Kansas Division of Emergency Management

Hazard Mitigation Grant Program

Project Application

Construction

Applicant:

Project Location:

(street, city, county, and state)

Project Title (descriptive):

Estimated Project Cost (total):

Rev 12/2013

THIS SECTION FOR STATE USE ONLY

FEMA--DR-KS

Standard HMGP or

HMGP 5% Initiative

FMA

Other:

Initial Submission or

Resubmission

Completeness Checklist

State Mitigation Plan

Eligible Applicant

Project Type(s)

Elevation

Drainage

Wind Retrofit

Tornado

Protection (Levee/Berm)

Other:

Community NFIP Status:

Participating Community

ID#

CRS Participant

In Good Standing

Sanctioned

State Application ID:

Date Received:

State Reviewer:

This application is for construction type Hazard Mitigation Grant Program (HMGP) proposals. Please complete ALL sections and provide the documents requested. If you require additional assistance with this application, please contact the Kansas Emergency Management Mitigation Division 785-274-1973.

To Fill Out This Application:complete all sections of the main application, if the project involves engineered drainage projects fill out the following supplemental worksheets:

Critical Facility Worksheet: Protection of Critical Facilities only
Drainage Worksheet: Drainage Projects only

Applicant Information

Applicant (Organization):

Applicant Type:

State or Local GovernmentRecognized Indian TribePrivate Non-Profit

County / Counties:
State Legislative district(s): Congressional District(s):
Tax I.D. Number: FIPS Code (if known):
DUNS#:

Point of Contact and Authorized Agent for the Grant

Ms. Mr. Mrs. First Name: Last Name:

Title:

Street Address:

City: State: Zip Code:

Telephone: () -Fax: () -

Email Address (if available):

Application Prepared by:

Ms. Mr. Mrs. First Name: Last Name:

Title: Telephone: () - Fax: () -

Chief Executive, (an individual with legal signatory authority for the respective applicant, e.g. City/County manager, Chairperson of the County Commission, Mayor, etc.)

Ms. Mr. Mrs. First Name: Last Name:

Title:

Street Address:

City: State: Zip Code:

Telephone: () -Fax: () -

Email Address (if available):

CERTIFICATION:1) By signing this document you declare to the best of your knowledge the data in this application are true and correct, the governing body has duly authorized the document and hereby applies for assistance in this application, and 2) the individual identified in block 7 above will act as the applicant’s agent in the performance of this grant.

Signature: ______Date:

I.History of Hazards / Damages in the Area to be Protected*

In this section describe all past damages from hazardous events in the project area. Include Presidential declared disasters as well as events that did not result in a Presidential declaration.

Overview of Past Damages

Provide a detailed past history of damages in the area, including direct and indirect costs. Include information for as many past incidents as possible. Attach any supporting documents. Direct costs should include damages to structures and infrastructure in the project area as a result of the hazard. Indirect costs should include the cost to the local government to respond to victims of the hazard in the project area, any interruption to local businesses, and losses of public services.

Level of

Date EventDamagesIndirect costs (describe)____

[e.g. 10/7/89 50 year flood Total of $195,000 in damages to 16 homes in project area Emergency Services Evacuation of 58 people.]

[e.g. 8/18/92 100 year flood Total of $1,895,000 in damages to 23 homes in project area Emergency Services Evacuation of 108 people.]

Describe other events and/or damages:

II.Project Description (Scope of Work)

A.Project Description / Protection Provided

Describe, in detail, the proposed project. Also, explain how the proposed project will solve the problem(s) and provide the level(s) of protection described in Section B.

Hazards to be Mitigated / Level of Protection
Select the type of hazards the proposed project will mitigate:

Flood Wind Seismic Other (list)

Fill in the level of protection the proposed project will provide (e.g. 23 structures protected against the 100-year (1%) flood. List data in Flood Levels (10, 50, 100, 500) or mph winds. (Critical facilities must be protected against the 500 year flood event)

structures protected against the

Engineered Projects Only (e.g. Drainage Improvements, Levees)

Include (attach to this page) ALL engineering calculations used to determine the above level of protection.

The following documents are attached (list):

Useful life of the project.

Proposed project will provide protection against the hazard(s) above for years.

Additional Scope of Work:

III.Project Location - Fully describe the location of the proposed project.

Site

Physical Location

Describe the area and/or population affected/protected by this project, include the location (street numbers or neighborhoods), city, county and zip codes.

