Contract 2024-016A2024-016A
Agreement Number: Z3649
FEDERALLY FUNDED SUBAWARD AND GRANT AGREEMENT for DR - 4680 - Hurricane Nicole
The following Agreement is made and information is provided pursuant to 2 CFR §200.332(a)(1):
Subrecipient's name: Clermont, City of
Subrecipient's unique entity identifier: T36XEEDA7QZ3
Federal Award Date: Dec 17, 2022
Subaward Period of Performance Start and End Date (Cat A-B): Nov 7, 2022 - June 13, 2023
Subaward Period of Performance Start and End Date (Cat C-G): Nov 7, 2022 - June 13, 2024
Amount of Federal Funds Obligated by this Agreement:
Total Amount of Federal Funds Obligated to the Subrecipient
by the pass -through entity to include this Agreement:
Total Amount of the Federal Award committed to the Subrecipient
by the pass -through entity:
Federal award project description (see Federal Funding
Accountability and Transparency Act (FFATA):
Name of Federal awarding agency:
Name of pass -through entity:
Contact information for the pass -through entity:
Assistance Listing Number (Formerly CFDA Number):
N/A
Grant for communities to respond to and
recover from maior disasters or
emergencies and for limited mitigation
measures.
Department of Homeland Securitv (DHS)
Federal Emergencv Management Aaencv
FEMA
Florida Division of Emergencv
Management (FDEM)
2555 Shumard Oak Blvd.
Tallahassee. FL 32399-2100
97.036
Disaster Grants - Public Assistance (Presidentially
Assistance Listinq Proqram Title (Formerly CFDA Droaram Title): Declared Disasters)
THIS AGREEMENT is entered into by the State of Florida, Division of Emergency Management, with
headquarters in Tallahassee, Florida (hereinafter referred to as the "Division"), and Clermont, City of
(hereinafter referred to as the "Subrecipient").
THIS AGREEMENT IS ENTERED INTO BASED ON THE FOLLOWING REPRESENTATIONS:
A. The Subrecipient represents that it is fully qualified and eligible to receive these grant funds to provide
the services identified herein;
B. The Subrecipient, by its decision to participate in this grant program, bears the ultimate responsibility for
ensuring compliance with all applicable State and Federal laws, regulations and policies, and bears the ultimate
consequences of any adverse decisions rendered by the Division, the Federal Awarding Agency, or any other State
and Federal agencies with audit, regulatory, or enforcement authority;
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C. This Agreement establishes the relationship between the Division and the Subrecipient to allow the
Division to pay grant funds to the Subrecipient.
THEREFORE, the Division and the Subrecipient agree to the following:
(1) APPLICATION OF STATE LAW TO THIS AGREEMENT
2 CFR § 200.302 provides: "Each state must expend and account for the Federal award in accordance with
state laws and procedures for expending and accounting for the state's own funds." Therefore, section 215.971,
Florida Statutes, entitled "Agreements funded with federal or state assistance," applies to this Agreement.
(2) LAWS. RULES. REGULATIONS AND POLICIES
a. Performance under this Agreement is subject to 2 CFR Part 200, entitled "Uniform Administrative
Requirements, Cost Principles, and Audit Requirements for Federal Awards."
b. In addition to the foregoing, the Subrecipient and the Division shall be governed by all applicable State
and Federal laws, rules, and regulations. Any express reference in this Agreement to a particular statute, rule, or
regulation in no way implies that no other statute, rule, or regulation applies. The applicable statutes, rules, or
regulations are the statutes, rules, or regulations in effect at the time of the declaration of the incident through which
federal funds are awarded, or as otherwise indicated as retroactively applied.
