Capitalization Grants for Drinking Water27458-Y3
PUBLIC WATER SYSTEM SECURITY SUBAWARD
BETWEEN
e
THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH
OFFICE OF DRINKING WATER AND ENVIRONMENTAL H AL C I ED
AND [_AUG, 18 2015
CITY OF BLAIR, NEBRASKA
DRINK WATER & ENV HEALTH
This subaward is entered into by and between the Nebraska Department of Health an -man
Services, DIVISION OF PUBLIC HEALTH OFFICE OF DRINKING WATER AND
ENVIRONMENTAL HEALTH (hereinafter "DHHS"), and the CITY OF BLAIR, NEBRASKA
(hereinafter "Subrecipient").
CFDA Title & #: Capitalization Grants for Federal Agency: U.S. EPA
Drinking Water State
Revolving Funds/66.468
Award Name: Drinking Water State Federal Award Identifier # FS997805
Revolving Fund
Issue Date: 6/8/2015 This award is not for research and
Award Date: 8/1/2015 does not include ARRA funds.
PURPOSE. The purpose of this subaward is: to provide funds to community and non -transient
non -community public water systems serving a population of 10,000 or less for improving the
protection of public water systems.
I. PERIOD OF PERFORMANCE AND TERMINATION
A. TERM. This award is in effect from August 1, 2015 the effective date through June 30,
2016, the completion date.
B. TERMINATION. This subaward may be terminated at any time upon mutual written consent
or by either party for any reason upon submission of written notice to the other party at least
Thirty (30) days prior to the effective date of termination. DHHS may also terminate this
subaward in accord with the provisions designated "FUNDING AVAILABILITY" and "BREACH
OF SUBAWARD." In the event either party terminates this subaward, the Subrecipient shall
provide to DHHS all work in progress, work completed, and materials provided by DHHS in
connection with this subaward immediately.
II. AMOUNT OF SUBAWARD
A. TOTAL SUBAWARD. DHHS shall pay the Subrecipient a total amount, not to exceed
$10,000.00 (ten thousand dollars and no cents) for the activities specified herein.
B. PAYMENT STRUCTURE. Payment shall be structured as follows:
A single payment will be paid to the Subrecipient upon receipt of items referenced in
Item IIIA.
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C. BUDGET CHANGES. The Subrecipient is permitted to reassign funds from one line item to
another line item within the approved budget. If funds are reassigned between line items, prior
approval from DHHS is required for cumulative budget transfer requests for allowable costs,
allocable to the subaward exceeding five percent (5%) of the current total approved budget.
Budget revision requests shall be submitted in writing to DHHS. DHHS will provide written
notification of approval or disapproval of the request within thirty (30) days of its receipt.
III. STATEMENT OF WORK
A. The Subrecipient shall:
1. Notify Andy Kahle at 402/471-0521 or andy.kahle(a),nebraska.gov that the
material/equipment in the application, Attachment 3, has been installed and is ready for
an inspection.
2. Provide a copy of the billing invoice(s) and a copy of the cancelled check(s) (front and
back) or a copy of the bank statement showing the check has cleared the bank for the
materials, equipment and installation.
3. Have a current public water system Emergency Response Plan that has been approved
by the DHHS.
4. Have a designated water system operator successfully obtain certification for completed
courses on Incident Command and the National Incident Management Systems
(Courses ICS 100, 200 and 700) and provide copies of the certification to the DHHS.
5. Provide a 10% match of Subrecipient's funds to improve the protection of the public
water system.
6. Pay Davis Bacon wage provisions if the contract cost is greater than $2000.00 (two
thousand dollars and no cents). If the Subrecipient performs the work (i.e., Force
Account), the Davis Bacon wage provisions do not apply.
B. DHHS shall inspect the installation of the materials/equipment before payment can be issued.
IV. GENERAL TERMS AND ASSURANCES
A. ACCESS TO RECORDS AND AUDIT RESPONSIBILITIES.
1. All Subrecipient books, records, and documents regardless of physical form, including
data maintained in computer files or on magnetic, optical or other media, relating to work
performed or monies received under this subaward shall be subject to audit at any
reasonable time upon the provision of reasonable notice by DHHS. Subrecipient shall
maintain all records for three (3) years from the date of final payment, except records that
fall under the provisions of the Health Insurance Portability and Accountability Act (HIPAA)
shall be maintained for six (6) full years from the date of final payment. In addition to the
foregoing retention periods, all records shall be maintained until all issues related to an
audit, litigation or other action are resolved to the satisfaction of DHHS. The Subrecipient
shall maintain its accounting records in accordance with generally accepted accounting
principles. DHHS reserves and hereby exercises the right to require the Subrecipient to
submit required financial reports on the accrual basis of accounting. If the Subrecipient's
records are not normally kept on the accrual basis, the Subrecipient is not required to
convert its accounting system but shall develop and submit in a timely manner such
accrual information through an analysis of the documentation on hand (such as accounts
payable).
