ORDER NO.29560
ACCEPT SUB-AWARD UNDER HOMELAND SECURITY GRANT
PROGRAM AND AUTHORIZE COUNTY JUDGE TO SIGN
ACCEPTANCE
Came to be heard this the 13th day of February, 2006, with a motion made
by Commissioner Baldwin, seconded by Commissioner Williams. The
Court unanimously approved by vote of 3-0-0 to:
Accept sub-award under Homeland Security Grant Program and authorize
County Judge to sign acceptance.
C, a-~
COMMISSIONERS' COURT AGENDA REOUEST
PLEASE FURNISH ONE ORIGINAL AND TEN COPIES OF THIS
REOUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT.
MADE BY: Pat Tinley OFFICE: County Judge
MEETING DATE: February 13, 2006 TIME PREFERRED:
SUBJECT: Consider, discuss and take appropriate action to accept sub-awazd under
Homeland Security Grant Pro and authorize County Judge to sign acceptance and
other documents in connection~ub-awazd.
EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON)
NAME OF PERSON ADDRESSING THE COURT: County Judge
ESTIMATED LENGTH OF PRESENTATION:
IF PERSONNEL MATTER -NAME OF EMPLOYEE:
Time for submitting this request for Court to assure that the matter is posted in
accordance with Title 5, Chapter 551 and 552, Government Code, is as follows:
Meeting scheduled for Mondays:
5:00 P.M. previous Tuesday.
ag 5~ a
THIS REQUEST RECEPJED BY:
THIS REQUEST RECEIVED ON:

All Agenda Requests will be screened by the County Judge's Office to determine if adequate
information has been prepazed for the Court's formal consideration and action at time of Court
Meetings. Your cooperation will be appreciated and contribute towards your request being
addressed at the earliest opportunity. See Agenda Request Rules Adopted by Commissioners'
Court.
The Honorable Pat Tinley
Judge, Kerr County
700 Main Street
Kerrville, TX 78028
II~~~II~~I~II~~~„I~II,~I„I~I~I
Kerr County
~,St,'CE OAS
z
DIVISION OF EMERGENCY MANAGEMENT
Office of the Governor
RICK PERRY
Governor
Mailine Address:
PO Box 4087
Austin, Texas 78773-0220
Contact Numbers: Physical Address:
512-424-2138 Duty Hours 5805 N. Lamar Blvd.
512-424-2277 Non-Duty Hours Austin, Texas 78752
512-424-2444 Fax
STEVEN McCRAW
Director
Office of Homeland Security
January 16, 2006
The Honorable Pat Tinley
Judge, Kerr County
700 Main Street
Kerrville, TX 78028
Dear Judge Tinley:
JACK COLLEY
Chief
I am pleased to inform you that the Governor's Division of Emergency Management (GDEM) has been
awarded the FY '04 Homeland Security Grant Program (HSGP). The enclosed Notice of Sub-recipient
Award for the 2004 HSGP is being sent to you as the chief elected official for Kerr County. Management
of [he FY '04 SHSP, initially administered by the Texas Engineering Extension Service has been moved
to the Governor's Division of Emergency Management.
In association with the transition, an extension of the grant period was authorized from November 30,
2005 to February 28, 2006 for encumbering costs. The deadline for submitting invoices to GDEM is
March 31, 2006. This encumbrance extension allows jurisdictions to order approved equipment that
might not have been ordered due to uncertainty when this award would be made to GDEM from the
federal Office of Grants and Training (GBT), formerly ODP. All jurisdictions have until Feb. 28, 2006 to
encumber funds and order equipment already listed and approved on their equipment list on the DPA
website.
The intent of the sub-grant is to aid your jurisdiction's ability to enhance its capacity to prevent, respond
to and recover from acts of terrorism and catastrophic events. Our Texas Domestic Preparedness
Assessment website indicates that Sheriff Rusty Hierholzer is the Point of Contact (POC) for your
jurisdiction. If the POC is no longer serving, please provide this letter and its attachments to the
individual who is now performing these duties and notify the SAA of this change as soon as possible.
The Notice of Sub-recipient Award must by signed by an individual authorized by the sovernint:
board of the iurisdiction or orsanization to accept grants and returned to GDEM in order to
activate the grant. At the city and county level, individuals authorized to accept grants may include
county judges, mayors, city managers, or chief financial officers. Other signatures will require an
accompanying statement from the senior elected official authorizing the individual to sign for the
jurisdiction. For agencies and organizations, authorized individuals typically include the Executive
Director or Director.