Population Affected

Provide the number of each type of structure (listed below) in the project area. Include all structures in project area.

residential properties

businesses / commercial properties

public buildings

schools / hospitals / houses of worship

Flood Insurance Rate Map (FIRM) showing Project Site

Attach a copy of the panel(s) from the FIRM, and, if available, the Floodway Map, with the project site and structures marked on the map (FIRMs are typically available from your local floodplain administrator who may be located in the planning, zoning, or engineering office. Maps can also be ordered from the Map Service Center at 1-800-358-9616. For more information about FIRMs, contact your local agencies or visit the FIRM site on the FEMA WebPages at ).

Using the FIRM, determine the flood zone(s) of the project site (Check all zones in the project area).

AE or A 1-30

AO or AH

A (no base flood elevation given)

B or X (shaded)

C or X (unshaded)

Floodway

Include a copy of the latest Flood Insurance Study (FIS) and/or copies of any study/analysis performed of the flood area.

If the FIRM for your area is not published, please attach a copy of the Flood Hazard Boundary Map (FHBM) for your area, with the project site and structures marked on the map.

Additional Notes:

Project Location (Continued)

City or County Map with Project Site and Photographs (check the box to indicated the attached maps)

Attach a copy of a city or county scale map (large enough to show the entire project area) with the project site and structures marked on the map.

USGS 1:24,000 topo map with project site marked on the map.

Attach overview photographs (2 copies each) for each project site. The photographs should be representative of the project area, including any relevant streams, creeks, rivers, etc. and drainage areas which affect the project site or will be affected by the project.

Additional Notes:

IV. Budget

In this section, provide the details of all costs of the project. As this information is used for the Benefit-Cost Analysis, reasonable cost estimates are essential. As project administrative costs are calculated on a sliding scale, do not include this in the budget.

Supplanting; have local funds budgeted for this project? No, Yes (if yes explain)

Do not include contingency costs in the budget.

CategoriesQuantity Total Budget

Legal

Demolition

Engineering & Design

Construction

Inspection

Other: (explain)

Total:

Funding Sources (round figures to the nearest dollar) The maximum FEMA share for HMGP projects is 75%. The other 25% can be made up of State and Local funds as well as in-kind services. HMGP funds may be packaged with other Federal funds, but other Federal funds (except for Federal funds which lose their Federal identity at the State level i.e. such as CDBG, ARS, HOME) may not be used for the State or Local match.

Estimated FEMA Share / $ / % of Total

Non-Federal Share

Estimated Local Share / $ / % of Total

(Include In-Kind Value)

Other Non-FEMA Share

(Identify Federal Agency)

List Funding Sources:

How was the budget formulated?

Additional Notes:

Performance

Project Milestones: List the major milestones in this project:

MilestoneNumber of Days to Complete

[e.g. Design of channel improvement project60 days]

Additional Notes:

Alternative Actions (This application cannot be reviewed if this section is incomplete.)

List twofeasible alternative projects to mitigate the hazards faced in the project area. One alternative is the "No Action Alternative" (section A).

No Action Alternative

Discuss the impacts on the project area if no action is taken and the estimated losses.

Other Feasible Alternative

Discuss a feasible alternative to the proposed project. This could be an entirely different mitigation method or a significant modification to the design of the current proposed project. Please include scope of work, engineering details (if applicable), estimated budget and the impacts of this alternative.

Other Feasible Project Description and Scope of Work

Describe, in detail, the alternative project and estimated cost. Also, explain how the alternative project will solve the problem(s) / provide protection from the hazard(s).

Other Feasible Project Location

Attach a map or diagram showing the alternative site in relation to the proposed project site.

Photographs (2 copies) of alternative site.

Reason for rejecting the “No Action” alternative and “Other Feasible” alternative.

VI.Environmental Documents

The applicant mustprovide the following environmental documentation to FEMA before starting construction activity or jeopardize project funding.

Other projects require certain environmental documentation depending upon the project type and its potential effects on the physical, biological and built environment. The various types of projects and their required environmental documentation follow:

Additional Notes:

Please address all these standard environmental issues as it pertains to the project

For each issue, determine the status by identifying and entering the number of the most appropriate response.

- Not in the project area.
- In the project area with no effect
- Presence in area undetermined
- In project area – effect unknown
- Adverse effect

# of

Standard issues are: Response Agency Contacted

Aquatic/Terrestrial Biotic Resources
Designated Floodplain/Floodway
Hazardous Materials
Historic Structures
Hydrology/Hydraulics
Land Use/development Patterns
Local Economy/Community Services
Low Income or Minority Population
Prime Farmland
Slopes and Soils
Special Status Natural Areas
Threatened/Endangered Species
Water Quality
Wetlands

Additional Notes:

FEMA can provide additional environmental technical assistance. Your State Hazard Mitigation Officer can provide FEMA Environmental points of contact.

