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HomeMy WebLinkAboutContract 60337CSC No. 60337 F EDERA SURPLUS APPLICATION FOR ELIGIBILITY INSTRUCTIONS FOR COMPLETING THE APPLICATION TO RECEIVE FEDERAL SURPLUS PROPERTY (41 CFR 102-37) • Complete pages 2-6 and return per the instructions at the bottom of this page. • Page 6 must be signed by your organization's AUTHORIZING OFFICIAL. An "Authorizing Official" is the chief executive or financial officer for the applicant organization with authority to execute legal documents on your organization's behalf. • Some organizations must submit supporting documentation with the application. See pages 8-11 for details. • Public/government agencies are eligible. Certain nonprofit organizations, Veterans Service Organizations, Service Educational Activities, volunteer fire/EMS/search & rescue departments and small businesses may also qualify. To determine if your organization may be eligible, please refer to the categories listed on pages 2 and 8-11 or contact us. • All organizations must reapply every three (3) years. • INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. IF YOU HAVE QUESTIONS OR NEED ASSISTANCE, PLEASE CONACT US AT (512) 962-4167 OR federal.surDlus @,tfc.texas.00v. • Narrative Forms, Add/Delete Representative Forms, and all other program forms are available for download from the "Forms" section of ourwebsite: www.SurolusTexas.gov/federal. • Instructions for completing page 2: o SECTION I: Provide the full legal name of your organization and Federal Employer ID #. Provide the complete mailing address of your organization as recognized by the U.S. Postal Service. If the street address is different from the mailing address, provide that address or directions if located on a rural or remote area. Provide a phone number (required), fax number (optional) and an email address (required). E-mail addresses provided will receive notices about program updates, account status, compliance actions, and available property. o SECTION II: Check the box that best describes your organization's type or primary purpose. If you are unable to determine which box to check, please see pages 8-11 for an explanation of the eligibility requirements for each type of organization, or contact our office for assistance. o SECTION III: Check only one box. o SECTION IV: Indicate source(s) of funding for your organization. Depending on your organization type, you may need to include a description of programs/services and facilities and/or supporting documentation regarding funding source(s). Public agencies (i.e., cities, counties, state agencies, public schools) are not required to submit additional documentation for this section. o SECTION V: Nonprofit organizations must provide a current, valid IRS Tax Exemption Letter indicating your organization is exempt under Section 501 of Internal Revenue Code. The name of the organization on the IRS letter must match the name provided in Section I of this application. If not, applicant must include sufficient evidence, such as amendments to Articles of Incorporation or Assumed Name filing certificates, to establish the connection. Public/government agencies, small businesses, Veterans Service Organizations, and VFDs are not required to submit documentation for this section. o SECTION VI: Most nonprofit organizations are required to submit evidence of current approval, accreditation or license from a nationally recognized accrediting or licensing organization. SBA 8(a) and Veteran owned small businesses must submit proof of approval from the SBA. Public/government agencies and VFDs are not required to submit additional documentation for this section. SUBMIT PAGES 2-6 OF APPLICATION TO: TEXAS FACILITIES COMMISSION FEDERAL SURPLUS PROPERTY PROGRAM Applications may be emailed, faxed or mailed. P.O. BOX 13047 OFFICIAL RECORD AUSTIN, TX 78711-3047 CITY SECRETARY TEL: (512) 962-4167 FAX: (512) 236-6173 federal. surDlusna.tfc.texas.aov FT. WORTH, Tx For more information about the Federal Surplus Property Program and to view available inventory, please visit: www.SurplusTexas.gov/federal Page 1 of 11 R.Y. 11912023 FIAMERAL 1� ii l0, APPLICATION FOR ELIGIBILITY I. ORGANIZATION NAME & INFORMATION: City of Fort Worth LEGAL NAME OF ORGANIZATION (include DBA name if applicable) FEDERAL EMPLOYER ID (EIN) 2nn TAXa-. gtrppt Fort Wirth TX 76102 STREET ADDRESS (no P.O. Boxes) CITY STATE ZIP CODE MAILING ADDRESS (if different from above) CITY STATE ZIP CODE Tarrant 817-392-4?22 COUNTY TELEPHONE # FAX # FISCAL YEAR END DATE: September 30, 2023 EMAIL: christopher.bookwalter((Dfortworthtexas.gov II. TYPE/PURPOSE OF ORGANIZATION: (Check the box that best describes your organization. See pages 8-11 for requirements for specific types of organizations.) © City ❑ Public School, School District or ESC ❑ Volunteer Fire Dept., EMS or Rescue Squad ❑ County ❑ Open -Enrollment Charter School ❑ Emergency Services District ❑ State Agency ❑ College or University ❑ Provider of Assistance to Impoverished Persons ❑ Conservation (i.e., soil, water, or ❑ Child Care Center or Preschool ❑ Provider of Assistance to Homeless Persons utility district) ❑ Economic Development or COG ❑ Foster Care or Adoption Services ❑ Program Funded for Older Americans ❑ Educational Radio or TV Station ❑ Sheltered Workshop / Vocational Rehabilitation Program ❑ SBA 8(a) Business ❑ Library ❑ Residential Treatment Center ❑ Veteran Owned Small Business ❑ Museum ❑ Heath Center (clinic, hospital, etc.) ❑ Veterans' Service Organization ❑ Zoo, Planetarium or Aquarium ❑ Service Educational Activity (e.g., Scouts) ❑ Historic Light Station III. APPLICANT STATUS: (check one) ❑■ Public/Government agency (includes public schools & vol. fire depts.) ❑ Nonprofit organization ❑ Small business IV. SOURCE(S) OF FUNDING: N Tax -supported ❑ Grants ❑ Contributions []Other V. (For nonprofit organizations only) HAS THE ORGANIZATION BEEN DETERMINED TO BE TAX EXEMPT UNDER SECTION 501 OF THE INTERNAL REVENUE CODE OF 1986? ❑ Yes ❑ No VI. IS THE ORGANIZATION APPROVED, ACCREDITED, OR LICENSED? ❑ Yes ❑ No Required for nonprofit education or health organizations, conservation organizations, Veterans' Service Organizations, small businesses and Service Educational Activities. IF YES, BY WHAT AUTHORITY? Page 2 of 11 Rev. 1192023 AUTHORIZED REPRESENTATIVES I. An "Authorized Representative" is a person authorized to sign for the release of property on your organization's behalf. An Authorized