In addition, a Direct Deposit Authorization form has been included and is available at the Texas State
Comptroller's website: httn://www.window.state.tx.us/taxinfo/taxforms/74-158.pdf. This form must also
be filled out and submitted with the signed sub-recipient agreement to GDEM. If you have already
submitted a completed direct deposit authorization form with your 2005 Grant Acceptance Notice you
DO NOT have to submit another. A copy of the signed Notice of Sub-recipient Award and Direct Deposit
Authorization should be made and retained for your grant files.
Continued
You will also find enclosed instructions for the process we would like for you to follow in the submission
of your invoices. We understand that many of you have encountered distress with the 2004 Grant
transition. We understand [he frustration and would like to ensure you we will do everything possible to
get your payments to you promptly, as we receive your completed invoices.
The SAA cannot make payments until a signed sub-recipient agreement is received. Jurisdictions are to
return their signed (original signature) sub-recipient agreements through the mail [o the SAA as soon as
possible. Once the signed sub-recipient agreement has been returned to [he SAA, invoices are to be
submitted using the instructions page that is a part of this award packet. Do not submit invoices prior to
February 1, 2006.
The deadline to return the signed Notice of Snb-recipient Award and the Direct Deposit
Authorization (if applicable) is February 28, 2006. The signed notice must be mailed or pos[mazked by
the due date. The offer of award will be withdrawn if the signed Notice of Sub-recipient Award is not
returned by the due date.
Please mail the signed Notice of Sub-Recipient Award to
Division of Emergency Management
Office of the Governor
Attention: SAA Section
PO Box 4087
Austin, Texas 78773-0270
If you have any program questions regarding the HSGP, please contact Ben Patterson, SAA Section
Manager at (512) 424-7809.
Congratulations, and we look forward to working with you.
Sincerely, /"J~~~~ -
Jack olle L ~J
Y
Chief
Enclosures: 2004 Notice of Sub-recipient Award
Direct Deposit Audwrization Form
/nsn-uctians for submissiun of Invoices
2004 HSGP - 48265- Ketr County
GOVERNOR'S DIVISION OF EMERGENCY	
MANAGEMENT (GDEM)	Grant Award Notice
	For
HOMELAND SECURITY GRANT PROGRAM	Kerr County
(HSGP)	
1. SUB-RECIPIENT NAME AND ADDRESS:	4. SUB-AWARD NUMBER: 2004 HSGP - 48265
The Honorable Pat Tinley	
Judge, Kerr County	5. PERFORMANCE PERIOD: FROM DEC. I, 2003 FEB. 28, 2006
700 Main Street	
Kemille, TX 78028	BUDGET PERIOD: FROM DEC. 1, 2003 -FEB. 28, 2006
2. FEDERAL GRANT TITLE:	6. DATE OF FEDERAL AWARD TO GDEM:
HOMELAND SECURITY GRANT PROGRAM	llECEMBER 28, 2005
3A. FEDERAL GRANT AWARD NUMBER:	7. AMOUNT OF SUBAWARD:
2004-GE-T4-4015	$ 549.05
3B. FEDERAL GRANTING AGENCY:	8. SUBAWARD DATE	9. ACTION
OFFICE FOR DOMESTIC PREPAREDNESS (ODP)	JANUARY 16. 2006	INITIAL AWARD
DEPARTMENT OF HOMELAND SECURITY (DHS)		
10. SPECIAL CONDITIONS
This Sub award is subject to the ODP FY 2004 Homeland Security Grant Program Guidelines and Application Kit. The Guidelines and
Kit can be accessed at http://www.ojp.usdoj.gov/odp/grants programs.htm. The ODP periodically publishes Information Bulletins to
release, update, amend or clarify grants and programs which it administers. ODP's Information Bulletins can be accessed at
http://www.ojp.usdoj.gov/odp/docs/bulletins.htm and are incorporated by reference into this Sub award. This Sub award is also subject
to the Federal Grant Award and to the rant uidance im osed u on GDEM b DHS.
Il. STATUTORY AUTHORITY FOR GRANT
This ro'ect is su orted under Public Law 108-9Q the De artment of Homeland Security A ro nations Act of 2004.
12. A-133 REPORTING REQUIREMENT:
All sub-recipients must submit an audit report to the Federal Audit Clearinghouse if they expended more than $500,000 in federal funds
in one fiscal year. The Federal Audit Clearinghouse suhmission requirements can be found at http://harvester.census.gov/sac/. A report
must be submitted to GDEM - SAA each year this grant is active. Sub-recipient shall comply with the audit requirements set forth in
OMB Circular A-133.