(3) CONTACT
a. In accordance with section 215.971(2), Florida Statutes, the Division's Grant Manager shall be
responsible for enforcing performance of this Agreement's terms and conditions and shall serve as the Division's
liaison with the Subrecipient. As part of his/her duties, the Grant Manager for the Division shall:
i. Monitor and document Subrecipient performance; and
ii. Review and document all deliverables for which the Subrecipient requests payment.
b. The Division's Grant Manager for this Agreement is:
Name Jennifer Stallings
Title Grant Proaram Manaaer
Bureau of Recovery
Address: Florida Division of Emeraencv Manaaement
2555 Shumard Oak Blvd.
Tallahassee. FL 32399-2100
Telephone: (850) 815-4408
Email: Jennifer. Stal linasrd)em. mvflorida.com
c. The name and address of the Representative of the Subrecipient responsible for the administration of
this Agreement is:
Name: Scott Borror
Address: 685 W Montrose
Clermont, FL 34711
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Telephone: 352-241-7368
Email: sborrol-0-dermontfl.ora
d. In the event that different representatives or addresses are designated by either party after execution of
this Agreement, notice of the name, title, and address of the new representative will be provided to the other party in
writing via letter or electronic email.
e. Systems Access: It is the Subrecipient's responsibility to maintain current active users in the Division's
grants management system in accordance with Attachment B to this Agreement ("Systems Access Form").
(4) TERMS AND CONDITIONS
This Agreement contains all the terms and conditions agreed upon by the parties.
(5) EXECUTION
This Agreement may be executed in any number of counterparts, of which may be taken as an original.
(6) MODIFICATION
Either party may request modification of the provisions of this Agreement. Changes which are agreed upon
shall be valid only when in writing, signed by each of the parties, and attached to the original of this Agreement.
(7) SCOPE OF WORK
The Subrecipient shall perform the work as approved by FEMA and provide the necessary documentation to
substantiate work completed.
(8) PERIOD OF AGREEMENT/PERIOD OF PERFORMANCE
The Period of Agreement establishes a timeframe for all Subrecipient contractual obligations to be completed.
Upon execution by both parties, this Agreement shall begin on the first day of the incident period for the disaster
applicable to the agreement and shall end upon closeout of the Subrecipient's account for this disaster by the Federal
Awarding Agency, unless terminated earlier as specified elsewhere in this Agreement. This Agreement survives and
remains in effect after termination for the herein referenced State and Federal audit requirements and the referenced
required records retention periods. Work may only be performed during the timeframes established and approved by
FEMA for each Category of Work type.
(9) FUNDING
a. The amount of total available funding for this subgrant is limited to the amount obligated by the Federal
Awarding Agency for all projects approved for this Subrecipient for DR - 4680 - Hurricane Nicole Payments
to Subrecipients are contingent upon the granting of budget authority to the Division.
b. Pursuant to section 252.37(5)(a), Florida Statutes, unless otherwise specified in the General
Appropriations Act, whenever the State accepts financial assistance from the Federal Government or its agencies
under the Federal Public Assistance Program and such financial assistance is conditioned upon a requirement for
matching funds, the State shall provide the entire match requirement for state agencies and one-half of the required
match for grants to Local governments. Affected Local governments shall be required to provide one-half of the
required match prior to receipt of such financial assistance. Section 252.37, Florida Statutes, does not
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apply to Subrecipients that are considered Private Non -Profit entities, therefore the entire non-federal share
shall be the responsibility of the Private Non -Profit Subrecipient.
c. The Executive Office of the Governor may approve a waiver to local governments for the Non -Federal
match requirement. The local government must apply for the waiver in accordance with Section 252.37(5)(b), Florida
Statutes. Local governments must apply for the match waiver independently from their respective County.
(10) PAYMENT
a. The payment method used by the Division is either a Cost Reimbursement or an Advance Payment.
Advance payments will be governed by Chapter 216, Florida Statutes.
b. The Division's Grant Manager, as required by section 215.971(2)(c), Florida Statutes, shall reconcile
and verify all funds received against all funds expended during the grant agreement period and produce a final
reconciliation report. The final report must identify any funds paid in excess of the expenditures incurred by the
Subrecipient.
