STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
FFATA FINANCIAL DISCLOSURE
OES-FPD-011 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
Cal OES ID No.:
UEI Number:
Previous Fiscal Year End Date:
FFATA Financial Disclosure
The Federal Funding Accountability and Transparency Act (FFATA) requires information on federal awards be made available to the public and is submitted by the California Governor’s Office of Emergency Services (Cal OES) to www.fsrs.gov. This is done in order that the government be held accountable for each spending decision. As a subrecipient of federal funds, you will be unable to draw down funds until this signed form is returned to Cal OES.
The Total Compensation and Names of the top five executives must be reported in the table on this form if your business or organization meets both of the following criteria:
a) 80% or more of annua
l gross revenues are from Federal awards (contracts, sub- contracts, and Federal financial assistance), and $25,000,000 or more in annual gross revenues from Federal awards; and,
b) Compensation informat
ion is not already available through reporting to the Securities and Exchange Commission.
If your business or organization does NOT meet BOTH criteria, check the box below, sign, and return to Cal OES Financial Processing Unit.
Not subject to FFATA Financial Disclosure.
Executive Name Title Annual
Salary
Annual Dollar
Value of Benefits
Total
Compensation
I,
Printed Name of Authorized Agent
, do hereby certify, as the authorized agent of
Entity Name
, the information contained in this document is true
and correct.
Title of Authorized Agent
Signature of Authorized Agent Date
Rev. 10-2022 OES-FPD-011
DRAFT
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
Disaster No:
Cal OES ID No:
UEI No:
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
SUBRECIPIENT’S NAME:
(Name of Organization)
PRIMARY MAILING ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE: FAX NUMBER:
CA ASSEMBLY DIST: CA SENATE DIST: U.S. CONGRESSIONA L DIST:
Visit sos.ca.gov/
elections/who-are-my-representati ves to find your dis trict number.
AUTHORIZED AGENT:
TITLE:
EMAIL ADDRESS:
ASSURANCES – CONSTRUCTION PROGRAMS
Note: Certain of these ass
urances may not be applicable to all your projects. If you have questions, please contact the California Governor’s Office of Emergency Services. Further, certain federal assistance awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.
As the duly authorized repres
entative of the applicant, I certify that the subrecipient named above:
1. Has the legal author
ity to apply for federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non- federal share of project costs) to ensure proper planning, management, and completion of the project described in this application.
2. Will give the awarding agency
, the Comptroller General of the United States,
Federal Office of Inspector General 2 CFR 200.336, 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 assistance; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives.
Rev. 10-2022 OES-FPD-089
DRAFT
Rev. 10-2022 Page 2 of 5 OES-FPD-089
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
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. Will 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. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gains.
8. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801 et seq.), which prohibits the use of lead-based paint in construction or rehabilitation of residential structures.
9. Will comply with all federa
l statutes relating to nondiscrimination. These
include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L 88- 352) which prohibits discrim
ination on the basis of race, color, or national
origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§ 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. § 794) which prohibit dis
crimination on the basis of handicaps; (d) the
Age Discrimination Act of 1975, as amended (42 U.S.C. §§ 6101-6107) which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 93-255) 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) §§ 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 DRAFT
Rev. 10-2022
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
1968 (42 U.S.C. § 36
01 et seq.), as amended, relating to nondiscrimination in the sale, rental, or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for federal assistance is being made, and (j) the requirements on any other non -
discrimination statu
te(s) which may apply to the application.
10. Will comply, or has alr
eady complied, with the requirements of Titles II and III of the Uniform 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 and federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of federal participation in purchases.
11. Will comply with the flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $5,000 or more.
12. 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.O . 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved state management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§ 1451 et seq.); (f) conformity of federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. § 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended (P.O. 93-205).
13. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.
14. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and preservation of historic properties), and the Archeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
OES-FPD-089 Page 3 of 5
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STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
15. Will comply with Standardized Emergency Management (SEMS) requirements as stated in the California Emergency Services Act, Government Code, Chapter 7 of Division 1 of Title 2, Section 8607.1(e) and CCR Title 19, Sections 2445, 2446, 2447, and 2448.
16. Subrecipients expending $750,000 or more in federal grant funds annually are required to secure an audit pursuant to OMB Uniform Guidance 2 CFR Part 200, Subpart F. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996.
