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HomeMy WebLinkAboutC2005-058 - 2/8/2005 - ApprovedPage 1 of 19 pages Contract Number 05-DEM-LEPC-1 AGREEMENT FOR HAZARDOUS MATERIALS EMERGENCY PREPAREDNESS PLANNING GRANT STATE OF TEXAS COUNTY OF TRAVIS PARTIES Pursuant to the authority of TEXAS GOVERNMENT CODE §§ 418.043 and 418.044 and/or § 791.011, this agreement for a Hazardous Materials Emergency Preparedness Planning grant is made by and between the State of Texas, acting by and through the Texas Department of Public Safety, Division of Emergency Management, hereinafter called the "STATE," and the City of Corpus Christi hereinafter referred to as the "CITY," serving as a fiscal agent for the City of Comus Christi/Nueces County Local Emergency Planning Committee (LEPC). WlTNESSETH WHEREAS, the STATE has no programmed resources to implement this requirement of federal law; and WHEREAS, the STATE will receive funds from the United States Department of Transportation to accomplish the tasks detailed in this agreement, AGREEMENT NOW, THEREFORE, the STATE and the CITY in consideration of the mutual covenants and agreements contained herein, do mutually agree as follows: The CiTY agrees to perform hazardous materials emergency preparedness planning activities in connection with the project as stated in the Articles to follow and outlined hereafter, and for having rendered such services, the STATE agrees to pay to the CITY compensation for these services as set out in this agreement. All services performed under this agreement shall be performed under the supervision of the State Coordinator, Governor's Division of Emergency Management (GDEM), represented by the Hazardous Materials Training Officer as the STATE project officer. TDPS 2005-058 02/08/05 Res026130 Page 2 of 19 pages 1. CONTRACT PERIOD This agreement shall become effective upon the date of final execution by the STATE and shall be completed by Au~lust 31, 2005, unless terminated in a manner defined herein. 2. SERVICES TO BE PROVIDED BY THE CITY The CiTY shall: A. Complete the following projects: Conduct a chemical spill exercise/drill and conduct a public education program as proposed by the Local Emerqencv Planninq Committee (LEPC). The purpose of these proiects is to better prepare local responders for hazardous materials response in Corpus Christi and Nueces Counb/. B. Provide the STATE the following deliverables: 1) Monthly progress reports as outlined in Section 6 below. 2) Monthly financial reports as outlined in Section 6 below. 3) A final project report as outlined in Section 6 below, together with a copy of the chemical spill exercise/drill report and a copy of public education products. 4) A copy of any contract between the City of Corpus Christi and any vendor for products or services related to the project as stated in Section 2 above. 3. SERVICES TO BE PROVIDED BY THE STATE The STATE shall provide planning assistance to the CITY in the form of guidance so the CITY can timely complete the deliverables listed above. 4. COMPENSATION AND METHOD OF PAYMENT A. The estimated total cost of the project which is the subject of this grant is: Sixteen thousand three hundred and twenty dollars ($16,320). B. The maximum amount payable by the STATE under this agreement is: Thirteen thousand and six hundred dollars ($13,600). Page 3 of 19 pages C. The CITY shall provide a cash or soft match of at least 20% of the total project cost or at least: Two thousand seven hundred and twenht dollars ($2,720). The soft match may include any of the following expenses that are reasonable, allowable and allocable to the project. 1) Salaries, fringe benefits, per diem, housing, or travel expenses incurred by any person other than a government employee while attending training classes or involved in program activities. 2) Private contributions such as corporate contributions of facilities or services such as free classroom space. 3) Voluntary contributions such as firefighter support, emergency personnel support, and the time of any LEPC member. 4) Equipment or facilities used for exercises, whether public or pdvate. 5) Facility space necessary to conduct activities for the grant program. 6) University students volunteering time to aid in collection of data. D. To receive reimbursement for allowable costs, the CITY shall submit as attachments to the monthly financial report an original and four copies of all invoices or receipts along with copies of canceled checks or other proof of payment for each invoice or receipt to the STATE for expenses paid by the CITY during the month covered by the report. E. The CI'I-Y shall furnish all equipment, materials and supplies required to perform the project, which is the subject of this grant. F. All payments to the CITY shall be made when the CITY, and a valid invoice or receipt pays expenses and proof of payment for each expense is submitted to the STATE. The total amount of the grant will be paid when all deliverables have been received and paid for by the CITY. G. The STATE shall make payment to the CITY within thirty (30) days from receipt of the CITY's reimbursable expenses, provided the request for payment is properly prepared, executed, and documented. H. The CITY agrees to spend the average of the CITY's Local Emergency Planning Committee expenditure for planning activities for the past two years, in addition to the CITY's twenty percent (20%) cost match for this grant. Page 4 ofl9pages 5. INITIATION OF PROJECT WORK The CITY shall not begin the work outlined herein until final execution of this agreement by the STATE. 