2. The Subrecipient shall provide DHHS any and all written communications received by the
Subrecipient from an auditor related to Subrecipient's internal control over financial
reporting requirements and communication with those charged with governance including
those in compliance with or related to Statement of Auditing Standards (SAS) 112
Communicating Internal Control related Matters Identified in an Audit and SAS 114 The
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Auditor's Communication with Those Charged With Governance. The Subrecipient agrees
to provide DHHS with a copy of all such written communications immediately upon receipt
or instruct any auditor it employs to deliver copies of such written communications to
DHHS at the same time copies are delivered to the Subrecipient, in which case the
Subrecipient agrees to verify that DHHS has received a copy.
3. The subrecipient shall immediately commence follow-up action on findings arising from
audits or other forms of review. Follow-up action includes responding to those conducting
such examinations with clear, complete views concerning the accuracy and
appropriateness of the findings. If the finding is accepted, corrective action, such as
repaying disallowed costs, making financial adjustments, or taking other actions should
proceed and be completed as rapidly as possible. If the subrecipient disagrees, it should
provide an explanation and specific reasons that demonstrate that the finding is not valid.
4. In addition to, and in no way in limitation of any obligation in this subaward, the
Subrecipient shall be liable for audit exceptions, and shall return to DHHS all payments
made under this subaward for which an exception has been taken or which has been
disallowed because of such an exception, upon demand from DHHS.
B. AMENDMENT. This subaward may be modified only by written amendment executed by both
parties. No alteration or variation of the terms and conditions of this subaward shall be valid
unless made in writing and signed by the parties.
C. ANTI -DISCRIMINATION. The Subrecipient shall comply with all applicable local, state and
federal statutes and regulations regarding civil rights and equal opportunity employment,
including Title VI of the Civil Rights Act of 1964; the Rehabilitation Act of 1973, Public Law 93-
112; the Americans with Disabilities Act of 1990, Public Law 101-336; and the Nebraska Fair
Employment Practice Act, NEB. REV. STAT. §§ 48-1101 to 48-1125. Violation of said statutes
and regulations will constitute a material breach of this subaward. The Subrecipient shall insert
this provision into all subawards and subcontracts.
D. ASSIGNMENT. The Subrecipient shall not assign or transfer any interest, rights, or duties
under this subaward to any person, firm, or corporation without prior written consent of DHHS.
In the absence of such written consent, any assignment or attempt to assign shall constitute
a breach of this subaward.
E. ASSURANCE. If DHHS, in good faith, has reason to believe that the Subrecipient does not
intend to, is unable to, has refused to, or discontinues performing material obligations under
this subaward, DHHS may demand in writing that the Subrecipient give a written assurance
of intent to perform. Failure by the Subrecipient to provide written assurance within the number
of days specified in the demand may, at DHHS's option, be the basis for terminating this
subaward.
F. BREACH OF SUBAWARD. DHHS may immediately terminate this subaward and agreement,
in whole or in part, if the Subrecipient fails to perform its obligations under the subaward in a
timely and proper manner. DHHS may withhold payments and provide a written notice of
default to the Subrecipient, allow the Subrecipient to correct a failure or breach of subaward
within a period of thirty (30) days or longer at DHHS's discretion considering the gravity and
nature of the default. Said notice shall be delivered by Certified Mail, Return Receipt
Requested or in person with proof of delivery. Allowing the Subrecipient time to correct a
failure or breach of this subaward does not waive DHHS's right to immediately terminate the
subaward for the same or different subaward breach which may occur at a different time.
DHHS may, at its discretion, obtain any services required to complete this subaward and hold
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the Subrecipient liable for any excess cost caused by Subrecipient's default. This provision
shall not preclude the pursuit of other remedies for breach of subaward as allowed by law.
G. CONFIDENTIALITY. Any and all confidential or proprietary information gathered in the
performance of this subaward, either independently or through DHHS, shall be held in the
strictest confidence and shall be released to no one other than DHHS without the prior written
authorization of DHHS, provided that contrary subaward provisions set forth herein shall be
deemed to be authorized exceptions to this general confidentiality provision. As required by
United States Department of Health and Human Services (hereinafter "HHS") appropriations
acts, all HHS recipients and DHHS Subrecipients must acknowledge Federal and DHHS
funding when issuing statements, press releases, requests for proposals, bid invitations, and
other documents describing projects or programs funded in whole or in part with Federal and
DHHS funds. Recipients are required to state: (1) the percentage and dollar amounts of the
total program or project costs financed with Federal and DHHS funds; and (2) the percentage
and dollar amount of the total costs financed by nongovernmental sources. This provision
shall survive termination of this subaward.
