organization Name FEMA/DHS
Address 1
536S Clark St
Address 2,.'
6Th Floor
City Chicago
State
IL
Zip
60605
Email insp-emhsdi§mIchlgan.gov
• "•
Is the application prepirer the Point of Contact? j No
. ,
...',. ' ' ':'' ! . •... .:!?::.' ''',n:. n '•::..: : !'.''.n - : •'";:nn•:':',":"!•'. 41-;!.X.;7' 'n:.•::-; • ' ':':' i;...•:•: y.1.pint a c..o.nactlrifOirnatiori'.',.:::::,;',:':,.:=4 ,:';'...:.:'::-,..,:.,-,•::::•:;:r::.,::',t,!..g.:;:-.•;:.....::.'.';':'/.:::-..":,!::.,',;.: ''.!..
Prefix . :„. .. Mr.
First Name • . . . .' •,, , Gary
Middle Initial . .
Last :Name . ,, Nigro
Title • ,. ,: .„- .. .. Assistant Chief Engineer
Agency/Organization . Oakland County Water Resources Commissioner .
Address 1 ., .. One Public Works Drive, Building 95 West
Address 2 ..
City - : :, . ." . Waterford
State .:.: '' . • .. MI
ZIP • ' .. 48328 - 1907
Phone , '. . " 245-858-5243
Fax ' 248-858-1066 .
Email • nigroggoalogov.com
:: :::-: •'„, ' : '' ::1:".2:.i.,;:•."::::::,.;;;;4.:',":,''.•:,`•„::;"••,i'l,':::Alielirikta Point efCanficrinfcmlation ....•.:;:','','1:':'',1:::;''''.','•::.......i :ii0','''''::'::;:';::: ':'.'•':'•:L •'..'•':].••;::::":3::::,:':::'::::,, . , ,
Prefix ' . ..
First Name '
tv1iddlethitial . . .
Last Name •
Title
Agency/Organization .
Address 1
Address 2
City ,•
State . . „ :
ZIP .
Phone , .. .'
Fax . . , .
Email
.,...:.:.•:.:J:.: .. • ,••„':..:.„ 1.., • ; „::,•• ' :-..• i•,: .•:r i!,;.';:!,..',,....."::•,: ::„;;.':, '•'.,A''•,::,•'•;:.:project Deaaription •-•:'.':'..Y,:::.":]'''.::',.:''.::jr•:'"i'..)'•:!::i',::::::‘;:;',''eOl'i::::•:.:1':'; •tr.,•:.::.:•....:.'i,:'•::•::,';'..,;',:-.;',;:.,"::::::•:E,,,',...r...:,'
Disaster Number. ' 4195
Pre-ApPlication Number: • PA-05-MI-4195-RPA-0052
Applicant ID: ' ' ' . . 125-U.J2P1-00
Applicant Name: . : OAKLAND COUNTY WATER RESOURCES COMMISSIONER,
Subdivision:.
Project Number. URP101
Standen:I Priaject Nurriberfratie: 699 - Public Utilities
Please indicate the Project type: Neither Alternate nor improved
Application Title: LUZPIO1 Retention Treatment Basin
Category: F.PUBLIC UTtL1TIES
Percentage Work Completed? :
As 'of Date: 11-17-2013
Comments .
Attachments
Damage Facilities (Pert 1 of 2)
Facility
Number Facility Name Address County City State ZIP Site Previously Damaged? Milan
1 Water Retention Basin Oakland MI No
Comments
Attachments
User • , '. pato;::) :Documant Type ; ra aDesciiptioe ralard Copy FileReference , •;,.., a "r Fate Name :a•14arr:aar .1 Action
DONALD CHASTAIN 01-10-2015 Map Location Mops Location Maps.pdf(877.41 kb) View
DONALD CHASTAIN 01-10-2015 Photos Site Photos OW Kuhn Photos.pdf(3.59 Mb) 'Zeta
DONALD CHASTAIN 01-10-2015 Miscellaneous Engineer Report Wade Trim Assoc Report.pdf(1.34 Mb) View
DONALD CHASTAIN 01-19-2015 Miscellaneous DOD-SOW ODO-SOW.pdf(383.83 kb) View
Facility Name: Water Retention Basin
Address 1:•
Address 21
Coantya Oakland
CRY: :
State: MI
ZIP:: . .
Was this site previously damaged? No
Percentage Work Completed?* 5.00%
Location;
PA-05-M1-4195-PW-00141(0);
1400 Ajax Drive, Madison Heights, MI
42.50775, -83,11177
• - . lion end Dimensions:- Damage Descri
: •
.
'
:
.
PA-054141-4195-PW-00141(0): -
During incident period August 11-13, 2014, heavy rains and excessive runoff overwhelmed the storm water
and sanitary collection systems In Oakland County resulting in backups and flooding. During storm events,
when combined sewage from the collection system exceeds the capacity of the downstream interceptor
system (which flows to Detroit for treatment), the flow overlaps the Influent weir of the George W Kuhn
Retention Treatment Facility (GWK RTF), This excess flow is normally retained, screened and disinfected
(approximately 126.4 million gallons of storage) and than pumped (from the facility) back into the collection
system to Detroit. During large storm events that exceed the capacity of GWK RTF, the flow Is chlorinated
and discharged into the Red Run Drain which flows into the Clinton River, Due to the Intensity and volume
of the rainfall during this event, the capacity of the GWK RTF was significantly exceeded, resulting In
surcharging within the facility and high velocity flows carrying excessive debris. At the peak of this event
the Red Run Drain was approximately 2 feet above its 500 year flood stage at the point of discharge from
the GWK RTF. This elevation was based on a surveyed high water mark of 620.23 feet (NAVD813). This
flood stage is approximately 9.44 feet above the effluent weir crest at the downstream end of the GWK
RTF. This extreme backwater from the Red Run drain had a direct impact within the GWK RTF.
The facility received mechanical, structure and electrical damages as follows:
GWK Main Facility (Screening Roam and Operation Rooms):
1) Flooded end submerged a hot water pressure washer,
2) Excessive sewer and storm drain water entered the screening room at a level of 13 to 14 vertical feet
above the normal high water level of the facility resulting in a cordless combo kit (includes 112 inch drive
Impact hammer and reciprocating saw),
3) Excessive debris being pumped through one of the six &watering pumps broke the volute (metal housing
that encloses the pump Impeller) from the rest of the pump body.
4) Pressure from the high water (estimated 6 ft deep) at the screening room vehicle entrance, caused the
rolling steel curtain overhead door to buckle an both edges end submerged and damaged the electric
open/close control box,
6) Sewer and storm drain water flooded the elevator pit,
6) Flooded and shorted out the motor for the sluicing trough.
7) Water came up through the floor drains In the chlorine storage tank room and the chlorine pump room, '
6) Water submerged two exhaust fans whIch damaged two electric fan motors and Internet breakers in the
disconnect boxes far these fan motors,
9) Water entered electrical conduits throughout the facility which then flowed through conduits and out of
central panels and junction boxes resulting In operations moms becoming flooded,
10) Silted in and damaged two submersible pumps that contribute to dewatering the basin.
GWK Retention Treatment Basks:
1) Sewer water and Moan drain water overlilled and surcharged the concrete enclosed retention treatment
basin which resulted in water backing up through the floor drains In 59 vaults along the 2.1 mlie facility. This
submerged and damaged the sub plates (electric circuit boards) and transformers for the sub plates as welt
as 236 pneumatic actuators and limit switches that operate the cleaning system for the basin and
disbursement of chlorine for treatment of the contaminated water within the bash.
2) Fast moving water broke, bent or displaced 78 pipe hangers that hold and brace the suspended flushinOtreatment pipe system for the basin.
3) Fast moving water and debris broke two chlorine line joints and two discharge nozzles.
4) Deposited an estimated 130 cy of conlamlnated debris throughout the 21 mile basin.
Dequindre Pump Station (Located at the discharge end of the OW Kuhn RTB):
1) Sewer and storm drain water entered six 4 inch conduits that enter the facility from the flushing vaults
and flowed into an electric pull box damaging electric actuater.valves and disconnect switches.
Henry Graham Drain:
1) Swift moving storm drain water filled with debris flowed through three conerete enclosed channels and
discharged from the Henry Graham Drain Into the SW Kuhn Basin. Each of the three channels has a 14 ft long x 9 ft tall steel pipe hinged security gate at the discharge point. The north gate sustained damage from
fast moving debris which broke the hinge and let the gate sag and fall resulting in damage to the security
gate arid hinge.
PA-05-M1-4195-PW-00141(0);
WORK COMPLETED:
Sulagrantee utilized an engineering firm (Wade Trim) to analyze damages and provide estimates for the
repair process. The report Is attached to this project worksheet.
Subgrantee utilized force account labor, equipment and contractors to make the repairs to the mechanical,
structural and electrical damages as follows:
GWK Main Facility (Screening Room and Operation Rooms):
1) Replace one each hot water pressure washer,
2) Replace one each cordless combo kit (includes 112 inch drive impact hammer and reciprocating saw),
3) Temporadiy plug the line at the broken volute with rubber flange and gasket,
4) Replace tolling steel curtain overhead door and control box,
SCOPE OF WORK (CON'T):
WORK COMPLETED:
6) Secure the elevator car and dewater and dean elevator pit,
6) Replace the meter for the sluicing trough pump,
7) Purchased leach wing nut plugs to temporarily plug the floor drains in the chlorine tank and pump reams.
GWK Retention Treatment Basin:
4) Utilized force account labor, equipment and materials (water) to flush the 2.1 mile basin three times to
remove contaminated debris from the concrete wails and floor Into the collection trough. This process is
normally accomplished with en° flushing after an event. Utilized force account labor and equipment to
remove an estimated 30 cy of contaminated debris from the collection trough to a 30 cy roll-off container
and an estimated 100 cy of contaminated debris to the drying pad for a total of 130 cy of debris. The 30 ay
roll-off container was delivered, picked up and dumped by Waste Management Systems at a local licensed
landfill, This debris is included as incidental to the repairs.
WORK TO BE COMPLETED: $1,214,838.70 Estimates provided by the Subgrantee. ' Damage inspection and repair estimates by Wade Trim Associates: $40,000.00
GWK Main Facility (Screening Room and Operation Rooms): $132,220.70
3) Replace the broken volute ($12,557.00) and repair/rebuild the volute pump ($3,742.76),
8) Replace 2 each exhaust fan motors ($10,000.00 each x 2 each = $20,000.00) end replace 2 each exhaust
fen disconnect breakers ($700.00 each x 2 each = $1,400.00),
9) Replace pull box, miscellaneous corroded/damaged disconnect breakers, grounding bar, box cover
gaskets and redo splices, cleanout boxes and apply lubekust inhibitor to 15 pull boxes ($1,900,00),
10) Remove and replace (4 man-hours x $46.16/hr average wage IncludIng fringe = $184.64) 2 each
submersible pumps (2 each KSB model KRT F 150-401/406K x $45,218.15 each = $92,426.30).
GWK Retention Treatment Basin: $978,648.00
1) Replace 59 each flushing vault panel sub plates and 59 each transformers ($523,664.00) and replace 236
each pneumatic valve actuators and limit switches (Paris = $292,640.00, Labor= $124,100.00)
2) Repair/Replace pipe support hangers ($27,765.00),
3) Replace 2 each chlorine line joints ($5,000.00) end replace 2 each flushing nozzles ($1,000.00),
4) Load and haul off an estimated 100 oy of contaminated Class 11 debris to Oakland Heights Development,
Me, 2350 Brown Road, Auburn 48326, License Number 9306 ($4,479.00). A copy of the operating
'license Is attached. This debris Is included as incidental be the repairs.