6. INSPECTION OF WORK AND PROGRESS REPORTING The CITY shall, from time to time during progress of the work defined herein, confer with the STATE. The STATE's project officer has the right to inspect work being performed pursuant to this agreement in a manner that will not unduly delay the work. The CITY shall prepare and present such information and data as may be pertinent and necessary or as may be requested by the STATE in order to evaluate the progress of the work to be performed by the CITY. B The CITY's project officer shall render required reports to the STATE's project officer, including: 1) Commencing with March 2005, monthly progress reports in the format outlined in Attachment 1 to this agreement. Reports should be dispatched not later than the 20~h of the month following that which the progress report covers. 2) Commencing with March 2005, monthly financial reports, with supporting documentation, in the format outlined in Attachment 2 to this agreement. Reports should be mailed not later than the 20Ih of the month following that which the financial report covers. 3) Not later than September 15, 2005, a final project report, which shall summarize the work, performed on the project and accomplishments and a final financial report with all remaining invoices for reimbursement, supported by appropriate documentation of expenses. Monthly progress reports and the final project report may be submitted by mail, facsimile, or e-mail. Financial reports, which require original supporting documentation, and the final project report must be sent by mail or courier. 7. TERMINATION A. This agreement may be terminated by any of the following conditions: 1) By mutual agreement and consent of both parties. 2) By the STATE upon written notice to the CITY as consequence of the CITY's failure to perform the services herein in a satisfactory manner and within the limits provided, with proper allowances being made for circumstances beyond Page 5 of 19 pages the control of the CITY as determined in good faith and reasonable business judgment by the STATE. 3) By the STATE for reasons of it's own and not subject to the mutual consent of the CITY upon not less than ten (10) days written notice to the CITY. 4) By satisfactory completion of all services and obligations described herein. Should the STATE terminate this agreement as herein provided, no expenses except those due and payable at the time of termination shall thereafter be paid to the CITY. Payment for the work at the time of termination shall be based upon work completed at that time. The termination of this agreement and payment of any amount in the settlement as prescribed herein shall extinguish all rights, duties, obligations and liabilities of the STATE and the CITY under this agreement. 8. DISPUTES The CITY shall be responsible for the settlement of all contractual and administrative issues arising out of procurement made by the CITY in support of this grant program. Any disputes concerning the work or obligations defined herein or additional costs, or any non-procurement issues shall be settled at the sole discretion of the Department of Public Safety. 9. INDEMNIFICATION To the extent authorized by the Constitution and Laws of the State of Texas the CITY shall indemnify and hold harmless the STATE, its officers and employees from all third party claims for injury to, or death of, persons and damage to, or loss of, physical property directly due to activities of itself, its agents, contractors, officers or employees, performed under this agreement and which result from the negligence or willful misconduct of the CITY or of any person employee by the CITY. The CITY shall also indemnify and hold harmless the STATE, its officers and employees from any and all expenses, including attorney fees which might be incurred by the STATE, its officers and employees as a result of such activities by the CITY, its agents, contractors, officers and employees. 