13. METHOD OF PAYMENT
Primary method is reimhunement. See the enclosed instructiuns fur the process to follow in the submission of invuices.
14. DEBARMENT / SCISPENSION CERTIFICATION:
By signing in block 19 below, the sub-recipient official certifies that any contractors utilized are not listed on the excluded parties listed
s stem at htt ://www.e Is. ov.
15. NON-SUPPLANTING CERTIFICATION:
By signing in block 19 below, the sub-recipient official certifies federal funds will be used to supplement existing funds, and will not
replace (supplant) funds that have been appropriated for the same purpose. Sub-recipient may be required [n supply documentation
certifying that a reduction in non-federal resources occurred for reasons other than the receipt ur expected receipt of federal fuuds.
AGENCY APPROVAL	SUB-RECIPIENT ACCEPTANCE
16. APPROVING GDEM OFFICIAL	17.TYPED NAME AND TITLE OF AUTHORIZED
Jack Colley, Chief	SUB-RECIPIENT OFFICIAL
Division of Emergency Management	

Office of the Governor	Pat Tinley, xerr county Judge
18. SIGNAT PPROVI GG GD
IAL	19. SIGNATURE OF AUTHORIZED	20. DATE
~	SUB-RECIPIENT OFFICIAL	
	S\O	E~R$ tuer b
21. AWARD BREAKDOWN O M1 ~y
'
~ ~
CFDA 97.073 SHSP 2004 $ 549.05 ~t = ~.
CFDA 92074 LETPP 2004 $ 0.00 ~~ fiQ
ryC
2004 HSGP Notice of Sub-Recipient Award AUNT
GOVERNOR'S DIVISION OF EMERGENCY
MANAGEMENT (GDEM) Grant Award Notice
For
HOMELAND SECURITY GRANT PROGRAM Kerr County
(HSGP)
AWARD NUMBER 2004 HSGP-48265
AWARD DATE: JANUARY 16, 2006
SPECIAL CONDIT/ONS
1) Purpose: Sub-gran[ funds will be used [o (a) provide assistance for homeland security and emergency operations
planning; (b) purchase specialized equipment [o enhance [he capability of state and local agencies [o prevent,
respond [o and mitigate incidents of terrorism involving the use of chemical, biological, radiological, nuclear,
explosive (CBRNE) and cyber attacks; (c) provide assistance for costs related to design, development and
conduct of a state CBRNE and cyber security [raining programs and attendance a[ ODP sponsored CBRNE
[raining courses; (d) provide assistance for cos[ related [o [he design, development, conduct and evaluation of
CBRNE and cyber security exercises; (e) provide assistance for costs associated with implementing state
homeland security assessments and strategies.
2) Overview: Funds provided shall be used to provide law enforcement and emergency response communities with
enhanced capabilities for detecting, deterring, disrupting, and preventing acts of terrorism as described in [he
Federal Program Guidelines, specifically: planning, equipment, [raining and exercise needs. All costs under these
categories must be eligible under OMB Circular No. A-87 Attachment A, located at
http://www. whitehouse.gov/omb/circulars/index.html.
3) The Notice of Sub-recipient Award is only an offer until the sub-recipient returns the signed copy of the
Notification ofSub-recipient Award in accordance with the date provided in the transmittal letter.
4) Sub-recipient agrees to comply with any additional requirements set by their council of governments, i.e. mutual
aid agreements and UASI working group approvals.
5) Sub-recipient agrees to comply with the applicable financial and administrative requirements set forth in the
current edition of the Office of Justice Programs (OJP) Financial Guide located at http://www.ojp.usdoj.gov/ocJ.
6) Sub-recipient agrees to comply with the organizational audit requirements of OMB Circular A-133, Audits of
States, Local Governments, and Non-Profit Organizations, as further described in the current edition of the OJP
Financial Guide.
7) Sub-recipient agrees to make no request for reimbursement prior to return of this agreement and signed by the
authorized sub-recipient representative.
8) Sub-recipient agrees to make no request for reimbursement for goods or services procured by sub-recipient prior
to [he performance period start date of this agreement.
9) Sub-recipient agrees to comply with [he U.S. Department of Homeland Security Fiscal Year 2004 Urban Areas
Security Initiative Grant Program Guidelines and Application Ki[ and the Notice of Award from ODP to GDEM.