17. Will disclose in writing any potential conflict of interest to the Federal awarding agency or pass-through entity in accordance with §200.112.
18. Will comply with all applicable requirements of all other federal laws, Executive Orders, regulations and
policies governing this program.
19. Has requested through the State of California, federal financial assistance to be used to perform eligible work approved in the subrecipient application for federal assistance. Will, after the receipt of federal
financial assistance,
through the State of California, agree to
the following:
a. The state warrant covering federal financial assistance will be deposited in a special and separate account and will be used to pay only eligible costs for projects described above.
b. To return to the State of California such part of the funds so reimbursed pursuant to the above numbered application, which are excess to the approved actual
expenditures as accepted by final audit of
the federal
or state government.
c. In the event the approved amount of the above numbered project application is reduced, the reimbursement applicable to the amount of the reduction
will be promptly refunded to the State of California.
20. The
non-Federal entity for a Federal award must disclose, in a timely manner, in writing to the Federal awarding agency or pass-through entity all violations of Federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the Federal award §200.113. Failure to make required disclosures can result in any of the remedies described in §200.338 Remedies for noncompliance, including suspension or debarment.
Rev. 10-2022 OES-FPD-089
DRAFT
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
21. Will not make any award or permit any award (subaward or contract) to any party which is debarred or suspended or is otherwise excluded from or ineligible for participation in Federal assistance programs under Executive Order 12549 and 12689, “Debarment and Suspension.”
“I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized by ____________________________________________________________ (Name of Organization)
to enter into this agreement for and on behalf of said subrecipient, and by my signature do bind the subrecipient to the terms thereof.”
PRINTED NAME
SIGNATURE OF AUTHORIZED AGENT
TITLE DATE
Rev. 10-2022 OES-FPD-089 Page 5 of 5
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DESIGNATION OF APPLICANT'S AGENT RESOLUTION FOR NON-STATE AGENCIES
BE IT RESOLVED BY THE OF THE
(Governing Body) (Name of Applicant)
THAT , OR
(Title of Authorized Agent)
, OR
(Title of Authorized Agent)
(Title of Aut
horized Agent)
is hereby authorized to execute for and on behalf of the , (Name of Applicant)
a public entity
establis
hed under the laws of the State of California, this application and to file it with the California Governor’s Office of Emergency Services for the purpose of obtaining federal financial assistance for any existing or future grant program, including, but not limited to any of the following:
- Federally declared Disaster (DR), Fire Mitigation Assistance Grant (FMAG), California State Only Disaster (CDAA), Immediate Services Program (ISP), Hazard Mitigation Grant Program (HMGP), Building Resilient Infrastructure and Communities (BRIC), Legislative Pre-Disaster Mitigation Program (LPDM) , under
- Public Law 93-288 as amended by the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988, and/or state financial assistance under the California Disaster Assistance Act.
- Flood Mitigation Assistance Program (FMA), under Section 1366 of the National Flood Insurance Act of 1968.
- National Earthquake Hazards Reduction Program (NEHRP) 42 U.S. Code 7704 (b) ((2) (A) (ix) and 42 U.S. Code 7704 (b) (2) (B) National Earthquake Hazards Reduction Program, and also The Consolidated Appropriations Act, 2018, Div. F, Department of Homeland Security Appropriations Act, 2018, Pub. L. No. 115-141 - California Early Earthquake Warning (CEEW) under CA G ov Code – Gov, Title 2,
Div. 1, Chapter 7, Article 5, Sect
ions 8587.8, 8587.11, 8587.12
That the , a public entity established under the
(Name of Applicant)
laws of the State of California, hereby authorizes its agent(s) to provide to the Governor’s Office of Emergency Services for all matters pertaining to such state
disaster assistance the assurances and agreements required.
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES
OES-
FPD-130 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
Cal OES ID No: _____________
OES-FPD-130 Rev. 10-2022 Page 1 of 4
DRAFT
Please check the appropriate box below
This is a universal resolution and is
effective for all open and future
disasters/grants declared up to three (3) years following the date of approval.
This is a disast
er/grant specific resolution and is effective for only
disaster/grant number(s):
Passed and approved this __day of , 20
(Name and Title of Governing Body
Representative)
(Name and Title of Governing Body
Representative)
(Name and Title of Governing Body
Representative)
CERTIFICATION
I, , duly appointed and of
(Name) (Title)
, do hereby certify that the abo ve is a true and
(Name of Applicant)
correct copy of a resolution passed and approved by the (Governing Body)
of the on the day of , 20 .