10.COMPLIANCE WITH LAWS The CITY shall comply with all federal, state and local laws, statutes, ordinances, rules, regulations, and the orders and decrees of any court, or administrative bodies or tribunals in any manner affecting the performance of this agreement. Page 6 of 19 pages 11.ASSURANCES The CITY assures that no person shall, on the grounds of race, creed, color, handicap, national origin, gender, political affiliation or beliefs, be excluded from, be denied benefit of, or be subject to discrimination under any program or activity funded in whole or in part under this agreement. Incorporated by reference the same as if specifically written herein are rules, regulations, and all other requirements imposed by law, including but not limited to compliance with those pertinent rules and regulations of the State of Texas and those of United States agencies providing funds to the State of Texas. 12.AUDIT REQUIREMENTS The CITY hereby agrees to comply with the requirements specified in the Single Audit Act, 31 U.S.C. §§ 7500 et seq. (Supp.1999) (Public Law 104-156), as applicable. 13. WRITTEN MODIFICATION No modification or amendment lo this Agreement shall become valid unless in writing and signed by both parties. 14. PROJECT OFFICERS The project officers for this agreement are: A. For the STATE: Name: Address: Telephone: Fax: E-mail: Edwin B. Staples Training & Exercise Unit Governor's Division of Emergency Management Texas Department of Public Safety PO Box 4087 Austin, Texas 78773-0225 (512) 424-5985 (512) 424-5647 edwin.staples~.txdps.state.b(.us Page 7 of 19 pages B. For the CITY: Name: Address: Rick Ramos, Sr. Management Assistant 2406 Leopard, Suite 300 Corpus Christi, TX 78408 Telephone: Fax: E-mail: 361-880-3938 361-887-8053 rickr@cctexas.com 15. SIGNATORY AUTHORITY The undersigned signatory for CITY hereby represents and warrants that he/she is an officer of the organization for which he/she has executed this agreement, and that he/she has full and complete authority to enter into this agreement on behalf of the CITY. IN TESTIMONY WHEREOF, the parties hereto have caused this agreement to be executed in duplicate effective the date of the last signature to this agreement. FOR THE STATE FOR THE cl'r'Y Texas Department of Public Safetv Name of Agency · Authorized S.~ature City of Corpus Christi Name of Jurisdiction BY: //,~uthorLz%Signature Oscar Ybarra Pdn[ed Name George K. Noe Printed Name Chief of Finance Title ~ I~II~IL ._-_ City Manager Title Date Page 8 of 19 pages Fiscal Year 2005 Hazardous Materials Emergency Preparedness Planning Grant ASSURANCES & CERTIFICATIONS APPENDIX A CERTIFICATION DRUG FREE WORKPLACE ACT OF '1988 Page 9 of 19 pages The recipient certifies that it will provide a drug-free workplace by: 1. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the recipient's workplace and specifying the actions that will be taken against employees for violation of such prohibition; 2. Establishing a drug-free awareness program to inform employees about: A. The dangers of drug abuse in the workplace: B. The recipient's policy of maintaining a drug-free workplace: C. Any available drug counseling, rehabilitation, and employee assistance programs; and D. The penalties that may be imposed on employees for drug abuse violations occurring in the workplace; 3. Making it a requirement that each employee to be engaged in the performance of the project be given a copy of the statement required by paragraph (a); 4. Notifying each employee in the statement required by paragraph that, as a condition of employment under the award, the employee must: A. Abide by the terms of the statement; and B. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than 5 days after such conviction; 5. Notifying the Award Official within 10 days after receiving notice under subparagraph (d)2, from an employee or otherwise receiving actual notice of such conviction; 6. Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)2, with respect to any employee who is so convicted: A. Appropriate personnel action against such an employee, up to and including termination; or Page 10 of 19 pages B. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency: Making a good-faith effort to continue to maintain a drug-free workplace through implementation of paragraphs 1, 2, 3, 4, 5, and 6. Place of Performance 2406 Leopard, Suite 300 Street address Corpus Christi, City, County Texas 78408 State, Zip Code Nueces Date City of Corpus Christi (Name of Grant Recipient) (S Authorized Official) Page 11 ofi9pages APPENDIX B U.S. DEPARTMENT OF TRANSPORTATION HAZARDOUS MATERIALS EMERGENCY PREPAREDNESS TRAINING AND PLANNING GRANTS CERTIFICATION OF COMPLIANCE WITH GOVERNMENT-WIDE GUIDANCE ON LOBBYING RESTRICTIONS (31 U.S.C. 1352) The City of Corpus Christi (Grant Recipient) Certifies, to the best of his or her knowledge and belief, that: No Federal appropriated funds have been paid or will be paid, by or on behalf of the Grant Recipient, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, and officer or employee of Congress, or an employee or 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, or modification of any Federal contract, grant, loan, or cooperative agreement. 