Download Broadband Micro-grant Application Form

Pennsylvania Broadband Technical Assistance
BROADBAND MINI-GRANT APPLICATION & Awardee Contract Terms Rev 2
A. APPLICANT INFORMATION
(1) Company/Organization Name
(2) Tax ID or EIN
(3) County
(4) Street Address
(5) City, State Zip+4 (lookup)
(6) Website
(7) Contact Name and Title
(8) Contact Phone Number
(9) Contact Email Address
(10) Company has previously received a Broadband Mini Grant? ( Yes/ No)
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B. APPLICANT BACKGROUND
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NAICS Code (http://www.naics.com/search.htm)
Industry (NAICS Title)
Brief description of the business and its products/services
When was your company/organization founded
Number of full time employees
Annual revenue
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C. PROJECT SUMMARY
(1) Describe in detail the broadband implementation project for which you are requesting funding
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(2) Explain how this project increases the utilization of Broadband, the Internet, Cloud Services and / or Remote Access
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(3) Explain the business challenge or problem that this broadband project will address or solve ( e.g. .the reason or rational for the project)
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(4) Describe the expected result(s) / deliverables from the project both for your company and those outside your company
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(5) List the expected quantitative impacts or results/ from the project (e.g. cost savings, increased revenues, capital investments, jobs created, jobs retained, etc.)
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(6) If this project is a website development or upgrade, explain how it does or allows for future support of mobile apps., social media and transferability
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(7) Provide any other information about your project that you feel would be of interest to the review committee
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D. PROJECT TIMELINE
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Project duration (in months)
Estimated start date
Estimated completion date
If this project is to be completed in phases, please identify the critical
milestones for the project and completion dates for each
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E. BROADBAND UTILIZATION
(1) Is broadband currently being used by the company?
(2) If YES, please indicate:
a. Will the company improve its broadband connectivity as a result of
this project?
(3) If NO, please indicate:
a. Is broadband available to the company? (broadband map)
b. Will the company obtain broadband connectivity as a result of this
project?
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F. PROJECT BUDGET
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Total project cost (equal to Grant Request+ Match)
Amount of mini-grant requested (Not to exceed 40% of Total Project)
Amount and source(s) of match provided by applicant
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ATTACH Project Description & Budget or Vendor Bid
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Pennsylvania Broadband Technical Assistance
BROADBAND MINI-GRANT APPLICATION & Awardee Contract Terms Rev 2
micro-grant funds and the uses of all matching funds
(5) Has an IT consultant/provider been selected to implement the project?
(Preference will be given to projects that have selected a vendor,)
(6) If YES, describe the process that was undertaken to select that service
provider and assure a competitive bid was received. (Include information
on who you received bids from and how the selection was made.)
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If NO, describe the process that will be undertaken to select a service
provider.
G. COMPANY APPLICANT CERTIFICATION
As an authorized representative of the organization listed in Section A, I
hereby certify and warrant the following (check all that apply):
 We are a Pennsylvania company;
 We are not debarred from state or federal contracting;
 We are not delinquent on state or federal taxes;
 The information contained in this application is true and correct;
 Our company understands that award of a broadband mini grant
is in no way either directly or indirectly contingent upon our choice
of vendors for the broadband project implementation. In addition,
we understand that there is no requirement either directly stated
or implied to utilize or pay the sponsoring agency in order to
receive a grant award.;
 If awarded a mini grant, we agree to the terms and conditions
surrounding the use of these funds as attached. This includes
providing documentation via canceled checks equivalent to the total
project cost as estimated in Section F.
 I understand and agree that contingent upon written notification of
Grant award, this application and associated terms and conditions
will become a contract.
date
signature
date
H. SPONSOR RECOMMENDATION
As a designated Broadband Technical Assistance partner, I hereby certify
that the applicant has completed the technical assistance process and I
recommend the project described herein for funding consideration as it aligns
with the recommendations which resulted from the assessment/assistance
provided.
Attach copy of Assessment/Plan
(1) Sponsor Name
(2) Sponsor Organization
(3) Sponsor Address
(4) Sponsor Phone
(5) Sponsor Email
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signature
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date
Pennsylvania Broadband Technical Assistance
BROADBAND MINI-GRANT APPLICATION & Awardee Contract Terms Rev 2
The IRC Network has contracted with the Commonwealth of Pennsylvania, Department of Community and Economic Development to
implement the Broadband Technical Assistance Mini Grant Program in accordance with the established Guidelines.
By virtue of the attached Broadband Mini Grant Application, the Company Applicant has requested a Broadband Mini Grant from The IRC
Network for implementation of the project as described in the Broadband Mini Grant Application in coordination with the project Sponsor.
Contingent upon receipt of written notification from The IRC Network of a Broadband Mini Grant Award (specifying the award number,
grant amount and Company cash match amount) these terms and conditions become a contract between the Company and The IRC
Network and apply to the use of the Broadband Mini Grant and project implementation in accordance with the application Guidelines.