(11) REPAYMENTS
a. Refunds or repayments of obligated funds may be paid to the Division through check or through a
payment plan as approved by the Department of Financial Services. Additionally, FEMA may permit the Division to
off -set against other obligated projects where deemed appropriate. In accordance with Chapter 255, Florida Statutes,
the Subrecipient has 30 days to repay the funds from the issuance of the invoice from the Division. The Division may
impose a 1 % per month interest fee for unpaid invoices.
b. All refunds or repayments due to the Division under this Agreement are to be made payable to the order
of "Division of Emergency Management," and must include the invoice number and the applicable Disaster and
Project number(s) that are the subject of the invoice, and be mailed directly to the following address:
Division of Emergency Management
Cashier
2555 Shumard Oak Boulevard
Tallahassee FL 32399-2100
(12) RECORDS
a. As required by 2 CFR § 200.334, and modified by Florida Department of State's record retention
requirements (Fla. Admin. Code R. 1 B-24.003), the Subrecipient shall retain sufficient records to show its compliance
with the terms of this Agreement and all relevant terms and conditions of the award paid from funds under this
Agreement, for a period of five (5) years from the date of submission of the final expenditure report. This period may
be extended for reasons including, but not limited to, litigation, fraud, or appeal. As required by 2 CFR § 200.303(e),
the Subrecipient shall take reasonable measures to safeguard protected personally identifiable information and other
information the Federal Awarding Agency or the Division designates as sensitive or the Subrecipient considers
sensitive consistent with applicable Federal, State, local, and tribal laws regarding privacy and responsibility over
confidentiality.
b. The Subrecipient shall maintain all records for the Subrecipient and for all subcontractors or consultants
to be paid from funds provided under this Agreement, including documentation of all program costs, in a form sufficient
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to determine compliance with the requirements and objectives of the award and all other applicable laws and
regulations.
(13) AUDITS
a. The Subrecipient shall comply with the audit requirements contained in 2 CFR Part 200, Subpart F.
b. As required by 2 CFR § 200.337(a), "The Federal awarding agency, Inspectors General, the Comptroller
General of the United States, and the [Division], or any of their authorized representatives, shall enjoy the right of
access to any documents, papers, or other records of the [Subrecipient] which are pertinent to the Federal award, in
order to make audits, examinations, excerpts, and transcripts. The right also includes timely and reasonable access
to the [Subrecipient's] personnel for the purpose of interview and discussion related to such documents." The right
of access is not limited to the required retention period but lasts as long as the records are retained (2 CFR §
200.337(c)).
c. As required by 2 CFR § 200.332(a)(5), the Division, the Chief Inspector General of the State of Florida,
the Florida Auditor General, or any of their authorized representatives, shall enjoy the right of access to any
documents, financial statements, papers, or other records of the Subrecipient which are pertinent to this Agreement,
in order to make audits, examinations, excerpts, and transcripts. The right of access also includes timely and
reasonable access to the Subrecipient's personnel for the purpose of interview and discussion related to such
documents.
(14) REPORTS
a. Consistent with 2 CFR § 200.329, the Subrecipient shall provide the Division with quarterly reports and
any applicable financial reporting, including reports required by the Federal Funding Accountability and Transparency
Act (FFATA). These reports shall include the current status and progress by the Subrecipient and, as applicable, all
subcontractors in completing the work described in the Scope of Work and the expenditure of funds under this
Agreement, in addition to any other information requested by the Division.
Subrecipient Report
Reporting Time Period Submittal Deadline
Quarter 1 (Q1) October 1 — December 31 January 15
Quarter 2 (Q2) January 1 — March 31 April 15
Quarter 3 (Q3) April 1 — June 30 July 15
Quarter 4 (Q4) July 1 — September 30 October 15
b. The Subrecipient agrees to submit quarterly reports to the Division no later than fifteen (15) days after
the end of each quarter of the program year and to submit quarterly reports each quarter until one quarter past the
closeout of each project in the Division's Grant Management System. The ending dates for each quarter of the
program year are March 31, June 30, September 30, and December 31.
c. The closeout report is due sixty (60) days after completion of each project worksheet associated with the
applicant executing this Agreement, or sixty (60) days after termination of this Agreement, whichever first occurs.