Additional Documentation and/or Site Visits May Be Required For Final Environmental Review

VIIMaintenance Agreement

Only applicants whose proposed project involves the retrofit or modification of existing public property or whose proposed project would result in the public ownership or management of property, structures, or facilities, should sign the following agreement prior to submitting their application to FEMA.

(NOTE: those applicants whose project only involves the retrofitting, elevation, or other modification to private property where the ownership will remain private after project completion DO NOT have to complete this form.)

The (City, Town, County)of , State ofKansas, hereby agrees that if it receives any Federal aid as a result of the attached project application, it will accept responsibility, at its own expense if necessary, for the routine maintenance of any real property, structures, or facilities acquired or constructed as a result of such Federal aid. Routine maintenance shall include, but not be limited to, such responsibilities as keeping vacant land clear of debris, garbage, and vermin; keeping stream channels, culverts, and storm drains clear of obstructions and debris; and keeping detention ponds free of debris, trees, and woody growth. For shelter projects, routine maintenance shall include responsibilities such as maintaining supply kits in shelter and shelter identification signs as well as updating shelter operations plan.

The purpose of this agreement is to make clear the Sub-grantee’s maintenance responsibilities following project award and to show the Sub-grantee’s acceptance of these responsibilities. It does not replace, supersede, or add to any other maintenance responsibilities imposed by Federal, State and Local laws or regulations and which are in force on the date of project award.

Signed by (printed or typed name of signing official) the duly authorized

(title) of (name of applicant),

this (day) of (month), (year).

Signature ______

OMB Approval No. 0348-0042

ASSURANCES — CONSTRUCTION PROGRAMS

Note:Certain of these assurances may not be applicable to your project or program. If you have questions,
please contact the Awarding Agency. 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 representative of the applicant I certify that the applicant:

1. Has the legal authority 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, 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.

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 on 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 specifica-
tions and will furnish progress reports and such
other information as may be required buy the
assistance awarding agency or State.

6.Will initiate and complete the work within the
applicable time fram 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
gain.

8. Will comply with the Intergovernmental
Personnel Act of 1970 (42 U.S.C. §§ 4728-4763)
relating to prescribed standards for merit systems
for programs funded under one of the nineteen
statutes or regulations specified in Appendix A of
OPM’s Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).

9. 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 residence
structures.

10.Will comply with all Federal 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 discrimination 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 discrimination on the basis of handicaps; (d) the
Age Discrimination Act of 1975, as amended (42
U.S.C. §§ 6101-6107), which prohibits discrimi-
nation on the basis of age; (e) the Drug Abuse
Office and Treatment Act of 1972 (P.L. 92-2S5), 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 nondiscrimi-
nation 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 1968 (42 U.S.C. § 3601 et seq.),
as amended, relating to non-discrimination 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
of any other nondiscrimination statute(s) which
may apply to the application.

Standard Form 424D (4-88)

Prescribed by OMB Circular A-102

11. Will comply, or has already complied, with the requirements of Titles II and 111 of the Uniform Relocation Assistance and Real Property
Acquisition Policies Act of 1970 (P.L. 91-646)
which provide for fair and equitable treatment
of persons displaced or whose property is
acquired as a result of Federal or federally
assisted programs. These requirements apply to
all interests in real property acquired for project
purposes regardless of Federal participation in
purchases.

12. Will comply with the provisions of the Hatch Act
(5 U.S.C. §§ 1501-1508 and 7324-7328) which
limit the political activities of employees whose
principal employment activities are funded in
whole or in part with Federal funds.

13. Will comply, as applicable, with the provisions of
the Davis-Bacon Act (40 U.S.C. §§ 276a to 276a
7), the Copeland Act (40 U.S.C. § 276c and 18
U.S.C. §§ 874), and the Contract Work Hours and
Safety Standards Act (40 U.S.C. §§ 327-333)
regarding labor standards for federally assisted
construction subagreements.

14.Will comply with flood insurance purchase
requirements of Section 102(a) of the Flood
Disaster Protection Act of 1973 (P.L. 93234)
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 $10,000
or more.

15. 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.L. 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 (Clear Air) Implementation Plans under
Section 176(c) of the Clear 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.L. 93-205).