A signed Emergency Debris Management Certification Form is included with this project,
'Dequindre Pump Station: $51,100,00
1)Replace 4 each Ratak actuators (4 each x $12,000.00 each = $48,000.00) and replace 4 each actuator
disconnects (4 each x $775,00.00 each e $3,100,00).
Henry Graham Drain: $12,870.00
1) Manufacture and install a new 14 ft long x 9 ft tall steel pipe hinged security gate at the discharge point of
Henry Graham Drain ($12,870.60),
Project Notes:
This CEF estimate Is completed to evaluate the applicants submitted estimates for cost effectiveness and
competitive pricing. Using the documentation submitted by the applicant the CEF specialist eompiled the
Part A using:
2015 RS Means Costworks for labor, equipment and material components.
Local Vendor and online supplier catalogs for current competitive pricing on actuators, subplates and
transformers.
Applicant's vendor submitted estimates for specialized immediate replacement of broken volute and pump.
Applicant's vendor submitted estimate for specialized repair of 2 submersible pumps.
Applicant submitted vender proposal for specialized service to remove and replace existing damaged valve
actuators.
The applicant did not submit an itemized estimate for the replacement of "sub plates" in the flushing valve vaults
therefore an allowance was added for the replacement of =trot connectors and the refurbishment of
existing panel boards/enclosures,
Subgrantee Is requesting mitigation to install backflow devices In 59 vaults. A Hazard Mitigation Proposer is
included with this project worksheet.
The Sub-Grantee Is requesting Direct Administrative Costs that are directly chargeable to this specific
project. Associated eligible work Is related to administration of the Sub-Grantee Application only and In
accordance with 44 CFR 13.22. These costs are treated consistently and uniformly as direct costs in all
federal awards and other Sub-Grantee activities and are not included in any approved Indirect cost rates.
44 CRF §13,36 Procurement. (b) Procurement standards. (1) Grantees and subgrantees will use their own
procurement procedures which reflect applicable State and local laws and regulations, provided that the
procurements conform to applicable Federal law and the standards identified in section 13.36.
As described in 44 CFR 13.42 (2)(b), 3(c), Sub-Grantee must maintain all work related records fee a period
of three (3) years from Sub-Grantee closure (final payment). All records relative to this Sub-Grantee
Application are subject to examination and audit by the State, FEMA and the Comptroller General of the
.. United States and must reflect work related to disaster specific costs.
Contracting Procedures:
As per Subgrantee:
Oakland County has many blanket contracts that we utilize for as-needed and emergency services. These
contracts are publically bid through our Purchasing Department and are usually a performance based bid
considering things such as work experience, responsiveness, references as well as labor and equipment
rates.
In the case with the 59 flooded valve vaulis.and the subsequent electrical damage, we utilized Motor City
• Electac who we have a current contract with for instrumentation and control services. The controls for this
• facility are unique and Motor City has extensive experience and knowledge of this system. in 2009, there
was some damage to 3 of the 59 valve vaults and the electrical sub-prates required replacing, same as we
are currently doing. Motor City was the contractor who performed the replacement work at a cost of
approximately $13,000 per valve vault which is what we had originally estimated for the recent damages.
However, it was discovered that all of the equipment is currently outdated and no longer available. Motor
City proposed to replace the damaged components with newer technology at a cost of approximately $9,000
per valve vault which is what we approved them to do. This is significantly less money than we originally
estimated.
In the weeks that followed, It was discovered that all of the limit switches and valve actuators in these
valve vaults were also destroyed. We did not have a current contract for these components, so we put them
• out for bids, Corrosion Fluid Products is the local representative for these components and was
subsequently the only bidder.
The WRC has recently gone cut for bids to procure several contracts for mechanical and plumbing
contractors to perform additional as-needed services, Cur office awarded 3 separate contracts for these
services and these contracts are now in place. For all of the remaining work yet to be completed, I intend to
havo theca three cartractort provide quotes to competitively hid against each other,
Hazard Mitigation Proposal..
.' is effective initigatien feasible.on this site? .. I Yes
,. . , . ..
If.yeu answered Yea to the above question, the next'qqe-StIOn'IS required • , ..-lr;ll_‘•:. ,,-,0i,?i:g.,:,• .(ial,.;••,; •-,:,-1,,.:.c,:.?..;„ ,.,:w.,,,:i.,,,,,.,.:::,,,,,;.,:... ,,, - ,, ,
Willmfitigatien be performed on this site? •IYes
.. . . . . . ..
If YOU answered Yes to tile above question the next Mreillon Is required :....:..;:'.!::i:!.!,1::::.' ',.,'2,k':;'';',:::;:'. ..' .b: ..::';','M.",:.:!:'-'..:::::''..Y::.:-.' .:•,,,',:,...;'.. ::.... ... ''.`:: ,.'.!,'.:7.:.::,;....
Do you Wish to attach a H a.z6rd. Mitigation' Ortip6sai? . Yes
,. . .
If you answered Yes to lho above question the next two questiona are epcluir44. :1','E ,•.,'.;i:.!:..:' , :'.•:.•.'::e4':',..!',:V-.,:':,'.::',',''r!':":i.2:.'..;:.',V=:':-:' ;
During Incident period August 11-13, 2014, heavy rains and excessive runoff
overwhelmed the storm water and sanitary collection systems in Oakland County
resulting in backups and flooding, During storm events when combined sewage from the
collection system exceeds the capacity of the downstream interceptor system (which
flows to Detroit for treatment), the flow overlaps the Influent weir of the George W Kuhn
Retention Treatment Facility (GWK RTF). Sewer water and storm drain water overfilled
and surcharged the concrete enclosed retention treatment basin which resulted in water
backing up through the floor drains in 59 vaults along the 2.1 mile facility. This submerged
and damaged the sub plates (electric circuit boards) and transformers for the sub plates
as well as 236 pneumatic actuators and limit switches that operate the cleaning system
for the basin and disbursement of chlorine for treatment of the contaminated water within
the basin,
To prevent future damages from a similar event, the subgrantes proposes to core drill a
larger hole (approximately 4 Inches in diameter) in place of the current smaller floor drain
Please provide the Scope or Work forthe estimate: hole in each vault to accomodate the check valves, and install a backwater style cheek
:Ona'Aimum4000.6naractdre.) : ' ' valve within the new hale. Installation of the backwater style check valve would prevent
water from flowing up through the floor drain, flooding the vault and damaging the
electrical components housed In the vault,
Cost of In-kind repairs is $940,404.00, Subgrantee has supplied a contractor estimate for
the proposed mitigation of $175,820.00, which is 18.7% of the cost to repair this site to
pre-disaster design and function. The estimate provided is for 60 vaults ($2,980.00 each)
of which only 59 received damage. This estimate for 6178,800.00 is reduced by $2,980.00
fore total of $175,820.00 to install the backwater style check valves in 59 damaged
vaults.
In accordance with FEMA Recovery Policy 9528.1, VII, 13.2 "certain mitigation measures
(Appendix A) determined coat effeetive, as long .
as the mitigation measure does not exceed 100% of the eligible cost of the eligible repair
work on the project. Appendix A, Paragraph C. Wastewater treatment plants- 2. Dry or
wet flood-proofing of buildings" or as In this case dry flood-proofing the flushing vaults.
Would you like to add the Hazard Mitigation
Proposal as a cost line item to the project cost? . , No
BIS Coordinates ' ' ,
Project 14catIon Latitude '. LahaltUde
GW Kuhn Retention Treatment Basin 42.50775 -83,11177 .
" ConsIderatioris];
1. 'Does the damaged fealty or Item.of work have Insurance cOverage and/or is it an Insurable risk (e.g,, buildings, equipment,.vehicles,
'ate)? • .. •
V you would like to make any comments, please enter them below,
Yes
Insurance Policy on file in PA Drive at the JFO •
2. is the damaged facility located within a floodplain or coastal high hazard area and/or does It have an Impact on a fioodplain or wetland? No 3. Is the damaged facility or item of work located within or adjacent to a Coastal Banter Resource System Unit or an Otherwise Protected • Area?, No
4. Will the proposed faciiity repairs/reconstruction change the pre-disaster conditions •(e.g., footprint, material, location,•capacity, use of function)? • : . . No
S. Does the applicant have a hazard mitigation proposal or Would the applicant like technical assistance fora hazard mitigation proposal? Yes
If you would like to make any comments, please enter them below: . ' (1110.1Murn 4acio diarecters) ,
Hazard Mitigation Propose/ Attached
• ,, 6, Is the damaged facility on the National Register of Historic Places or the state historic listing? is it olderthan 50 years? Are there more,
Similar buildings near the site? .
No
7, Are them any pristine or undisturbed areas•on, or near the project site? Are there large tracts of forestiend? ' No
8: Are there any hazardous Materials at or adjacent to the damaged facility and/or Item of work? .. •, No
9. Are there any other envirgnmental or controversial issues associated with the dareaged facility and/or item of work? , No
• , , Attachment .; , .. .. . ,.. ,...
User 1 Date 99Whent. .:;ie';c.''iip..t.ion 1:1Td Copy F..1,(.6 ' '.':,,•Fi'le 'Na ,ms Aden
DONALD
CHASTAIN
01-10-
2015 Miscellaneous Debris Cart Form and Landfill
Permit Debris Cent-Landfill LIcanse.pdf(889.37
kb) View
DONALD
CHASTAIN
01-10-
2015 Map Flood Map Flood Maps.pdf(9.23.76 kb) VIEW
• : ...I.'. ::•"'',•::'.:' !:•::',: ' ''.::•'':•:4,;,:•,• r . " .2. '.. • . i;, ; . '.For Category c, p,:E;F, and 0 Pr8Je0ts,..onfi .:::Q:::..ii".;:..':':.I.:'.qV.,,:::,',..::.::'...::,:;`;:-;:',':.:::::,',!...g,,-
is:effective mitigation feasible on this project? . Yes
If you'ansWered Yes to the ebovo.question, the next question is required ''•'.' •,. ;:'....1.:::11..;;::',.,:i •:',. : ,..,:•:::,, :j. :,,,,, ',...,..,:.:•.:,•:::,-,...7,,....;.,.,,..,..:t!..;;:::-.•.,,......•,:, t.: t , : .::,:,,.n:!,.; :: tr.::
Will mitigation be performed on any sites in this project? • ,. 'Yes . ... If you answered Yea te the above geestion, the next :question is required . : •;:::::::•;:,:.•,:.:,,:i.•:•..•.!,:„;0:i.::., •..i::,:::•,:,::,;,,:•,,, t,t, :ih,.•;:.::: :..;,;'.'4; .:.,...;',.:.1,,..:',... ,: , ,,.;:,';.,, '
Do you Wish to attach a Hazard Mitigation Proposal? ' • Yes .. „ If you ensivered Yes to the 'aboVe:question, the next two questions are required :.'1.:•: : • . ... • ..AH. .:....... .::.,..,,,,, : .,,,.:...::,.• , ..,.. , ,...::.,;. .. ;•,,,,,,,,......: :, ::,
" . . . „
.