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 Grant Recipient shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. The Grant Recipient 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 for such failure. Date City of Corpus Christi (Name of Grant Recipient) by (S~nature of Authorized Official) Page 12 of 19 pages APPENDIX C ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 US DEPARTMENT OF TRANSPORTATION The State of Texas (hereinafter referred to as the "Recipient") HEREBY AGREES THAT as a condition to receiving any Federal financial assistance from the Department of Transportation it will comply with Title VI of the Civil Rights Act of 1964, 78 Stat. 252, 42 U.S.C. 2000d-42 U.S.C. 2000d-4 (hereinafter referred to as the Act) and all requirements imposed by or pursuant to Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the Secretary, Part 21, Nondiscrimination in Federally-assisted Programs of the Department of Transportation- Effectuation of Title VI of the Civil Rights Act of 1964 (hereinafter referred to as the Regulations) and other pertinent directives, to the end that in accordance with the Act, Regulations, and other pertinent directives, no person in the United States shall, on the grounds of race, color, sex or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Recipient receives Federal financial assistance from the Department of Transportation, and HEREBY GIVE ASSURANCE THAT it will promptly take any measures necessary to effectuate this agreement. This assurance is required by subsection 21.7(a)(1) of the Regulations. More specifically and without limiting the above general assurance, the Recipient hereby give the following specific assurance with respect to the project. That the Recipient agrees that each "program" and each "facility" as defined in subsections 21.23(e) and 21.239(b) of the Regulations, will be (with regard to a "program") conducted, or will be (with regard to "facility") operated in compliance with all requirements imposed by, or pursuant to, the Regulations. That the Recipient shall insert the following notification in all solicitations for bids for work or material subject to the Regulations and, in adapted form in all proposals for negotiated agreements: The Recipient, in accordance with Title VI of the Civil Rights Act of 1964, 78 State. 252, 42 U.S.C. 2000d to 2000d-4 and Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the Secretary, Part 21, Nondiscrimination in Federally-assisted Programs of the Department of Transportation issued pursuant to such Act, hereby notifies all bidders that it will affirmatively insure that in regard to any Page 13 of 19 pages contract entered into pursuant to this advertisement, minodty business enterprises will be afforded full opportunity to submit bids in response to this invitation and will not be discriminated against on the grounds of race, color, sex or national origin in consideration for an award. That the Recipient shall insert the clauses of Appendix B of this assurance in every contract subject to the Act and the Regulations. That this assurance obligates the Recipient for the period during which Federal financial assistance is extended to the project. The Recipient shall provide for such methods of administration for the program as are found by the Secretary of Transportation or the official to whom he delegates specific authority to give reasonable guarantee that it, other recipients, subgrantees, contractors, subcontractors, transferees, successors in interest, and other participants of Federal financial assistance under such program will comply with all requirements imposed or pursuant to the Act, the Regulations and this assurance. The Recipient agrees that the United States has a right to seek judicial enforcement with regard to any matter arising under the Act, and Regulations, and this assurance. THIS ASSURANCE is given in considerations of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts or other Federal financial assistance extended after the date hereof to the Recipient by the Department of Transportation and is binding on it, other recipients, subgrantees, contractors, subcontractors, transferees, successors in interest and other participants in the Department of Transportation Program. The person or persons who signatures appear below are authorized to sign this assurance on behalf of the Recipients. City of Corpus Christi (Name of Grant Recipient) by (Signa~.