(Name of Applicant)
(Signature) (Title)
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES
OES-
FPD-130 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
OES-FPD-130 Rev. 10-2022 Page 2 of 4
DRAFT
Cal OES Form 130 Instructions
A Designation of Applicant’s Agent Resolution for Non-State Agencies is required of all Applicants to be eligible to receive funding. A new resolution must be submitted if a previously submitted resolution is older than three (3) years from the last date of approval, is invalid, or has not been submitted.
When completing the Cal OES For
m 130, Applicants should fill in the blanks on pages 1
and 2. The blanks are to be filled in as follows:
Resolution Section:
Governing Body: This is the group respons
ible for appointing and approving the
Authorized Agents.
Examples include: Board of Directors, City Council, Board of Supervisors, Board of Education, etc.
Name of Applicant: The public entity established
under the laws of the
State of California.
Examples include: School District, Office of Education, City, County or Non-profit agency that has applied for the grant, such as: City of San Diego, Sacramento County, Burbank Unified School District, Napa County Office of Education, University Southern California.
Authorized Agent: These are the individuals that are
authorized by the Governing Body
to engage with the Federal Emergency Management Agency and the California Governor’s Office of Emergency Services regarding grants for which they have applied.
There are two ways of completing this section:
1. Titles Only: The titles of the Authorized Agents should be entered here, not their names. This allows the document to remain valid if an Authorized Agent leaves the position and is replaced by another individual. If “Titles Only” is the chosen method, this document must be accompanied by either a cover letter naming the Authorized Agents by name and title, or the Cal OES AA Names document. The supporting document can be completed by any authorized person within the Agency (e.g., administrative assistant, the Authorized Agent, secretary to the Director). It d
oes not require the Governing Body’s signature.
2. Names and Titles: If the Governing Body so chooses, the names and titles of the Authorized Agents would be listed. A new Cal OES Form 130 will be required if any of the Authorized Agents are replaced, leave the position listed on the document, or their title changes.
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES
OES-
FPD-130 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
OES-FPD-130 Rev. 10-2022 Page 3 of 4
DRAFT
Checking Universal or Disaster-Specific Box: A Universal resolution is effective for all past disasters and for those declared up to three (3) years following the date of approval. Upon expiration it is no longer effective for new disasters, but it remains in effect for disasters declared prior to expiration. It remains effective until the disaster goes through closeout unless it is superseded by a newer resolution.
Governing Body Representative: These are the names and titles of the approving Board Members.
Examples include: Chairman of the Board, Director, Superintendent, etc. The names and titles cannot be one of the designated Authorized Agents. A minimum of three (3) approving board members must be listed. If less than three are present, meeting minutes must be attached in order to verify a quorum was met.
Certification Section:
Name and Title: This is the individual in attendance who recorded the creation and approval of this resolution.
Examples include: City Clerk, Secretary to the Board of Directors, County Clerk, etc. This person cannot be one of the designated Authorized Agents or Approving Board Member. If a person holds two positions (such as City Manager and Secretary to the Board) and the City Manager is to be listed as an Authorized Agent, then that person could sign the document as Secretary to the Board (not City Manager) to eliminate “Self-Certification.”