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Acceptance – Entire Agreement
Acceptance of the Broadband Mini Grant Award shall be unqualified, unconditional and subject to and expressly limited to the terms and
conditions herein which in combination with the Company’s Broadband Mini Grant Application and the written Notice of Broadband Mini
Grant Award (specifying the award number, grant amount and Company cash match amount) from The IRC Network shall constitute the
entire agreement between The IRC Network and the Company. This Contract and associated Broadband Mini Grant Application and
written Notice of Broadband Mini Grant Award contains the entire understanding among the parties hereto with respect to the subject
matter hereof and supersedes all prior and contemporaneous agreements and understandings, inducements or conditions, expressed or
implied, oral or written.
Obligations of IRC Network
Upon Company’s completion (including payment) of the project prior to April 30, 2016 and provision of an invoice by no later than May
16, 2016 with accompanying payment documentation (copies of canceled checks) of project expenses equal to the total project budget as
stated in the Grant Application, The IRC Network shall provide payment of the Mini-Grant up to the maximum Grant Award but not to
exceed 40% of the documented total project costs. Should a project require less than the proposed budget, The IRC Network will decrease
the Mini-Grant Award in proportion to the decrease in documented total project costs while maintaining the minimum 60% Company cash
match as required.
Obligations of Company
The Company Applicant is: expected to implement the broadband project as outlined and described in the Broadband Mini Grant
Application by no later than April 30, 2016 in accordance with the program Guidelines and Broadband Mini Grant Awardee Requirements;
expected to keep the project Sponsor and The IRC Network apprised of project status throughout the project term; expected to comply with
these Terms and Conditions; expected to provided cash match to the grant at a minimum of 60% of the total project costs; expected to keep
financial records and payment documentation (invoices and canceled checks) of all project-related expenses per the Application and
provide copies of said documentation upon project completion; expected to provide an invoice no later than May 16, 2016 to The IRC
Network which references the Broadband Mini Grant Award number and is accompanied by proof of payment documentation (copies of
invoices and canceled checks) equal to the total project budget and costs (failure to meet the invoicing deadline or provide adequate proof
of payment is justification for non-payment of the Broadband Mini Grant Award on The IRC Network’s behalf); and expected to complete
an Impact Survey after project work is complete, upon the request of the Sponsor.
Obligations of the Sponsor
The project Sponsor shall monitor the project implementation and assist with the administration of the project as described in the
Broadband Mini Grant Application.
Consultant
Any third party consultant providing services within the originating project and contract scope is not an employee, servant nor agent of The
IRC Network and has been selected independently by the Company in their sole discretion.
Warranty
The IRC Network cannot and does not guarantee, in any way, the services or materials of the Sponsor, any consultant or third party vendor
the Company engages as part of this Project. Company shall have sole responsibility for the consequences of any use or inability to use
information, apparatus, method, or process obtained by virtue of this Broadband Mini Grant, the Sponsor, any consultant or third party
vendor and The IRC Network’s employees, agents, officers, and directors shall have no legal liability therefor. THE TOTAL LIABILITY
OF IRC Network UNDER THIS CONTRACT FOR BREACH OF WARRANTY, OR FOR ANY OTHER BREACH OF THIS
AGREEMENT OR FOR ANY OTHER CLAIM RELATED TO THE SERVICES, SHALL NOT EXCEED THE AMOUNT OF THE
BROADBAND MINI GRANT PAID TO THE COMPANY HEREUNDER. The IRC Network SHALL NOT BE LIABLE FOR ANY:
INCENDENTAL OR INCONSEQUENTIAL DAMAGES; LOSS OF PROFITS OR REVENUE; LOSS OF USE; LOSS OF
PRODUCTION; OR PROGRESS OF CONSTRUCTION. ANY LEGAL ACTION AGAINST THE IRC NETWORK MUST BE
COMMENCED WITHIN NINTY (90) DAY AFTER THE OCCURRENCE OR OMISSION GIVING RISE TO THAT ACTION OR IT
SHALL BE FOREVER BARRED AND DEEMED WAIVED.
Force Majeure
No liability under this Agreement shall result to either party from any delay in performance or nonperformance when caused by
circumstances reasonably beyond the control and without the fault or negligence of such party, including but not limited to, fire, flood, war,
governmental regulations, labor disputes, or specifically in the case of The IRC Network, withdrawal or shortage of funding or key
personnel. In that event, The IRC Network reserves the right to allocate funds or personnel among its awardees on such basis as The IRC
Network deems appropriate.