~f Authorized Official) Page 14 of 19 pages APPENDIX D ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 US DEPARTMENT OF TRANSPORTATION During the performance of this contract, the contractor, for itself, its assignees and successors in interest (hereinafter referred to as the "contractor") agrees as follows: Compliance with Requlations: The contractor shall comply with the Regulations relative to nondiscrimination in Federally assisted programs of the Department of Transportation (hereinafter, "DOT") Title 49, Code of Federal Regulations, Part 21, as they may be amended from time to time, (hereinafter referred to as the Regulations), which are herein incorporated by reference and made a part of this contract. Nondiscrimination: The contractor, with regard to the work performed by it during the contract, shall not discriminate on the grounds of race, color, sex, or national origin in the selection and retention of subcontractors, including procurement of materials and leases of equipment. The contractor shall not participate either directly or indirectly in the discrimination prohibited by Section 21.5 of the Regulations, including employment practices when the contract covers a program set forth in Appendix B of the Regulations. Solicitation for Subcontracts, Includina Procurement of Materials and Eauipment: In all solicitations either by competitive bidding or negotiation made by the contractor for work to be performed under a subcontract, including procurements of materials or leases of equipment, each potential subcontractor or supplier shall be notified by the contractor of the contractor's obligations under this contract and the Regulations relative to nondiscrimination on the grounds of race, color, sex, or national origin. Information and Reports: The contractor shall provide all information and information required of a contractor is in the exclusive possession of another who fails or refuses to furnish this information the contractor shall so certify to the State of Texas or the Research and Special Programs Administration as appropriate, and shall set forth what efforts it has made to obtain the information. Sanctions for Noncompliance: In the event of the contractor's noncompliance with nondiscrimination provisions of this contract, the State of Texas shall impose contract sanctions as it or the Research and Special Programs Administration may determine to be appropriate, including, but not limited to: Page 15 of 19 pages (a) withholding of payments to the contractor under the contract until the contractor complies; and/or (b) cancellation, termination, or suspension of the contract, in whole or in part. Incorporation of Provisions: The contractor shall include the provisions of paragraphs (1) through (6) in every subcontract, including procurements of materials and leases of equipment, unless exempt by the Regulations, or directives issued pursuant thereto. The contractor shall take such action with respect to any subcontract or procurements as the State of Texas or the Research and Special Programs Administration may direct as a means of enforcing such provisions including sanctions for noncompliance: Provided, however, that in the event a contractor becomes involved in, or is threatened with, litigation with a subcontract or supplier as a result of such direction, the contractor may request the State of Texas to enter into such litigation to protect the interests of the State of Texas, and, in addition the contractor may request the United States to enter into such litigation to protect the interests of the United States. City of Corpus Christi (Name of Grant Recipient) by (si~e of AL~thorized Official) Page 16 of ! 9 pages APPENDIX E ASSURANCE OF COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 US DEPARTMENT OF TRANSPORTATION The following clauses shall be included in all deeds, licenses, permits, or similar instruments entered into by the State of Texas. The [grantee, licensee, lessee, permittee, etc., as appropriate] for herself/himself, his/her heirs, personal representatives, successors in interest, and assigns, as a part of the consideration hereof, does hereby covenant and agree [in the case of deeds and leases add "as a covenant running with the land"] that in the event facilities are constructed, maintained, or otherwise operation on the said property described in this [deed, license, lease, permit, etc.] for a purpose for which a Department of Transportation program or activity is extended or for another purpose involving the provision of similar services or benefits, the [grantee, licensee, lessee, permittee, etc.] shall maintain and operate such facilities and services in compliance with all other requirements imposed pursuant to Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the Secretary, Part 21, Nondiscrimination of Federally-Assisted Programs of the Department of Transportation - Effectuation of Title VI of the Civil Rights Act of 1964, and as said Regulations may be amended. [Include in licenses, leases, permits, etc.]