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR
'S OFFICE OF EMERGENCY SERVICES
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES
OES-FPD-130 (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
OES-FPD-130 Rev. 10-2022 Page 4 of 4
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STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
REIMBURSEMENT REQUEST FORM PROJECT EXPENDITURES
OES-FPD-400 (Rev. 11-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
Email Reimbursement Request to:
[email protected]
Mail Reimbursement Request to:
California Governor’s Office of Emergency Services
Recovery Financial Processing Unit
3650 Schriever Avenue
Mather, CA 956
55 Subrecipient
FIPS ID #:
Disaster/Subaward #
: _______________________________
___ ______ _________________________
_
:
Please mark this box to
_________________ _ _____
indicate a
change in the Ma iling Address in the
Authorized Agent section below
Project Number
Cumulative Project
Expenditures
to date
Reimbursement Request for
the period of
_____________ to _
________ ____________________
_______________
___________________
____________________________________________ ____________________________________ ________________________________ ________________________________________ __________________
____________
$ $
Under penalty of perjury, I certify that:
• I am the duly authorized officer of the claimant herein and this claim is for costs incurred within the Grant Performance Period
• By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729–3730 and 3801–3812) Authorized Agent (Per Governing Body Resolution)
Printed Name Title Phone Number
Signature Date Email Address
__________________________________________________
New Mailing Address Only
Cal OES 400 (this section is for Cal OES use only)
Obligated Amount
Expenditures to Date
Cost Share at 75%
Less Retention
Prior Payments Made
Amount Allowable for Payment
__________________________________________________________ ________________________________________________________ Reviewer Title Date Approver Title Date
Rev. 11-2022 OES-FPD-400Page 1 of 2
DRAFT
Instruction Sheet
Subrecipient
The subrecipient
is the entity
as identified in the original grant application. Do
not identify any sub-departments or offices as the subrecipient.
FIPS ID # This is the subrecipient’s identification number as identified on the Notification of Approval Letter.
Disaster/
Subaward
#
The disaster/subaward number can be found
on the Notification of Approval
Letter.
Address
Change
Indicate a
change in address by checking the box shown and noting the new address
on the
line
labeled
“New Mailing Address
Only”
in the Authorized
Agent section.
Project Number The project number can be found on the Notification of Approval Letter.
Provide the full, total grant expenditures incurred to date for this project (including applicable local share).
The subrecipient may request reimbursement of all, or a portion of, grant expenditures incurred since the last Reimbursement Request. Indicate the month, day, and year for the beginning of the period covered to the end of the period covered during which these expenditures were incurred. This is not the Project/Budget Period listed on the subaward. HMGP Disaster Grants: No fiscal year restrictions. All other grants: A request period cannot cross the State fiscal year, which ends June 30 and begins July 1.
Complete all line items
as
requested and ensure that the form is signed by an
Authorized Agent named
on the Governing Body
Resolution.
The signature
date must be on or after the final day of the indicated request period.
This form can be sent to Cal OES via email or regular mail. The subrecipient should maintain duplicate records of all documents sent to Cal OES.
Supporting documents are not required to be submitted with the Reimbursement Request; however, Cal OES reserves the right to request documentation at any time. Subrecipients are reminded to maintain documents that support the expenditures and reimbursement amounts shown on the request.
For additional assistance regarding this Reimbursement Request Form, please contact the
Recovery/Hazard Mitigation
Financial
Processing
Unit at
(916) 845-8110 or at [email protected].
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
REIMBURSEMENT REQUEST FORM PROJECT EXPENDITURES
OES-FPD-400 (Rev. 11-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
Cumulative
Expenditures
to
Date
Reimbursement
Request Period
Authorized
Agent
Information
Mail
Supporting
Documents
Rev. 10-2022
OES-FPD-400Page 2 of 2
Additional
Assistance
Rev. 11-2022
DRAFT
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
SUBRECIPIENT MGMT COST REIMBURSEMENT REQUEST
OES-FPD-400SRMC (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
Email Reimbursement Request to:
Mail Reimbursement Request to:
California Governor’s
Office of
Emergency
Services
Recovery
Financial
Processing
Unit
3650 Schriever Avenue
Mather, CA 95655
Subrecipient
FIPS
ID #:
Disaster/Subaward #
: _______________________________
___ ______ _________________________ _
:
Please mark this box to
_________________ _ _____
indicate a
change
in the Mailing Address in the
Authorize
d Agent section below
Project Number
Cumulative Subrecipient
Management Costs
to date
Reimbursement Request for the period of
_____________ to _
NOTE: This form is for subrecipient management costs only. Do not include
any
project
expenditures or other costs that were approved as part
of your initial grant
application.
________ ____________________
_______________
___________________
____________________________________________ ____________________________________ ________________________________ ________________________________________ __________________
____________
$ $
Under penalty of perjury, I certify that:
• I am the duly authorized officer of the claimant herein and this claim is for costs incurred within the Grant Performance Period
• By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729–3730 and 3801–3812) Authorized Agent (Per Governing Body Resolution)
Printed Name Title Phone Number
Signature Date Email Address
__________________________________________________
New Mailing Address Only
Cal OES 400SRMC (this section is for Cal OES use only)
Obligated Funding for Subrecipient
Management Costs
Subrecipient Management Costs to Date
Prior Payments Made
Amount Allowable for Payment
__________________________________________________________ ________________________________________________________ Reviewer Title Date Approver Title Date
Rev. 10-2022 OES-FPD-400SRMCPage 1 of 2
DRAFT
Instruction Sheet
Subrecipient
The subrecipient
is the entity
as identified in the original grant application. Do
not identify any sub-departments or offices as the subrecipient.
