2019-03-30 Grant from DHHS for Water Treatment PlantDocuSign Envelope ID: F4C8E3C8-4428-4F88-BE3F-015AF412CFDA
SU BAWARD
BETWEEN
THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
CITY OF BLAIR, NEBRASKA
This federal funds grant agreement, including any addenda and attachments (collectively, "Subaward') is
entered into by and between the Nebraska Department of Health and Human Services, Division of Public
Health Drinking Water Program ("DHHS") and City of Blair, Nebraska ("Subrecipient").
PURPOSE: The purpose of this Subaward is to provide funds to community and non -transient non-
community public water systems searing a population of 10, 000 or less for improving the
protection of their public water systems.
RESEARCH: This Subaward does not involve research and development. See 2 CFR § 200.87 or 45
CFR § 75.2.
1. DURATION
1.1. TERM. This Subaward is in effect from the date of full execution or the beginning of the Period of
Performance, whichever is later, until the end of the Period of Performance. If there are multiple
Periods of Performance, this Subaward ends at the latest Period of Performance.
1.2. PERIOD OF PERFORMANCE. The Period of Performance of this Subaward is set forth in
Attachment 1.
1.3. TERMINATION NOTICE PERIOD. This Subaward may be terminated in accordance with
Addendum A. If Subrecipient terminates this Subaward, it shall provide days prior to the effective
date of termination.
2. PAYMENT TERMS AND STRUCTURE
2.1. TOTAL SUBAWARD. Forthe Project Description specified herein, DHHS awards the total amount
of funds as set forth in Attachment 1.
2.2. PAYMENT STRUCTURE. Payment shall be structured as follows:
2.2.1. As consistent with all applicable federal statutes, regulations, and policies, DHHS shall
reimburse Subrecipient for its costs to perform the project described herein, as consistent
with the terms set forth herein.
2.2.2. Subrecipient shall submit a single request for payment from DHHS.
2.2.3. Final Invoice and Spend Date. To be paid by DHHS under this Subaward, all costs must be
invoiced no later than December 31, 2019 and finalized and spent by the Subrecipient no
later than December 31, 2019. Failure to meet these deadlines may result in DHHS
disallowing costs or taking any other available remedy, as provided herein.
2.3. INDIRECT COSTS. Indirect costs shall not be paid as part of this subaward. T
3. PROJECT DESCRIPTION
3.1. THE SUBRECIPIENT has agreed to complete the following activities:
3.1.1. Notify Andy Kahle at 402-471-0521 or and .ky ahle@nebraska.govthat the project
identified in Attachment 2 has been completed and is ready for an inspection.
3.1.2. Provide a copy of the billing invoice(s) and a copy of the bank statement(s) as proof of
payment for the project identified in Attachment2.
3.1.3. Have a current public water system Emergency Response Plan that has been approved
by DHHS.
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3.1.4. Provide evidence to DHHS that the water system operator has obtained certification in
Federal Emergency Management Agency Incident Command (Courses ICS 100, 200 and
700).
3.1.5. Provide a 10% match of the Subrecipient's funds to improve the protection of the public
water system.
3.1.6. In determining whether a noncompetitive proposal can be used by the Subrecipient for
any subcontractor, as provided in 2 CFR § 200.320, DHHS provides the following
example as guidance: a community's listing in the Nebraska Directory of Municipal
Officials (published by the League of Nebraska Municipalities) documenting the same
engineer of record for the past three (3) years, or in case of relying on a circuit rider for
professional services, that it can be shown the community has been a member for that
same three (3) year time period. See also Addendum A, Section 36.
3.2. DHHS has agreed to do the following:
3.2.1. Inspect the installation of materials/equipment to ensure completion of approved project,
before payment will be issued.
4. ADDENDA
A. DHHS General Terms — Subaward
5. ATTACHMENTS
1. Award of Initial Funds
2. Public Water System Water Security Subgrant Application
6. NOTICES
6.1. Notices shall be in writing and shall be effective upon mailing. Unless otherwise specified herein,
all notices, reporting requirements, and other communications concerning this Subaward shall be
sent to the following individuals and addresses.
DHHS SUBAWARD MANAGER:
Andy Kahle
DHHS Drinking Water Program
PO Box 98922
Lincoln NE 68509-8922
402-471-0521
andy. kahle@nebraska.gov
FOR SUBRECIPIENT:
James Realph
City of Blair, Nebraska
218 S 161' St
Blair NE 68008-1674
4024264191
jrealph@blairnebraska.org
6.2. Either party may change the individual to be noticed under this section via letter to the other party
sent by U.S. Mail, postage prepaid, or via email.
7. SIGNATURES AND CERTIFICATIONS
7.1. AUDIT CERTIFICATION. As the Subrecipient named within this agreement, do you anticipate
spending $750,000 or morefrom all Federal Financial Assistance sources, including commodities,
during your fiscal year? Instructions:
DS
Subrecipieffs Response: Yes
If this information changes, and Subrecipient is subject to a Single Audit or no longer subject
to a Single Audit, Subrecipient shall notify DHHS immediately.
7.2. EXECUTIVE COMPENSATION REPORTING REQUIREMENT. At the time of execution of this
Subaward, Subrecipient must notify DHHS, in writing, if it is required to report executive
compensation pursuant to the Federal Funding Accountability and Transparency Act, Pub. L. 109-
282, as amended by section 6202 of Pub. L. 110-252, and associated regulations at 2 CFR §§
170 et seq. This is required for Subrecipients who receive more than $25,000,000 or more in
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annual gross revenue in federal contracts, subcontracts, awards orsubawards, and meet the other
regulatory criteria listed in those sections. If Subrecipient meets these criteria, it must indicate
"YES" below and fill out the executive compensation disclosure attachment (see Attachments,
above). Subrecipient shall notify DHHS immediately if funding it receives changes such that it must
report salaries under this requirement.