* That in the event of breach of the above nondiscrimination covenants, State of Texas shall have the right to terminate the [license, lease, permit, etc.] and to re-enter and repossess said land and the facilities thereon, and hold the same as if said [licenses, lease, permit, etc.] had never been made or issued. [Include in deeds]* That in the event of breach of any of the above nondiscrimination covenants, State of Texas shall have the right to re-enter said lands and facilities thereon, and the above described lands and facilities shall thereupon revert to and vest in and become the absolute property of State of Texas and its assigns. The following shall be included in all deeds, licenses, leases, permits, or similar agreements entered into by State of Texas. The [grantee, licensee, lessee, permit'tee, etc., as appropriate] for herself/himself, his/her personal representatives, successors in interest, and assigns, as a part of the consideration hereof, does hereby covenant and agree [in case of deeds, and leases Page 17 ofl9 pages add "as a covenant running with the land"] that (1) no person on the grounds of race, color, sex, or national origin shall be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination in the use of said facilities, (2) that in the construction of any improvements on, over or under such land and the furnishing services thereon, no person on the grounds of race, color, sex, or national origin shall be excluded from the participation in, be denied the benefits of, or be otherwise subjected to discrimination, and (3) that the [grantee, licensee, lessee, permittee, etc.] shall use the premises in compliance with all other requirements imposed by or pursuant to Title 49, Code of Federal Regulations, Department of Transportation, Subtitle A, Office of the Secretary, Part 21, Nondiscrimination in Federally-Assisted Programs of the Department of Transportation - Effectuation of Title vi of the Civil Rights Act of 1964, and as said Regulations may be amended. [Included in licenses, leases, permits, etc.]* That in the event of breach of any of the above nondiscrimination covenants, State of Texas shall have the right to terminate the [license, lease, permit, etc.] and to re-enter and repossess said land and the facilities thereon, and hold the same as if said [license, lease, permit, etc.] had never been made or issued. [Include in deeds]* That in the event of breach of any of the above nondiscrimination covenants, State of Texas shall have the right to re-enter said land and facilities thereon, and the above described lands and facilities shall thereupon revert to and vest in and become the absolute property of State of Texas and its assigns. * Reverter clause and related language to be used only when it is determined that such a clause is necessary in order to effectuate the purpose of Title VI of the Civil Rights Act of 1964. City of Corpus Christi (Name of Grant Recipient) by (S.~re~ o~/~uthorized Official) Page 18 of 19 pages ATTACHMENT 1 MONTHLY PROGRESS REPORT FORMAT HMEP PLANNING GRANT MONTHLY PROGRESS REPORT LEPC: Jurisdiction acting as fiscal agent: For the Month of: 1. Project Progress During the Month: (Should include a description of the work that has been performed, major purchases, if any, and an estimate of the percent of the project completed to date. For projects that involve multiple tasks, discuss each and indicate which tasks, if any, are complete.) 2. Problems Impeding Project & Actions Taken to Resolve Those Problems: 3. Planned Project Work for the Next Month: (Should include a description to work to be performed and major purchases planned, if any. For projects that involve multiple tasks, discuss each.) 4. Estimated Project Completion Date: Signature of Local Project Officer Title of Local Project Officer Page 19 of 19 pages ATTACHMENT 2 MONTHLY FINANCIAL REPORT FORMAT HMEP PLANNING GRANT MONTHLY FINANCIAL REPORT LEPC: Jurisdiction acting as fiscal agent: For the Month of: 1. Project Cost (from Grant Agreement) 2. State Share (from Grant Agreement) 3. Local Match Share (from Grant Agreement) 4. Expenses previously submitted for State reimbursement $ $ $ $ 5. State reimbursement requested - this report Paid To Date Amount Purpose (An original and four copies of valid invoices or receipts and proof of payment for expenses (in the form of canceled checks, bills marked "paid in full", or other proof) must be attached to this repod in order to receive state reimbursement for allowable expenses.) 6. Local match expenditures incurred (Local match may be a cash match or a soft match, which could be one or more of the following: A. Salaries, fringe benefits, per diem, lodging, or travel expenses incurred by any person other than a government employee while attending training classes or involved in program activities. B. Public or pdvate contributions of goods, such as paper, or services, such as printing, at fair market value. C, Voluntary contributions of labor by either public or private employees, valued at their normal rate of pay. D. Equipment used for exercises, whether public or private, valued at its normal rental rate. E. Facilities necessary to conduct activities for the grant program, valued at market lease rates. F. Students volunteering time, valued at prevailing minimum wage.) 7. State Share balance (Line 2- [4+5]) 8. Local Match Share balance (Line 3-6) Signature of Local Financial Officer Title of Local Financial Officer