Representative must sign in the "Signature" provided space below to sian for the release of property. II. Persons listed below without a signature may visit our warehouses and will be included in email broadcasts from our office but will not be able to sign for the release of property. III. All representatives listed in prior applications or account updates will be deleted from the account. Iv. E-MAIL ADDRESSES PROVIDED MAY RECEIVE NOTICES ABOUT PROGRAM UPDATES, ACCOUNT STATUS, COMPLIANCE ACTIONS, AND AVAILABLE PROPERTY. V. Valid driver's license or state issued photo ID may be required prior to entering state or federal facilities. VI. The Authorizina Official (sianina on naae 6 of the Anolication) will automatically be included as an Authorized Representative unless indicated below: a. (initial here) I, as the Authorizing Official, do NOT want to be an Authorized Representative able to sign for property. (Leave blank if the Authorizing Official should be an Authorized Representative.) IMPORTANT NOTE REGARDING SIGNATURES: Unauthenticated digital signatures, signature stamps or signature images will not be accepted. A physical signature is preferred. If a physical signature cannot be obtained, we can also accept digital signatures authenticated by a third party such as Docu-Sign or Adobe Acrobat. NAME TITLE TELEPHONE and SIGNATURE EMAILADDRESS (example) John Doe County Judge (512)123-4567 JohwDoe� John.doe@gmail.com Brian S. Keenum Police 682-404-6021 Lieutenant Brian. Keen um@fortworthtexas.g ov Christopher Bookwalter Police Sergeant 817-392-4285 ch ristopher. bookwalter@fortworth texas.gov Javier Romero Police Corporal 817-392-6475 javier.romero@fortworthtexas. go v Charles Harn Police Captain 817-392-3510 Charles. Harn@fortworthtexas.go v Jeff Cunningham Police Sergeant 817-392-6477 jeff.cunningham@fortworthtexas.gov Page 3 of 11 Rev. VW023 NONDISCRIMINATION ASSURANCE City of Fort Worth the donee, agrees that the program for or in connection with (Legal Name of Applicant Organization) which any property is donated to the donee will be conducted in compliance with, and the donee will comply with and will require any other person (any legal entity) who through contractual or other arrangements with the donee is authorized to provide services or benefits under said program to comply with all requirements imposed by or pursuant to the regulations of the General Services Administration (41 CFR 101-6.2 and 101-8) issued under the provisions of Title VI of the Civil Rights Act of 1964, as amended, Section 606 of Title VI of the Federal Property and Administrative Services Act of 1949, as amended, Section 504 of the Rehabilitation Act of 1973, as amended, Title IX of the Education Amendments of 1972, as amended, Section 303 of the Age Discrimination Act of 1975, and the Civil Right Restoration Act of 1987, to the end that no person in the United States shall on the ground of race, color, national origin, sex, or age, or that no otherwise qualified handicapped person shall solely by reason of the handicap, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity for which the donee received Federal assistance from the General Services Administration; and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement. The donee further agrees (1) that this agreement shall be subject in all respects to the provisions of said Federal statutes and regulations (2) that this agreement obligates the donee for the period during which it retains ownership or possession of the property, (3) that the United States shall have the right to seek judicial enforcement of this agreement, and (4) that this agreement shall be binding upon any successor in interest of the donee and the word "donee" as used herein includes any such successor in interest. COUNTY/COUNTIES SERVED BY APPLICANT ORGANIZATION: Tarrant. Denton. Johnson. Parker, Wise PAYMENT INFORMATION Payment is due 30 days from the invoice date. Payment for property must be in the form of a check drawn on the account of your organization or parent/charter organization. State agencies must pay via Interagency Transaction Voucher (ITV). Our agency code is 303. If you have questions about how to submit a payment, please contact us at 512-962-4167 or federal. surplus @,tfc.texas.aov. For new accounts for nonprofit organizations, small businesses, and volunteer fire / EMS / search & rescue departments, please submit the following with your application: • A voided check or deposit slip, copy of recent bank statement or letter from bank certifying payment account name. The name on the account must match the name on your application and IRS letter (if applicable). If your organization has a "DBA" that you will be submitting payment under, and that is not listed on your IRS letter, then you must submit evidence that your "DBA" has been registered with the proper authority. • If a parent/charter organization will be submitting payment on your behalf, then you must also provide an explanation of the relationship between your organization and parent organization. For account renewals for nonprofit organizations, small businesses, and volunteer fire / EMS / search & rescue departments, please check one of the following: ❑ Our organization will continue using the same payment account in our organization's name. ❑ Our organization will have a parent organization pay on our behalf. Name of Parent Organization: Relationship: ALL applicant organizations must provide a Payment Point of Contact who will receive notices regarding overdue payments: Name: Tracv Lona Title: Administrative Assistant Email: cad Dcas(a)fortworthtexas.aov Phone: 817-392-4226 Page 4 of 11 Rev. 119/1023 DONEE CERTIFICATIONS & AGREEMENTS NOTE: "State agency = Texas Facilities Commission, 'Donee" = your organization (a) THE DONEE CERTIFIES THAT: (1) It is a public agency, a nonprofit institution or organization exempt from taxation under section 501 of the Internal Revenue code of 1954, a Veteran -Owned Small Business or an SBA 8(a) business; within the meaning of section 2030) of the Federal Property and Administrative Services Act of 1949, as amended, and/or the regulations of the General Services Administration (GSA), the Department of Veterans Affairs (VA) or Small Business Administration (SBA). (2) If a public agency, the property Is needed and will be used by the recipient for carrying out or promoting for the residents of a given political area one or more public purposes, or