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. . . • • .n , ' Please provide the Scope of work
or the estimate: •
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During Incident period August 11-15, 2014, heavy rains and excessive runoff
overwhelmed the storm Water and sanitary collection systems in Oakland County
resulting in backups and flooding, During storm events, when combined sewage from the
collection system exceeds the capacity of the downstream interceptor system (which
flows to Detroit for treatment), the flow overtops the influent weir of the George W Kuhn
Retention Treatment Facility (GWK RTF). Sewer water and storm drain water overfilled
and surcharged the concrete enclosed retention treatment basin which resulted in water
backing up through the floor drelns in 59 vaults along the 2.1 mile facility, This submerged
and damaged the sub plates (electric circuit boards) and transformers for the sub plates
as well as 236 pneumatic actuators and limit switches that operate the cleaning system
for the basin and disbursement of chlorine for treatment of the contaminated water within
the basin. To prevent future damages from a similar event, the subgrantee proposes to
core drill a larger hole (approximately 4 inches in diameter) In place of the current smaller
floor drain hole in each vault to accomodate the check valves, and Install a backwater
style check valve within the new hole, installation of the backwater style check valve
would prevent water from flowing up through the floor drain, flooding the vault and
damaging the electrical components housed in the vault. Cost of in-kind repairs is
$940,404.00. Subgrantee has supplied a cantractor estimate for the proposed mitigation of
$176,820.00, which Is 18.7% of the cost to repair this site to pre-disasterdesIgn and
function. The estimate provided is for 60 vaults ($2,980.00 each) of which only 59
received damage. This estimate for $178,800.00 is reduced by $2960.00 for a total of
6175,820.00 to Install the backwater style check valves in 59 damaged vaults. In
accordance with FEMA Recovery Policy 9526.1, Vii. B.2 "certain mitigation measures
(Appendix A) determined cost effective, as long as the mitigation measure does not
exceed 100% of the eligible cost of the eligible repair work on the project. Appendix A,
Paragraph C. Wastewater treatment plants- 2. Dry or wet flood-proofing of buildings" or
as In this case dry flood-proofing the flushing vaults,
Would you like to add the Hazard Mitigation
Proposal as a cast line item to the project cost? . . . Yes
Hazard Mitigation Proposal ..- 0909
# Code' Material enctior Description Unit
Quantity
Unit of.
Measure
. 1
•Unit Price : • : Subaralit Budget Class . , Type Cost Estimate "Action
***Version 0 *"
-I 1 0909 'Mitigation A 1 i LS f $ 175,820.00 I, 1 $ 175,820,00
..•.'.1::.;',;(:::,,;?„:-.!'::'.1•:...:,.,:,.t!.Q ,.:.:2?:::.,•:....:•'•::-.::,.IJ.i.... ":' •'-''.:':'•.'••:-'•'.'-:1":•,•ii'':'•.'•••:•"t::.:2 ...:::',)k..il::,;,,:.;::,:.:,:,- ...,,..;:...4:.,;,,.........,::;,....;.;: ,.!T:.0;,;.,:.,...1 .::.:..:'....L ,',T661 000144175,020,0
. . . , . , Comments. • . ' . •,•• .
. . , .: , . , . , . . Attachments ' .. ... _ .
.•:: •-•',':.: ':',User''1,!•''' H. ''.•:..". e:•.•::.:: Decynient TYpe,, •i'l.' .'=:'•:•:•:;`))e,StiPtiO'ri.,:,.'..,,.;:i.'.',;!t': ,:•HaridbaPYFileRe'feienee .: :.:'::::;•::::1FIle'N'ame 'I .,..!.-..::::', .• %Aefirin
DONALD CHASTAIN 01-10-2015 Miscellaneous HMP and Estimate HMP with Estimate.pdf(78,97 kb) View
DONALD CHASTAIN 01-20-2015 • Miscellaneous. Signed Mitigation Proposal Signed FEMP.pelf(452.47 kb) View,
Is this Project Worksheet for j Cost Estimate Format
(Preferred) 'iitebalr' V''.,' ' '• '. '..' ''.:',...': '.:',;': ',: .....• r;.::.•,':.,:,::.. :...,:,..:,..:•,.•:;;•.:..., ,...5. :.................,:i. .11', •:•.:::•1!•:;'.. '''.:::',4::•:.'• " .'H''';• •:,11. "l,'l ;:. • ' ....f:V
Sequence Code Materiel andlor Description. Unit
Quantity
Unit of
Measure
1 i„,, pri,.,,,
"''''' Price
' •Subgrant
' • Bidet Class Type Cost Estimate Action
***Version 0 ".
Work Completed
1 0001 Contract 1 LS $ 7,149.72 CONTRACTUAL Work Completed $ 7,149.72
2 9007 Labor 1 LS $ 28.482.97 PERSONNEL Work Completed $ 28,462.97
3 9008 Equipment 1 LS $ 6,246.75 EQUIPMENT Work Completed $ 6,246.75
4 9009 Material 1 LS $ 9,385,35 SUPPLIES Work Completed $ 9,385.35
Work To Be Completed
5 9000 CEF Cost Estimate (See Attached
Spreadsheet) 1 LS Work To Be $ 935,593.00 CONSTRUCTION Cornpleted $ 936,593.00
Direct Subgrantee Achille Cosi
6 9901 Direct Administrative Casts (Subgrantee) 1 LS $ 4,377.65 INDIRECT
CHARGES
Direct Subgrantee
Admin Cost
$ 4,377.65
;',:•;1."...';'. "5'.•• • ";•:.• ',:,....I',:.L:::'..::!;, :':.,,,' ...‘.., •"': • •::•:;•.e'iii.::,: ' " ,'•':5'.' '''• •;.'J';';'...N.'.;!:,..:•,..:.','''..'.:', ' '...,.'2..:,''5,l',Tatai Boa; ....$ 991,21644 '''..., :;.......
Insurance Adjustments (Deductibles': Proceeds and Settlements) '.:•5900/5901 (.'' . ::';'':.•,',•',.:' — '' , :,.:. 1 ;1:',',•!:;:. ':::":,,:'•::::,. :%;....,.,.,'...':.;'?.;',....':A•:,•
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HazeniMiligatIon Pmposel 4 0909 "''..".,A...,,..,..:, ',.';,:••,.,i,r.''''::•....',!:'..a:,•'...."..'.!.;".i..':;:E.:;:::;SY;:•'.i...1::::'.."..."•'-...43.,;',''."'",..s-:',!:" '-r."',..il,.'•'''."•'•'•'•:l':'','': •:'",:',;..--••••'.'''2''•""•.'•;::.'''''I'''"
Sequence Code ., '. •• ' Material sod/or Description QuaUnititity. ryenasit uofre Unit Price' - Budget Class Type • Cost Estimate Action
"k V erSIOn a
0900 Mitigation 1 LS $ i70,e2a.00 1 $ .f 75,820.00
TotaJ Goat Eetimater.).;
':..:ZP14(irred Es 12.1161e Type Li. lrsorane'a.lAdjuilnifinti
Comments ' ; .
Attachments '. • .
User. ; • ' :.' ' . .5: : .:.:" .. ',.:. .1Date:'.`: ••:•'.i:1 Document Type -e:14:2:',....',:•• • ' ' ; : :. ::::•,,DesonptIon ,"•,: ',..,:'
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DONALD
CHASTAIN
01-10-
2015 Miscellaneous Contract Sheet with
Invoices
Contract Sheet - Invoices.pdf(1.96 Mb) View
DONALD
CHASTAIN
01-10-
2015
Contract
Document Motor City Contract Contract-
. Motor City Eleetric Technologles,pdr(4.97 Mb)
View
DONALD
CHASTAIN
01-10.
2015
Contract
Document
Contract Procedures
Letter Contract Procedure Lettenpa(336.70 kb) YieM
DONALD
CHASTAIN
01-10-
2015 Miscellan eous Materials
invoices
Sheet with Materials Sheet - Invoices.pdf(2.13 Mb) 1./Jela
DONALD
CHASTAIN 2015 Miscellaneous Pay Policy Salary and Overtime Pay Policy.pdf(53.88 kb) View,
DONALD
CHASTAIN
01-10-
2016 Miscellaneous Fringe Benefits Sheet Fringe Beneffts Sheet.pdf(230.32 kb) View,
DONALD
CHASTAIN
01-10-
2015 Miscellaneous DAC DAC.pdr(1,43 Mb) View
DONALD
CHASTAIN
01-10-
2015 Miscellaneous Estimates for Repair Work To Be Completed Estimates.pd1(2.53 Mb) View,
DONALD
CHASTAIN
01-19-
2015 Force Account FA Labor and Equipment FA Labor & Equipment.pdf(816,52 kb) view
DONALD
CHASTAIN 131-19- 2015 Miscellaneous GEF CEF.prif(1.44 Mb) view
• :` ''''''',; ''':•':',':::".'..'..'"... 1; ::: ;•'.''.l:: '• '''' .'' .':''', ' '.'''':'''''.: •••1';';',Eirstin6 Insurance Information ::•:''l',': ''.;:.;;;!'..:::'....:',, '.'•:•'''',".i6::;:::::;li:L:i.]' • ;'':- ,:-,:: : !'::;•;.:::...;,:::•',..;:;::'::-,.,:..'..
Insurance Type ' PrAcy 'NO. Bldg/Property • .
' Amount
Content
'Amount
Insurance .
Amount
Deductible
Amount
Years
Required ..,
Comments
Insurance Denial Letter
Attachments .
• User., '.'.'...` '-'.r.P0i.''!' 'Poi4y,r,-*g ty09 ,: -.s.cr.ipkIt.ri ..;;%,...•:, Hal Copy Pile
,z• :::,,:, ft f - c•e',:....:;,':;: d'e'•:s:',.;,`:,:',:;....T.-::•:•.:Ai,::-;':;... :,.!...:.,;•: • ie'el A011on
CORLISS
TOOTLE
02-23-
2015
Insurance
Document
Insurance Denial
Letter
The Water Resource Commission Disclaimenpdf(121,25
kb) View
Comments and Attachments
Name of Seclkin Comment ' Attachment .
Location Maps.ndf '
OW Kuhn Photes pdf
Damage Faeriti es 16LadtakttLea9StRePt2lia
DDD-SOW Doff
Spacial Considerations Debris Oen-Landfill License.odf
Flood Maos.pdf
Mktg ation HMP with EstImatetd(
alaggd.J:IMP_Eff
Cost Estimate
Contract Sheet - involcas.orif
Contract-Motor City Electric Technologies ,od(
Contract Procedure Letter.cdt
Materials Sheet - Invoices.ocif
SeIn, and Overtime Pay Polley. od(
Fame Benefits Sheel,pdf
DAC Jig '
Work To no Comoteted_Estimatesxdf
FA Labor & Eouloment,od(
CEE.orlf
Insurance Information Insurance Denial Letter The Water Resource Commission Discialmerxdf
Form 90-91 Signed 90-91.ndf
Signed DACixt(
Bundle Reference # (Amendment tl)
Date Awarded PA-05-Mt-4195.State,0021 (20) 03-05-2015
Subgrant Application FEMA Form 90-91
Note: The Effective Cost Share for this application is 75%
FEDERAL EMERGENCY MANAGEMENT AGENCY
PROJECT WORKSHEET
DISASTER ii, PROJECT NO. PALO NO.