H. CONFLICTS OF INTEREST. In the performance of this subaward, the Subrecipient shall
avoid all conflicts of interest and all appearances of conflicts of interest. The subrecipient shall
not acquire an interest either directly or indirectly which will conflict in any manner or degree
with performance and shall immediately notify DHHS in writing of any such instances
encountered.
COST PRINCIPLES AND AUDIT REQUIREMENTS. The Subrecipient shall follow the
applicable cost principles in 2 CFR 200 Subpart F Federal audit requirements are dependent
on the total amount of federal funds expended by the Subrecipient., set in the table below and
Attachment 1, Audit Requirement Certification. Audits must be prepared and issued by an
independent certified public accountant licensed to practice. A copy of the annual audit is to
be made electronically available or sent to: Nebraska Department of Health and Human
Services, Financial Services, P.O. Box 95026, Lincoln, NE 68509-5026.
Amount of annual federal expenditure Audit Type
$100,000 to $749,999 Financial Statement Audit
750, 000 or more in federal expenditure Single Audit
DATA OWNERSHIP AND COPYRIGHT. Except as otherwise provided in the Federal Notice
of Award, DHHS shall own the rights in data resulting from this project or program. The
Subrecipient may copyright any of the copyrightable material and may patent any of the
patentable products produced in conjunction with the performance required under this
subaward without written consent from DHHS. DHHS and any federal granting authority
hereby reserve a royalty -free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use the copyrightable material for federal or state
government purposes. This provision shall survive termination of this subaward.
K. DEBARMENT SUSPENSION OR DECLARED INELIGIBLE. The Subrecipient certifies that
neither it nor its principals are presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this transaction by any federal
department or agency.
L. DOCUMENTS INCORPORATED BY REFERENCE. All references in this subaward to laws,
rules, regulations, guidelines, directives, and attachments which set forth standards and
procedures to be followed by the Subrecipient in discharging its obligations under this
subaward shall be deemed incorporated by reference and made a part of this subaward with
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the same force and effect as if set forth in full text, herein.
M. DRUG-FREE WORKPLACE. Subrecipient agrees, in accordance with 41 USC §701 et al., to
maintain a drug-free workplace by: (1) publishing a drug-free workplace statement; (2)
establishing a drug-free awareness program; (3) taking actions concerning employees who
are convicted of violating drug statutes in the workplace; and (4) in accordance with 2 CFR
§182.230, identify all workplaces under its federal awards.
N. FEDERAL FINANCIAL ASSISTANCE. The Subrecipient shall comply with all applicable
provisions of 45 C.F.R. §§ 87.1-87.2. The Subrecipient certifies that it shall not use direct
federal financial assistance to engage in inherently religious activities, such as worship,
religious instruction, and/or prose lytization.
O. FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT REPORTING. The
Subrecipient shall complete the Subrecipient Reporting Worksheet, Attachment 2, sections B
and C. The Subrecipient certifies the information is complete, true and accurate.
P. FORCE MAJEURE. Neither party shall be liable for any costs or damages resulting from its
inability to perform any of its obligations under this subaward due to a natural disaster, or
other similar event outside the control and not the fault of the affected party ("Force Majeure
Event"). A Force Majeure Event shall not constitute a breach of this subaward. The party so
affected shall immediately give notice to the other party of the Force Majeure Event. Upon
such notice, all obligations of the affected party under this subaward which are reasonably
related to the Force Majeure Event shall be suspended, and the affected party shall do
everything reasonably necessary to resume performance as soon as possible. Labor disputes
with the impacted party's own employees will not be considered a Force Majeure Event and
will not suspend performance requirements under this subaward.
Q. FUNDING AVAILABILITY. DHHS may terminate the subaward, in whole or in part, in the
event funding is no longer available. Should funds not be appropriated, DHHS may terminate
the award with respect to those payments for the fiscal years for which such funds are not
appropriated. DHHS shall give the Subrecipient written notice thirty (30) days prior to the
effective date of any termination. The Subrecipient shall be entitled to receive just and
equitable compensation for any authorized work which has been satisfactorily completed as
of the termination date. In no event, shall the Subrecipient be paid for a loss of anticipated
profit.
R. GRANT CLOSE-OUT. Upon completion or notice of termination of this grant, the following
procedures shall apply for close-out of the subaward:
1. The Subrecipient will not incur new obligations after the termination or completion of the
subaward, and shall cancel as many outstanding obligations as possible. DHHS shall
give full credit to Subrecipient for the federal share of non -cancelable obligations properly
incurred by Subrecipient prior to termination, and costs incurred on, or prior to, the
termination or completion date.