if a nonprofit tax-exempt Institution or organization, the property Is needed for and will be used by the recipient for educational or public health purposes, including research for any such purpose, or for programs for older individuals, or SEA organizations, or assistance to homeless/impoverished, or assistance to Veterans. (3) If an SBA file) business or Veteran -Owned Small Business, the business is located and operated within the Stale, and that It will use the acquired surplus personal property In the normal conduct of Its business activities. Personal or non -business use is prohibited. (4) The property is not being acquired for any other use or purpose, or for sale or other distribution; or for permanent use outside the Slate, except with prior approval of the Stale agency and GSA. (6) Funds are available to pay all costs and charges Incident to donation. (6) This transaction shall be subject to the nondiscrimination regulations governing the donation of surplus personal property Issued under Title VI of the Civil Rights Act or 1964, Title VI Section 606 of the Federal Property and Administrative Services Act of 1949, as amended, and Section 504 of the Rehabilitation Act of 1973, as amended, Title IX of the Education Amendments of 1972, as amended, and Section 303 of the Age Discrimination Act of 1975 and the Civil Right Restoration Act of 1987. (7) In accordance with 28 C.F.R. Section 42,401-42.415, the Federal Surplus Property Program collects Information related to a donees race and national origin in order to provide GSA officials, upon request, with enough information for determining compliance with applicable civil rights laws. Data is collected for those donees who; (1) are eligible to participate In the FSP Program; (2) those actually participating in the recipient's programs and activities; (3) those denied participation In the reciplent's program. (8) If a SBA 8(a) business, the terms Identified In (b), (c), and (d) may not apply. SBA 8(a) businesses must follow SBA guidelines. (b) THE DONEE AGREES TO THE FOLLOWING FEDERAL CONDITIONS: (1) All items of property shall be placed in use for the purpose(s) forwhich acquired within one year of receipt. Property shall be continued in use for such purposes for at least one year from the dale the property was placed in use. Some property must be used longer than one year (see Section (c)). In the event the property Is not so placed in use, or continued In use, the donee shall Immediately notify the Stale agency, and at the donee's expense, return such property to the Stale agency, or otherwise make the property available for transfer or other disposal by the State agency, provided the property is still usable as determined by the Stale agency. (2) Such special handling or use limitations as are Imposed by General Services Administration (GSA) on any Item(s) or property. (3) In the event the property is not used or handled as required by (b)(1) and (2), title and right to the possession of such property shall at the option of GSA revert to the United Slates of America and upon demand the donee shall release such property to such person as GSA or its designee shall direct. (c) THE DONEE AGREES TO THE FOLLOWING FEDERAL CONDITIONS, APPLICABLE TO ITEMS WITH A UNIT ORIGINAL ACQUISITION COST OF $5,000 OR MORE AND PASSENGER MOTOR VEHICLES, REGARDLESS OF ACQUISTION COST. THE FOLLOWING CONDITIONS DO NOT APPLY TO VESSELS 50 FEET OR MORE IN LENGTH AND AIRCRAFT, FOREIGN GIFTS OR OTHER ITEMS OF PROPERTY REQUIRING SPECIAL HANDLING OR USE LIMITATIONS, REGARDLESS OF THE ACQUISTION COST OR PURPOSE FOR WHICH ACQUIRED: (1) The property shall be used only for the purpose(s) for which acquired and for no other purpose(s). (2) There shall be a period of restriction which will expire after such property has been used for the purpose(s) for which acquired for a period of 18 months from the dale the property is placed in use. Not applicable to Service Educational Activities (SEAS). (3) In the event the property is not used or handled as required by (b)(1) and (2) and (c)(1) and (2), title and right to the possession of such property shall at the option of GSA revert to the United Slates of America and upon demand the donee shall release such property to such person as GSA or Its designee shall direct. (d) THE DONEE AGREES TO THE FOLLOWING TERMS, RESERVATIONS, AND RESTRICTIONS: (1) From the date it receives the property and through period(s) of time the conditions imposed by (b), (c) and (f) remain in effect, the donee shall not sell, trade, lease, lend, bail, cannibalize, encumber, or otherwise dispose of such property, or remove it permanently, for use outside the Stale, without the prior approval of GSA under (b) and (f), or the Stale agency under (c) and (0. The proceeds from any sale, trade, lease, loan, bailment, encumbrance or other disposal of the property shall be remitted promptly by the donee to GSA or the Slate agency, as the case may be. SBA 8(a) businesses and Veteran -Owned Small Businesses must also obtain prior approval from SBA in addition to the Slate agency and GSA. (2) In the event any of the property is sold, traded leased, loaned, bailed, cannibalized, encumbered, or otherwise disposed of by the donee from the date it receives the property through the period(s) of time the conditions imposed by (b), (c) and (1) remain In effect, without prior approval of GSA or the Slate agency, the donee, at the option of GSA or the State agency, shall pay to GSA or the Slate agency, as the case may be, the proceeds of the disposal or the fair market value or the fair rental value of the property at the time of such disposal, as determined by GSA or the State agency. (3) If at any time, from the date it receives the property through the period(s) of time the conditions Imposed by (b), (c) and (0 remain in effect, any of the property Is no longer suitable, usable, or further needed by the donee for the purpose(s) for which acquired, the donee shall promptly notify the Slate agency, and shall, as directed by the Stale agency, return the property to the Stale agency, release the property to another donee or another Slate agency, a department or agency of the United Slates, sell or otherwise dispose of the property. The proceeds from any sale shall be remitted promptly by the donee to the Slate agency. (4) The donee shall make reports to the Slate agency on the use, condition, and location of the property and on other pertinent