125•1JJZPI-00 DATE
01-204015 CATEGORY
F FEMA 14186 1- 1DR HI LUZP101
APPLICANT; OAKLAND COUNTY WATER RESOURCES COMMISSIONER WORK COMPLETE AS OF:
11-17-2013 :5 %
Site 1 cif 1
DAMAGED FACILITY:
Water Retention Seen COUNTY: Oeidand
LOCATION:
PA-05.MI•4196,PW.00141(0);
1400 Ajax Drive, Madison Heights, MI
42.60776, -93.11177
LATITUDE:
42.50776 LONGITUDE: .83.11177
DAMAGE DESCRIPTION AND DIMENSIONS:
PA-05-Mt-4195-PW-00141(0):
During incident period August v1.13.2014, heavy mine end excessive runeff overwhelmed the starm water end sanitary calbction systems In Oakland County resulting in backups end flooding, During
storm events, when combined sewege front the collection system exoaods the caparityof the downstream interceptor system (which tows to Petrol for treatment), the flow overlaps the Infltient welr of
the George W Kuhn Retention Treatment Feeley (GWK RTF). This excess bow is normelly retained, screened and disinfected (approximately 126.4 meion gallons of atorage) end then pumped (from the reedy) back into the collection system to Detroit. During lerge storm events that exceed the capec ity of GWK RTF, the flew 0 chlorinated and discharged Into the Rod Run Drain which limos into the Clinton River. Duo to the Intensity and volume attire rainfaliduring this event, the capacity attire GWKRTF was signifitently 014:Coded, restilting In surdiargIng within the facility and high velocity flewe carrying eXCEISelV0 debris. At the peek of this event the Red Run Drain was approximately Sleet above its 500 year flood stage at the point of discharge from the GWK RIP. This elevation was based on a surveyed high water mark of 620.23 feat (NAVD88). Thiele:Jed stage Is approximately 8.44 Met above he effluent weir crest at [he downstream end or the GWK RIP. This extreme backwater from the Red Run drain had a direct Impact within the 9WK RTF.
The facility received mechanicaL structural and electrieal demages as (dews:
GVVX Main Facility (SceeenIng Room and Operation Rooms): 1) Flooded and submerged a flamer pressure weehar,
2) Extessive sewer and storm drain water entered the sereening morn at a level of 13 to 14 vertical feet above the normal high water level of the fadity resulting In a cordless combo Idt (Inciudes 1/2 inch drive impact hummer and federate:fling saw),
3) EXCVSSIVE1 debris being pumped through one of the six dawaterIng pumps broke the volute (metal housing Met encloses the pump impeller) from the rest of the pump body.. 4) Pressure from the high water (estimated Oft deep) at the screening room vehicle entrance, caused the ruling steel curtsh overhead door to buckle on both edges and submerged and damaged the electric open/dose control box,
5) Sewer and storm drain water flooded the elevator pit, 6) Flooded and shorted cart the motor for Me sluldng trough.
7) Water came up through the floor drains In the chlorine storage lank room and the chlorine pump room.
8) Water submerged two exheust fans which damaged two eiecilie fan motors and internal breakers In the disconnect boxes for these fan motors,
9) Water entered electrical conduits throughout the fac illtywhich then Rowed throegh conduits and out of control panels and junction boxes resulting in operatione rooms becoming needed, 10) Silted in and damaged Mb submersible pumps that coninhule to dewetering the basin.
GWK Retention Treatment Basin:
1) Sewer water and storm drain water owned end surcharged the concrete enclosed retentice treatment basin which resulted in water backing up through the toot drains 11 59 vaults along the 2J
mile fadlity. This submerged and damaged he sub plates (electric circult boards) and transformers for the sub pfales as wee as 236 pneumatic 8duators and kilt switches that operate the Cleaning system forte heels end disbursement of chlorine for treatment of the conteininated water within the basin. 2) test moving water broke, beater *placed 70 pipe hangers that held and brace the suspended Fuehinghrealment pipe system for the basin. 3) Feet moving Water end debris broke hoe chlorine line joints ord two discharge nozzles. 4) Deposited an ellimated 130 cy of contaminated debris throughout the 2.1 Mile basin.
Dequindre Pump Station (Located at the discharge end of the SW Kuhn RTE): 1) Sewer and etorm draki water entered six 4 inch mnrfulls that enter the fealty from the flusbing vaults end flowed Into an electric pull box damaging electrie actuator values and disconnect switches.
Henry Graham Drain: . . 1) Swift moving storm drolly water flied with debris flowed through three concrete endosed channels and discharged from the Henry Cilllil El rn Drain Into the SW Kuhn Boole. Each of the three channels Lion a 14 ft long x9 ft tall steel pipe hinged eeetnetygate either discharge point. The noith pie sustained damage from fast moving debris which broke the hinge and let the gate sag and fell resulting In
damage to Pre security gate and hinge.
SCOPE OF WORK,:
PA-05-M1-4196-PW-00141(0):
WORK COMPLETED: Subgrantee utilized an engineering firm (Wade Trkn) to analyze damages end provide estimates for the repair process. The report Is attached to this project worksheet,
&temente° utetzed force account Mbar, equipment and centractors to make the repairs to the rneohaokat structural and &mince' damages as follows:
GWK Main Facity (Screening Room and Operation Rooms):
1} Replace ono each hot water pressure washer, . 2) Replace ono each cordless combo kit (includes 1/2 Inch drive /mead hemmer and redpmeating saw),
3) Temporarily Am Me fin at the broken Volute with rubber flange and gasket,
4) Reploco rolling steel curtain overhead door and control box,
SCOPE OF WORK (CCNT):
WORK COMPLETED:
5) Secure She elevator car and %water and dean elevator Pit,
6) Replace the motor for the sluicing trough pump,
7) Purchased 7 %id) wing nut plugs to temporarily plug Lim goer drains in the chlorine tank and pump rooms.
GWK Retention Treatment Basin:
4) Unfixed force account labor, equipment and materials (water) to flush the 2,1 mile bash three times to remove contaminated debris from the concrete Walls and- floor into the collection trough, Thls
process Is normally accomplished with one flushing alter an event. Ulikesci force account labor end equipment to remove an estimated 30 cy of contaminated debris from lite collodion trough to 030 ey
roll.off container and an estimated 100 cy of contaminated debris to 4hts drying pad far a total of 120 cyst debris. The 30 cy roil-off container was delivered, picked up and dumped hy Waste
Management Systems.' a local tomcod landfill. Tills debris is Included as incidental to Me repairs.
WORK TO BE COMPLETED: 51,214,938.70 Estimates provided by the Subgrantee.
Damage inspection and repair estimates by Wade Trim Assodates: $40,000.00
GWK Main Facility (Screening Room and Operation Rooms): $132,220.70
3) Replace the broken volute ($12557.00) and repaidrebuikt lite volute pump ($3,742.76).
8) Replace 2 each exhaust fan motors (510,000,00 each 52 each =$20,000.00) and replace 2 each exhaust fan disconnect breakers ($70600 each s2 each $1,400.00).
9) Replace pull box, miscellaneous oorrodod(damaged ellsconned breakers, greilnding bar, box cover gaskets and coda splices, deeneut boxes and apply kbetrust inhttior to 16 pull boxes (S1,900.00).
10) Remove and roplace (4 man-hours x $46.16Thr average wage including fringe = 3104.64) 2 each submersible pumps (2 each KSB medal KRT F 150-4011408X x540,210.10 each = 592,436.30).
WYK Relentian Treatment Basin: $978,648.00
1) Replace 69 ouch flushing vault panel sub plates and 59 each transformers ($523,064.00) and replace 236 each pneumatic valve actuators and limit switches (Purls = $292,640.00, Labor c
$124,100.00)
2) Repair/Replace pipe support hangers (327,765,00),
3) Replace 20000 ohbrine Ina Mats (55,000,00) and replace 2 each flushing nozzles (01,000,00),
4) Load and haul off en estimated 103 cy of contaminated Class II debris to Oakland Heights Development, Inc, 2350 Brown Road, Auburn Hill, MI40326, License Number 9308 (54,479,02). A ropy of
the operating 11Cansa is attached. This debris is included as in6deotal to the repairs.
A signed Emergency Debris Management Certification Form is Inckuled with thle proried.
Deg:Andre Pump station: 551,100.00
11Replace 4 each Ratak actuators (4 each S12,060.0E1 COCh 640,000.00) and replace 4 each actuator disconnects (4 each x 5775,00,00 each = $3,100.00).
Henry Graham Drain: $12,870.00
1) Manufacture and Install a row 1411 long 09 Fiat steel pipe hinged security gate at the discharge point of Henry Graham Drain ($12,070.00).
Project Notes:
This COP estimate is completed to evaluate the applicants submitted estimates for toot effectiveness and competitive pricing. Using the documentation submitted by the applicant the CEF spedebt
compiled the Part A using:
2015 RS Means CosrwOrke for labor, equipment and material coMpenants.
Local vendor end online supplier catalogs for currant competitive pricing an actuators, subplatea and transformers.
Applicant's vendor submitted estimates for spedaked immediate replacement of broken volute and pump.
Applicants vendor submitted estimate for speciaNad repair sf2 submersible pumps.
Applicant submitted vendor proposal for specialized service to remove and replace odeting damaged valve actuators,
The applicant did riot submit an fiernized estimate for the replacement of 'sub plates In the flushing valve vaults
Mei elute ari atlowanca was added for the roptocomonl arc-antral col-merino and Me reftehlabmant of existing poor! boards1enclosuros.
Subgrantes is requesting mitigation to Instal beckflow devices In 59 yanks. A Hazard Mitigation Proposal Is Included veto Ns project worksheet.
The Sub-Grantee is requesting Direct Adminiatrativa Costs that era dlredly chargeable to thlig specific project. Associated eigible work is related to administration of the Sub-Grantee Application only and
in accordance with 44 OFR 13.22. These costs are treated consistently and uniformly ea direct cells in eti federal awards and other Sub-Grantee activities and are not included In any approved indirect
cost rates.
44 CRF §13.35 Proturemant. (b) Procurement standards. (1) Grantees and subgrentees will use their own procurement prarodures which ratted applcable Stale and boat Taws and regulations,
provided that the procurements conform to applicable Federal law and the elandards identified In section 13,36,
As de Sedbed in 44 CFR 13.42 (2)(b), 3(0), Sub-Grantee must maintain atworhretuled records far a period of three (3) years from Sub-Grantee closure (final payment). Ail records re blive to thin Sub-
Grantee Appficallen are subject to examinatian and audit by the Stele, FEMA and the Comptroller General of the United States and must roiled work related to &ester spedlic casts.
Contracting Procedures:
As per Subgrantee:
Oaidand County has many blanket contracts that we utilize for as-needed and emergency services. These contracts are pubkaily hid thmugh our Purchasing Department end are usuely a performance
based bid considering things such as work experience resportsWonoss, references as wall as labor and equipment ratios,
lathe case with the 59 flooded valve vaude end Me subsequent electrical damages, we utilized Motor City Electric who we have a current contract tokh for instrumentation and control services. The
controls for this facility are unique end Motor City ties extensive somerlence and knowledge of this system. In 2009, there was some darnage to 3 of the 59 valve vaults and the electrical sublieles
required repladng, same as we are currently doing. Motor Citywas the contractor who performed the replacement work at a cost of approximately $13,000 par valve vault which is what wo had originally
estimated for tile recent damages. HOW0V91-, It was discovered that an of the equipment is currently outdated and no longer scalable, Meter City proposed to replace the damaged components with
sower technolcmy at a cost of apprckknately39,000 par valve vela which ls what w4 approved them to do.Thls le significantly less money than we orighelly enameled.
In the weeks that followed, it was discovered theist of the limit switches and valve actuators in Masa valve vaults ware also destroyed. We dldnot have a currant contract for Mese components, sown
mit them out for bids. Corrosion Fluid Products to the local representative for these Components and was subsequently the /ant/bidder.