2. Subrecipient shall immediately return to DHHS any unobligated balance of cash advanced
or shall manage such balance in accordance with DHHS instructions.
3. Within a maximum of 90 days following the date of expiration or completion, Subrecipient
shall submit all financial, performance, and related reports required by the Subrecipient
Reporting Requirements. DHHS reserves the right to extend the due date for any report
and may waive, in writing, any report it considers to be unnecessary.
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4. DHHS shall make any necessary adjustments upward or downward in the federal share
of costs.
5. The Subrecipient shall assist and cooperate in the orderly transition and transfer of
subaward activities and operations with the objective of preventing disruption of services.
6. Close-out of this subaward shall not affect the retention period for, or state or federal rights
of access to, Subrecipient records, or Subrecipient's responsibilities regarding property or
with respect to any program income for which Subrecipient is still accountable under this
subaward. If no final audit is conducted prior to close-out, DHHS reserves the right to
disallow and recover an appropriate amount after fully considering any recommended
disallowances resulting from an audit which may be conducted at a later time.
S. GOVERNING LAW. The award shall be governed in all respects by the laws and statutes of
the United States and the State of Nebraska. Any legal proceedings against DHHS or the
State of Nebraska regarding this award shall be brought in Nebraska administrative or judicial
forums as defined by Nebraska State law. The Subrecipient shall comply with all Nebraska
statutory and regulatory law.
T. HOLD HARMLESS.
1. The Subrecipient shall defend, indemnify, hold, and save harmless the State of Nebraska
and its employees, volunteers, agents, and its elected and appointed officials ("the
indemnified parties") from and against any and all claims, liens, demands, damages,
liability, actions, causes of action, losses, judgments, costs, and expenses of every nature,
including investigation costs and expenses, settlement costs, and attorney fees and
expenses ("the claims"), sustained or asserted against the State of Nebraska, arising out
of, resulting from, or attributable to the willful misconduct, negligence, error, or omission
of the Subrecipient, its employees, consultants, representatives, and agents, except to the
extent such Subrecipient's liability is attenuated by any action of the State of Nebraska
which directly and proximately contributed to the claims.
2. DHHS's liability is limited to the extent provided by the Nebraska Tort Claims Act, the
Nebraska Contract Claims Act, the Nebraska Miscellaneous Claims Act, and any other
applicable provisions of law. DHHS does not assume liability for the action of its
Subrecipients.
U. HUMAN TRAFFICKING PROVISIONS. The subrecipient shall comply and be subject to the
requirements of Section 106(g) of the "Trafficking Victims Protection Act of 2000" (22 USC
7104). The full text of this requirement is found at: http://www.acf.hhs.gov/grants/award-
term-and-condition-for-trafficking-in-persons
V. INDEPENDENT ENTITY. The Subrecipient is an Independent Entity and neither it nor any of
its employees shall, for any purpose, be deemed employees of DHHS. The Subrecipient shall
employ and direct such personnel, as it requires, to perform its obligations under this
subaward, exercise full authority over its personnel, and comply with all workers'
compensation, employer's liability and other federal, state, county, and municipal laws,
ordinances, rules and regulations required of an employer providing services as contemplated
by this subaward.
W. REIMBURSEMENT REQUEST. Requests for payments submitted by the Subrecipient shall
contain sufficient detail to support payment. Any terms and conditions included in the
Subrecipient's request shall be deemed to be solely for the convenience of the parties.
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X. INTEGRATION. This written subaward represents the entire agreement between the parties,
and any prior or contemporaneous representations, promises, or statements by the parties,
that are not incorporated herein, shall not serve to vary or contradict the terms set forth in this
subaward.
Y. LOBBYING.
1. Subrecipient certifies that no Federal appropriated funds shall be paid, by or on behalf of
the Subrecipient, 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 award for: (a) the awarding
of any Federal agreement; (b) the making of any Federal grant; (c) the entering into of any
cooperative agreement; and (d) the extension, continuation, renewal, amendment, or
modification of any Federal agreement, 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 subaward, the Subrecipient shall complete and submit
Federal Standard Form -LLL, "Disclosure Form to Report Lobbying," in accordance with
its instructions.
Z. MANDATORY DISCLOSURES. The subrecipient must disclose to the State, in a timely
manner and in writing, all violations of Federal criminal law involving fraud, bribery, or gratuity
violations potentially affecting this subaward in accordance with 2 CFR §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. (See also 2 CFR part 180 and 31
U.S.C. 3321).
AA. NEBRASKA NONRESIDENT INCOME TAX WITHHOLDING. Subrecipient acknowledges
that Nebraska law requires DHHS to withhold Nebraska income tax if payments for personal
services are made in excess of six hundred dollars ($600) to any Subrecipient who is not
domiciled in Nebraska or has not maintained a permanent place of business or residence in
Nebraska for a period of at least six months. This provision applies to: individuals; to a
corporation, if 80% or more of the voting stock of the corporation is held by the shareholders
who are performing personal services, and to a partnership or limited liability company, if 80%
or more of the capital interest or profits interest of the partnership or limited liability company
is held by the partners or members who are performing personal services.
The parties agree, when applicable, to properly complete the Nebraska Department of
Revenue Nebraska Withholding Certificate for Nonresident Individuals Form W-4NA or its
successor. The form is available at:
http://www.revenue.ne.gov/tax/current/f w-4na.pdf or
http://www.revenue.ne.gov/tax/current/fill-in/f w-4na pdf
BB. NEBRASKA TECHNOLOGY ACCESS STANDARDS. The Subrecipient shall review the
Nebraska Technology Access Standards, found at http://www.nitc.nebraska.gov/standards/
and ensure that products and/or services provided under the subaward comply with the
applicable standards. In the event such standards change during the Subrecipient's
performance, the State may create an amendment to the subaward to request that Subrecipient
comply with the changed standard at a cost mutually acceptable to the parties.
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CC. NEW EMPLU v i Y s i A1"US. The Subrecipient shall use a federal
immigration verification system to determine the work eligibility status of new employees
physically performing services within the State of Nebraska. A federal immigration verification
system means the electronic verification of the work authorization program authorized by the
Illegal Immigration Reform and Immigrant Responsibility Act of 1996, 8 U.S.C. § 1324a, known
as the E -Verify Program, or an equivalent federal program designated by the United States
Department of Homeland Security or other federal agency authorized to verify the work
eligibility status of a newly hired employee.
If the Subrecipient is an individual or sole proprietorship, the following applies:
1. The Subrecipient must complete the United States Citizenship Attestation Form, available
on the Department of Administrative Services website at www.das.state.ne.us.
2. If the Subrecipient indicates on such attestation form that he or she is a qualified alien, the
Subrecipient agrees to provide the U.S. Citizenship and Immigration Services
documentation required to verify the Subrecipient's lawful presence in the United States
using the Systematic Alien Verification for Entitlements (SAVE) Program.
3. The Subrecipient understands and agrees that lawful presence in the United States is
required and the Subrecipient may be disqualified or the subaward terminated if such
lawful presence cannot be verified as required by NEB. REV. STAT. § 4-108.
DD. PUBLICATIONS. Subrecipient shall acknowledge the project was supported by the Code of
Federal Award Number, name of award, federal agency and DHHS in all publications that
result from work under this subaward.
EE. PROGRAMMATIC CHANGES. The Subrecipient shall request in writing to DHHS for approval
of programmatic changes. DHHS shall approve or disapprove in whole or in part in writing
within thirty (30) days of receipt of such request.
FF. PROMPT PAYMENT. Payment shall be made in conjunction with the State of Nebraska
Prompt Payment Act, NEB. REV. STAT. §§ 81-2401 through 81-2408. Unless otherwise
provided herein, payment shall be made by electronic means.
Automated Clearing House (ACH) Enrollment Form Requirements for Payment.
The Subrecipient shall complete and sign the State of Nebraska ACH Enrollment Form and
obtain the necessary information and signatures from their financial institution. The completed
form must be submitted before payments to the Subrecipient can be made. Download ACH
Form:
http://www.das.state.ne.us/accounting/nis/address book info.htm
GG. PUBLIC COUNSEL. In the event Subrecipient provides health and human services to
individuals on behalf of DHHS under the terms of this award, Subrecipient shall submit to the
jurisdiction of the Public Counsel under NEB. REV. STAT. §§ 81-8,240 through 81-8,254 with
respect to the provision of services under this subaward. This clause shall not apply to
subawards between DHHS and long-term care facilities subject to the jurisdiction of the state
long-term care ombudsman pursuant to the Long -Term Care Ombudsman Act.
HH. RESEARCH. The Subrecipient shall not engage in research utilizing the information obtained
through the performance of this subaward without the express written consent of DHHS. The
term "research" shall mean the investigation, analysis, or review of information, other than
aggregate statistical information, which is used for purposes unconnected with this subaward.
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SEVERABILITY. If any term or condition of this subaward is declared by a court of competent
jurisdiction to be illegal or in conflict with any law, the validity of the remaining terms and
conditions shall not be affected, and the rights and obligations of the parties shall be construed
and enforced as if this subaward did not contain the particular provision held to be invalid.
JJ. SMOKE FREE, Public Law 103-227, also known as the Pro -Children Act of 1994 (Act),
requires that smoking not be permitted in any portion of any indoor facility owned or leased or
contracted for by an entity and used routinely or regularly for the provision of health, day care,
early childhood development services, education or library services to children under the age
of 18, if the services are funded by Federal programs either directly or through State or local
governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to
children's services that are provided in indoor facilities that are constructed, operated, or
maintained with such federal funds. The law does not apply to children's services provided in
private residences; portions of facilities used for inpatient drug or alcohol treatment; service
providers whose sole source of applicable Federal funds in Medicare or Medicaid; or facilities
where WIC coupons are redeemed. Failure to comply with the provisions of the law may
result in the imposition of a civil monetary penalty of up to $1000 for each violation and/or the
imposition of an administrative compliance order on the responsible entity. By signing, the
Subrecipient certifies that the Subrecipient will comply with the requirements of the Act and
will not allow smoking within any portion of any indoor facility used for the provision of services
for children as defined by the Act.
KK. SUBRECIPIENTS OR SUBCONTRACTORS. The Subrecipient shall not subaward or
subcontract any portion of this award without prior written consent of DHHS. The Subrecipient
shall ensure that all subcontractors and subrecipients comply with all requirements of this
subaward and applicable federal, state, county and municipal laws, ordinances, rules and
regulations.
LL. TIME IS OF THE ESSENCE. Time is of the essence in this subaward. The acceptance of late
performance with or without objection or reservation by DHHS shall not waive any rights of
DHHS nor constitute a waiver of the requirement of timely performance of any obligations on
the part of the Subrecipient remaining.
NOTICES. Notices shall be in writing and shall be effective upon receipt. Written notices, including
all reports and other written communications required by this subaward shall be sent to the
following addresses:
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FOR DHHS: FOR SUBRECIPIENT:
Andy Kahle James Realph
NE Department of Health & Human Services City of Blair
PO Box 95026 218 S 16th St
Lincoln, NE 68509-5026 Blair NE 68008-1674
402/471-0521 402/426-4191
IN WITNESS THEREOF, the parties have duly executed this subaward hereto, and each party
acknowledges the receipt of a duly executed copy of this subaward with original signatures.
FOR DHHS:
Mary Sue Se rens
Environmental ealth Unit Administrator
DATE: g - I Q - 15
Subgrant
Rev. 10/2011
FOR SUBRECIPIENT:
a es Realph
Mayor
DATE: '� 1 I I I I
Attachment 1
NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
AUDIT REQUIREMENT CERTIFICATION
Subrecipients receiving funds from the Nebraska Department of Health and Human Services
(DHHS) are required to complete this certification
Subrecipient's Name: City of Blair
Address: 218 S 16th St
City: Blair State: NE Zip Code: 68008-1674
Subrecipient's Fiscal Year CaC C ( , 20to 36 , 2016
All written communications from the Certified Public Accountant (CPA) engaged under #2 or #3
below, given to the subrecipient related to Statement of Auditing Standards (SAS) 112
Communicating Internal Control related Matters Identified in an Audit and SAS 114 The Auditor's
Communication with Those Charged With Governance and any additional reports issued by the
auditor as a result of this engagement must be provided to the DHHS immediately upon receipt,
unless the Subrecipient has directed the CPA to provide the copy directly to the DHHS and has
verified this has occurred.
Check either 1, 2, or 3
1. _ As the subrecipient named above, we expect to expend less than $750,000 from all
Federal Financial Assistance sources and do not expect to receive $100,000 or more in
subawards from DHHS, including commodities, during our fiscal year Therefore, we are
not subject to the audit requirements of 2 CFR 200 and do not need to submit our audited
financial statements to DHHS.
2. _ As the subrecipient named above, we expect to expend less than $750,000 from all
Federal Financial Assistance sources and expect to receive $100,000 or more in
subawards from DHHS, including commodities, during our fiscal year Therefore, we are
not subject to the audit requirements of 2 CFR 200.
We are, however, responsible for engaging a licensed Certified Public Accountant (CPA)
to conduct an audit of our organization's financial statements. We acknowledge that the
audited financial statements should be presented in accordance with generally accepted
accounting principles (accrual basis). If another basis of accounting is more appropriate
or if the accrual basis of accounting is overly burdensome, we will notify the DHHS of this
issue and request a waiver of this requirement prior to the end of our fiscal year. We
further acknowledge the audit must be completed no later than nine months after the end
of our organization's current fiscal year. A copy of the report must be submitted to DHHS
within the earlier of 30 days after receipt of the auditor's report(s), or nine months after the
end of the audit period.
3. -� As the subrecipient named above, we expect to expend $750,000 or more from all Federal
Financial Assistance sources, including commodities in our current fiscal year. Therefore,
we are subject to the single audit requirements of 2 CFR 200.
Subaward Page 11 of 14
Rev. 01/2015
We will engage a licensed Certified Public Accountant to conduct and prepare the audit of
our organization's financial statements and components of the single audit pertaining to
those financial statements. We acknowledge that the audited financial statements should
be presented in accordance with generally accepted accounting principles (accrual basis).
If another basis of accounting is more appropriate or if the accrual basis of accounting is
overly burdensome, we will notify the DHHS of this issue -and request a waiver of this
requirement prior to the end of our fiscal year. We further acknowledge the audit must be
completed no later than nine months after the end of our current fiscal year.
We further acknowledge, that a single audit performed in accordance with 2 CFR 200
must be submitted to the Federal Audit Clearinghouse. The reporting package, as
evidence the audit was completed must contain:
• financial statements,
• a schedule of Expenditure of Federal Awards,
• a Summary Schedule of Prior Audit Findings (if applicable),
• a corrective action plan (if applicable) and
• the auditor's report(s) which includes an opinion upon financial statements and
Schedule of Expenditures of Federal Awards, a report of internal control, a report of
compliance and a Schedule of Findings and Questioned Costs.
We further acknowledge the auditor and this subrecipient must complete and submit with
the reporting package a Data Collection Form for Reporting on Audits of States, Local
Governments and Non -Profit Organizations (SF -SAC).
We further acknowledge a copy of the subrecipient's financial statements, auditor's report
and SF -SAC must be submitted to the DHHS within the earlier of 30 days after receipt of
the auditor's report(s), or nine months after the end of the audit period. .
For items #2 and #3 above the required information must be submitted to:
Nebraska Department of Health and Human Services
Internal Audit Section
P.O. Box 95026
Lincoln, NE 68509-5026
Signature Date
Name P S TlQ2 i}
Title C% app
Subaward Page 12 of 14
Rev. 01/2015
Attachment 2
Subrecipient Reporting Worksheet
Section A — Federal Award Information
Federal Award Identifier Number (FAIN) (Federal Cash)
(Must Match Notice of Award)
Federal Awarding Agency Name
Award Date
CFDA Program Number
(Must Match Notice of Award) Subaward Amount From This
Award: $
*See instructions if the subaward is funded from more than one funding source
JC6LIV11 � — JUu1CGlt.lIC11� IIIIVIIIIbILIVII
Subrecipient DUNS:
16-444-3947
(Unique Entity Identifier)
Subrecipient Name: City of Blair
Subrecipient Address:
Street: 218 S 1611 St
City: Blair
Country: USA
Congressional District: 1
Amount of Subaward
$10,000.00
Subrecipient Principal
City: Blair
Place of Performance:
Country: USA
Congressional District: 1
State: NE
Zip Code + 4: 68008-1674
Subaward Date: 8/1/2015
State: NE
Zip Code + 4: 68008-1674
Subaward Number: 27458-Y3 (y3 number assigned once approvals completed)
Signature Date (Date Subaward signed by DHHS or last party)
Subaward Project Description: Public Water System Security Enhancements
For Grants Management Use Only:
Received by Grants: FFATA Processed By:
Report MonthNear:
Subaward Page 13 of 14
Rev. 01/2015
OULA U11 V — V111L;UV 1+U111PU1Md11U11
1. In your business or organization's previous fiscal year, did your business
organization (including parent organization, all branches, and all affiliates
worldwide) receive 80% or more of your annual gross revenues in U.S. federal
contracts, subcontracts, loans, grants, subawards, and/or cooperative agreements
AND $25,000,000 or more in annual gross revenues from U.S. federal contracts,
subcontracts, loans, grants, subawards, and/or cooperative agreements?
❑ Yes — answer Question 2
9 No — not required to provide officer compensation
2. Does the public have access to information about the compensation of the senior
executives in your business or organization (including parent organization, all
branches, and all affiliates worldwide) through periodic reports filed under section
13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d))
or section 6104 of the Internal Revenue Code of 1986?
❑ Yes — not required to provide officer compensation
❑ No — provide the names and total compensation of the five most highly
compensated officers of the entity below
1.
Subaward
Rev. 01/2015
Compensation
$
Compensation
Compensation
Compensation
Compensation
Page 14 of 14
Name
2.
Name
3.
Name
4.
Name
5.