Subreci pient s Response
• Yes
7.3. SIGNATURES.
FOR SUBRECIPIENT:
In witness hereof, I hereby execute this Subamard; I acknowledge the terms on the funding
contained in this Subaward, certifyas provided above, and furthercertify that/ have authority
to legally bind the Subrecipient to this Subaward.
DocuSfgned by:
K&.tt4 RaaA.SUA,
Richard Hansen
City of Blair, Nebraska
Mayor
3/28/2019 1 11:23:10 CDT
DHHS AWARDING OFFICIAL:
In witness hereof, I hereby execute this Subaward and authorize the funds included in
Attachment 1 to be awarded to the Subrecipient, subject to the conditions contained in this
Subaward. I further certify that/ have the authority to legallybind DHHS to this Subaward.
DocuSfgned''bylI:
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Darrell Klein
Deputy Director Public Health Licensure
Department of Health and Human Services
301 Centennial Mall South
P.O. Box 95026
Lincoln, NE 68509-5026
3/30/2019 1 15:38:39 CDT
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ADDENDUM A
DHHS GENERAL TERMS - SUBAWARDS
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Note: This Addendum A cites the Uniform Grant Guidance, 2 CFR §§ 200 et seq. ("UGG"), which applies to
awards from the United States Department of Agriculture (USDA), the Department of Housing and Urban
Development (HUD), the Department of Labor (DOL), the Environmental Protection Agency (EPA) or other
federal agencies that have adopted the UGG. The United States Department of Health and Human Services
(HHS) has adopted the UGG, but has implemented and recodified it at 45 CFR §§ 75 et seq.; for awards
funded by HHS, those regulations apply. 45 CFR §§ 75 et seq., including 45 CFR §§ 75 Subpart E ("Cost
Principles'; UGG equivalent 2 CFR 200 §§ Subpart E) shall apply to block grant awards authorized by the
Omnibus Budget Reconciliation Act of 1981 (`block grant subawards'); otherwise, as provided herein, those
block grant subawards are governed by 45 CFR §§ 96 et seq.
Definitions: For the purposes of this Addendum, "Federal Funding Agency" means the United States federal
agency providing funding for this Subaward. Unless otherwise specified herein, the definitions in 2 CFR §§
200 Subpart A or 45 CFR § 75.2 shall apply to all terms used herein. For DOL subawards, the definitions in 2
CFR §§ 2900 Subpart A also apply.
ACCESS TO RECORDS.
1.1. Subrecipient shall provide access for DHHS, or its authorized representative, to any documents,
papers, or other records pertinent to Subaward, in order to make audits, examinations, excerpts,
and transcripts. The Subrecipient shall provide the same access to the Federal Funding Agency,
the Inspectors General, the Comptroller General of the United States, or any of their authorized
representatives. These rights also includes timely and reasonable access to Subrecipient's
personnel for the purpose of interview and discussion related to such documents, papers or other
records. These rights are not limited to the retention periods included herein but continue as long as
the records are retained by Subrecipient.
1.2. Subrecipient shall maintain all financial records, supporting documents, statistical records, and all
other records pertinent to Subaward, for three (3) years from the date of submission of the final
expenditure report.
1.3. In addition to the foregoing retention periods, all records must be retained as specified in 2 CFR §§
200.333 (a) through (f) or 45 CFR §§ 75.361 (a) through (f), as applicable. This includes, but is not
limited to: if any litigation, claim, or audit is started before the expiration of the three-year period, the
records must be retained until all litigation, claims, or audit findings involving the records have been
resolved and final action taken.
1.4. The above access to record and retention requirements apply for block grant subawards.
1.5. Different Retention Periods Required by Law.
1.5.1. If the federal law requires a different record retention length, that shall apply. These include
but are not limited to subawards with funding from the EPA and HUD, and may be more
fully set forth herein.
1.5.2. As required by law, records that fall under the provisions of the Health Insurance Portability
and Accountability Act (HIPAA) and all associated rules and regulations, including but not
limited to the policies and procedures identified in 45 CFR § 164.316, shall be maintained
for six (6) years from the date of their creation or date when the policy or procedures were
last in effect.
1.6. For subawards funded by HUD Emergency Solutions Grants (ESG), Subrecipient must provide
citizens, public agencies, and other interested parties with reasonable access (consistent with
federal, state and local laws regarding privacy and obligations of confidentiality) to records
regarding any uses of ESG funds the Subrecipient received during the preceding five (5) years.
Source: 2 CFR §§ 200.333 through .337; 45 CFR §§ 75.361 through 75.364; 45 CFR § 160 and § 164,
including § 164.316; 24 CFR § 576.500. Other statutes and regulations may apply.
2. ACKNOWLEDGEMENT OF FUNDING.
2.1. If Subaward involves funds from HHS, the following applies: Subrecipient 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. Subrecipient is required to state: (1) the percentage and dollar amounts of the total
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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.
2.2. If this Subaward involves funds from USDA, Subrecipient shall comply with 2 CFR § 415.2, and
shall acknowledge USDA and DHHS support of any audiovisual or publication, as set forth in said
regulation.
2.3. Subrecipient shall comply with any other requirement regarding publications contained herein, with
the applicable Federal Notice of Award, and with law.
Source: Departments of Labor, HHS, and Education and Related Agencies Appropriations Bill; 2 CFR
§ 415.2.
3. AUDIT AND ACCOUNTING RESPONSIBILITIES.
3.1. The Subrecipient shall comply with all applicable federal audit requirements, including but not
limited to those in 2 CFR § 200 Subpart F or 45 CFR § 75 Subpart F; an audit required by these
regulations must be prepared and issued by an independent auditor in accordance with generally
accepted government auditing standards. A copy of the 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.