The WRC has recently gone out for bids to procure several contracts for mechanical and plumbing contractors to perform additional as-needed services. Our office awarded 3 separate contracts for
these services and these contracts are non/is place, For ail of line remaining work yet to be completed, I intend lo have these three contractors protide quotes to compathively hid againsl each other,
Does the Scope of Work change the pre-disaster condtbns at the site? . Yes
'it No
Special Conskferations included? v*" Yes ; Ns
Hazard Mitigation proposal Included? 4, Yes I No is there insurance coverage ran this Wily? Idl Yes ' Na
PROJECT COST
ITEM CODE NARRATIVE QUANTITY/UNIT UNIT PRICE COST
Version 0 ***
Work Completed
1 9001 Contract 1/LS $ 7,149.72 $ 7,149,72
2 9007 Labor 1/LS $ 28,462.97 $ 28,462.97
3 9008 Equipment 1/LS $ 6,246.75 $ 6,246.75
4 9009 Material 1/LS $ 9,385.35 $ 9,385.35
Work To Bo Completed
8 9000 CEF Cost Estimate (See Attached Spreadsheet) liLS $ 938,59100 $ 935,593,00
Direct Subgrantee Admin Cost
6 9901 Direct Administrative Costs (Subgrantee) 1/LS $ 4,377,65 $ 4,377.85
7 0909 Hazard Mitigation Proposal 1/LS $ 175,820.00 $ 175,820.00
TOTAL COST $ 1,167,035,44
PREPARED BY DONALD CHASTAIN TITLE SIGNATURE
APPLICANT REP. Gary Nigro TITLE Assistant Chief Engineer SIGNATURE
OAKLAND COUNTY WATER RESOURCES COMMISSIONER t PA-06-MI-4195-PW-00141
Conditions Information
Review Name Condition Type Condition Name Description Monitored Status '
Final Review Other (EHP) Standard
Condition #1
Any change to the approved scope of work will require re-evaluation for compliance with NEPA and other Laws and Executive Orders. No Approved
Final Review Other (E1-119 Standard
Condition #3
If ground disturbing activities occur during construction, applicant wiii monitor
ground disturbance and if any potential archeological resources are discovered, will
immediately cease construction in that area and notify the State and FEMA. No Approved
Final Review Other (EHP)
,.-
Standard
Condition #2
This review does not address all federal, stale and local requirements. Acceptance
of federal funding requires recipient to comply with all federal, state and local laws.
Failure to obtain all appropriate federal, state and local environmental permits and
clearances mayleoperdlze federal funding.
No Approved
El-IF Review Other (EHP) Standard Condition #3
if ground disturbing activities occur during construction, applicant wit monitor
ground disturbance and if any potential archeological resources are discovered, wit
immediately cease construction in that area and notify the State and FEMA.
No Recommended
EHP Review Other (EHP) Standard
Condition #2
This review does not address ail federal, state and local requirements. Acceptance
of federal funding requires recipient to comply with ail federal, state and local laws.
Failure to obtain all appropriate federal, state and local environmental permits and
clearances May jeopardize federal funding. .
No Recommended
SF-IF Review Other (EHP) Standard
Condition #1
Any change to the approved scope of work wit require re-evaluation for compliance
with NEPA and other Laws and Executive Orders. No Recommended
insurance
Review
Conditions
(Grant Specific)
insurance
Requirement
02/22/2015 The applicant asserts that during incident period August 11-13, 2014
heavy rains and excessive runoff overwhelmed the storm water and sanitary
collection systems in Oakland County resulting in backups and flooding. The
applicant do net have any insurance affording coverage for the items listed on the
pw (see attached denial letter), There WIII not be a deduction taken for Insurance
proceeds as this in an uninsured loss, No purchase requirement of insurance
necessary. Coarse Tootle PA/insurance Specialist
No Recommended
: Internal Comments
NO. Queue User . Date/Time Reviewer Comments
5
'
Grantee Reviev EICKHOLT JAY 02-26-2015 06:30 PM GMT
'The acceptance of federal funding requires recipient to comply
with ell federal, state and local laws. Failure to obtain all
appropriote federal, stale and local environmental permits and
clearances may jeopardize federal funding.
In addition, applicant must maintain all grant-related records for
a period of three (3) years following receipt of your grant
closeout packet. All records relative to the grant are subject•to
examination and audit by the State and FEMA.
The applicant must comply with relevant local, state and federal
procurement laws and regulations. Federal rules are found In the
44 Code of Federal Regulations (CFR) 13.36 for State and Local
Governments or2 CFR Part 216 for Institutions of Higher
Education, Hospitals and Non-Profit Organizations.
'
4
•
EHP Review POULSON KAREN 02-23-2015 05:10 PM GMT
OAKLAND COUNTY WATER RESOURCES
COMMISSIONER. Wayne County, Repairs to retention
treatment basin contaminated debris removal to licensed facility,
mechanical, electrical, and structural repairs retention
description. Approved hazard mitigation proposal includes
Installation of backwater style check valves. (42,50775
-03.11177).
'
This project has bean determined to be Categorically Excluded
from the need to prepare either an Environmental Impact
Statement or Environmental Assessment In accordance with 44
CF R Part 10.8(d)(2)(15). Particular attention should be given to
the project conditions before and during project implementation.
Failure to comply with these conditions may jeopardize federal
assistance including funding,
- kpculson - 02123/2015 17:03:21 GMT
Per sub-grantee application, debris disposed at 2350 Brown
Road, Auburn, ivil. Sea attached Debris Certification - kpoulson
-02/23/2015 17:06:47 GMT
Par Flood insurance Rate Map (FIRM) panel (number), dated
(Month, DO, YYYY), the proleot is located outside the mapped
Special Flood Hazard Area (SFHA). - kpoulson -02123/2015
16:55:33 GMT
Per Flood insurance Rate Map (FIRM) panel (26126C0563F),
dated Seplember 29, 2006, the project is located outside the
mapped Special Flood Hazard Area (SFHA), - - kpouison -
0212312015 17:09:59 GMT
Per Programmatic Allowances adopted October 31, 2014, SOW
meets allowance Tier] A.1.d and Tier B.3.a and 8.3.f ,
pertaining to retention treatment basin contaminated debris
removal to licensed facility, mechanical, electrical, and
structural repairs with installation of backwater style check
valves. - kpouison - 02123/2015 14:09:06 GMT
3 insurance Review TOOTLE CORLISS 02-23-2015 02:38 AM GMT
02/22/2015 The applicant asserts that during Incident period
August 11-13, 2014 heavy rains and excessive runoff
overwhelmed the storm water and sanitary collection systems in
Oakland County resulting in backups and flooding. The
applicant do not have any insurance affording coverage for the
Items listed on the pw (see attached denial letter). There will
not be a deduction taken for insurance proceeds us this is art
uninsured loss. No purchase requirement of insurance
necessary. Cortes Tootle PA/insurance Specialist
2 Mitioation Review WORKMAN JAMES 01-21-2015 12:34 PM GMT
The mitigation measures incorporated Into this repair project are
consistent with R & R Policy 9526.1, VII. 9.2 (Appendix A) and
1 Initial Review
Initial review complete It Is recommended that all costs be
considered ellgibld. GKW 1120/15 WEBB GERALD 01-20-2015 09:12 PM GMT
Page 2 of 2
Generated Date: 03/10/2015 13:38
Federal Emergency Management Agency
Project Cam olefin and CartMeatiest Report (P,4)
Disaster; FEMA-4195-DR-MI
Applicant PEPS ID: I 25.U.TZPI.G0 Applicant/Subdivision Name: OAKLAND COUNTY WATER RESOURCES COMMISSIONER
Certification
I hereby certify that to the best of my knowledge and belief all work and costs claimed are eligible in I certify that all funds were expended in accordance with the provisions of the signed accordance with the grant conditions, all work claimed has bean completed, and all costs claimed hove FEMA-Stata Agreement and( riecaurriend an approved amount of $ been paid in fall.
Signed: Date:
Applicads Authorized Representative
Signed: Date:
Governor's Authorized Representative
https://isouree.fema.gov/emmie/common/view/p4Reportjsp?printBtn=print&app jds,----125... 3/10/2015
U. S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
ASSURANCES.CONSTRUCTION PROGRAM
O.M.B. No. 1860-0025
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 corner 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.
NOTE"
Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the Awarding Agency. Further, certain
federal assistance awarding agencies may require applicants to certify 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 cost) 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 States, through any
authorized representative, access to and the right to examine all
records, books, papers, or documents related to the assistance;
and will establish a paper accounting system in accordance with
generally accepted accounting standards or agency directives.
3. Will not dispose of, modify the use of, or change the terms of
the real property title, or other interest in the site and facilities
without permission and Instructions from the awarding agency.
WM record the Federal interest in the title of real property in
accordance with awarding agency directives and will include a
covenant in the title of real property acquired in whole or in part
with Federal assistance funds to assure nondiscrimination during
the useful life of the project.
4. Will comply with the requirements of the assistance awarding
agency with regard to the drafting, review and approval of
construction plans and specifications.
5. Will provide and maintain competent and adequate engineering
supervision at the construction site to ensure that the complete
work conforms with the approved plans and specifications and will
furnish progress reports and such other information as may be
required by the assistance awarding agency or state.
6. Will Initiate and complete the work within the applicable time
frame after receipt of approval of the awarding agency.
7. Wei establish safeguards to prohibit employees from using their
positions for a purpose that constitutes or presents the
appearance of personal or organizational conflict to Interest, or
personal gain.
8. Will comply with Intergovernmental Personnel Act of 1970 (42
U.S.C. Sections 4728-4763) 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 a Merit System of Personnel Administration (5 C.F.R.
900-subpart F).
9. Will comply with the Lead-Based Paint Poisoning 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.
10. Will comply with all Federal statues relating to
non-discrimination. 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. Sections 794)
which prohibits discrimination on the basis of; (d) the Age
Discrimination Act of 1975, as amended (42 U.S.C. Sections
8101-61-7) which prohibits discrimination on the basis of age; (e)
the Drug Abuse Office Treatment Act of 1972 (P.L 93-255), as
amended, relating to non-discrimination on the bases of abuse;
(1) the Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment and Rehabilitation Act of 1970
(Pl. 91-616), as amended, relating to nondiscrimination on the
bases 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 Act of
1988(42 U.S.C. Sections at seq.), as amended, relating to
non-discrimination in the sale, rental or financing of housing; (i)
and other non-discrimination provisions in the specific statutes(s)
under which application for Federal assistance Is being made, and
0) the requirements on any other non-discrimination Statues(s)
which may apply to the application,
11. 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 (FL. 91-646) which
provides for fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal and Federally
assisted programs. These requirements apply to all interest in
real property acquired for project purpose regardless of Federal
participation In purchases.
12. Will comply with the provisions of the Hatch Act (5 U.S.C.
Sections 1501-1508 and 7324-7328) which limit the political
activities of employment activities are funded in whole or impart
with Federal funds.
13. Will comply, as applicable, with the provisions of the
Davis-Bacon Act (40 U.S.C. Sections 27a to 276a-7), the
Copeland Act (40 U.S.C. Section 276c and 18 U.S.C. Section
674), the Contract Work Hours and Safety Standards Act (40
U.S.C. Sections 327-333) regarding labor standards for Federally
assisted construction subagreements.
FEMA Form 20-16B, OCT 04 PREVIOUS EDITION OBSOLETE
U.S DEPARTMENT OF FIOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
ASSURANCES-NONCONSTRUCTION PROGRAMS
0.M.13. No. 1660-0025
Expires July 31, 2007
Paperwork Burden Disclosure Notice
Paperwork reporting burden for this form is estimated to average 1,7 hours per response The burden estimate includes 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 corner of this form. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing the burden estimate to: information Collection Management, U. S. Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472. NOTE: Do not send your completed form to the above address.
NOTE:
Certain of these assurances may not be applicable to your project or program. If you have any questions, please contact the awarding agency. Further,
certain Federal awarding agencies may require applicants to certify to additional assurances. If such lathe 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 fonds 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,
6. Will comply with the intergovernmental Personnel Act of 1970 (92
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 1685-1886), 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 a) 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!!
and ill 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 subegreements.