]0) Sub-recipient agrees to monitor the activities of program participants as necessary to ensure [hat federal awards
are used for authorized purposes in compliance with laws, regulations, and [he pruvisions of contracts or grant
agreements and that the performance goals are achieved.
11) Notwithstanding any other agreement provisions, the parties hereto understand and agree that GDEM's
obligations under this agreement are contingent upon the receipt of adequate funds to meet GDEM's liabilities
hereunder- GDEM shall not be liable to the Sub-recipient for costs under this Agreement which exceed the
amount specified in the Notice of Sub-recipient Award.
12) Projects identified in the Domestic Preparedness Assessment website (www.texasdpa.com) must identify and
relate [o the goals and objectives indicated by the applicable Texas Homeland Security Strategic Plan for the
grant period of performance.
2004 HSGP Notice of Sub-Recipient Award
<uuv novr - yo<w- nen
13) Sub-recipient agrees to comply with all reporting requirements and shall provide such information as required [o
GDEM for reporting as noted in the 2004 Federal Gran[ Guidelines.
14) Sub-recipient must prepare and submit quarterly performance reports to GDEM for [he duration of the grant
performance period or until all grant activities are completed and the grant is formally closed. Sub-recipient may
also be required to submit additional information and data requested by GDEM.
]5) Sub-recipient agrees [hat exercise and training funds will be retained by GDEM (State Administrative Agency)
who will contract with National Emergency Response and Training Center (NERTC) to provide [raining and
exercise services for local jurisdictions.
I6) Sub-recipient agrees [ha[, during [he performance period of this grant, any and all changes to [heir sub-recipient
agreement regarding planning, training, equipment, and exercises must be routed through the appropriate
reviewing authority, either the local Council of Government or Urban Areas Security Initiative (UASI) Working
Group.
17) During [he performance period of [his gran[, sub-recipient must maintain an emergency management plan a[ [he
Basic Level of planning preparedness, as prescribed by GDEM. This may be accomplished by a jurisdiction
maintaining its own emergency management plan or participating in an in[erjurisdictional emergency
management program that meets the reyuired standards. If GDEM identifies deficiencies in [he sub-recipient's
plan, sub-recipient will correct deficiencies within 60 days of receiving notice of such deficiencies from GDEM.
] 8) During the performance period of this grant, sub-recipient agrees that it will participate in alegally-adopted
county and/or regional mutual aid agreement.
19) If the sub-recipient is a participant in a UASI program, during the performance period of this gran[, sub-recipient
agrees to adhere [o [he UASI strategy, goals, objectives, and implementation steps.
20) Sub-recipient agrees that, during the performance period of this grant, all communications equipment purchases
must be reviewed and approved by the UASI points of contact (voting members) Imeroperability Committee.
21) GDEM may perform periodic reviews of sub-recipient performance of eligible activities and approved projects.
These reviews may include, without limitation: performance of on-site audit and compliance monitoring -
including inspection of all grant-related records and items, comparing actual sub-recipient activities to those
approved in the sub-award application and subsequent modifications if any, ensuring that advances have been
disbursed in accordance with applicable guidelines, confirming compliance with grant assurances, information
provided un performance reports and psyment requests, needs and threat assessments and strategies.
22) GDEM may suspend or terminate sub-award funding, in whole or in part, or other measures may be imposed for
any of [he following reasons: failing to comply with the requirements or statutory objectives of federal law,
failing w make satisfactory progress toward [he goals or objectives set forth in [he sub-award application, failing
to follow gram agreement requirements or special conditions, failing to submit reyuired reports, filing a false
certification in the application or mher report or document.
23) GDEM will close asub-award after receiving sub-recipient's final performance report indicating that all approved
work has been completed and al] funds have been disbursed, completing a review to confirm the accuracy of the
reported information, and reconciling actual costs to awards modifications and payments. If the close out review
and reconciliation indicates [hat the sub=recipient is owed additional funds, GDEM will send the final payment
automatically [o the sub-recipient. If the sub-recipient did no[ use al] the funds received, GDEM will issue an
invoice to recover the unused funds.
24) Sub-recipient understands and agrees that it cannot use any federal funds, either directly or indirectly, in support
of the enactment, repeal, modification or adoption of any law, regulation or policy, at any level of government,
without the express prior written approval of ODP.
2004 HSGP Notice of Sub-Recipient Award
zvvv Haar - vazoa Herr
25) The sub-recipient agrees that all allocations and use of funds under this grant will be in accordance with the Fiscal
Yeaz 2004 Homeland Security Grant Program Guidelines and Application Ki[ and must support [he goals and
objectives included in [he S[a[e Homeland Security Strategy and [he Urban Area Homeland Security Strategies.