3.2. Subrecipient shall comply with 2 CFR §§ 200.508 through 200.512 or 45 CFR §§ 75.508 through
75.512, as applicable, including but not limited to: (a) procure or otherwise arrange for the audit
required by this part in accordance with § 200.509 (§ 75.509), and ensure it is properly performed
and submitted when due in accordance with § 200.512 (§ 75.512); (b) prepare appropriate financial
statements, including the schedule of expenditures of Federal awards in accordance with § 200.510
(§ 75.510); (c) promptly follow up and take corrective action on audit findings, including preparation
of a summary schedule of prior audit findings and a corrective action plan in accordance with §
200.511 (§ 75.511); (d) provide the auditor with access to personnel, accounts, books, records,
supporting documentation, and other information as needed for the auditor to perform the audit
required by law.
3.3. In addition to, and in no way in limitation of any obligation in this Subaward, 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 that has been disallowed because of such an exception,
upon demand from DHHS.
3.4. The Subrecipient shall maintain its accounting records in accordance with generally accepted
accounting principles. DHHS reserves the right to require Subrecipient to submit required financial
reports on the accrual basis of accounting. If Subrecipient's records are not normally kept on the
accrual basis, 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).
Source: 31 U.S.C. §§ 7501 et seq.; 2 CFR §§ 200 Subpart F; 45 CFR §§ 75 Subpart F.
4. AMENDMENT. This Subaward may be modified only by written amendment executed by both parties. No
alteration or variation of the terms of Subaward shall be valid unless made in writing and signed by the
parties. Notwithstanding the above, DHHS may add additional funding as specifically set forth in the
paragraph entitled "Award of Additional Funding" in the Subaward.
5. 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 material noncompliance with
Subaward.
CLOSEOUT AND POST -CLOSEOUT,
6.1. Closeout. The following closeout procedures apply to this Subaward at the end of each Period of
Performance:
6.1.1. Subrecipent shall follow all invoicing and liquidation requirements contained in the
Subaward.
6.1.2. Consistent with the terms of the federal award, and after all reports are received, DHHS
shall make any necessary adjustments upward or downward in the federal share of costs.
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6.1.3. DHHS shall make prompt payments, as consistent with the terms set forth herein, for all
actual and allowable costs under the terms of this Subaward.
6.1.4. Subrecipient shall immediately return to DHHS any unobligated balance of cash advanced
or shall manage such balance in accordance with DHHS instructions.
6.2. Post -Closeout Adjustments and Continuing Responsibilities. The closeout of the Subaward does not
affect any of the following:
6.2.1. The right of DHHS to disallow costs and recover funds on the basis of a later audit or other
review. DHHS shall make any cost disallowance determination and notify Subrecipient
within the record retention period.
6.2.2. The obligation of Subrecipient to return any funds due as a result of later refunds,
corrections, or other transactions including final indirect cost rate adjustments.
6.2.3. Audit requirements in 2 CFR § 200 Subpart F or 45 CFR § 75 Subpart F.
6.2.4. As applicable, property management and disposition requirements in 2 CFR §§ 200.310
through 200.316 or 45 CFR §§ 75.317 through 75.323.
6.2.5. Records retention as required Section 1 of this Addendum.
6.3. After closeout of the federal award, a relationship created under the federal award may be modified
or ended in whole or in part with the consent of DHHS and the Subrecipient, provided the
responsibilities of the Subrecipient referred to above, including those for property management as
applicable, are considered and provisions made for continuing responsibilities of the Subrecipient,
as appropriate.
6.4. At the end of the latest running Period of Performance identified in Attachment 1, Subrecipient shall
assist and cooperate in the orderly transition and transfer of Subaward activities and operations with
the objective of preventing disruption of services, if necessary.
Source: 2 CFR § 200.331 or 45 CFR § 75.352(a)(6); 2 CFR § 200.343 or 45 CFR § 75.386; 45 CFR §
75.309; 2 CFR § 200.344 or 45 CFR § 75.386.
7. COMPLIANCE WITH CIVIL RIGHTS AND EQUAL OPPORTUNITY EMPLOYMENT LAW.
7.1. The Subrecipient shall comply with all applicable local, state and federal law regarding civil rights,
including but not limited to: Title VI of the Civil Rights Act of 1964, 42 U.S.C. §§ 2000(d) et seq.; the
Rehabilitation Act of 1973, 29 U.S.C. §§ 794 et seq.; the Americans with Disabilities Act of 1990, 42
U.S.C. §§ 12101 et seq.; the Age Discrimination in Employment Act, 29 U.S.C. §§ 621 et seq.; the
Age Discrimination Act of 1975, 42 U.S.C. §§ 6101 et seq.; and the Nebraska Fair Employment
Practice Act, Neb. Rev. Stat. §§ 48-1101 to 48-1125.
7.2. If this Subaward contains funding from HHS, Subrecipient, by execution of Subaward, also
understands and acknowledges this Subaward is subject to the regulations regarding
nondiscrimination in HHS awards at 45 CFR §§ 75 et seq., 45 CFR §§ 80 et seq., 45 CFR §§ 84 et
seq., 45 CFR §§ 85 et seq., 45 CFR §§ 86 et seq., 45 CFR §§ 87 et seq., and 45 CFR §§ 91 et seq.
7.3. Violation of the above statutes and regulations will constitute material non-compliance with the
terms of this Subaward and may result in any of the Remedies for Noncompliance listed herein, or
any other remedy available under law.
7.4. To comply with law, including but not limited to Neb. Rev. Stat. § 48-1122, Subrecipient shall insert
a similar provision to .1, above, into all subawards and contracts under this Subaward.
Source : Statutes and regulations cited above.
8. CONFIDENTIALITY.
8.1. 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,
however, that contrary provisions in this Subaward shall be deemed to be authorized exceptions to
this general confidentiality provision.
8.2. If this Subaward involves HUD ESG funds, the Subrecipient shall develop and implement written
procedures to ensure:
8.2.1. All records containing personally identifying information (as defined in HUD's standards for
participation, data collection, and reporting in a local Homeless Management Information
System) of any individual or family who applies for and/or receives DHHS assistance will be
kept secure and confidential;
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8.2.2. The address or location of any domestic violence, dating violence, sexual assault, or
stalking shelter project assisted under this Subaward shall not be made public, except with
written authorization of the person responsible for the operation of the shelter; and
8.2.3. The address or location of any housing of a program participant shall not be made public,
except as provided under a preexisting privacy policy of the recipient or subrecipient and
consistent with state and local laws regarding privacy and obligations of confidentiality.