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 (EC) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EC
11990; (d) evaluation of flood hazards in floodplains in accordance with EC)
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 at seq.); (f) conformity of Federal
actions to State (Clear Air) Implementation Plans under Section 170 (c) of
the Clear Air Act of 1955, as amended (42 U.S.C. Section et seq.); (9) 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 at seq.) related to protecting components of the national
wild and scenic rivers systems.
13. MI assist the awarding agency In assuring compliance with Section
106 of the National Historic Preservation Act of 1986, as amended (16
U.S.C. 470), EC) 11693 (Identification and protection of historic properties),
and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C.
469e-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 at 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
14. Will comply with the flood Insurance purchase requirements of
Section 102(a) of the Flood Disaster Protection Act of 1973 (Pt.
93-234) which requires recipients In a spedal flood hazard area to
participate in the program and to purchase flood insurance in the
total cost of insurable construction and acquisition is 10,000 or
more.
15. 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 (PL. 91-190) and Executive
Order (6.0.) 11514: (b) notification of violating facilities pursuant
to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d)
evaluation of flood hazards In floodprains In accordance with 50
11988; (e) assurance of project consistency with the approved ,
State management programs developed under the Coastal Zone
Management Act of 1973 (16 U.S.C. Sections 1451 et seq.); (f)
conformity of Federal actions to State (Clean Air) Implementations
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, (PL. 93-523); (H) Protection of
Endangered species Act of 1973, as amended, (P.L. 93-205).
16. Will comply with the Wild and Scenic Rivers Act of 1968 (16
U.S.C. Sections 1271 et seq.) related to protecting components or
potential components of tho national wild and scenic rivers
system.
17. 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), E0 11593 (Identification and
preservation of historic properties), and the Archaeological and
Historic Preservation Act of 1974 (16 U.S.C. 46s-1 at seq.).
18. VVill cause to be performed the required financial and
compliance audits in accordance with the Single Audit Act of
1984.
19. Will comply with all applicable requirements of all other
Federal laws, Executive Orders, regulations and policies
governing this program.
20, 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.
21. It will obtain approval by the appropriate Federal agencies of
the final working drawings and specifications before the project is
advertised or placed on the market for bidding; that It will
construct the project, or cause it to be constructed, to final
completion in accordance with the application and approved plans
and specifications; that It will submit to the appropriate Federal
agency for prior approval changes that alter the cost of the
project, use of space, or functional layout; that it will not enter into
a construction contract(s) for the project or undertake other
activities until the conditions of the construction grant program(s)
have been met.
22. It will operate and maintain the facility in accordance with the
minimum standards as may be required or prescribed by the
applicable Federal, State, and local agencies for the maintenance
and operation of such facilities,
23.. It will require the facifity to be designed to comply with the "American
Standard Specifications for Making Buildings and Facilities Accessible to,
and Usable by, the Physically Handicapped; Number A117-1961, as
modified (41CFR 101-17.703). The applicant will be responsible for
conducting inspections to ensure compliance with these specifications by
the contractor.
24. If any real property or structure thereon is provided or improved with
the aid of Federal financial assistance extended to the applicant, this
assurance shall obligate the applicant, or in the case of any transfer of such
property, any transferee, for the period during which the real property or
structure Is used for a purpose for which the Federal financial assistance Is
extended or for another purpose Involving the provision of similar services
or benefits.
25. In making subgrants with nonprofit institutions under this
Comprehensive Cooperative Agreement, it agrees that such grants will be
subject to OMB Circular A-122, "Cost Principles for Non-profit
Organization" including but not limited to, the "Lobbying Revision"
published in vol 49, Federal Register, pages 18260 through 18277 (April
27, 1984).
EMD-053 (1212014)
MICHIGAN STATE POLICE
Emergency Management and Homeland Security Division
AUDIT CERTIFICATION
AUTHORITY: 1976 PA 390, MCL 30.407a, Single Audit Act of 1984, PL 98-502, as amended;
COMPLIANCE: Voluntary, but necessary to be considered for grant assistance
Federal Audit Requirements
Non-federal organizations which expend $500,000 or more In federal funds during their current fiscal year or expend
$750,000 or more in federal funds in a fiscal year beginning on or after December 26, 2014, are required to have an audit
performed in accordance with the Single Audit Act of 1984, as amended, and Office of Management and Budget (OMB)
Circular A-133 or 2 CFR 200 after December 26, 2014. Subgrantees MUST submit a copy of their audit report for each
year they meet the funding threshold to: Michigan State Police, Grants and Community Services Division, 333 South
Grand Avenue, Lansing, Michigan 48933.
Program Name CEDA Number
•.' • ..,. ...: ubgrantee Information
Jurisdiction Name
Street Address City State ZIP Code
II. , Certification far FiScal.Year
Subgrantee Fiscal Year Period: to .
Er I certify that the subgrantee shown above does NOT expect it will be required to have an audit
the Single Audit Act of 1984, as amended, and the OMB Circular, as revised, for the above listed
n . I certify that the subgrantee shown above expects it will be required to have an audit performed
Audit Act of 1984, as amended, and the OMB Circular as revised, during at least one fiscal year
for the above listed program. A copy of the audit report will be submitted to: Michigan State and Community Services Division, 333 South Grand Avenue, Lansing, Michigan 48933.
Signature of Subgrantee's Authorized Representative
performed under
program.
under the Single
funds are received
Police, Grants
Date
Submit Completed Document To:
Emergency Management and Homeland Security Division
Michigan Department of State Police
Attention: Grants Development Unit
4000 Collins Road
Lansing, Michigan 48910
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.8. 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 corner 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, "Government-wide Debarment and Suspension (Nonprocurement)
and Government-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. Cade, 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 01 t:ongress, 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 subreclpients shall certify and disclose
accordingly.
Standard Form-LLL "Disclosure of Lobbying Activities" attached
(This form must be attached to certification if nonapproprlated 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
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 he 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- Place of Performance (Street address, City, County, State, Zip code)
(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:
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.
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse for public burden disclosure.)
Approved by OMB
0348-0046
1. Type of Federal Action: 2. Status of Federal Action:
award
a. bid/offer/application
3. Report Type:
change
Change Only;
quarter
a. contract a. initial filing
b. grant
c, cooperative agreement
d, loan
e. loan guarantee
f. loan insurance
1b. initial
c. post-award
b. material
For Material
year
date of last report
4. Name and Address of Reporting Entity:
, if known:
4c
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:
Congressional District, if known:
lil Prime 0 Subawardee
. Tier
Congressional District, if known:
6. Federa Department/Agency: 7. Federal Program Name/Description:
OFDA Number, if applicable: --
8. Federal Action Number, if known: 9. Award Amount, if known:
$
10. a. Name and Address of Lobbying Registrant
(if individual, last name, first name, M1):
b. Individuals Performing Services (including address if
different from No. 10a) ,
(last name, first name, M1):
it Information requested through this form Is authorized by llite 31 LI.S.C. section
1352. This disclosure of lobbying activities is a material representation of fact
upon which reliance woo placed by the Our above when this transaction won made
or entered Into. This disclosure Is required pursuant lo 31 U.S.C. 1352. This
information will be available for public Inspection. Any person who fella to file the
required disclosure shail be subject Los civil penalty of not lass than $10.000 and
not more then $100,000 for each such failure.
Signature:
Print Name:
Title:
Telephone No.: Date:
Federal Use Only:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)
INSTRUCTIONS FOR COMPLETION OF SE.LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make
payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or empioyeeof
Congress, or an amployeeof a Memberof Congress in connection with a covered Federal action. Completeall items that apply for both the initial filing and material
change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information,
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. identify the appropriate classification of this report. if this is a followup report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the data of the last previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification
of the reporting entity that designates if it Is, or expectsto be, a prime or subaward recipient. Identify the tier of the subawardee,e.g., the first subawardee
of the prime is the 1st tier. Subawards Include but are not limited to subcontracts, subgrente and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevel below agency name, if known. For
example, Department of Transportation, United States Coast Guard.
7, Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.
0. Enter the most appropriate Federal identifying number available for the Federal action identified In item 1 (e.g., Request for Proposal (RFP) number;
Invitation for Bid (1FB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number
assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001,"
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity Identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity Identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the Individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless It displays a valid OMB Control
Number. The valid OMB control number for this information collection is OMB No. 048-0046. Public reporting burden for this collection of Information is
estimated to average 10 minutes per response, Including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of Information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington,
DC 20503.
US. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
SUMMARY SHEET FOR ASSURANCES AND CERTIFICATIONS
0.M.B. No. 1660-0026
Expires July 31, 2007
FOR CA FOR (Name of Recipient)
II FY
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
Part II
Part ill
Part IV
FEMA Form 20-16A, Assurances-Nonconstruction Programs
FEMA Form 20-1613, Assurances-Construction Programs
FEMA Form 20-160, Certification Regarding Lobbying;
Debarment, Suspension, and Other Responsibility
Matters; and Drug-Free Workplace Requirements
SF LLL, Disclosure of Lobbying Activities Of applicable)
As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the identified
attached assurances and certifications.
Typed Name of Authorized Representative Title
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 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, 600 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.
FEIVIA Form 2046, OCT 04 PREVIOUS EDITION OBSOLETE
Form W-9
(Rev. December 2014)
Department of the Treasury
internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
1 Name (as shown on your income tax return). Name is required on this line; do not reeve this line blank,
2 Business name/disregarded entity name, If different from above
3 Check appropriate box for fedora) tax classification; check only one of the following seven boxes:
0 individual/sole proprietor or 0 0 Corporation 0 S Corporation 0 Partnership 0 Trust/estate single-member LLC
0 Limited liability company. Enter the tax classification (0=0 corporation, S=S corporation, P=partnership)i
Note. For a single-member LLG that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.
0 Other (see instructions) IP,
4 Exemptions (codes apply only to
certain entitles. not Individuals: see
Instructions on page 8):
Exempt payee code (f any)
Exemption from FATCA reporting
code (If any)
Oppros to accounts malof &nod Made. the U.S.)
5 Address (number, street and apt. or suite no.)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Requester's name and address (optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part instructions on page 3. For other
entities, It Is your employer identification number (E1N). If you do not have a number, see How to get a TIN on page 3.
Note. If the account lain more than one name, see the Instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
GEN Certification
Social security number
or
Employer identification number
Under penalties of perjury, I certify that:
1, The number shown on this form is my correct taxpayer Identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (If any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
Instructions on page 3.
Sign
Here Signature of
U.S. person 0- Date*
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release It) is at www,Irs.govilw9.
Purpose of Form
An Individual or entity (Form W-9 requester) who is required to file an Information
return with the IRS must obtain your correct taxpayer identification number (FIN)
which may be your social security number (SSN). Individual taxpayer Identification
number (ITIN), adoption taxpayer Identification number (AM), or employer
Identification number (EN), to report on an information return the amount paid to
you, or other amount reportable on an information return. Examples of Information
returns include, but are not limited to, the following:
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by
brokers)
• Form 1099-S (proceeds from real estate transactions)
P Form 1099-K (merchant card and third party network transactions)
• Form 1028 (home mortgage Interest), 1098-E (student loan Interest), 1098-T
(tuition)
• Form 1099-G (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-G only if you are a U.S. person (including a resident alien), to
provide your correct TIN,
if you do not return Form W-9 to the requester with a TIN, you might be subject
to backup withholding. See What is backup withholding? on page 2.