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d. The Subrecipient shall provide additional program reports, updates, or information that may be required
by the Division or the Federal awaEding agency.
(15) MONITORING
a. The Division shall monitor the performance of the Subrecipient under this Agreement to ensure that the
Scope of Work is being accomplished within the specified time periods, and that other performance goals are being
met.
b. The Subrecipient agrees to comply and cooperate with any monitoring procedures/processes deemed
appropriate by the Division. In the event that the Division determines that an audit of the Subrecipient is appropriate,
the Subrecipient agrees to comply with any additional instructions provided by the Division to the Subrecipient
regarding such audit.
c. Small Projects, as defined in 44 CFR § 206.203, that are obligated above the Federal Simplified
Acquisition Threshold (SAT) will be subject to enhanced oversight and monitoring by the Division as authorized by 2
CFR § 200.332(a)(2).
(16) LIABILITY
a. Unless the Subrecipient is a State agency or political subdivision, as defined in section 768.28(2), Florida
Statutes, the Subrecipient is solely responsible to third parties it deals with in carrying out the terms of this Agreement.
As authorized by section 768.28(19), Florida Statutes, Subrecipient shall hold the Division harmless against all claims
of whatever nature by third parties arising from the work performance under this Agreement. For purposes of this
Agreement, Subrecipient agrees that it is not an employee or agent of the Division but is an independent contractor.
b. As required by section 768.28(19), Florida Statutes, any Subrecipient which is a State agency or political
subdivision, as defined in section 768.28(2), Florida Statutes, agrees to be fully responsible for its negligent or tortious
acts or omissions which result in claims or suits against the Division and agrees to be liable for any damages
proximately caused by the acts or omissions to the extent set forth in section 768.28, Florida Statutes. Nothing herein
is intended to serve as a waiver of sovereign immunity by any Subrecipient to which sovereign immunity applies.
Nothing herein shall be construed as consent by a State agency or subdivision of the State of Florida to be sued by
third parties in any matter arising out of any contract.
(17) TERMINATION
This Agreement terminates upon the completion of all eligible work and payment of all eligible costs in
accordance with the Public Assistance Program requirements. The Division and Subrecipient agree that all records
will be maintained until the conclusion of any record retention period.
(18) PROCUREMENT
a. The Subrecipient must ensure that any procurement involving funds authorized by the Agreement
complies with all applicable Federal and State laws and regulations, including 2 CFR §§ 200.318 through 200.327 as
well as Appendix II to 2 CFR Part 200 (entitled "Contract Provisions for Non -Federal Entity Contracts Under Federal
Awards"). Additional requirements, guidance, templates, and checklists regarding procurement may be obtained
through the FEMA Procurement Disaster Assistance Team. Resources found here:
hftr)s://www.fema.aov/arants/r)rocurement.
b. The Subrecipient must include all applicable federal contract terms for all contracts for which federal
funds are received.
If the Subrecipient contracts with any contractor or vendor for performance of any portion of the work required under
this Agreement, the Subrecipient must incorporate into its contract with such contractor or vendor an indemnification
clause holding the Federal Government, its employees and/or their contractors, the Division, its employees and/or
their contractors, and the Subrecipient and its employees and/or their contractors harmless from liability to third parties
for claims asserted under such contract.
c. The Subrecipient must monitor and document, in the quarterly report, the contractor's progress in
performing its work on its behalf under this Agreement in addition to its own progress.
d. The Subrecipient must ensure all contracts conform to sections 287.057 and 288.703, Florida Statutes,
as applicable.
(19) ATTACHMENTS
a. All attachments to this Agreement are incorporated as if set out fully.
b. In the event of any inconsistencies or conflict between the language of this
Agreement and the attachments, the language of the attachments shall control, but only to the extent of the conflict
or inconsistency.
c. This Agreement has the following attachments:
i. Attachment A —Certification Regarding Debarment
ii. Attachment B — Systems Access Form
iii. Attachment C — Certification Regarding Lobbying
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement.