8.2.4. The confidentiality procedures of Subrecipient shall be in writing and must be maintained in
accordance with this section.
8.3. For the purposes of this section, "confidential or proprietary information" means any information
subject to any legal restriction governing its use or disclosure. This may include, but is not limited to,
protected health information as defined by HIPAA.
Source: Various statutes as may apply to the particular information being gathered, including but not
limted to HIPAA; 24 CFR § 576.500.
CONFLICTS OF INTEREST.
9.1. In the performance of this Subaward, Subrecipient shall avoid all conflicts of interest and all
appearances of conflicts of interest. Subrecipient shall not acquire an interest either directly or
indirectly that will conflict in any manner or degree with performance, and shall immediately notify
DHHS in writing of any such instances encountered.
9.2. If this Subaward involves funds from HHS, Subrecipient must be in accordance with applicable
HHS awarding agency (the organization or component of HHS authorized to make and administer
awards) policy. Current policies may be found online.
9.3. If this Subaward involves funds from the USDA, Subrecipient must maintain written standards of
conduct covering conflict of interest and governing the performance of its employees in the
selection, award and administration of federal awards, as consistent with 2 CFR § 400.2(b)(1)
and (2).
9.4. If this Subaward involves funds from the EPA, Subrecipient shall comply with subsection 1,
above, as consistent with the EPA's Final Financial Assistance Conflict of Interest Policy,
currently available online at: httl)s://www.epa.,qov/qrants/epas-final-financial-assistance-conflict-
interest-policy.
9.5. If this Subaward involves ESG funds from HUD, Subrecipient must also follow 24 CFR § 576.404,
as applicable.
Source: 2 CFR § 200.112 or 45 CFR § 75.112; 2 CFR § 400.2.
10. COSTS.
10.1. Under this Subaward, DHHS shall only pay for actual and allowable costs (as defined in this
section) incurred during the Period of Performance.
10.1.1. To be allowable, all costs must be:
• Necessary for the performance of the subaward activites;
• Reasonable, as provided in 2 CFR § 200.404 or 45 CFR § 75.404;
• Allocable to the federal award, as provided in 2 CFR § 200.405 or 45 CFR §
75.405;
• Consistent with all other requirements of the Cost Principles; and
• Consistent with all other law, regulation, policy, or other requirements applicable
to the state or federal funds involved.
10.1.2. To be actual, all costs must be finalized and spent by the appropriate dates set forth
in Close and Post Close -Out and as otherwise set forth herein.
10.2. For HUD subawards, all costs must also meet the requirements of 24 CFR §§ 570 et seq., 24
CFR §§ 574 et seq., and 24 CFR §§ 576 et seq., as applicable.
10.3. For DOL subawards, all costs must also meet the requirements of 2 CFR §§ 2900 Subpart E.
10.4. If anything in any budget attached to this Subaward conflicts with the regulations cited herein, or
with any applicable law or the federal Notice of Award, the regulations, and law and federal
Notice of Award shall govern.
10.5. If this Subaward is a block grant award, DHHS will apply the requirements in .1 of this section,
above, to determine whether the costs shall be paid. Said costs must also be consistent with the
requirements for the particular block grant in 45 CFR §§ 96 et seq.
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10.6. If this Subaward involves both federal and state funds, any requirements applicable to the federal
funds shall also be applied to the state funds.
Source: Regulations cited in this section.
11. DATA OWNERSHIP AND INTELLECTUAL PROPERTY.
11.1. Data. Except as may be otherwise provided in the Federal Notice of Award, DHHS shall own all
rights in data resulting from this Subaward. The Federal Funding Agency reserves the right to
obtain, reproduce, publish, or otherwise use the data produced under this Subaward, and to
authorize others to receive, reproduce, publish, or otherwise use such data for federal purposes.
11.2. Copyright. As consistent with federal law, Subrecipient may copyright any of the copyrightable
material and may patent any of the patentable products produced in conjunction with the Scope
of Work under Subaward without written consent from DHHS. DHHS and any Federal Funding
Agency 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.
11.3. Patent. All patent rights under this Subaward shall be as set forth in the clause contained in 37
C.F.R. § 401.14, and consistent with all other applicable federal law.
11.4. This section shall survive termination or expiration of this Subaward.
Source: Various statutes depending on information; 2 CFR § 200.315 or 45 CFR § 75.322; HHS Grants
Policy Statement; 37 CFR §§ 401 et seq.; Federal Notices of Award (as applicable).
12. DEBARMENT SUSPENSION OR DECLARED INELIGIBLE. The Subrecipient certifies that neither it nor
its principals are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any state or federal department or agency. The
Subrecipient certifies that it is registered with the System of Award Management (SAM)
(https://www.sam.gov), in good standing, and that the entity will maintain annual certification in
accordance with Federal Acquisition Regulations. Failure to comply with this section, including
maintaining an active registration and/or good standing with SAM, may result in withholding of payments
or immediate termination of the Subaward.
Source: 2 CFR § 200.213 or 45 CFR § 75.213; 2 CFR §§ 180 et seq.; 2 CFR §§ 25 et seq.
13. DOCUMENTS INCORPORATED BY REFERENCE. All references in this Subaward to laws, rules,
regulations, guidelines, directives, addenda, and attachments, which set forth standards or procedures to
be followed by Subrecipient in discharging its obligations under Subaward, shall be deemed incorporated
by reference and made a part of Subaward with the same force and effect as if set forth in full text herein.
14. DRUG-FREE WORKPLACE. Subrecipient certifies that it maintains a drug-free workplace environment to
ensure worker safety and workplace integrity. Subrecipient shall provide a copy of its drug-free workplace
policy at any time upon request by DHHS.