By signing the filled-out form, you:
1. Certify that the TIN you are giving Is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding If you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of
• any partnership income from a U.S. trade or business Is not subject to the
withholding tax on foreign partners' share of effectively connected Income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct. See What Is FATCA repotting? on page 2 for further information.
Cat. No. 10231X Form W-9 (Rev. 12-2014)
Form W-9 (Rev, 12-2014) Page 2
Note. If you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requester's form if it is substantially
similar to this Form W-9.
Definition Of a U.S. person. For federal tax purposes, you are considered a U.S.
person if you are:
• An individual who is a U.S. citizen or U.S. resident alien;
• A partnership, corporation, company, or association created Or organized In the
United States or under the laws of the United States;
• An estate (other than a foreign estate); or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in
the United States are generally required to pay a withholding tax under section
1446 on any foreign partners' share of effectively connected taxable Income from
such business, Further, in certain cases where a Form W-9 has not been received,
the rules under section 1446 require a partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
U.S. person that is a partner in s partnership conducting a trade or business In the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership Income.
In the cases below, the following person must give Form WI to the partnership
for purposes of establishing its U.S. status and avoiding withholding on its
allocable share of net income from the partnership conducting a trade or business
In the United States:
• In the case of a disregarded entity with a U.S, owner, the U.S. owner of the
disregarded entity and not the entity;
• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally,
the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
In the case of a I S, trust {other than a grantor trust), the U.S. trust (other than a
grantor trust) and not the beneficiaries of the bust,
Foreign person. If you are a foreign person or the U.S. branch of a foreign bank
that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use
the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax
on Nonresident Aliens and Foreign Entitles).
Nonresident alien who becomes a resident alien. Generally, only a nonresident
alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a provision Known as
a "saving clause." Exceptions specified In the saving clause may permit an
exemption from tax to continue for certain types of income even after the payee
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception contained in tine
saving clause of a tax treaty to claim an exemption from U.S. tax on certain types
of income, you must attach a statement to Form W-9 that specifies the following
five items;
1. The treaty country. Generally, this must be the same treaty under which you
claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the saving
clause and its exceptions.
4. The type and amount of income that qualifies for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the treaty
article,
Example. Article 20 of the U,S.-China Income tax treaty allows an exemption
from tax for scholarship Income received by a Chinese student temporarily present
In the United States, Under U.S. law, this student will become a resident alien for
lax purposes if his or her stay in the United States exceeds 5 calendar years.
However, paragraph 2 of the first Protocol to the U.S.-ChIna treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply even after the
Chinese student becomes a resident alien of the United States, A Chinese student
who qualifies for this exception (under paragraph 2 of the first protocol) and Is
relying on this exception tre claim an exemption from tax on his or her scholarship
or fellowship income would attach to Form W-9 a statement that includes the
Information described above to support that exemption.
if you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233,
Backup Withholding
What is backup withholding? Persons making certain payments to you must
under certain conditions withhold and pay to the IRS 28% of such payments. This
is eailed 'backup withholding." Payments that may be subject to backup
withholding include interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, payments made in
settlement of payment card and third party network transactions, and certain
payments from fishing boat operators, Real estate transactions are not subject to
backup withholding.
You will not be subject to backup withholding on payments you receive if you
give the requester your correct TIN, make the proper certifications, and report all
your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II instructions on page
3 for details),
3. The IRS tells the requester that you furnished an Incorrect TIN,
4, The IRS tells you that you are subject to backup Withholding because you did
not report all your Interest and dividends on your tax return (for reportable Interest
and dividends only), or
5. YOU do not certify to the requester that you are not subject to backup
withholding under 4 above (for reportable Interest and dividend accounts opened
after 1963 only).
Certain payees and payments are exempt from backup withholding. See Exempt
payee code an page 3 and the separate instructions for the Requester of Form
W-9 for more information.
Also see Special rules for partnerships above.
What is FATCA reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign
financial institution to report all United States account holders that are specified
United States persons. Certain payees are exempt from FATCA reporting. See
Exemption from FATCA reporting code on page 3 and the Instructions for the
Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be
an exempt payee if you are no longer en exempt payee and anticipate receiving
reportable payments In the future from this person. For example, you may need to
provide updated information if you are a 0 corporation that elects to be an S
corporation, or if you no longer are tax exempt. In addition, you must furnish a new
Form W-9 if the name or TIN changes for the account; for example, if the grantor
of a grantor trust dies,
Penalties
Failure to furnish TIN. II you fail to furnish your correct TN to a requester, you sio
subject to a penalty of $50 for each such failure unless your failure is due to
reesonable cause and not to willful neglect,
Civil penalty for false Information with respect to withholding. If you make a
false statement with no reasonable basis that results in no backup withholding,
you are subject to a Om penalty.
Criminal penalty for falsifying information. Willfully falsifying certifications or
affirmations may subject you to criminal penalties including fines and/or
imprisonment.
Misuse of TINs. if the requester discloses or uses TiNs in violation of federal law,
the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1 .
You Must enter one of the following on this line; do not leave this line blank, The
name should match the name on your tax return.
If this Form W-9 Is for a joint a0count, list first, and then circle, the name of the
person or entity whose number you entered le Part I of Form W-9.
a. individual. Generally, enter the name shown on your tax return. If you have
changed your Fast name without Informing the Social Security Administration (SSA)
of the name change, enter your first name, the last name as shown on your social
security card, and your new last name.
Note. ITIN applicant: Enter your Individual name as it was entered on your Form
W-7 application, line la. This should also be the same as the name you entered on
the Form 1040/1040A/1040EZ you filed with your application.
b. Sete proprietor or single-member LLC. Enter your individual name as
shown on your 1040/1040N1040EZ an line 1. You may enter your business, trade,
or "doing business Ele (DBA) name on line 2.
o. Partnership, LLC that Is not a single-member LLC, C Corporation, or S
Corporation. Enter the entity's name as shown on the entity's tax return on line 1
and any business, trade, or DBA name on line 2.
d. Other entitles. Enter your name as shown on required U.S. federal lax
documents on line -1.1We name should match the name shown on the charter or
other legal document creating the entity. You may enter any business, trade, or
DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner Is treated as a "disregarded
entity," See Regulations section 301.7701-2(c)(2)011). Enter the owner's name on
line 1. The name of the entity entered on line 1 should never be a disregarded
entity. The name on line I should be the name shown on the income tax return on
which the Income should be reported. For example, if a foreign la.C. that is treated
as a disregarded entity for U.S. federal tax purposes has a single owner that is a
U.S. person, the U.S. owner's name Is required to be provided on line 1. If the
direct owner of the entity Is also a disregarded entity, enter the first owner that is
not disregarded for federal tax purposes. Enter the disregarded eraity'th name on
line 2, "Business name/disregarded entity name." if the owner of the disregarded
entity is a foreign person, the owner must complete an appropriate Form W-8
instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.
Form IN-9 (Rev. 12-2014)
Page 3
Line 2
If you have a business name, trade name, DBA name, or disregarded entity name,
you may enter It on line 2.
Line 3
Check the appropriate box in line 3 for the U.S. federal tax olasslfication of the
person whose name Is entered on line /. Check only one box In line 3.
Limited Liability Company (LLC). If the name on Ilne lean LLC treated as a
partnership for U.S. federal tax purposes, check the "Limited Liability Company"
box and enter "P" in the space provided. If the LLC has filed Form 8832 or 2553 to
be taxed as a corporation, check the "Limited Liability Company" box and In the
space provided enter '0" for C corporation or "S" for S corporation. If it is a
single-member LLC that Is a disregarded entity, do not oheck the "Limited Liability
Company' box; Instead cheolcthe first box in Eno 3 "inclividuaVsole proprietor or
sIngle-member LLC."
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter In the
appropriate space in line 4 any code(s) that may apply to you
Exempt payee code.
* Generally, Individuals (including sole proprietors) are not exempt from backup
withholding.
• Except as provided below, corporations are exempt from backup withholding
for certain payments, including interest and dividends.
* Corporations are not exempt from backup withholding for payments made in
settlement of payment card or third party network transactions.
• Corporations are not exempt from backup withholding with respect to attorneys'
fees or gross proceeds paid to attorneys, and corporations that provide medical or
health care services are not exempt with respect to payments reportable on Form
1099-MISC.
The following codes Identify payees that are exempt from backup withholding.
Enter the appropriate code In the space In line 4.
1—An organization exempt from tax under section 5131(a), any IRA, or a
custodial account under section 403(b)(7) if the account satisfies the requirements
of section 401(f)(2)
2—The United States or any of its agencies or inetrumentaiities
3—A state, the District of Columbia, a U.S. commonwealth or possession, or
any of their political subdivisions or Instrumentalities
4—A foreign government or any of Its political subdivisions, agencies, or
Instrumentalities
5—A corporation
6--A dealer in securities or commodities required to register in the United
States, the District of Columbia, or a U.S. commonwealth or possession
7—A futures commission merchant registered with the Commodity Futures
Trading Commission
8—A real estate investment trust
9—An entity registered at all limes during the tax year under the Investment
Company Act of 1940
1D—A common trust fund operated bet a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described In section 4947
The following chart shows types of payments that may be exempt from backup
Withholding. The chart applies to the exempt payees listed above, 1 through 13.
IF the payment Is for. .. THEN the payment is exempt far ...
Interest and dividend payments Al exempt payees except
for 7
Broker transactions Exempt payeee 1 through 4 and 6
through 11 and all C corporations. 8
corporations must not enteran exempt
payee code because they are exempt
only for sales of noncovered securities
acquired prior to 2012.
Barter exchange transactions and
patronage dividends .
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over $5,000
Generally, rexempt payees
1 through 5e
'
Payments made In settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
See Form 1099-MISC, Miscellaneous income, and its heath:lions.
2 However, the following payments made to a corporation and reportable on Form
1099-M1SC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney reportable under
section 6045(0, and payments for services paid by a federal executive' agency.
Exemption from FATCA reporting code. The following codes identify payees
that are exempt from reporting under FATCA. These codes apply to persons
submitting this form for accounts maintained outside of the United States by
certain foreign financial institutions. Therefore, If you are only submitting this form
for an account you hold In the United States, you may leave this field blank,
Consult with the person requesting this form if yeiu are uncertain if the financial
Institution is subject to these requirements. A requester may Indicate that a code is
not required by providing you with a Form W-9 with "Not Applicable" (or any
similar indication) written or printed on the line for a FATCProxemption code.
A—An organization exempt from tax under section 501(a) or any individual
retirement plan es defined In section 7701(s)(37)
• El—The United States or any of its agencies or instrumentalities
C—A state, the District of Columbia, a U.S. commonwealth or possession, or
any of their political subdivisions or Instrumentalities
D—A corporation the stock of which is regularly traded on one or more
established securities markets, as described In Regulations section
1.1472-1(0)MM
E—A corporation that le a member of the same expanded affiliated group as a
corporation described in Regulations section 1.1472-1(c)(1)(1)
F—A dealer in securities, commodities, or derivative financial Instruments
(including notional principal contracts, futures, forwards, and options) that Is
registered as such under the laws of the United States or any state
G—A real estate investment trust
I-I—A regulated investment company as defined in section 851 or an entity
registered at all times during the tax year under the investment Company Act of
1940
I—A common trust fund as defined in section 584(a)
,J—A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described In section 4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g) plan
Note. You may wish to consult with the financial institution requesting this form to
determine whether the FATCA code and/or exempt payee code should be
completed.
Line 5
Enter your address (number, street, and apartment or suite number). This Is where
the requester of this Form W-9 will mail your Information returns.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box, if you are a resident alien and you do not
have and are not eligible to get an SSN, your TIN Is your IRS individual taxpayer
identification number (ITIN). Enter It in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
if you are a sole proprietor and you have an SIN, you may enter either your SSN
or SIN, However, the IRS prefers that you use your SSN.