SUBRECIPIENT: Clermont, City Of
By: _
(Signature)
Name: Tim Murry
Title: Mayor, City of Clermont
Date:I
STATE OF FLORIDA
DIVISION OF EMERGENCY MANAGEMENT
By:
Governor's Authorized Representative
Date:
Agreement Number: Z3649
Attachment A
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
and VOLUNTARY EXCLUSION
The Subrecipient certifies, to the best of its knowledge and belief, that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
2. Have not within the five-year period preceding entering into this Agreement had one or more public
transactions (Federal, State, or Local) terminated for cause or default; and
3. Have not within the five-year period preceding entering into this proposal been convicted of or had a civil
judgment rendered against them for:
a) the commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or
performing a public (Federal, State, or Local) transaction or a contract under public transaction, or b)
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.
The Subrecipient understands and agrees that the language of this certification must be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, contracts under grants, loans, and
cooperative agreements) and that all contractors and sub -contractors must certify and disclose accordingly.
The Subrecipient further understands and agrees that this certification is a material representation of fact upon which
reliance was placed when this transaction was made or entered into.
By: �
Signaturee
Tim Murry, Mayor
Name and Title
685 West Montrose Street
Street Address
Clermont, FL, 34711
City, State, Zip
Date
Clermont, City of
Subrecipient's Name
Z3649
DEM Contract Number
0
Attachment B
SYSTEMS/ACCESS
The System Access Form is submitted with each new disaster or emergency declaration to identify the
Subrecipient's contacts for the FDEM Grants Management System in order to enter notes, review notes and
documents, and submit the documentation necessary to work the new event. The Systems Access Form is originally
submitted as Attachment "B" to the PA Funding Agreement. The Subrecipient is responsible for regularly reviewing
its contacts. Contacts should be removed within 14 days of separation, retirement, or are reassignment by the
Subrecipient. A new form will only be needed if all listed contacts have separated from the Agency. If a new Systems
Access form is submitted. all Aoencv Representatives currently listed as contacts that are not included on the undated
form will be deleted from FDEM Grants Manaoement Svstem for the specified Grant. All users must log in on a
monthly basis to keep their accounts from becoming locked. Note: the Systems Access Form is NOT a delegation
of authority. A signatory must have an attached delegation of authority as appropriate.
Instructions for Completion
Complete the form in its entirety, listing the name and information for all representatives who will be working in the
FDEM Grant Management System. Users will be notified via email when they have been granted access. The user
must log in to the FDEM Grants Management System within twelve (12) hours of being notified or their account will
lock them out. Each user must log in within a sixty (60) day period or their account will lock them out. In the event
you try to log in and your account is locked, users must submit a request for unlocking to
RPA.HeIp(cDem.mvflorida.com.
The form is divided into twelve blocks; each block must be completed where appropriate.
Block 1: "Authorized Agent" — This should be the highest authority in your organization who is authorized to sign
legal documents on behalf of your organization. A subsequent new Authorized Agent must be designated through a
letter on letterhead from the Subrecipient's Authorized Representative. It is recommended to delegate this authority
to an organizational staff member to avoid delays in grant management (Only one Authorized Agent is allowed, and
this person will have full access/authority unless otherwise requested).
Block 2: "Primary Contact" — This is the person designated by your organization to receive all correspondence and
is our main point of contact. This contact will be responsible for answering questions, uploading documents, and
submitting reports/requests in FDEM Grants Management System. The Authorized Agent may designate a new
Primary Contact. (Only one Primary Contact is allowed, and this contact will have full access).
Block 3: "Alternate Contact" — This is the person designated by your organization to be available when the Primary
is not. Either the Authorized Agent or Primary Contact may designate a new Alternate Contact. (Only one Alternate
Contact is allowed, and this contact will have full access).
