Okaloosa County BOCC — November 15, 2016 — 5339 Application FFY2017 — reading text

inaccessible vehicle. Such public entities not receiving FTA funds shall also file the certification with the appropriate state office program. Such public entities receiving FTA funds under any other section of the FTA Programs must file the certification with the appropriate FTA regional office. This certification is valid for no longer than one year from its date of filing. Executed this day of , 20 . ______________________________________________ (Signature of authorized representative) ______________________________________________ (Name and title of authorized representative) Florida Department of Transportation – 5339 Application– FFY17 14  EXHIBIT G: APPLICANT CERTIFICATION AND ASSURANCES TO FDOT _______ (undersigned) _______________________________certifies and assures to the Florida Department of Transportation in regard to its Application under U.S.C. Section 5339 dated ___________: 1) It shall adhere to all Certifications and Assurances made to the federal government in its Application. 2) It shall comply with Florida Statues: a. Section 341.051- Administration and financing of public transit and intercity bus service programs and projects b. Section 341.061 (2) - Transit Safety Standards; Inspections and System Safety Reviews 3) It shall comply with Florida Administrative Code a. Rule Chapter 14-73 - Public Transportation b. Rule Chapter 14-90 - Equipment and Operational Safety Standards for Bus Transit Systems c. Rule Chapter 14-90.0041 - Medical Examination for Bus System Driver d. Rule Chapter 41-2 - Definitions 4) It shall comply with the FDOT’s: a. Bus Transit System Safety Program Procedure No. 725-030-009 b. Public Transit Substance Abuse Management Program Procedure No. 725-030-035 c. Transit Vehicle Inventory Management Procedure No. 725-030-025 d. Public Transportation Vehicle Leasing Procedure No. 725-030-001 e. FDOT Guidelines for Acquiring Vehicles f. Procurement Guidance for Transit Agencies Manual 5) It has the fiscal and managerial capability and legal authority to file the application. 6) Local matching funds will be available to purchase vehicles/equipment at the time an order is placed. 7) It will carry adequate insurance to maintain, repair, or replace project vehicles/equipment in the event of loss or damage due to an accident or casualty. 8) It will maintain project vehicles/equipment in good working order for the useful life of the vehicles/equipment. 9) It will return project vehicles/equipment to FDOT if, for any reason, they are no longer needed or used for the purpose intended. 10) It recognizes FDOT’s authority to remove vehicles/equipment from its premises, at no cost to the FDOT, if the Department determines the vehicles/equipment are not used for the purpose intended, improperly maintained, uninsured, or operated unsafely. 11) It will not enter into any lease of project vehicles/equipment or contract for transportation services Florida Department of Transportation – 5339 Application– FFY17 15  with any third party without prior approval of FDOT. 12) It will notify FDOT within 24 hours of any accident or casualty involving project vehicles/equipment, and submit related reports as required by the Department. 13) It will submit an annual financial audit report to FDOT (FDOTSingleAudit@dot.state.fl.us), if required by FDOT. Date: _______ _______________________________________ ________________________________ (Typed name and title of authorized representative) (Signature of authorized representative) Florida Department of Transportation – 5339 Application– FFY17 16  EXHIBIT J: STANDARD LOBBYING CERTIFICATION FORM The undersigned [Contractor] certifies, to the best of his or her knowledge and belief, that: (1) 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 an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for making lobbying contacts to an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form--LLL, "Disclosure Form to Report Lobbying," (a copy the form can be obtained from http://www.dot.state.fl.us/transit/Pages/grantsadministration.shtm) in accordance with its instructions [as amended by "Government wide Guidance for New Restrictions on Lobbying," 61 Fed. Reg. 1413 (1/19/96). Note: Language in paragraph (2) herein has been modified in accordance with Section 10 of the Lobbying Disclosure Act of 1995 (P.L. 104-65, to be codified at 2 U.S.C. 1601, et seq.)] (3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. [Note: Pursuant to 31 U.S.C. § 1352(c)(1)-(2)(A), any person who makes a prohibited expenditure or fails to file or amend a required certification or disclosure form shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such expenditure or failure.] The Contractor, ___________________, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. A 3801, et seq., apply to this certification and disclosure, if any. __________________________ Signature of Contractor's Authorized Official __________________________ Name and Title of Contractor's Authorized Official ___________________________ Date Florida Department of Transportation – 5339 Application– FFY17 17  EXHIBIT K: FTA SECTION 5333 (B) ASSURANCE (Note: By signing the following assurance, the recipient of Section 5311 and/or 5311(f) assistance assures it will comply with the labor protection provisions of 49 U.S.C. 5333(b) by one of the following actions: (1) signing the Special Warranty for the Rural Area Program (see FTA Circular C 9040.1E, Chapter X); (2) agreeing to alternative comparable arrangements approved by the Department of Labor (DOL); or (3) obtaining a waiver from the DOL.) ____________________________________ (hereinafter referred to as the “Recipient”) HEREBY ASSURES that the “Special Section 5333 (b) Warranty for Application to the Small Urban and Rural Program” has been reviewed and certifies to the Florida Department of Transportation that it will comply with its provisions and all its provisions will be incorporated into any contract between the recipient and any sub-recipient which will expend funds received as a result of an application to the Florida Department of Transportation under the FTA Section 5339 Program. Dated ______________________ ____________________________________ (Name and Title of Authorized Representative) _____________________________________ (Signature of Authorized Representative) Note: All applicants must complete the following form and submit it with the above Assurance. LISTING OF RECIPIENTS, OTHER ELIGIBLE SURFACE TRANSPORTATION PROVIDERS, UNIONS OF SUB-RECIPIENTS, AND LABOR ORGANIZATIONS REPRESENTING EMPLOYEES OF SUCH PROVIDERS, IF ANY (See Appendix for Example) 2 4 1 Site Project by Name, 3 Identify Unions (and Identify Recipients of Description, and Provider Identify Other Eligible Providers) Representing Transportation Assistance (e.g. Recipient, other Surface Transportation Employees of Providers in Under this Grant. Agency, or Contractor) Providers (Type of Service) Columns 1, 2, and 3 Florida Department of Transportation – 5339 Application– FFY17 18  TITLE VI PROGRAM If an applicant has not previously submitted their Title VI plan to the Department, a copy must be included here. LOCAL CLEARINGHOUSE AGENCY LETTER If grant application is for facilities, please include a copy of the cover letter submitted to the local clearinghouse agency or RPC. EXHIBIT H: PROTECTION OF THE ENVIRONMENT Required if the proposed project is for the construction of facilities. Please see Grant Application Instruction Manual for details. END OF APPLICATION 5310 Grant Application Revised on 23 September 2016 Revised by: Kayla Costello FDOT Public Transit Office 605 Suwannee Street (MS 26) Tallahassee, Florida 32399-0450 Work Phone: 850-414-4239 Email: kayla.costello@dot.state.fl.us Florida Department of Transportation – 5339 Application– FFY17 19