If you are a single-member LLC that is dIsregareed as an entity separate from its
owner (see Limited Liability Company (LW) on this page), enter the owner's SSN
(or SIN, If the owner has one). Do not enter the disregarded entity's EN. If the LLC
Is classified as a corporation or partnership, enter the entity's EIN.
Note. See the chart on page 4 for further clarification of name and TIN
combinations.
How to get a TIN, if you do not have a TIN, apply for one immediately. To apply
for an SSN, get Form 68-5, Application for a Social Security Card, from your local
SSA office or get this form online at www.ssa.gov. You may also get this form by
calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer
Identification Number, to apply for an iTIN, or Form SS-4, Application for Employer
identification Number, to apply for an EIN. You can apply for an EIN online by
accessing the IRS website at www.irs.govlbusinesses and clicking on Employer
Identification Number (BIN) under Starting a Business, You can get Forms W-7 and
53-4 from the IRS by visiting iRS.gov or by calling 1-800-TAX-FORM
(1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN
and write 'Applied For" in the space for the TIN, sign and dale the form, and give it
to the requester. For Interest and dividend paymeets, and certain payments made
with respect to readily tradable Instruments, generally you will have 60 days to get
a TIN and give it to the requester before you are subject to backup withholding on
payments. The 60-day rule does not apply to other types of payments. You will be
subject to baokup withholding on all such payments until you provide your TIN to
the requester.
Note, Entering "Applied For' means that you have already applied for a TIN or that
you intend to apply for one soon.
Caution; el disregarded U.S. entity that has a foreign owner must use the
appropriate Form W-8.
Form W-9 (Rev. 12-2014) Page 4
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien,
sign Form W-9. You may be requested to sign by the withholding agent even if
items 1, 4, or 5 below Indicate otherwise.
For a joint account, only the person whose TIN is shown in Part I should sign
(when required). In the case of a disregarded entity, the person identified on line 1
must sign. Exempt payees, see Exempt payee code earlier.
Signature requirements. Complete the certification as indicated In items 1
through 5 below.
1. Interest, dividend, and barter exchange accounts opened before 1984
and broker accounts considered active during 1983. You must give your
correct TIN, but you do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange accounts opened after
1983 and broker accounts considered inactive during 1983. You must sign the
certification or backup withholding will apply. If you are subject to backup
withholding and you are merely providing your correct TIN to the requester, you
must cross out Item 2 In the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out
item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not have to sign
the certification unless you have been notified that you have previously given an
Incorrect TIN. "Other payments" include payments made in the course of the
requester's trade or business for rents, royalties, goods (other than bills for
merchandise), medical and health care services (including payments to
corporations), payments to a nonempioyee for services, payments made in
settlement of payment card and third party network transactions, payments to
certain fishing boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations),
S. Mortgage intattat paid by you, acquisition or abandonment of cocurad
properly, cancellation of debt qualified tuition program payments (under
section 529), IRA, Coverdelt ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct TIN, but you
do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account: Give name and SSN of:
1. Individual
2. Two or more individuals (joint
account)
3. Custodian account of a minor
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
trust (grantor Is also trustee)
b. So-called trust account that Is
not a legal or \mild trust under
state law
5. Solo proprietorship or disregarded
entity owned by an individual
6. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations section 1,671-4(b)(2)(1)
(A))
The Individual
The actual owner of the account or,
if combined funds, the first
individual on the account'
The minor'
The grantor-trustee'
The actual owner'
The owner'
The grantor'
For this type of account: Give name and EiN of:
7. Disregarded entity not owned by an
individual
8. A valid trust, estate, or pension trust
9. Corporation or 110 electing
corporate status on Form 8832 or
Form 2553
10. Association, club, religious,
charitable, educational, or other tax-
exempt organization
11. Partnership or multi-member LLC
12. A broker or registered nominee
13. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
14. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(1)
(B))
1115 owner
Legal entity'
The corporation
The organization
The partnership
The broker or nominee
Tile public entity
The trust
List first and-circle the nanle of the person whose number you furnish. If only one person on e
Joint account has an 5514, that person's number must be furnished.
2 Circle theMinors name and furnish the minor's SSN.
'You must show your individual name and you rnay also enter your business or DBA name on
the 'Business name/disregarded entity" name line. You may use either your SSN or BM (11 you
have one), but the IRS encourages you to use your SSW.
'List fret and circle the name of the trust, estate, or pension trust. (Co not furnish ihe TIN of the
personal representative or trustee unless the legal entity itself is eat designated 'nth° account
title.) wco see Spec fa! rules far partnerships tn page S.
'Note. Grantor also must provide e Form w-9 to trustee of frost.
Note. If no name Is circled when more than one name is listed, the number will be
considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
identity theft occurs when someone uses your personal information such as your
name, SSN, or other identifying information, without your permission, to commit
fraud or other crimes. An Identity thief may use your SSN to get a job or may flea
tax return using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your ssnt, and
• Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a notice from
the IRS, respond right away to the name and phone number printed on the IRS
notice or letter.
If your tax records are not currently affected by identity theft but you think you
are at risk due to a lost or stolen purse or wallet, questionable credit card activity
or credit report, contact the IRS identity Theft Hotline at 1-800-908-4490 or submit
Form 14039.
For more information, see Publication 4535, Identity Theft Prevention and Victim
Assistance.
Victims of identity theft who are experiencing economic harm or i system
problem, or are seeking help in resolving tax problems that have not been resolved
through normal channels, may be eligible for Taxpayer Advocate Service (TAS)
assistance. You can reach TAS by calling the TAS toil-free case Intake line at
1-877.7774778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious smalls or phishing schemes. Phlshing is the
creation and use of email and websites designed to mimic legitimate business
emails and websites. The most common act is sending an email to a user falsely
claiming to be an established legitimate enterprise In an attempt to scam the user
Into surrendering private information that wit be used for identity theft.
The IRS does not initiate contacts with taxpayers via smells. Also, the IRS does
net request personal dote/lad information through email or ask taxpayers for the
PIN numbers, passwords, or similar secret access information for their credit card,
bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this
message to phishing@ire.gov. You may also report Misuse of the IRS name, logo,
or other IRS property to the Treasury Inspector General for Tax Administration
(TIGTA) at 1-800-380-4484. You can forward suspicious emails to the Federal
Trade Commission at: spemcituce,gov or contact them at www.ftc.goWidtheft or
4-877-IDTHEFT (1-877-438-4338).
Visit IRS.gov to learn more about identity theft and how to reduce your risk.
Privacy Act Notice
Section 0109 of the Internal Revenue Code requires you to provide your correct
TIN to persons (including federal agencies) who are required to file information
returns with the IRS to report Interest, dividends, or certain other income paid to
you; mortgage interest you paid; the acquisition or abandonment of secured
property; the cancellation of debt; or contributions you made loan IRA, Archer
MSA, or NSA. The person collecting this form Uses the information on the form to
file information returns with the IRS, reporting the above information. Routine uses
of this information include giving it to the Department of Justice for civil and
criminal litigation and to cities, states, the District of Columbia, and U.S.
commonwealths and possessions for use in administering their laws. The
information also may be disclosed to other countries under a treaty, to federal and
state agencies to enforce olvil and criminal laws, or to federal law enforcement and
Intelligence agencies to combat terrorism. You must provide your TIN whether or
not you are required to file a tax return. Under section 3400, payers roust generally
withhold a perosintage of taxable Interest, dividend, and certain other payments to
a payee who does not give a MN to the payer. Certain penalties may also apply for
providing false or fraudulent information.
FISCAL NOTE (MISC #15123) May 6, 2015
BY: Finance Committee, Tom Middleton, Chairperson
IN RE: HEALTH AND HUMAN SERVICES - HOMELAND SECURITY DIVISION — STATE OF
MICHIGAN PUBLIC ASSISTANCE GRANT AGREEMENT - OAKLAND COUNTY WATER RESOURCES
COMMISSIONER - ACCEPTANCE
To the Oakland County Board of Commissioners
Chairperson, Ladies and Gentlemen:
Pursuant to Rule XII-C of this Board, the Finance Committee has reviewed the above-referenced
resolution and finds:
1. Pursuant to the President of the United States declaring a disaster for Macomb, Oakland and
Wayne Counties as a result of damage from severe storms and flooding during the period of
August 11-13, 2014, a Project Application Grant Report was submitted and Oakland County has
been notified by the Michigan Department of State Police, Emergency Management and
Homeland Security Division that $875,277 of funding is eligible for the Water Resources
Commissioner related costs.
2. The purpose of this agreement is to provide supplementary financial assistance for disaster relief
including funds for emergency and permanent work.
3. A portion of the funding, in the amount of $865,624, received from the grant award has been used
for replacement and rehabilitation of electrical, controls, mechanical equipment and structures for
the South Oakland County Sewage Disposal System (SOCSDS) also known as the George W
Kuhn Retention and Treatment Basin.
4. The remaining portion of the funding, in the amount of $9,653, received from the grant award has
been used for the purchase and installation of a security gate at the discharge point of the Henry
Graham Chapter 20 Drainage District.
5. This grant requires a 25% match totaling $291,759 in the SOCSDS Pollution Control Fund
(#58520) and Henry Graham Drain Ch20 Fund (#82494) expenses, bringing the overall program
costs to $1,167,036.
6. The FY 2015 Budget is amended as follows to reflect the grant award:
SOCSDS POLLUTION CONTROL FUND (#58520)
Project ID 100000002004
FY 2015
Revenues
6010101-149667-690191 Capital Contr-Federal Grants
Total Revenues
$ 865.624
$ 865,624
Expenses
6010101-149667-796500 Budgeted Equity Adjustments
Total Expenses
$ 865,624
$ 865,624
HENRY GRAHAM DRAIN CH20 FUND (#82494) FY 2015
Project ID 100000002004
Revenues
6010101-1 55020-6103 14 Federal Capital Grants
Total Revenues
$ 9,653
$ 9,653
Expenses
6010101-155020-796500
Budgeted Equity Adjustments
Total Expenses
$ 9,653
$ 9,653
FINANCE COMMITTEE VOTE:
Motion carried unanimously on a roll call vote with Quarles absent.
Resolution #15123 May 6, 2015
Moved by Fleming supported by McGillivray the resolutions (with fiscal notes attached) on the amended
Consent Agenda be adopted (with accompanying reports being accepted).
AYES: Fleming, Gershenson, Gingell, Gosselin, Hoffman, Jackson, KowaII, Long, Matis,
McGillivray, Middleton, Scott, Spisz, Taub, Weipert, Woodward, Zack, Bowman, Crawford. (19)
NAYS: None. (0)
A sufficient majority having voted in favor ; the resolutions (with fiscal notes attached) on the amended
Consent Agenda were adopted (with accompanying reports being accepted).
1
I MANDY AI ,PHOV T IS RESOLUTION
CHIEF DEPUTY COUNTY EXECUTIVE
ACTING PURSUANT TO MCL 45.559A (7)
STATE OF MICHIGAN)
COUNTY OF OAKLAND)
I, Lisa Brown, Clerk of the County of Oakland, do hereby certify that the foregoing resolution is a true and
accurate copy of a resolution adopted by the Oakland County Board of Commissioners on May 6, 2015,
with the original record thereof now remaining in my office.
In Testimony Whereof, I have hereunto set my hand and affixed the seal of the County of Oakland at
Pontiac, Michigan this 6th day of May 2015.
/7"7/./.-z"
Lisa Brown, Oakland County