Source: State of Nebraska Drug -Free Workplace Policy.
15. FEDERAL FINANCIAL ASSISTANCE / FAITH -BASED ACTIVITIES.
15.1. Federal Financial Assistance. 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, or proselytization.
This provision, however, does not apply to subawards listed in 45 CFR § 87.2, or to subawards
funded with HUD funds.
15.2. Faith -Based Activities. If this Subaward involves HUD funds, and as per 24 CFR § 576.406 or 24
CFR § 574.300(c), as applicable, the Subrecipient shall comply with the requirements found in 24
CFR § 5.109 for full participation by Faith -Based and Community Organizations. These
requirements may be more fully set forth herein.
Source: 45 C.F.R. §§ 87.1-87.2; 24 CFR § 576.406; 24 CFR § 574.300(c).
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16. FORCE MAJEURE. Neither party shall be liable for any costs or damages resulting from its inability to
perform any of its obligations under 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 noncompliance with 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 Subaward
which are reasonably related to the Force Majeure Event shall be suspended, and the affected party shall
do everything reasonably necessary to resume the work described in the Project Description 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 any requirements under Subaward.
17. 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
Subrecipient written notice thirty (30) days prior to the effective date of any termination under this section.
DHHS shall give full credit to Subrecipient for noncancelable obligations properly incurred by Subrecipient
prior to termination, and costs incurred on, or prior to, the termination date.
18. GOVERNING LAW.
19.1. Notwithstanding any other provision of Subaward, or any amendment or addendum(s) entered into
contemporaneously or at a later time, the parties understand and agree that, (1) the State of
Nebraska is a sovereign state and DHHS' authority to subaward is therefore subject to limitation by
the State's Constitution, statutes, common law, and regulation; (2) Subaward will be interpreted and
enforced under the laws of the State of Nebraska, except where preempted by federal law; (3) any
action to enforce the provisions of Subaward must be consistent with federal and state law; (4) the
person signing Subaward on behalf of DHHS does not have the authority to waive the State's
sovereign immunity, statutes, common law, or regulations; (5) the indemnity, limitation of liability,
remedy, and other similar provisions of the final agreement, if any, are entered into subject to the
State of Nebraska's Constitution, statutes, common law, regulations, and sovereign immunity; and,
(6) all terms of the final Subaward, including but not limited to any clauses concerning third party
use, licenses, warranties, limitations of liability, governing law and venue, usage verification,
indemnity, liability, remedy or other similar provisions of the final agreement are entered into
specifically subject to the State of Nebraska's Constitution, statutes, common law, regulations, and
sovereign immunity.
19.2. The parties shall comply with all applicable federal, state, and local law in the performance of
Subaward, and with all terms and conditions established by the Federal Funding Agency in the
applicable Terms and Conditions or Federal Notice of Award, and in the HHS Grants Policy
Statement, if this is applicable and the Subaward involves HHS funds. Legal obligations required
hereunder include, but are not limited to: 2 CFR §§ 200 et seq. or 45 CFR §§ 75 et seq., all statutes
and regulations specific to the funds involved, and all applicable confidentiality and privacy statutes
and regulations, current and as amended, including but not limited to HIPAA.
19. HUMAN TRAFFICKING PROVISIONS. Subrecipient shall comply with and be subject to the requirements
of the Trafficking Victims Protection Act of 2000, 22 USC §§ 7101 et seq.
19.1. The Subrecipient, its employees, any subrecipients the Subrecipient may award under this award,
and subrecipients' employees may not -
19.1.1. Engage in severe forms of trafficking in persons during the period of time that the award is
in effect;
19.1.2. Procure a commercial sex act during the period of time that the award is in effect; or
19.1.3. Use forced labor in the performance of the Subaward.
Source: 22 USC §§ 7101 et seq.
20. INDEMNIFICATION.
20.1. The Subrecipient shall defend, indemnify, hold, and save harmless DHHS 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
DHHS, arising out of, resulting from, or attributable to the willful misconduct, negligence, error, or
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omission of Subrecipient, its employees, consultants, representatives, and agents, except to the
extent such Subrecipient's liability is attenuated by any action of DHHS that directly and proximately
contributed to the claims.
20.2. DHHS' 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.
20.3. Notwithstanding the above, if Subrecipient is a local governmental agency or political subdivision of
the State of Nebraska, nothing in Subaward shall be construed as an indemnification by one party
of the other for liabilities of a party or third parties for property loss or damage or death or personal
injury arising out of and during the performance of Subaward. Any liabilities or claims for property
loss or damages or for death or personal injury by a party or its agents, employees, contractors or
assigns or by third persons shall be determined according to applicable law.
21. INDEPENDENT ENTITY. 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 the project activities under the 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 completing work
as contemplated by this Subaward.
22. 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.
23. LOBBYING.
23.1. No federal or state funds paid under this Subaward shall be paid for any lobbying costs as set forth
herein.
23.2. Lobbying Prohibited by 31 U.S.C. § 1352 and 45 CFR §§ 93 et seq,. and Required Disclosures.
23.2.1. Subrecipient certifies that no federal or state appropriated funds shall be paid, by or on
behalf of 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.
23.2.2. 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 Subaward, Subrecipient shall complete and submit Federal
Standard Form -LLL, "Disclosure Form to Report Lobbying," in accordance with its
instructions.
23.3. Lobbying Activites Prohibited under Federal Appropriations Bills.
23.3.1. No funds under Subaward shall be used, other than for normal and recognized executive -
legislative relationships, for publicity or propaganda purposes, for the preparation,
distribution, or use of any kit, pamphlet, booklet, publication, electronic communication,
radio, television, or video presentation designed to support or defeat the enactment of
legislation before the Congress or any State or local legislature or legislative body, except in
presentation of the Congress or any State or local legislature itself, or designed to support
or defeat any proposed or pending regulation, administrative action, or order issued by the
executive branch of any state or local government itself.