matters as may be required time to time by the Stale agency. (5) At the option of the State agency, the donee may abrogate the State conditions set forth in (c) and the Slate terms, reservations, and restrictions pertinent thereto In (d) by payment of any amount as determined by the Stale agency. (e) THE DONEE AGREES TO THE FOLLOWING CONDITIONS, APPLICABLE TO ALL ITEMS OF PROPERTY: (1) The property acquired by the donee is on an "as Is, where is' basis, without warranty of any kind, and the Government of the United States of America, the Slate of Texas, Its agencies or assigns, and employees thereof will be held harmless from any or all debts, liabilities, judgments, costs, demands, suits, actions, or claims of any nature arising from or Incident to the donation of the property, its use, or final disposition. (2) Where a donee carries insurance against damages to or loss of property due to fire or other hazards and where loss of or damage to donated property with unexpired terms, conditions, reservations or restrictions occurs, GSA or the State agency, as the case may be, will be entitled to reimbursement from the donee out of the Insurance proceeds, of any amount equal to the unamortized portion of the fair market value of the damaged or destroyed donated Items. (f) THE DONEE AGREES TO THE FOLLOWING ADDITIONAL TERMS AND CONDITIONS APPLICABLE TO THE DONATION OF AIRCRAFT AND VESSELS (50 FEET OR MORE IN LENGTH) HAVING AN ACQUISITION COST OF $5,000 OR MORE, AND FOREIGN GIFTS OR OTHER ITEMS OF PROPERTY REQUIRING SPECIAL HANDLING OR USE LIMITATIONS, REGARDLESS OF THE ACQUISITION COST OR THE PURPOSE FOR WHICH ACQUIRED: (1) The donation shall be subject to the additional special terms, conditions, reservations, and restrictions set forth In the Conditional Transfer Document or other agreements executed by the authorized donee representative. (g) THE DONEE CERTIFIES by signing and submitting this lower tier proposal, the prospective lower tier participant, as defined In 41 CFR105-68, certifies to the best of Its knowledge and belief that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared Ineligible, or voluntarily excluded from participation In this transaction by any Federal department or agency. (b) Where the prospective lower tier participant Is unable to certify to any of the above, such prospective participant shall attach an explanation to this proposal. (h) THE DONEE UNDERSTANDS that by execution of this document, it is considered a sub recipient of federal financial assistance pursuant to the Single Audit Act of 1984 and further agrees to provide the State agency with results of the audit required by OMB ClrcularA-133. (1) THE DONEE UNDERSTANDS that e-mail addresses provided may receive notices about program updates and available property. Additionally. Information on nronertv donated to vour organization. Includina olctures and service charaelsl paid, rnav be used by Federal Surplus Pronertv Proaram for marketing and outreach purposes. Page 5 of 11 Rov. 102023 PROPERTY COMPLIANCE PERIOD Participating organizations (referred to as "donees") are required to use the property obtained through the program for a specific amount of time before the property can be sold, transferred or otherwise disposed of. The compliance period is often determined by the "original acquisition cost" of the item. The "original acquisition cost" is defined as the amount the federal government paid when it was initially purchased. • Property must be used for the program(s) approved for participation in the Federal Surplus Property program. • All property must be placed into use within one year of the invoice date. • Property is considered "in use" as soon as it is ready and able to serve its intended purpose. • The compliance period varies according to item and donee type but is at least 12 months from date put into use. o For property valued at less than $5,000 in original acquisition cost, the compliance period is 12 months from the date put into use. o For property valued at $5,000 or more in original acquisition cost and all passenger motor vehicles, the compliance period is 18 months from the date put into use. Not applicable to Service Educational Activities. • TFC staff performs scheduled and unscheduled onsite property compliance visits to ensure the property is being used as represented. The donee agrees to make the property available for visual inspection by TFC staff in a timely manner. • If the property is not paid for in full or is not being used or handled as required, the donee will be required, at its expense, to return the property to TFC or offer for transfer to another donee, as instructed by TFC. • Property must be used and stored at the street address listed on page 2 of this Application, or at other appropriate donee -managed satellite locations in Texas (for example, county precinct barns, district fire stations, school campuses, maintenance/transportation warehouse). Property may not be removed indefinitely from an approved location, or from the State of Texas, without prior, written approval from TFC. • Property may not be stored at a personal residence, unrelated business or storage facility, or any other location that is not managed by the donee organization. Property is not for personal use; it must be readily accessible to all donee staff. • Donees are required to complete reports regarding property use as a condition of participating in the program. • During the compliance period, the donee may not sell, trade, lease, lend, bail, cannibalize, encumber, or otherwise dispose of such property, or remove it permanently, for use outside the State, without the prior, written approval of TFC and/or GSA. SBA approval may also be required for small businesses. • If property is sold, transferred, or otherwise disposed of during the compliance period, the donee may be subject to penalties and fines, as well as possible state or federal prosecution. IMPORTANT NOTE FOR SBA 8(a) APPLICANTS: If applying as an SBA 8(a) business, I understand that the property compliance terms identified above do not apply to my business and that as an SBA 8(a) business I must follow SBA property compliance guidelines. Additionally, I understand that I may not have access to certain items — including aircraft or property with an original acquisition cost of $5,000 or more — if my business is due to graduate from the SBA 8(a) program with insufficient time to cover the entire federally