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Pennsylvania Broadband Technical Assistance
BROADBAND MINI-GRANT APPLICATION & Awardee Contract Terms Rev 2
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Termination and Suspension
The IRC Network may suspend performance or terminate this Contract and the Broadband Mini Grant Award on written notice to the
parties for a material violation of any of its terms; for any material misrepresentation Company made in connection with any proposal,
solicitation, request, Contract or Application relied upon by The IRC Network; for lack of sufficient progress on the project as outline in
the Broadband Mini Grant Application; as may be practicable at any time it is notified by the Commonwealth of Pennsylvania that the
funding of The IRC Network is or will be terminated or suspended; in the event of a termination of the grant, a withdrawal or shortage of
funding; in the event that the Company becomes debarred from state or federal contracting, becomes delinquent on state or federal taxes, is
convicted of a criminal act, becomes insolvent, has a petition in bankruptcy filed by or against it, makes an assignment for the benefit of
creditors; in the event the Company fails to pay its Fees to Consultants or vendors on time, or is otherwise in breach of this Agreement.
Payment of any Grant or Broadband Mini Grant shall at times be subject to the availability of funds for the purposes of this Contract.
Modification and Waiver
This Contract shall not be modified, extended, or changed except by written amendment executed by or on behalf of each of the parties. No
waiver by any party of a breach of any provision of this Contract shall be taken or held to be a waiver by such party of any succeeding
breach or such provision of any other provisions to the Contract.
Controlling Law
This Contract shall be governed by the laws of the Commonwealth of Pennsylvania.
Role of Commonwealth of Pennsylvania and the United States of America
The Commonwealth of Pennsylvania and its agencies, officers, employees and agents are not parties to the Contract. Consequently, you
have no right pursuant to this Contract for breach of the Contract against the Commonwealth of Pennsylvania, its agencies, employees and
agents. You are also on notice of the terms and conditions of the Agreement between the Commonwealth of Pennsylvania and The IRC
Network, including those provisions providing for the termination of the Agreement between the Commonwealth of Pennsylvania and The
IRC Network by the Commonwealth of Pennsylvania.
Unless otherwise prohibited by law, the Parties agree to indemnify and hold harmless The IRC Network, the Commonwealth of
Pennsylvania, and the United States Government for any loss, claim, damage, or liability of any kind involving its employees
arising in connection with this agreement.
Assignment
Company may not assign or transfer its rights or obligations under this contract without the prior written consent of The IRC Network.
Beneficiaries
The rights, benefits and indemnification under this Contract shall run to the benefit of The IRC Network, its officers, directors, employees,
agents, subcontractors and assigns, if any.
Federal and State Procurement
Each Party certifies that it is not limited on the General Services Administration’s List of Parties Excluded from Federal Procurement or
Non-procurement Programs in accordance with E.O.s 12549 and 12689 “Debarment and Suspension”, or that it is not otherwise debarred,
suspended, or excluded by agencies, and contractors declared ineligible under statutory or regulatory authority other than E.O. 12549.
Company further certifies that it has no tax delinquency or other Commonwealth obligations.
Equal Employment Opportunity & Non-Discrimination
Each Party agrees to abide by the requirements of the following, as applicable: Title VI and VII of the Civil Rights Act of 1964, as
amended by the Equal Employment Opportunity Act of 1972; Federal Executive Order 11246, as amended by Federal Executive Orders
11375 and 12086; the Federal Rehabilitation Act of 1973, as amended; the Vietnam Era Veteran’s Readjustment Assistance Act of 1974;
Title IX of the Educational Amendments of 1972; The Age Discrimination Act of 1975, as amended; and the requirements of the
Americans with Disabilities Act of 1990. The parties agree to continue their respective policies of nondiscrimination based on Title VI of
the Civil Rights Act of 1964 in regard to sex, age, race, color, creed, national origin, Title IX of the Education Amendments of 1972 and
other applicable laws, as well as the Americans with Disabilities Act. The Company further agrees not to discriminate in its employment
practices, and will execute the project under this Contract without regard to race, color, religion, sex, national origin, veteran status,
political affiliation, disabilities, or, in accordance with Federal Executive Order EWE 92-7, because of an individual’s sexual orientation.
Company must maintain a written sexual harassment policy, inform employees that sexual harassment will not be tolerated. Any act of
discrimination or sexual harassment committed by the Company, or failure to comply with these statutory obligations, when applicable,
shall be grounds for termination of this Contract. Company agrees to indemnify The IRC Network for any loss or damage sustained
because of Company’s noncompliance. The Company further agrees to furnish books and records as request to confirm compliance with
the above.
Auditable Records
The Company shall maintain such records as are necessary to assure accuracy and validity of any performance data submitted to The IRC
Network, project Sponsor or Commonwealth. The Company shall establish and maintain such records in a manner enabling identification
and documentation of both the funds provided pursuant to the Contract and the funds furnished by the Company or other sources.
Form W-9
Upon notification of Award, the Company must complete and return Form W-9 “Request for Taxpayer Identification Number and
Certification”.
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