Block 4, 5, and 6: "Other" (Finance/Point of Contact, Risk Management -Insurance, and Environmental -Historic).
Providing these contacts is essential in the coordination and communication required between State and Local subject
matter experts. We understand that the same agent may be identified in multiple blocks, however we ask that you
enter the name and information again to ensure we are communicating with the correct individuals.
Block 7 — 12: "Other" (Read Only Access) — There is no limit on "Other" contacts, but we ask that this be restricted
to those that are going to actually need to log in and have a role in reviewing the information. This designation is only
for situational awareness purposes as individuals with the "Other Read -Only" designation cannot take any action in
FDEM Grants Management System.
Note: The Systems Access Form is NOT a delegation of authority. A signatory must have an attached
delegation of authority as appropriate.
HE
SYSTEMS ACCESS FORM (CONTACTS)
FEMA/GRANTEE PUBLIC ASSISTANCE PROGRAM
FLORIDA DIVISION OF EMERGENCY MANAGEMENT
Subrecipient: Clermont, City of
Box 1:
Name
Authorized Agent (Full Access) Box 2: Primary Contact (Full Access)
Tim Murry
Signature _..
Organization / Official Position
City of Clermont, vor
Mailing Address
P85 W Montrose St
City, State, Zi
Clermont. Florida 34711
Daytime Telephone
352-241-735R
E-mail Address
tmurrv(a).clermontfl.orq
Box 3: Alternate Contact (Full Access)
Name Scott Keyes
Signature qq
Organizatio" Of $on
Grants & SDecial Proiects Manaaer
Mailing Address
685 W Montrose .Rt
City, State, Zip
r`iprTont- Flnridn 34711
Daytime Te�epone
�P2-241-7324
E-mail dress
skeves(cDclermontfl.orq
Box 5: Other -Risk Mgmt-Insurance (Full Access)
Name
Signature
Organization / Official Position
Mailing Address
City, State, Zip
Daytime Telephone
E-mail Address
Name Scott rror _
Signature
Org nizatign cial Posdio' n
interim Finance Director
Mailing Address
685 W Montrose St
City, State, Zip
(;lermnnt, Flnricta 34711
Daytime Telephone
52-241-7368
E-mai Address
sborror(@clermontfl.ora
Box 4: Other-Finance/Point of Contact (Full Access)
Name
Signature
Organization / Official Position
Mailing Address
City, State, Zip
Daytime Telephone
E-mail Address
Box 6: Other -Environmental -Historic (Full Access)
Name
Signature
Organization / Official Position
Mailing Address
City, State, Zip
Daytime Telephone
E-mail Address
The above contacts may utilize the FDEM Grants Management System to perform the Subrecipient's responsibilities regarding the Public
Assistance Grant according to their level of access. The Subrecipient is responsible for ensuring that all contacts are correct and up-to-date.
M
Subrecipient Aut �rlze&rese tative Signature
y
Date
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SYSTEMS ACCESS FORM (CONTACTS)
FEMA/GRANTEE PUBLIC ASSISTANCE PROGRAM
FLORIDA DIVISION OF EMERGENCY MANAGEMENT
Subrecipient: Clermont, City of Date:
Box 7: Other (Read Only Access) Box 8: Other (Read Only Access)
Name Name
Signature Signature
Organization / Official Position Organization / Official Position
Mailing Address Mailing Address
City, State, Zip City, State, Zip
Daytime Telephone Daytime Telephone
E-mail Address E-mail Address
Box 9: Other (Read Only Access)
Name
Signature
Organization / Official Position
Mailing Address
City, State, Zip
Daytime Telephone
E-mail Address
Box 11: Other (Read Only Access)
Name
Signature
Organization / Official Position
Mailing Address
City, State, Zip
Daytime Telephone
E-mail Address
Box 10: Other (Read Only Access)
Name
Signature
Organization / Official Position
Mailing Address
City, State, Zip
Daytime Telephone
E-mail Address
n
Box 12: Other (Read Only Access)
Name
Signature
Organization / Official Position
Mailing Address
City, State, Zip
Daytime Telephone
E-mail Address
Subrecipient's Fiscal Year (FY) Start: Month: CiCt Day: 1 St
Subrecipient's Federal Employer's Identification Number (EIN) 59-6000290
Subrecipient's Grantee Cognizant Agency for Single Audit Purposes: Florida Division of Emergency Management
Subrecipient's: FIPS Number (If Known) 069-12925-00
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Attachment C
Certification Regarding Lobbying
APPENDIX A. 44 CFR PART 18 — CERTIFICATION REGARDING LOBBYING
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned 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
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this
Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit
Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award documents
for all subawards at all tiers (including subcontracts, subgrants, 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 section 1352, title 31, U.S. Code. 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.