required compliance period for that item. IMPORTANT NOTE FOR VETERAN OWNED SMALL BUSINESS APPLICANTS: If applying as a veteran -owned small business, I certify that the small business is unconditionally owned and controlled by one or more eligible veterans, service - disabled veterans, or surviving spouses; and the business has registered, and is in "certified" status in the SBA's VetCert program database under the procedures found in 13 CFR § 128. IMPORTANT NOTE REGARDING SIGNATURES: Unauthenticated digital signatures, signature stamps or signature images will not be accepted. A physical signature is preferred. If a physical signature cannot be obtained, we can also accept digital signatures authenticated by a third party such as Docu-Sign or Adobe Acrobat. I certifv that the information provided on this Application is accurate and uo to date to the best of my knowledge, and that I understand and agree to the terms and conditions listed on pages 2-6 of the Application, including terms regarding nondiscrimination, property compliance and reporting, and the Certifications & Agreements. I also certifv that I have executive authority to execute legal documents on behalf of the applicant organization. FPrnandn C;nsta FIRST & LAST NAME (typed or printed) Assistant City Manager - Police TITLE x' .C.I._ SIGNATURE OF AUTHORIZING OFFICIAL (ex. Chief Executive or Financial Officer, Mayor/City Manager, County Judge, Superintendent, President, Fire Chien Oct 19)2023 DATE Page 6 o111 Rev. IM12023 DONEE FEEDBACK & PROPERTY REQUEST LIST Completing this page is optional but highly encouraged. We appreciate your feedback! Donee Organization Name: How did you hear about us? ❑ Co-worker ❑ VA ❑ SBA ❑ Email broadcast ❑ From another similar organization ❑ At an event (please specify): ❑ Other (please explain): Where would you prefer to shop? ❑ San Antonio Warehouse ❑ Fort Worth Warehouse ❑ Both How do you prefer to shop? (check as many as you like) ❑ Looking at the "New Arrivals & Specials" email broadcasts ❑ Browsing our online inventory ❑ In -person at the warehouse What attracted you to using the FSP program (when compared to buying brand new)? (check as many as you like) ❑ Low fees ❑ Variety/Type of Items Available ❑ Convenience/Quicker process compared to your organization's traditional purchasing process ❑ Only option due to limited budget ❑ Level of Customer Service/Past Positive Experience with Federal Surplus Property Program ❑ Ability to submit requests ❑ Other (please explain) What item(s) is your organization in need of? Please be as specific as possible (e.g., make, model, size, type, etc.). Who should we contact when the requested property becomes available? Name: Title: Email: Phone: Name: Title: Email: Phone: Page 7 of 11 Rm 02023 DETAILED REQUIREMENTS FOR SPECIFIC TYPES OF ORGANIZATIONS Please review to determine which eligibility category best describes your organization, and If you are required to submit additional documentation, Questions? Please contact us at (512) 962-4167 or federal.surolus(Wc. texas.aov. Government or Public Aaencv 1. Public agency includes (a) State or department, agency, or instrumentality thereof; (b) Political subdivision of the state, Including any unit of local government or economic development district or any department, agency or instrumentality thereof; or (c) Instrumentality created by contract or other agreement between states or political subdivisions. Public agency purposes include, but are not limited to, programs such as conservation, economic development, education, parks and recreation, public health and public safety, and to provide services to homeless or impoverished persons. 2. Cities, counties, state agencies and public schools are NOT required to submit any additional documentation. 3. Other public agencies must submit proof of public agency status (i.e., charter or statute creating agency or evidence of tax - supported status) and/or a narrative describing the services provided by agency. See other categories listed below for details. Emeraencv Services District 1. Required additional documentation that must be submitted with application: a. Narrative that contains information on the department, including: i. number of firefighters and/or emergency services personnel; ii. geographical area(s) covered; and iii. training schedule. b. Proof of Public Agency Status (i.e., election results, charter, enabling legislation, reference in state or local law,organizing document, or other evidence of approval by proper government authority or tax -supported status). (Required for initial application; may not be required for account renewal if still on file.) Volunteer Fire Department. Search & Rescue, or Emeraencv Medical Services 1. To be eligible under this category, must be funded annually in whole or part by state, county, city or emergency se rvicesdi strict. "Funding" may be in the form of monetary support or the provision of other support (e.g., facilities, vehicles/equipment). Must submit funding information annually. 2. Required additional documentation that must be submitted with application: a. Narrative that contains information on the department, including: I. number of firefighters and/or emergency services personnel; ii, geographical area(s) covered; and iii. training schedule. b. Evidence that department is endorsed by AND receives funding from a government entity, such as the state, county, city or emergency services district. Examples: letter of endorsement from the head of the government entity (e.g., county judge, city mayor/administrator, or ESD president) or a copy of a current, signed contract. c. Signed articles of incorporation, bylaws, charter or other organizing document (optional) Conservation (includes both public aaencies and nonorofrts) 1. Includes soil, water, irrigation, and utility districts, and nonprofit water supply corporations. Must be a public agency (i.e., city - owned) or nonprofit organization. For -profit organizations do not qualify under this category. 