26) When implementing Office of State and Local Government Coordination and Preparedness (SLGCP) funded
activities, the sub-recipient must comply with all federal civil rights laws, to include Title VI of the Civil Rights
Act, as amended. The sub-recipient is required to take reasonable steps [o ensure persons of limited English
proficiency have meaningful access [o language assistance services regarding the development of proposals and
budgets and conducting SLGCP funded activities.
27) The sub-recipient agrees that all publications created with funding under this grant shall prominently contain the
following statement: `This Document was prepared under a grant from the SLGCP, United States Department of
Homeland Security. Point of view or opinions expressed in [he document are [hose of [he authors and do no[
necessarily represent [he official position or policies of SLGCP or [he U.S. Department of Homeland Security.'
28) The sub-recipient agrees that any equipment purchased with gran[ funding shall be prominently marked as
follows: 'Purchased with funds provided by [he U.S. Department of Homeland Security.' Exceptions to this
requirement are limited to items where placing of the mazking is not possible due ro [he nature of the equipment.
29) The. sub-recipient agrees to cooperate with any assessments, national evaluation efforts, or information or data
collection requests, including, but no[ limited ro, the provision of any information required for the assessment or
evaluation of any activities within this project.
30) Approval of this award does no[ indicate approval of any consultant rate in excess of $450 per day. A detailed
justification must be submitted to and approved by GDEM prior to obligation or expenditure of such funds.
31) Sub-recipient acknowledges that SLGCP reserves aroyalty-free, non-exclusive, and irrevocable license to
reproduce, publish, or otherwise use, and authorize others to use, for Federal government purposes: (I) the
copyright in any work developed under an award or sub-award; and (2) any rights of copyright to which a
recipient or sub-recipient purchases ownership with Federal support. The Recipient agrees to consult with SLGCP
regarding the allocation of any patent rights that arise from, or are purchased with, this funding.
32) Sub-recipiem shall provide the assurances required by ODP. Pailure to comply may result in the withholding of
funds, termination of [he award or other sanc[iuns.
33) Sub-recipient must register as a user of the Texas Regional Response Network (TRRN) and identify all major
resources such as vehicles and trailers, eyuipment costing $5,000 or more and specialized teams/response units
equipped and/or trained using grant funds (i.e. hazardous material, decontamination, search and rescue, etc.).
This registration is to ensure jurisdictions or organizations are prepared [o make grant funded resources available
to other jurisdictions through mutual aid.
34) Sulrrecipients must maintain an updated inventory of equipment purchased through this grant program.
35) If a financial hardship exists, asub-recipient may request an advance of gran[ funds for expenditures incurred
under this program. Requests must be made in writing by the chief elected official and submitted [o GDEM.
Letters must also indicate that a financial hardship exists for the sub-recipient's organization. GDEM will
determine whether an advance will be made.
36) If asub-recipient is approved for an advance, the funds must be deposited in a separate interest bearing account
and are subject to the rules outlined in the Uniform Rule 28 CFR Par[ 66, Uniform Administrative Requirements
for Grants and Cooperative Agreements to State and Local Governments, at
ht[p://www.aceess.gpo.gov/nara/cfr/waisidx 04/28cfrv2_04.h[ml and [he Uniform Rule 28 CFR Part 70,
Uniform Administrative Reyuirements for Grants and Agreements (including sub-awards) with Ins[itu[iuns of
Higher Education, Hospitals, and other Nonprofit Organizations, a[
http://www.access.gpo.gov/nara/cfr/waisidx 03/28cfr70 03.htm1 . Any interest earned in excess of $100 must,
on a yusrterly basis, be remitted to:
2004 HSGP Notice of Sub-Recipient Award
cvvv n~vr - 4ocw- nen
United States Department of Health and Human Services
Division of Payment Management Services
P.O. Box 6021
Rockville, MD 20852
Sub-recipients must report any interest remitted to CDEM.
37) Notice. All notices or communication required or permitted to be given by either pazty hereunder shall be
deemed sufficiently given if mailed by registered mail or certified mail, return receipt requested, or sent by
overnight courier, such as Federal Express, [o [he other party a[ its respective address se[ forth below or to such
other address as one party shall give notice of to the other from time to time hereunder. Mailed notices shall be
deemed to be received on the third business day following the date of mailing. Notices sent by overnight courier
shall be deemed received [he following business day.
The Honorable Pat Tinley
Judge, Kerr County
700 Main Street
Kerrville, TX 78028
Jack Colley, Chief
Division of Emergency Management
Office of [he Governor
PO Box 4087
Austin, TX 78773-0220
2004 HSGP Notice of Sub-Recipient Award
2004 HSGP - 48265- Kerr County
Important
The SAA will begin accepting 2004 SHSP, LETPP and UASI
invoices for approved items on February 1, 2006. All necessary
forms and information can be obtained at www.texasdpa.com.
The process for submitting invoices is as follows:
After logging into the Texasdpa site, check the "Information
Page" link on the Homepage for the latest instructions.
1. Locate the item in your 2004 grant equipment
spreadsheet.
2. Click on °iNeeds Invoice".
3. Complete all information on the invoice page.
4. At this point you will have the option of saving this
information and entering additional invoices for other
items or printing the cover sheet(s) required to submit
the invoice(s).
5. Place the invoice behind the appropriate system-
generated cover page.
6. Fax all pages and invoices to the SAA at 512-424-7825.
Again, this process will not be available until February 1, 2006.
If you have problems with this process please call 877-612-4357
for assistance.
Important
2004 HSGP Notice of Sub-Recipient Award
2004 HSGP - 48265- Kerr County
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DIRECT DEPOSIT AUTHORIZATION
INSTRUCTIONS
• Use on3y BLllE or BLACK wok. • Section 7 must be competed by Cfie paying state agency
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TRANSACTION TYPE
Far further insrrUCrrons, see the back aF rhis form.
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2004 HSGP Notice of SuLrRecipient Award
2004 HSGP - 48265- Kerr County
INSTRUCTIONS FOR
DIRECT DEPOSIT AUT}#ORIZATION
Under Ch. 559,.. Government Code, }rou are entitled fo renew, request, and correct information we have on file about y`oq
with Yimited exceptions in accordance witA Ch. 552, Government Code.
SECTION I: Check the appropriatebox(esj
• NEW SETUP - If payee is not currently on direct deposi! with the state.
a. Complete Seckorrs. 2, 3 6 4.
b. Section 4 is recommended to be eampleted by financial instiWtion.
• CANCELLATION - If payee wishes to stop direct deposit with the state.
a. Payee completes Sections 2 8 3.
• INTERAGENCY TRANSFER -For state employees only who transfer fmm one stale agency to another.
a. Employee wmpletes Sections 2 & 3
b. Employee strand submit form to the new paying state agency for completion of Section 7
EXEMPTION - If payee claims an exemption granted by Tex. Go~4. Code Ann. §403A96.
a. Payee completes Sections 2 & 5.
• CHANGE FINANCIAL INSTITUTION
s. Payee completes Sections 2 & 3.
b. Section 4 is mcommended to be completed by financial institution-
•CHANGEACCOUNTNUMBER.
a. Payee completes Sections 2 & 3.
b. Section d is recommended to be completed by financial rnstdudon
•CHANGEACCOUNTTYPE
a. Payee completes Sections 2 & 3.
6. 5ec4on 4 is recommended to 6e completed by financial institution-
SECTION Z: PAYEE IDENTIFICATION
ttem 1 Leave the shaded boxes blank if you do not have your f1-digit Compteo€ler Payee Idantrfcatian number. The
paying state agency will provide the information to fie entered in the shaded boxes. Enter your 9-digit Social
Security number or your Federal Employer's Identificahon (FEI}number.
Item 2 If your 3-digit mail code is not known, it will be assigned by the paying sQaie agency.
SECTION 3: AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION
Items 1D, 11 The individual authorizing musC sign, print their name and date the form.
8 92
NOTE: No akera8ons to this sechan will be allowed.
SECTION 4: FINANCIAL INSTITUTION
Section & is recommended to be completed by financial institution.
NOTE: Alterations to routing andlor account number must be initiated by the financial institution repeesentative
or the payee.
SECTION 5: EXEMPTION
a. ff you quality for an exemption, check the appropriate box.
b, Complete items 27, 28 and 29
NOTE: Exemption tomes are maintained by the payrng state agency.
SECTION 6: CANCELLATION BY AGENCY
Sections 6 & 7 mustbe completed by the paying state agency
SECTION 7: PAYkNG STATE AGENCY
Section 7 must be completed by the paying state agency before the form can be processed.
Submd the completed form to your paying state agency.
2004 HSGP Notice of Sub-Recipient Award