FIPS ID # This is the subrecipient’s identification number as identified on the Notification of Approval Letter.
Disaster/
Subaward
#
The disaster/subaward number can be found
on the Notification of Approval
Letter.
Address
Change
Indicate a
change in address by checking the box shown and noting the new address
on the
line
labeled
“New Mailing Address
Only”
in the Authorized
Agent section.
Project Number The project number can be found on the Notification of Approval Letter.
Cumulative
Subrecipient
Management
Costs to Date
Identify total subrecipient management costs
incurred to date for this project.
Include only costs covered
under FEMA’s
award for subrecipient management
cost funding. Do not include
any
project expenditures or other costs
that were
approved as part of the initial grant
application
for this project.
Reimbursement
Request Period
The subrecipient may request reimbursement of all, or a portion of, subrecipient management costs incurred since the last Reimbursement Request. Indicate the month, day, and year for the beginning of the period covered to the end of the period covered during which these costs were incurred. This is not the Project/Budget Period listed on the subaward. HMGP Disaster Grants: No fiscal year restrictions. All other grants: A request period cannot cross the State fiscal year, which ends June 30 and begins July 1.
Authorized
Agent
Information
Complete all line items
as
requested and ensure that the form is signed by an
Authorized Agent named
on the Governing Body
Resolution.
The signature
date must be on or after the final day of the indicated request period.
Mail
This form can be sent to Cal OES via email or regular mail. The subrecipient should maintain duplicate records of all documents sent to Cal OES.
Supporting
Documents
Supporting documents are not required to be submitted with the Subrecipient Management Cost Reimbursement Request Form; however, Cal OES reserves the right to request documentation at any time. Subrecipients are reminded to maintain documents that support the expenditures and reimbursement amounts shown on the request.
Additional
Assistance
For additional assistance regarding this Reimbursement Request Form, please contact the
Recovery/Hazard Mitigation
Financial
Processing
Unit at
(916) 845-8110 or at [email protected].
STATE OF CALIFORNIA
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
SUBRECIPIENT MGMT COST REIMBURSEMENT REQUEST
OES-FPD-400SRMC (Rev. 10-2022)
RECOVERY DIRECTORATE
FINANCIAL PROCESSING DIVISION
Rev. 10-2022 OES-FPD-400SRMCPage 2 of 2
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California Governor's Office of Emergency Services
SUPPLEMENTAL GRANT SUBAWARD INFORMATION SHEET
The California Governor’s Office of Emergency Services (Cal OES), makes a Grant Subaward of funds set forth to the following:
1. Subrecipient: ___________________________________________ 1a. SAM ID: __________________
2. Implementing
Agency: _________________________________________ 2a. SAM ID: __________________
3. Implementing
Agency Address: ________________________________________________________________________ Street City State ZIP+4
4. Location of Project: ____________________________________________________________________ City County ZIP+4
5. Federal Award
Identification Number: ___________________ 6. Performance Period: ___________ to___________
7. Indirect Cost Rate: N/A 10% de minimis Federally Approved ICR: __________
8. Federal Awarding Agency Section
Federal Program Fund
/ CFDA # Federal Awarding Agency Total Approved Project Amount Hazard Mitigation
Grant Program /
97.039
U.S. Department of Homeland
Security, Federal Emergency
Management Agency
9. Primary Authorized Agent:
Name: _________________________________________ Title: ____________________________________ Phone: ____________________________ Email: _______________________________________________ Payment Mailing
Address:
_________________________________________________________________________ Street City State ZIP+4
10. Additional Correspondence Contacts (optional):
Name: _______________________________________ Email: _____________________________________ Name: _______________________________________ Email: ________________ _____________________
Cal OES 2-101a Page 1 of 2
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California Governor's Office of Emergency Services
SUPPLEMENTAL GRANT SUBAWARD INFORMATION SHEET
Cal OES Contact Information Section:
Governor’s Office of Emergency Services
Nancy Ward, Director
3650 Schriever Avenue
Mather, CA 95655
Phone: (916) 845-8510
11. Supplement Information
Supp
No. Federal Share Non-Federal
Share SR Mgmt Cost Total Supplement
Cost
Fed / Non-Fed
Cost Share
Totals:
Total Project Cost: __________________
12. Project Description Section:
__________________________________________________________________________________________
13. Research and Development Section:
Is this S
ubaward a Research and Development Grant? Yes No
Cal OES Use Only
Cal OES #
FIPS #
Subaward #
PCA
Federal Award
Dates
(incl SRMC)
Cal OES 2-101a Page 2 of 2
DRAFT
SUPPLEMENTAL GRANT SUBAWARD INFORMATION SHEET Instructions Please complete the sections marked with an asterisk (*)
1. Subrecipient
The subrecipient is the unit of government or community-based organization (CBO) that has the legal responsibility for these grant subaward funds (e.g., Alameda County, City of Fresno, or Women’s Place of Merced).
