Ffy 2011Section 5310 Program(Cfda 20.513)

State of New York, Department of Transportation

FFY 2011SECTION 5310 PROGRAM(CFDA 20.513)

Application Form

PART I

PLEASE SEE THE 5310 APPLICATION MANUAL FOR ASSISTANCE WITH THESE FORM QUESTIONS

Application Deadline is May 4, 2011

(Application Cover Sheet)

Applicant Type (Please place “x” in only one) – See Page 4 of Application Manual under Eligible Applicants

Not-For-Profit Applicant: (If not-for-profit, state tax exempt no. & charities reg. no. must be provided, or other proof of 501(c)(3) status)

Governmental Authority Applicant: (If governmental authority, (a.) certification letter or resolution, or (b.) memorandum must accompany this application form)

First Time Applicant? Yes No Is the applicant a Native American Indian Tribe? Yes No

APPLICANT

Legal Name of Applicant:

Doing Business As (dba):

County of Operation (please only identify one):

Congressional District No.:

Applicant Primary Contact Information (primary contact will receive all grant correspondence)

Name:

Mr. Address:

Ms.

Telephone No.:

Email:

Applicant Website:

Coordinated Plan Lead Agency(name of MPO, County, or other):

Coordinated Plan Referenced Page # for Proposed Project Vehicle(s):

Date Coordinated Plan Last Updated:

Not-for-profit proof of eligibility(valid numbers must be provided for applicant eligibility)

Applicant State Tax Exempt No.:

Applicant Federal Employer Identification No.:

Applicant Department of Law Charities Registration No.:

(It is important that your charities registration is current. If exempt, documentation must be provided that proves the exemption.)

Type of Grant Vehicle Request(Place “x” in one or both)

Vehicle(s) for Expansion of Services and/or Replacement of Services

If “Replacement of Services” for existing Section 5310 Program Vehicle(s) that are, or will be, eligible for

retirement by the time grant vehicles are awarded and delivered, please list existing vehicle(s) below:

VIN Number (Last 5 digits) / Vehicle Year / Current Odometer Miles

(Application Cover Sheet)(cont.)

GRANT REQUEST AMOUNT

Federal Share (80%):$

(Copied from Part II.B.b.)

Applicant Share (20%):$

(Copied from Part II.B.c.)

Estimated Total Cost of Project Vehicle(s)*:$

(Copied from Part II.B.a.)

*TOTAL COST OF PROJECT VEHICLE(S) BEING REQUESTED MAY NOT EXCEED $350,000

Explain the primary purpose of your organization (as stated within articles of incorporation):

Describe the Type of vehicle(s), quantity, and related equipment proposed to be purchased through this Grant Project Application(number of grant vehicles being requested may not exceed a total of four):

Certification by Chief Executive Officer of Applicant

I hereby certify that the accompanying information and data in this Section 5310 grant application (Part I & Part II) are true and correct to the best of my knowledge and belief and are supported by our records.

Signature of Chief Executive OfficerDateSignature of Notary and SEAL

Name and Title of Chief Executive Officer(please type/print):

FFY 2011 (Application Cover/Part I)PAGE 1

1. DESCRIPTION OF PROJECT SERVICES AND NEED

1. Enter the number of consumers your organization currently provides services to on adaily basis(all services, not just transportation):

Elderly Individuals

and Individuals with

Disabilities 1 OtherTotal

No. of consumers daily

1. Enter the number of consumers your organization currentlyprovides transportation to on adaily basis(transportation only, either by organization vehicle(s) or other means):

Elderly Individuals

and Individuals with

Disabilities 1 OtherTotal

No. of consumers daily*

1. Enter the number of one-way passenger trips1your organizationcurrently provides transportation services tosemi-annually(every 6 months):

Elderly Individuals

and Individuals with

Disabilities 1 OtherTotal

One-way passenger trips1

1. Anticipatingapproval of this grant, enter the number ofadditional consumers that will be provided transportation on adaily basis:

Elderly Individuals

and Individuals with

Disabilities 1 OtherTotal

No. of consumers daily*

1. Anticipating approval of this grant, enter the number ofadditionalone-way passenger trips1your organization expects to provide transportation services to semi-annually(every 6 months):

Elderly Individuals

and Individuals with

Disabilities 1 OtherTotal

One-way passenger trips1

* Question 2 & Question 4 (under this PART I.A.) together should reflect the total number of consumers your organization will transport on a daily basis for the transportation service being proposed through this application, anticipating award of the Section 5310 grant vehicles being requested.