23.3.2. No funds under this Subaward shall be used to pay the salary or expenses of any grant or
subaward recipient, or agent acting for such recipient, related to any activity designed to
influence the enactment of legislation, appropriations, regulation, administrative action, or
Executive order proposed or pending before the Congress or any State government, State
legislature or local legislature or legislative body, other than normal and recognized
executive legislative relationships or participation by an agency or officer of an State, local
or tribal government in policymaking and administrative processes within the executive
branch of that government.
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23.3.3. The prohibitions in the two sections immediately above shall include any activity to
advocate or promote any proposed, pending or future federal, state or local tax increase, or
any proposed, pending, or future requirement or restriction on any legal consumer product,
including its sale of marketing, including but not limited to the advocacy or promotion of gun
control.
23.4. Lobbying Costs Unallowable Under the Cost Principles. In addition to the above, no funds shall be
paid for executive lobbying costs as set forth in 2 CFR § 200.450(b) or 45 CFR § 75.450(b). If
Subrecipient is a nonprofit organization or an Institute of Higher Education, other costs of lobbying
are also unallowable as set forth in 2 CFR § 200.450(c) or 45 CFR § 75.450(c).
Source: 31 U.S.C. § 1352; 45 CFR §§ 93 et seq.; Appropriations bills; 2 CFR § 200.450 or 45 CFR §
75.450.
24. MANDATORY DISCLOSURES, The Subrecipient must disclose to DHHS, 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 or 45 CFR § 75.113, as applicable. Failure
to make required disclosures can result in any of the remedies described in 2 CFR § 200.338 or 45 CFR
§ 75.371, as applicable, including suspension or debarment. (See also 2 CFR § 180 et seq. and 31
U.S.C. § 3321).
Source: 2 CFR § 200.113 or 45 CFR § 75.113.
25, 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/fill-in/f w-4na.pdf
26. NEBRASKA TECHNOLOGY ACCESS STANDARDS. The Subrecipient shall review the Nebraska
Technology Access Standards, found at http://www.nitc.nebraska.gov/standards/2-201.html and ensure
that products or services provided under the Subaward comply with the applicable standards. In the
event such standards change during Subrecipient's performance, DHHS may create an amendment to
the Subaward to request that Subrecipient comply with the changed standard at a cost mutually
acceptable to the parties.
27. NEW EMPLOYEE WORK ELIGIBILITY STATUS.
27.1. The Subrecipient shall use a federal immigration verification system to determine the work eligibility
status of new employees physically performing project activities 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. § 1324(a), 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.
27.2. If Subrecipient is an individual or sole proprietorship, the following applies:
27.2.1. The Subrecipient must complete the United States Citizenship Attestation Form, available
on the Department of Administrative Services website at www.das.state.ne.us.
27.2.2. If Subrecipient indicates on such attestation form that he or she is a qualified alien,
Subrecipient agrees to provide the U.S. Citizenship and Immigration Services
documentation required to verify Subrecipient's lawful presence in the United States using
the Systematic Alien Verification for Entitlements (SAVE) Program.
27.2.3. The Subrecipient understands and agrees that lawful presence in the United States is
required and Subrecipient may be disqualified or the Subaward terminated if such lawful
presence cannot be verified as required by Neb. Rev. Stat. § 4-108.
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Source: Neb. Rev. Stat. § 4-108 et seq.
28. NOTICE OF STATE -DESIGNATED CLUSTER OF PROGRAMS. Pursuant to 2 CFR § 200.331 or 45
CFR § 75.352, this provision provides notice that DHHS has designated the Public Health Emergency
Preparedness / Hospital Preparedness Program grants (CFDAs 93.069 and 93.889, under 93.074) as a
Cluster of programs. For auditing purposes, and as set forth in 2 CFR § 200.518 or 45 CFR § 75.518, a
Cluster of programs must be considered as one program for Major program determinations.
Source: 2 CFR § 200.17 or 45 CFR § 75.2.
29. ORDER OF PREFERENCE.
29.1. Unless otherwise specifically stated in an amendment to this Subaward, in case of any conflict
between the incorporated documents, the documents shall govern in the following order of
preference:
1. Amendments to the Subaward with the most recently dated amendment having highest
priority;
2. The Subaward, with the following addenda in order of preference: DHHS General Terms —
Subawards; DHHS HIPAA Business Associate Agreement Provisions — Subawards (if
included); DHHS Insurance Requirements — Subawards (if included).
3. Any attachments to this Subaward.
29.2. These documents constitute the entirety of the Subaward. Any ambiguity or conflict in the Subaward
discovered after its execution, not otherwise addressed herein, shall be resolved in accordance with
the rules of interpretation as established in the State of Nebraska, unless other rules are set forth
according to federal law.
30. PAYMENT AND PAYMENT REQUESTS.
30.1. Payment. Unless otherwise provided herein, and if payment is being made by reimbursement,
DHHS will make payment to the Subrecipient within 30 days of receipt of Subrecipient's payment
request, unless the request is improper or contains deficiencies. Payments may be withheld as set
forth in 2 CFR § 200.305(a)(6) or 45 CFR § 75.305(a)(6), as otherwise provided herein, or
according to other applicable law.
30.2. Payment Requests. All requests for payments submitted by Subrecipient shall contain sufficient
detail to support payment. Subrecipient must be able to provide source documentation or other
verification of all claimed costs, either provided with its request for payment, or available to DHHS.
30.3. ACH. The Subrecipient shall complete and sign the State of Nebraska Automated Clearing House
(ACH) Enrollment Form and obtain the necessary information and signatures from its financial
institution. The completed form must be submitted before payments to Subrecipient can be made.
ACH Form: http://www.das.state.ne.us/accounting/nis/address book info.htm
Source: Neb, Rev. Stat. §§ 81-2401 through 81-2408; 2 CFR § 200.302 or 45 CFR § 75.302.
31. 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 project activities under
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.
Source: Neb. Rev. Stat. § 73-401.