Name
Subaward
Rev. 01/2015
Compensation
$
Compensation
Compensation
Compensation
Compensation
Page 14 of 14
Section A — Federal Award Information (Continuation)
Use this page only if the subaward is being funded by multiple sources (multiple federal grants
or a combination of federal and state funds)
Federal Award Identifier Number (FAIN)
Federal Awarding Agency Name
CFDA Program Number
Federal Award Identifier Number (FAIN)
Federal Awarding Agency Name
CFDA Program Number
Federal Award Identifier Number (FAIN)
Federal Awarding Agency Name
CFDA Program Number
Award Date
Subaward Amount From This
Award: $
Award Date
Subaward Amount From This
Award: $
Award Date
Subaward Amount From This
Award: $
Amount funded from Federal Grants $ total of grants in Section A
Amount funded from State General Funds $
Amount funded from State Cash Funds $
Amount funded from Federal Cash Funds $10,000.00 fed sources other than grants
Total amount funded from all sources $10,000.00 should equal total of subaward
Subaward Page 15 of 14
Rev. 01/2015
AttaA IAV E D
JUL 10 2014
Nebraska Department of Health and Human Services Division of Public Health
Public Water System Water Security Subgrant Application
1. Public Water System Name: City of Blair, Nebraska (Entity
requesting grant funding) County: Washington
Public Water System ID #: NE31- 17905
Federal Tax ID #:.A] (0000 l NP
218 S 16th Street, Blair, Nebraska 68008 A -B +�r 5-75-700
2. Mayor/Board Chairperson/Owner
Name/Title: Mayor James Realph
Phone: 402-426-4191 Email: irealph@ci.blair.ne.us
(valid phone number and e-mail address required)
3. Contact Person for Further Information on Application
Name/Title: Al Schoemaker
Phone: 402-426-4191 Email: ars@ci.blair.ne.us
(valid phone number and a -mail address required)
4. Identify the security/emergency response improvements that will be addressed by this public
water system security grant for each facility (well, storage, etc.) and include estimated cost
for each facility. Please make this an itemized list with the individual cost associated with
each item (i.e., locks, $$$; cameras, $$$, etc.). [Attach additional page(s) if needed.]
Please refer to attached proposals.
Al Schoemaker, Director of Public Works 402-426-4191
PWS Representative'Name/Title (Please Print) Phone
Signature
7/9/2014
Date
Fax or Mail Completed Application to:
Kristin Luebbe, Water System Security Coordinator
Nebraska Department of Health and Human Services
Division of Public Health
P.O. Box 95026
Lincoln, NE 68509-5026
Fax: 402/471-6436
K
Proposal Number: 9090-19-0
Date: 1/10/2014
2
Arecont Vision
AV3256PMIR-3966
1
Arecont Vision
AV12186DN-3966
1
Arecont Vision
MD-WMT2
1
D-Link
DES -1210
1
DNF Security
FALCERT3000GBsw64
5
EXACQ
EVIP-01
TECHNOLOGIES,
INC
5
EXACQ
EVIP-05
TECHNOLOGIES,
INC
1,000 Hitachi Cable
301808
1
SE!
SEi Labor
1
SEi
SEi Labor
Scope Of Work
Schedule of Protection
3MP Bullet Style Day/Night IP66 Rated Can
12MP WDR Panoramic 180 Indoor Camera
Megadome 2 Series Wall Mount
24 Port PoE Switch
3TB Drive for Video System
Exacq Camera License.
Exacq Software Support
CAT6 BURIAL WIRE
Relocate NetGear Switch to Electical Building
Trench Between Building
Financial Summary
System Total: $11,232
Monthly Services: $70
Attachment 3
* This proposal for the above described protection does not include tax and is covered by a one (1) year parts, labor and service
guarantee
13505 "C" Street, Omaha, NE, 68144 1 P: (402) 778-37211 F: (402) 333-7616
www.sel-secudty.com 9 Des Moines, IA • Kansas City, KS . Lincoln, NE • Omaha, NE
Proposal Number: 9090-21-0
LDat6: 1 /10/2014
Scope Of Work
Schedule of Protection
Attachment 3
Financial Summary
System Total: $10,661
Monthly Services: $61
13505 "C" Street, Omaha, NE, 681441 P: (402) 778-37211 F: (402) 333-7616
www.sei-security.com • Des Moines, IA. Kansas City, KS . Lincoln, NE • Omaha, NE
Liao- ICI u
24 Port POE Switch
1
DNF Security
FALCERT3000GBsw64
3TB Drive for Video System
1
EXACQ
EVI13-01
Exacq Camera License
TECHNOLOGIES,
INC
1
EXACQ
EVIP-05
Exacq Software Support
TECHNOLOGIES,
INC
300
Hitachi Cable
301808
CAT6 BURIAL WIRE
1
KBC Networks
MESHII-AA-OA
Dual Radio Mesh Node
1
KBC Networks
PAT5M
Directional Antenna
1
SEI
Pole for 360
Pole to Mount Mesh Radio On
Financial Summary
System Total: $10,661
Monthly Services: $61
13505 "C" Street, Omaha, NE, 681441 P: (402) 778-37211 F: (402) 333-7616
www.sei-security.com • Des Moines, IA. Kansas City, KS . Lincoln, NE • Omaha, NE
m