*1a. Federal SAM ID Number (Subrecipient)
Enter the subrecipient’s 12-digit Unique Entity ID number provided by the federal System of Award Management (SAM) database. This number must have a current and active registration in SAM for the duration of this grant subaward. Note: A SAM ID number is required only for federally funded grants.
*2. Implementing Agency
Enter the complete name of the agency responsible for the day-to-day operation of the grant subaward (e.g., Sheriff’s Department, Fire Department, or Department of Public Works).
If the implementing agency is the same as the subrecipient, enter the subrecipient’s name again.
*2a. Federal SAM ID Number (Implementing Agency)
Enter the implementing agency’s 12-digit Unique Entity ID number provided by the federal System of Award Management (SAM) database. This number must have a current and active registration in SAM for the duration of this grant subaward. Note: A SAM ID Number is required only for federally funded grants.
*3. Implementing Agency Address
Enter the address of the implementing agency. Provide the complete nine-digit ZIP code (ZIP+4).
*4. Location of Project
Enter the city and county/operational area where the project is located. Provide the complete nine-digit ZIP code (ZIP+4).
5. Federal Award Identification Number (FAIN)
This section shows the Federal Award Identification Number associated with this funding source/disaster. Example: 4301-DR-CA or FEMA-4301-DR-CA.
6. Performance Period
This section shows the beginning and ending dates of this grant subaward’s project performance period.
*7. Indirect Cost Rate
Indicate whether the subrecipient is using the 10% de minimis based on Modified Total Direct Costs (MTDC) or the indirect cost rate approved by the subrecipient’s cognizant agency agreement. A copy of the approved ICR Negotiation Agreement must be enclosed with the application. Indicate N/A if the subrecipient will not be claiming indirect costs under this grant subaward. Indirect costs may not be allowable under certain federal fund sources.
DRAFT
SUPPLEMENTAL GRANT SUBAWARD INFORMATION SHEET Instructions Please complete the sections marked with an asterisk (*)
8. Federal Awarding Agency Section
This section shows the federal awarding agency, federal program, and the Catalog of Federal Domestic Assistance (CFDA) number for the obligated funding. Also shown is the total approved project amount related to this grant subaward.
*9. Primary Authorized Agent
The primary authorized agent will be the main contact for Financial Processing Unit correspondence and must be one of the authorized agents named in the governing body resolution. Enter the name, title, phone number, and email address of the primary authorized agent for this project. Enter the payment mailing address where reimbursement payments should be mailed (payments will be sent to this address to the attention of the primary authorized agent).
10. Additional Correspondence Contacts (optional)
Enter the names and email addresses of individuals whom the subrecipient would like to be included in Financial Processing Unit (FPU) correspondence. The FPU will cc these individuals when emailing correspondence to the primary authorized agent. Please note that although individuals listed in this section do not need to be authorized agents, only authorized agents have signature- and decision-making authority regarding this grant subaward.
11. Supplement Information
This section features the FEMA supplement numbers, the federal and non-federal shares, and applicable subrecipient management costs for this grant subaward. The grant subaward’s project cost share percentage is displayed in the far-right column.
12. Project Description Section
This section features the name or a short description of the project.
13. Research and Development Section
This section indicates whether this grant subaward is for research and development.
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