2. Required additional documentation that must be submitted with application: (Required for initial application. May not be required for account renewal if still on file.) a. Certificate of approval or charter from proper authority demonstrating services are provided to the public (i.e., Certificate of Convenience and Necessity from Texas Commission on Environmental Quality or Public Utility Commission, or creation documentation/charter/enabling legislation) b. (Nonprofits only) IRS letter certifying tax-exempt status. Signed articles of incorporations, bylaws, or other organizing document (optional) Health Oraanization (Public Aaencvj 1. Required additional documentation that must be submitted with application: a. Proof of Public Agency Status (e.g., election results, charter, enabling legislation, reference in state or local law,organizing document, or other evidence of approval by proper government authority or tax -supported status. (Required for initial application; may not be required for account renewal if still on file.) b. Narrative about agency, including: i. description of services provided; ii. number and type of patients served; iii. location and description* of facilities, including number of beds (if applicable); iv. number and status of total staff (# paid/volunteer, # full-time/part-time); and v, list of key staff and their qualifications. SBA 8(a) Business 1. Businesses that are currently part of the U.S. Small Business Administration's 8(a) Business Development Program may participate in the FSP program. Businesses are only eligible to receive property during their nine (9) year membership in the 8(a) program. IMPORTANT NOTE: Some of the terms and conditions on pages 5-6 do not apply to SBA 8(a) businesses. As an SBA 8(a) business, you must follow SBA property compliance guidelines. Please contact your SBA District Office for their complete terms and conditions. 2, Required additional documentation that must be submitted with initial application (not required foraccount renewal): a. Letter from U.S. Small Business Administration certifying membership in 8(a) Business Development Program. Pago a of 11 Rw MOD DETAILED REQUIREMENTS FOR SPECIFIC TYPES OF ORGANIZATIONS Please review to determine which eligibility category best describes your organization, and if you are required to submit additional documentation. Questions? Please contact us at (512) 962-4167 or federal. surolusOtfc.texas. aov. Service Educational Activitv 1. The following Service Educational Activities are eligible: American National Red Cross, Armed Services YMCA of the USA, Big Brothers/Big Sisters of America, Boys & Girls Clubs of America, Boy Scouts of America, Camp Fire, Inc., Center for Excellence in Education, Girl Scouts of the USA, Little League Baseball, Inc., Marine Cadets of America, National Association for Equal Opportunity in Higher Education, National Civilian Community Corps, National Ski Patrol System, Inc., Naval Sea Cadet Corps, Operation Raleigh, United Service Organizations, Inc., U.S. Olympic Committee, Young Marines of the Marine Corps, and League/Marine Corps League, 2. Required additional documentation that must be submitted with application: a. Proof of association with the national organization (e.g., Charter from Boy Scouts of America). Education Organization IN onorof it) *Public schools & colleges should see the Government or Public Agency category on page 8. 1. This category includes charter schools, private schools, research organizations, child care centers and vocational rehabilitation programs/ sheltered workshops receiving grants from Texas Workforce Commission to train persons with physical or mental disabilities 2. Must be accredited or approved by nationally recognized accrediting agency (i.e., Texas Education Agency, Texas Private School Accreditation Commission, Southern Association of Colleges & Schools' Commission on Colleges, Texas Department of Family and Protective Services or Texas Workforce Commission) or the current recipient of research grants by a recognized authority (e.g., National Institute of Education) or a similar national advisory organization. 3. Required additional documentation that must be submitted with application: a. Certificate of accreditation or letter of approval from a nationally recognized accrediting agency OR research grant from National Institute of Education or similar national advisory organization. b. Letter from IRS certifying status as a 501 nonprofit. If letter does not list current name and address, please include brief explanation. (Required for initial application. May not be required for account renewals If still on file and name/address has not changed.) c. Narrative about organization, including: I. course/degrees offered; ii. current enrollment; iii. description of facility and location; iv. number and status of total staff (# paid/volunteer, # full-time/part-time); v, list of key staff and their qualifications; and vi. criteria for admission including any religious requirements, (must be accepting of all faiths to be eligible). d. Financial information (e.g., latest annual financial statement, tax return, year-end bank statement, or budget). e. Signed articles of incorporation, bylaws, charter or other organizing document (optional) f. List of additional research grants awarded (optional) Provider of Assistance to Impoverished Persons (Nonorofit) 1. Services to impoverished persons (as defined in section 673 of the Community Services Block Grant Act) (42 U.S.C. 9902) mustbe rima function. If applicant operates a broad spectrum of programs through which assistance to impoverished is peripheral and incidental, the applicant is not eligible. If located in or around a religious facility, food banks must have a direct entrance notrequiring entrance through a place of worship to be eligible. 2. Required additional documentation that must be submitted with application: a. Letter from IRS certifying status as a 501 nonprofit. If letter does not list current name and address, include brief explanation. (Required for initial application; may not be required for account renewal If still on file and name/address has not changed.) b. Public Recognition as an Impoverished Assistance Provider. Please provide letter from a chief public official (Mayor, City Manager, County Judge, County Commissioner, State Representative, or the head of a public agency) indicating services provided. The letter must be on letterhead, signed and dated, and the name must match the IRS document. It also must indicate that assistance to impoverished persons is the organization's primary focus. c. Narrative about organization, including: I. complete description of services (assistance to impoverished must be primary mission); ii. number of individuals receiving assistance and frequency of assistance (daily, weekly or monthly); iii. requirements for clients to be eligible