32. REMEDIES FOR NON-COMPLIANCE.
32.1. DHHS may, if Subrecipient fails to comply with federal statutes, regulations, or with the terms of the
Subaward:
32.1.1. Impose any of the Specific Conditions listed in 2 CFR § 200.207 or 45 CFR § 75.207;
32.1.2. Temporarily withhold any payments pending the correction of the deficiency by
Subrecipient;
32.1.3. Disallow all or part of the cost of the activity or action not in compliance;
32.1.4. Wholly or partly suspend or terminate Subaward (see also Termination, below);
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32.1.5. Recommend suspension or debarment proceedings be initiated by the Federal Funding
Agency; and
32.1.6. Take any other remedies that may be legally available.
32.2. If DHHS imposes items .3, .4, or .6, above, DHHS may withhold future payments or seek repayment
to recoup costs paid by DHHS.
32.3. If DHHS has determined, in its sole discretion, that this Subaward is also a contract for services as
defined in Chapter 73 of the Nebraska Revised Statutes, the following provisions apply:
32.3.1. Corrective Action Plan. If Subrecipient fails to meet the Scope of Work as set forth in the
Subaward, DHHS may require Subrecipient to complete a Corrective Action Plan
(hereinafter "CAP").
32.3.1.1. DHHS shall set a deadline for the CAP to be provided to DHHS, but shall provide
Subrecipient reasonable notice of said deadline. In its notice, DHHS shall identify
each issue to be resolved.
32.3.1.2. The CAP will include, but is not limited to, a written response noting the steps being
taken by Subrecipient to resolve each issue(s), including a date that the issue(s) will
be resolved.
32.3.1.3. If Subrecipient fails to provide a CAP by the deadline set by DHHS, fails to provide
DHHS with a CAP demonstrating the issues regarding performance will be remedied,
or fails to meet the deadline(s) set in the CAP for resolution of the issue(s), DHHS
may withhold payments (for the work or deliverables) related to the issues identified
by DHHS, or exercise any other remedy set forth in this Subaward or available under
law.
32.3.2. Breach of Subaward. DHHS may terminate the Subaward, in whole or in part, if
Subrecipient fails to perform its obligations under the Subaward in a timely and proper
manner. DHHS may, by providing a written notice to Subrecipient, allow Subrecipient to
cure a breach within a period of thirty (30) days or longer at DHHS's discretion, considering
the gravity and nature of the breach. Said notice shall be delivered by Certified Mail, Return
Receipt Requested, or in person with proof of delivery. Allowing Subrecipient time to cure a
breach does not waive DHHS's right to immediately terminate the Subaward for the same
or different breach at a different time.
32.3.2.1. DHHS' failure to make payment shall not be a breach, and the Subrecipient shall retain
all available statutory remedies and protections.
32.4. Nothing in this section shall preclude the pursuit of other remedies as allowed by law.
Source: 2 CFR § 200.338 or 45 CFR § 75.371.
33. RESEARCH. The Subrecipient shall not engage in research utilizing the information obtained through the
performance of 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.
Source: Various privacy statutes, rules and regulations depending on information; DHHS Research
Policy.
34. SEVERABILITY. If any term or condition of 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 Subaward did
not contain the particular provision held to be invalid.
35. 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
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�I�
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 this Subaward, Subrecipient
certifies that 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.
Source: Public Law 103-227.
36. SUBRECIPIENTS OR CONTRACTORS UNDER THIS SUBAWARD.
36.1. Subreceipient shall not subaward nor contract any portion of Subaward without written notice to
DHHS (a budget attached to this Subaward or approved, in writing, by DHHS shall be considerd
written notice for this section). DHHS reserves the right to reject a subrecipient or contractor, but
such rejection shall not be arbitrary or capricious.
36.2. In contracting or subawarding any portions of Subaward, Subrecipient shall follow 2 CFR §§
200.318 through 200.326 or 45 CFR §§ 75.327 through 75.335, as applicable. If subawarding out
any portion of Subaward, Subrecipient shall monitor the subaward as necessary to ensure that the
subaward is used for authorized purposes, in compliance with federal statutes, regulations, and the
terms and conditions of the subaward; that subaward performance goals are achieved. As
applicable, Subrecipient shall follow the requirements for pass-through entities, including but not
limited to 2 CFR § 200.331 or 45 CFR § 75.352.
36.3. Subrecipient shall maintain copies of all procurement contracts and documentation of its compliance
with the provisions cited above.
36.4. Subrecipient shall ensure that all contractors and subrecipients comply with all requirements of this
Subaward and applicable federal, state, county and municipal laws, ordinances, rules, and
regulations.
Source: follow 2 CFR §§ 200.318 through 200.326 or 45 CFR §§ 75.327 through 75.335; 2 CFR §
200.331 or 45 CFR § 75.352.
37. SURVIVAL. All provisions hereof that by their nature are to be performed or complied with following the
expiration or termination of Subaward, including but not limited to those clauses that specifically state
survival, survive the expiration or termination of this Subaward.
38. TERMINATION.
38.1. This Subaward may be terminated in whole or in part as follows:
38.1.1. DHHS may terminate the Subaward if the Subrecipient fails to comply with the terms of this
Subaward; for cause; or as otherwise set forth in Addendum A, applicable law, or the
Subaward.
38.1.2. The Subrecipient may terminate the Subaward upon sending written notification to DHHS
setting forth the reasons for such termination, the effective date, and, in the case of partial
termination, the portion to be terminated. However, if DHHS determines in the case of
partial termination that the reduced or modified portion of the Subaward will not accomplish
the purposes for which the Federal award was made, DHHS may terminate the Subaward
in its entirety. In either case, the effective date shall be as provided by the Subrecipientand
as consistent with the period set forth in the Subaward.
38.1.3. DHHS and the Subrecipient may agree to terminate this Subaward; however, the two
parties must agree, in writing, upon the termination conditions, including the effective date
and, in case of partial termination, the portion to be terminated.
38.2. All notices of termination must be consistent with 2 CFR § 200.339 or 45 CFR § 75.372 and shall
provide a notice period and effective date as set forth in this Subaward.