The Subrecipient or contractor, ,City of Clermont , 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. Chap. 38, Administrative Remedies for False Claims and Statements,
apply to this certification and disclosure, if any.
Signature of Subre ipient/con ctors Authorized Official
Tim Murrv, Mavor
Name and Title of Subrecipient/contractor's Authorized Official
,�)11--�12c2
Date
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B. Applicant Information:
FEMA-4680-DR-FL DISASTER NAME: Nicole
Title of Project: Station 3 Generator
1. Applicant (Organization): Citv of Clermont Fire Decartment
2. Applicant Type: ® State or Local Government ❑ Native American Tribe ❑ Private Non -Profit ❑ Special District
3. County: Lake
4. State Legislative Senate District(s): 32; State Legislative House District(s): 22 ;
Congressional House District(s): FL15
5. Federal Tax I.D. Number: 59-6000290
6. Data Universal Numbering System (DUNS): 619260710
7. Federal Information Processing Standards (FIPS) Code*: 069-12925-0 (*if your FIPS code is not known, see
guidance)
8. National Flood Insurance Program (NFIP) Community Identification Number: 120133
(this number can be obtained from the FIRM map for your area)
9. Point of Contact: (Applicant staff serving as the coordinator of project)
®Ms. ❑Mr. First Name: Rick Last Name: Casler
Title: Assistant Chief Administration
Address: 439 W. HWY 50
City: Clermont State: FI Zip Code: 34711
Telephone: 352 241-2217 Email: rcaslerCclermontfl.orri
10. Application Prepared by:
®Ms. ❑Mr. First Name: Kathy Last Name: Johnston
Title: Assistant Chief Administration
Address: 439 W. HWY 50
City: Clermont State: FI Zip Code: 34711
Telephone: 352-241-2213 Email: kiohnston rgciermontfl.org
Organization: City of Clermont, Florida
11. Authorized Applicant Agent (proof of authorization authority required)
❑Ms. ®Mr. First Name: Tim Last Name: Murry
Title: Mayor
Address: 685 W. Montrose Street
City: Clermont State: FI _ Zip Code: 34711
Telephone: 352-241-7358 Email: tmurry@clermontfl.org
Signature:
Date: _19r1ohe r-
12. Local Mitigation Strategy (LMS) Compliance
a. All proposed projects must be included in the county's Local Mitigation Strategy (LMS) Project List, and on file
with FDEM's Mitigation Bureau Planning Unit. Does your jurisdiction have a current FEMA Approved
Mitigation Plan and this project is listed? ® Yes ❑ No
b. Attached is a letter of endorsement for this project from the county's LMS Coordinator. ® Yes ❑ No
Ensure the LMS endorsement letter contains both the Total Estimated Projects Cost (Section IV. D.), along
with the Estimated Federal Share (Section IV. 1.1.) allocated to this project.
c. The LMS project list and endorsement letter both have an estimated cost column and Federal Share amount
that is within $500.00 between the two. ® Yes ❑ No
13. Has this project been submitted under a previous disaster event? ® No
2
27P-22-.007 F.A.0 FDEM Form No. HMGP Application (01-2020) (Eff. 01-2020)