to receive services, including any required fees; iv. description of facilities; v, hours/days of operation; vi. description of funding source(s) with supporting documentation, (e.g., latest annual financial statement, tax return, year-end bank statement, or budget); vii. number and status of total staff (# paid/volunteer, # full-time/part-time); and viii. list of key staff and their qualifications. d. Description of how the organization determines eligibility to receive assistance and if that person is impoverished. Oraanization's orimary function must be to provide monev. Goods, or services to families or individuals whose annual incomes are below the ooverty line as defined in section 673 of the Communitv Services Block Grant Act (42 U.S.C. 9902 . If recipients are required to complete an application before receiving services, please attach a sample application. e. Proof of current accreditation, approval or licensing if appropriate (e.g., child care or medical/health center) f. Signed articles of incorporation, bylaws, charter or other organizing document g. Brochures (or other printed materials) or link to website (optional) Page 9 of 11 Rov 119/2023 DETAILED REQUIREMENTS FOR SPECIFIC TYPES OF ORGANIZATIONS Please review to determine which eligibility category best describes your organization, and if you are required to submit additional docurnentation. Questions? Please contact us at (512) 962-4167orfederal. surolusla tfc.texas, aov. Provider of Assistance to Homeless Persons (Nonprofit) 1. Examples of eligible programs include: a. Overnight, daytime and around -the -clock shelters, including shelters for battered spouses, abused children, and orphans; (Child care/day care centers should see "Education Organization (Nonprofit) " category.) b. Foster care and adoption agencies; c, Transitional housing for temporary residence of parolees, or persons with mental health or addiction issues; and d. Food banks that provide food directly to facilities where homeless people are fed. If located in or around religious facility, food banks must have direct entrance not requiring entrance through place of worship. 2. Services to homeless persons must be the primary mission. Applicants who operate a broad spectrum of programs through which assistance to homeless persons is peripheral and incidental are not eligible. 3. Required additional documentation that must be submitted with application: a. Letter from IRS certifying status as a 501 nonprofit. If letter does not list current name and address, please include brief explanation. (Required forinitial application. May not be required for account renewal if still on file and name/address has not changed.) b. Public Recognition as a Homeless Assistance Provider. Please provide letter from a chief public official (Mayor, City Manager, County Judge, County Commissioner, State Representative, or the head of a public agency) indicating services provided. The letter must be on letterhead, be signed and dated, and the name must match the IRS document. It also must indicate that assistance to homeless persons is the organization's primary focus. c. Narrative about organization, including: i. complete description of services provided (assistance to homeless must be primary mission); ii. number of individuals receiving assistance and frequency of assistance (daily, weekly or monthly); iii. requirements for clients to be eligible to receive services, including any required fees; iv. description of facilities; v. hours/days of operation; vi. description of funding source(s) with supporting documentation (e.g., latest annual financial statement, tax return, year-end bank statement, or budget); vii. number and status of total staff (# paid/volunteer, # full-time/part-time); and viii. list of key staff and their qualifications. d. Proof of current accreditation, approval or licensing if appropriate (e.g., child care or medical/health center). e. Signed articles of incorporation, bylaws, charter or another organizing document f. Brochures (or other printed materials) or link to website (optional) Provider of Assistance to Older Individuals (Nonprofit) 1. Includes adult day care, multi -purpose senior centers, and social, transportation, nutrition or legal services. 2. Required additional documentation that must be submitted with application: a. Letter from IRS certifying status as a 501 nonprofit. If letter does not list current name and address, please include brief explanation. (Required for initial application. May not be required for account renewal if still on file and name/address has not changed.) b. Certification establishing that applicant is receiving state, federal or local government funds for operation of program under the Older Americans Act of 1965, Title IV or Title XX of the Social Security Act, Titles VII I and X of the Economic Opportunity Act of 1964, or Community Services Block Grant Act. c. Narrative about organization, including: i, description of services provided; ii. description of facilities; iii. number of individuals receiving assistance and frequency of assistance (daily, weekly or monthly); iv, number and status of total staff (# paid/volunteer, # full-time/part-time); and v. list of key staff and their qualifications. d. Proof of current accreditation, approval or licensing if appropriate (e.g., medical center) e. Signed articles of incorporation, bylaws, charter or other organizing document (optional) Health Oraanization (Nonprofit) 1. Includes, but not limited to, hospitals, clinics, residential treatment centers, rehabilitation facilities, and blood/tissue banks. 