38.3. In addition to the procedures set forth in Close -Out and Post Close -Out, above (if applicable), if this
Subaward is terminated by Subrecipient, or by DHHS for any reason including but not limited to
Remedies for Noncompliance, the Subrecipient shall not incur new obligations after the notice of
termination of the Subaward, and shall cancel as many outstanding obligations as possible. DHHS
shall give full credit to Subrecipient for the federal share of noncancelable obligations properly
incurred by Subrecipient prior to termination, and costs incurred on, or prior to, the termination date.
Source: 2 CFR § 200.339 or 45 CFR § 75.372.
Addendum A — DHHS General Terms — Subawards Page 11 of 11
Ver. 8/2018
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DocuSign Envelope ID: F4C8E3C8-4428-4F88-BE3F-015AF412CFDA
Attachment 246981 Y3
Nebraska Department of Health and Human Services Division of Public Health
Public Water System Water Security Subgrant Application
1. Public Water System Name: e?(Entity
requesting grant funding) County:
Public Water System ID #: NE31- Federal Tax ID #: '" L° 1 % �
Address: f�tl` �pw trdr—�� Ev
2. Mayor/Board Chairperson/Owner
Namelfitle: 64 t t k
Phone: �2 Gi " �-i r �' Email: e� ,^
(:valid phone number and e-mail addr ss required)
3. Contact Person for Further Information on Application
Name/Title; � '+�, �
n (/L I
Phone: L !J Z _ 44 `" Lj Email:
(valid phone number and e-mail address requil'ed)
4. Identify the securitylemergency 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 add/t/onal page(s) If needed.]prks�A P _
rc,..>w3pti j �Lp� rtrG
eviks
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PWS Representative Name/Title (Please Print) Phone
nature
Fax or Mail Completed Application to:
Andy Kahle
Nebraska Department of Health and Human Services
Division of Public Health
�
PO Box 95026 fJ �`a�
Lincoln, NE 68509-5026
Fax: 402/471-6436
andV.kahle@nebraska.gov
3
RECEIVED
JUL 03 r1i�
DRINK WATER & ENV. HEALTH
IN 4; 1GuRItP
Certificate Of Completion
-- - - -
Envelope Id: F4C8E3C844284F88BE3FO15AF412CFDA Status: Completed
Subject: Please DocuSign: 46981 Y3 Blair Drinking Water
Division: Public Health
Envelope Type: Subaward
Document #: 46981 Y3
Source Envelope:
Document Pages: 16 Signatures: 2
Certificate Pages: 5 Initials: 2
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC -06:00) Central Time (US & Canada)
Envelope Originator:
Procurement Services
301 Centennial Mall S
Lincoln, NE 68508-2529
dhhs.servicecontractsandsubgrants@nebraska.gov
IP Address: 164.119.6.173
Record Tracking
Status: Original Holder: Procurement Services Location: DocuSign
2/8/2019 3:57:42 PM
dhhs.servicecontractsandsubgrants@nebraska.gov
Signer Events Signature Timestamp
Richard Hansen by: Sent: 2/8/2019 3.59 32 PM
rhansen@blairnebraska.org [Dmu$lgn.d
&A4 t6's' Resent: 2/25/2019 11:22:26 AM
Mayor 9D126Di5F26841I... Viewed: 3/28/2019 10:41:20 AM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 3/28/2019 10:41:20 AM
ID:d249159b-9615-4fb2-9897-71c28da0af80
Darrell Klein
Darrell. Klein@nebraska.gov
Deputy Director Public Health Licensure
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted: 3/30/2019 3:37:49 PM
ID:144f518a-1fbd-4de1-9176-abb422a2c74d
Signature Adoption: Pre -selected Style
Using IP Address: 209.74.238.70
CDoau8lgned by:
aYYt(� R6w
14AD854DE81443D...
Signature Adoption: Pre -selected Style
Using IP Address: 164.119.5.252
Signed: 3/28/2019 11:23:10 AM
Sent: 3/28/2019 11:23:11 AM
Viewed: 3/30/2019 3:37:49 PM
Signed: 3/30/2019 3:38:39 PM
In Person Signer Events
Signature
-
Timestamp
Editor Delivery Events
Status
Timestamp
Agent Delivery Events
Status
Timestamp
Intermediary Delivery Events
Status
Timestamp
Certified Delivery Events
Status
Timestamp
Carbon Copy Events
Status
-
Timestamp
Janell Miller I --,. I n
I Sent: 2/8/2019 3:59:31 PM
Janell.Miller@nebraska.gov
Security Level: Email, Account Authentication
(None)
Carbon Copy Events Status Timestamp
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Andy Kahle
Hashed/Encrypted 3/30/2019 3:38:41 PM
Certified Delivered
Sent: 2/8/2019 3:59:31 PM
Andy.Kahle@nebraska.gov
c 0 P
Completed
Viewed: 2/22/2019 3:35:31 PM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Al Schoemaker
Sent: 3/30/2019 3:38:41 PM
ars@blairnebraska.org
COPIED
Viewed: 4/1/2019 8:31:21 AM
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Brenda Wheeler
Sent: 3/30/2019 3:38:41 PM
brwheeler@blairnebraska.org
COPIED
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Kaitlyn Tsai
Sent: 3/30/2019 3:38:41 PM
dhhs.grants@nebraska.gov
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted 3/30/2019 3:38:41 PM
Certified Delivered
Security Checked 3/30/2019 3:38:41 PM
Signing Complete
Security Checked 3/30/2019 3:38:41 PM
Completed
Security Checked 3/30/2019 3:38:41 PM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: 2/11/2018 10:43:44 PM
Parties agreed to: Richard Hansen, Darrell Klein
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How to contact Nebraska Department of Health & Human Services:
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to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: john.canfield@nebraska.gov
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To let us know of a change in your e-mail address where we should send notices and disclosures
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To confirm to us that you can access this information electronically, which will be similar to
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