1 See page 9 of the Application Manual for definitions of “elderly individual,” “individual with a disability” and“one-way passenger trip.”

1. DESCRIPTION OF PROJECT SERVICES AND NEED (CONT.)

1. Explain the requirements necessary for people to participate in your organization's programs(attach additional page if necessary, clearly labeled Part I.A.6.):

Is membership or registration required? Yes No (If yes, please explain further under question 6)

1. Explain your organization’s method fordeciding who may receive transportation,how often, and when they are to receive it(attach additional page if necessary,clearly labeled Part I.A.7.):

1. Describe the geographic areas that will be served by the vehicle(s) you propose to acquire through this grant application (attach additional page if necessary, clearly labeled Part I.A.8.):

1. For your proposed transportation service only(which includes your current transportation services and services anticipating approval of grant), provide the number and percentage of totalof minority and non-minority consumers to be served on a daily basis. The following definitions are to be used:

a.African American - A person having origins in the racial groups of Africa.

b.Hispanic American - A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

c.Asian or Pacific Islander American - A person having origins in any of the countries of the Far East, Southeastern Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example: China, Japan, Korea, the Philippine Islands, and Samoa.

d.American Indian or Alaskan Native American - A person having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.

e.Non-Minorities - All persons not included in any of the above definitions.

(Number)(% of Total)

9a.African American

9b.Hispanics

9c.Asian or Pacific Islanders

9d.American Indians or Alaskan Natives

9e.Non-minorities

TOTAL* 100% (daily basis)

* Should equal PART I.A. question 2 + question 4.

1. DESCRIPTION OF PROJECT SERVICES AND NEED (CONT.)

1. Attach a separate narrative page(s), clearly labeled Part I.A.10.explainingwhy the public transportation services in the above service area (public transit, private bus or taxi, etc.) cannot provide the transportation service your organization is proposing for the vehicle(s) requested in this application.

1. Attach a separate narrative page(s), clearly labeled Part I.A.11.explaining the services your organization proposes to provide with the vehicle(s) being requested in this application and why they are necessary to provide transportation to the elderly and individuals with disabilities.

(Include days of the week in service, hours of operation, and number of runs per day)

1. Is your organization, or is your organization’s name, in anyway affiliated with a religion, religious institution, or religious organization?

YesNo

(If the answer to this question is yes, please explain this affiliation below that also includes a statement that your transportation services are open to every person, regardless of their religious preference. Attach an additional page if necessary, clearly labeled PART I.A.12.)

1. Does your organization operate exclusive school transportation service?

YesNo

(If the answer to this question is yes, please fully explain this service below. Attach an additional page if necessary, clearly labeled PART I.A.13.)

1. Does your organization have an exemption to the school bus restrictions as permitted under 49CFR605?

YesNo

(If the answer to this question is yes, a copy of the exemption must be attached to this application, and clearly labeled PART I.A.14.)

FFY 2011 (Part I)PAGE 1

B. PROPOSED SCHEDULE OF BUS OPERATIONS

(SCHEDULE ANTICIPATING AWARD OF SECTION 5310 GRANT VEHICLE(S) BEING REQUESTED)

Include current vehicles operated that transport elderly individuals and individuals with disabilities by VIN #

(i.e. omit staff vehicles, service trucks, etc.) and all proposed 5310 grant vehicles by Type

VIN #
(last 5 digits only) / Area or Route Served / Day(s) of the Week / TIME OF DAY & DESCRIPTION OF
SERVICES PROVIDED
(please enter beginning time and ending time for each type of service described; enter “IDLE” for idle time periods) / Total Hours of Actual Vehicle Use Per Day for Elderly & Disabled1 Individuals

1 See page 9 of the Application Manual for definitions of “elderly individual,” “individual with a disability” and“one-way passenger trip.”

FFY 2011 (Part I)PAGE 1

FFY 2011 (Part I)PAGE 1

C1. VEHICLE INVENTORY for EXISTING VEHICLES

Vehicle Inventory / Current Service / Proposed Service*
*(If vehicle being retired, insert “To Be Retired”)
VIN #
(last 5 digits) / Model Year / Current Odometer Reading / Section 5310 Funded? / Agency Owned? / Leased? / Gasoline (G) or Diesel (D) / Ambulatory/Wheelchair Capacity / Avg. No. of Hours & Miles Vehicle Carries Elderly & Disabled1 Passengers Per Day / Elderly & Disabled1 / Other / Avg. No. of Hours & Miles Vehicle to Carry Elderly & Disabled1 Passengers Per Day / Elderly & Disabled1 / Other

FFY 2011 (Part I)PAGE 1

1 See page 9 of the Application Manual for definitions of “elderly individual,” “individual with a disability” and“one-way passenger trip.”

FFY 2011 (Part I)PAGE 1

C2. VEHICLE INVENTORY for PROPOSED SECTION 5310 VEHICLES

Please list all vehicles being requested under this grant application – not to exceed 4 total

Vehicle Inventory
(List requested vehicles in priority order) / Proposed Service
Vehicle Type
(Type I, I-A, II, III or IV) / Expansion (E) or Replacement (R) / Gasoline (G), Diesel (D) or Hybrid (H) / Ambulatory2/Wheelchair Capacity / Avg. No. of Hours & Miles Vehicle to Transport Elderly & Disabled1 Passengers Per Day / No. of Days in Service Per Week / Estimated Mileage on Vehicle Per Year3 / Elderly & Disabled1 / Other
1.
2.
3.
4.

1 See page 9 of the Application Manual fordefinitions of “elderly individual,” “individual with a disability” and “one-way passenger trip.”

2 Ambulatory seating should reflect permanent ambulatory seating as well as optional flip seats.

3 Mileage estimate should adequately reflect first three (3) years that vehicle is in-service.

FFY 2011 (Part I)PAGE 1

PART I.D., PART I.E. & PART I.F.

D.PROJECT INVOLVEMENT IN A LOCALLY DEVELOPED HUMAN SERVICE PUBLIC TRANSIT COORDINATED TRANSPORTATION PLAN

Has your organization been involved in the process and are the vehicle(s) you are applying for through this grant submission proposal included in the development (as part of the strategy) of the local coordinated plan in your area?

Yes No

(If No, your application will be deemed ineligible for funding)

As required under this Part, attach a separate narrative page(s), clearly labeled PART I.D. Narrative, and theCERTIFICATION LETTER provided by the Metropolitan Planning Organization (MPO), County Planning Office, (or other lead coordinator for the plan in your area)as is described in further detail under Part I.D. of the application manual.

Optional Comments:

E.INVOLVEMENT OF PRIVATE FOR PROFIT OPERATORS THROUGH PUBLIC NOTICE

Did your organization receive any responses to the public notice requirement stipulated under Part I.E. of the application manual?

Yes No

(If Yes, you must explain how you addressed the inquiries as is outlined in the application manual)

As required under this Part, attach a copy of the various items as described in further detail under Part I.E. of the application manual, relating to the proof of public notice to private for-profit operators of your grant application request for federally funded vehicle(s).

Optional Comments:

F. INVOLVEMENT OF SERVICES WITH OTHER PRIVATE NON-PROFIT OPERATORS (optional)

Attach copies of agreements that exist for your organization, if any, and a description of these arrangements on a separate page clearly labeled Part I.F.,that have been established to coordinate existing transportation services for elderly individuals and individuals with disabilities.

Please do not submit copies of letters from other private non-profit operators indicating support or approval of your application for Section 5310 grant funding. Part I.F. is requesting specific agreements your organization may have established with other agencies/organizations to coordinate existing transportation services. This is separate from the locally developed coordinated plan requirement, and is optional.

Optional Comments:

PART I.G.

G.JUSTIFICATION FOR PROPOSED SECTION 5310 VEHICLE(S) AND

DESCRIPTION OF CAPABILITIES

Attach a separate page(s), clearly labeled PART I.G., that provides a response to each of the five(5) items listed below. Please use complete sentences and respond to each item individually.

1.Explain why your organization is asking for the size/category (i.e. Type) of vehicle(s) being requested through this grant application submission.

2.If your organization is requesting Expansion vehicle(s), provide a justification for the need for new vehicle(s). If your organization is requesting Replacement vehicle(s), provide a justification for the replacement, and explain any maintenance problems and major repairs, andprovide the odometer readings. Please list the order of priority for each of the requested vehicles by Type and Expansion or Replacement request.

3.Describe the arrangements your organization will make for preventive maintenance and garaging for the proposed grant vehicle(s), including the washing of vehicles.

(If applicable, include information on arrangements to lease vehicles to a third party operator)

4.Describe the administrative and managerial capabilities of your organization to manage and operate this service.

(If applicable, include information on arrangements to lease vehicles to a third party operator)

5.Describe your organization’s financial capabilities to pay for the required 20% local match of this grant, as well as the ongoing operation and maintenance of the vehicle(s) proposed in this application.

(If applicable, include information on arrangements to lease vehicles to a third party operator)

Optional Comments:

FFY 2011 (Part I)PAGE 1