2. Required additional documentation that must be submitted with application: b. Letter from IRS certifying status as a 501 nonprofit. If letter does not list current name and address, please include brief explanation. (Required for initial application, May not be required for account renewal if still on file and name/address has not changed.) c. Narrative about organization, including: i. description of services provided; ii. number and type of patients served; iii. location and description of facilities, including number of beds (if applicable); iv. number and status of total staff (# paid/volunteer, # full-time/part-time); and v. list of key staff and their qualifications. d. Certificate of accreditation, license, or letter of approval from a nationally recognized accrediting or licensing agency (i.e., Health & Human Services Commission, Dept. of State Health Services) OR research grant from National Institutes of Health or similar national advisory organization e. Financial information, (e.g., latest annual financial statement, tax return, year-end bank statement, or budget) f. Signed articles of incorporation, bylaws, charter or other organizing document (optional) Page 10 of 11 Nov. 192013 DETAILED REQUIREMENTS FOR SPECIFIC TYPES OF ORGANIZATIONS Please review to determine which eligibility category best describes your organization, and if you are required to submit additional documentation. Questions? Please contact us at (512) 962-4167 or federal. s urolusOtfc. texas. oov. Museum. Librarv. Nature Center. Planetarium. Aauarium or Zoo 1. Must be open to the public, and, at minimum, accede to any request submitted for access during "business hours" (interpreted to be approximately 9:00 am to 4:00 pm, although reasonable variation from these hours may be considered due to individual circumstances, such as a museum located in a commercial location with strict business hours, or restrictions based on zoning or other state or local ordinances). Exhibits must be primary focus, and must not be incidental to the primary function of the Institution. Also, must have a minimum of one full-time staff member or the equivalent (i.e., one staff member who works 40 hours per week or two staff members who work 20 hours each per week). 2. Required additional documentation that must be submitted with application: a. Letter from IRS certifying status as a 501 nonprofit. If letter does not list current name and address, please include brief explanation. (Required for initial application. May not be required for account renewals if still on file and name/address has not changed.) b. Narrative about organization, including: I. description of type(s) of exhibits & location(s); ii. staff roster, including name of curator (or equivalent) whose primary job is to care for the museum and its exhibits, and average number of hours each staff member works per week (may be volunteer or paid); iii. days and hours open to the public; iv. admission fee (if any); v, description of the local community and population served by the museum; and vi. square footage of the museum. c. Pictures of exhibits, exhibit signage, facilities, and posted hours of operation d. Signed articles of incorporations, bylaws, charter or other organizing document e. Financial information (e.g., latest annual financial statement, tax return, year-end bank statement, or budget) f. Museum Access Agreement. Available for download from "Forms" section of our website: www.SurplusTexas.00v/federal. g. Brochures, pamphlets, website, or other promotional materials (optional) h. Organizational Memberships (optional) Veterans' Service Oraanization 1. The Department of Veterans Affairs maintains a searchable database of recognized Veterans Service Organizations, Examples of organizations and its local chapters/districts that may be eligible: African American PTSD Association, American Ex -Prisoners of War, Inc., American GI Forum National Veterans Outreach Program, American Legion, AMVETS, Armed Forces Services Corporation, Army and Navy Union, U.S.A., Inc., Associates of Vietnam Veterans of America, Blinded Veterans Association, Catholic War Veterans of the U.S.A., Inc., Disabled American Veterans, Fleet Reserve Association, GoldStar Wives of America, Inc., Italian American War Veterans of the United States, Inc., Jewish War Veterans of the U.S.A., Legion of Valor of the United States of America, Inc., Marine Corps League, Military Order of the Purple Heart, NationalAmputation Foundation, Inc., National Association for Black Veterans, Inc., National Association of County Veterans Service Officers, Navy Mutual Aid Association, Non Commissioned Officers Association of the U.S.A, Paralyzed Veterans of America, Polish Legion of American Veterans, U.S.A, The Retired Enlisted Association, United Spanish War Veterans, United Spinal Association, Inc., Veterans of Foreign Wars of the United States, Veterans of the Vietnam War, Inc. & the Veterans Coalition, Vietnam Era Veterans Association, and Vietnam Veterans of America. 2. Required additional documentation that must be submitted with application: a. Narrative about organization, including: I. description of services provided; ii. percentage of membership comprised of veterans; and iii. facility information & location. b. Proof of affiliation with an eligible veterans organization recognized by the Secretary of Veterans Affairs under section 5902 of title 38 of the FORVETS Act of 2013. See Dept. of Veterans Affairs' website for complete list: httD://www.va.aov/oac/amps/accreditation/index.asp. (Required for initial application. May not be required for account renewals if still on file and name/address has not changed.) Veteran Owned Small Business 1. Business must be registered and in "certified" status in the U.S. Small Business Administration's (SBA) VetCert program database found at https://veterans.certifv.sba.aov, 2. Required additional documentation that must be submitted with application: a. Narrative about the business, including: I. description of services provided and/or products sold; ii, description of customers served (e.g., direct to consumer, business to business, government); iii. address of location(s). If multiple locations, description of each location, including which location is primary; iv. number of employees; v, list of key staff and their roles; and A. website/social media (optiollan. Page 11 of 11 Rev. Vsaozs APPLICATION FOR ELIGIBILITY F E1l)l�l�l��� r� ACCEPTED AND AGREED: CITY OF TORT WORTH By: Name: Fernando Costa Title: Assistant City Manager Date: Oct19,2023 APPROVAL RECOMMENDED: By: Robert Allen A dredge Jr. (Oct 19, 202316:22 CDT) Name: Robert A. Alldredge, Jr. Title: EXeeLItive Assistant Chief ATTEST: By: Name: Jannette Goodall Title: City Secretary CONTRACT COMPLIANCE MANAGER: By signing I acknowledge that I am the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. Kelly Cleveland By: Kelly Cleveland (Oct 18, 2023 16:41 CDT) Name: Kelly Cleveland Title: Sr. Contract Compliance Specialist APPROVED AS TO FORM AND LEGALITY: 44vovnb a FORrIl4 / aF00000 a pro 0°� By: o=o Name: Taylor Paris o pdQ�ooTitle: Assistant City Attorney a`�a4q EXASoaa �24444 CONTRACT AUTHORIZATION: M&C: (None Required) Date Approved: Form 1295 Certification No.: N/A OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX