Loading...
HomeMy WebLinkAbout20- Local Govt Entity Reimbursement for COVID-19 Grant Updated 6/4/20 Local Government Entity (LGE) Certification Form For reimbursement provided to local governments by the Governor's Coronavirus Relief Fund (the Fund) contained in the Coronavirus Aid, Relief, and Economic Security Act ("CARES Act") and assistance through the Federal Emergency Management (FEMA) Public Assistance (PA) grant program. REIMBURSEMENT REQUEST FOR COSTS INCURRED FROM MARCH 1, 2020 THROUGH MAY 31, 2020 ALL FIELDS ARE REQUIRED Local Government Entity (LGE) Information Name Address City State Zip Federal Employer Identification Number (FEIN) Contact Information for Reimbursement Request Last Name First Name Address City State Zip Phone Email Certification ☐I/we hereby certify that to my/our knowledge the LGE named above has not received reimbursement for the attached incurred costs from any federal funding source. (We recognize this application may include FEMA- eligible costs.) ☐I/we hereby certify that the attached information is true, complete, and accurate to the best of my/our knowledge and belief. THIS FORM REQUIRES SIGNATURES FROM ONE OR MORE MEMBERS OF THE GOVERNING BODY __________________________ __________________________ ___________________________ Signature Signature Signature __________________________ __________________________ ___________________________ Name Name Name _________________________ __________________________ ___________________________ Title Title Title __________________________ __________________________ ___________________________ Date Date Date City of Bozeman 121 N Rouse Ave Bozeman MT 59715 EIN 81-6001238 Donald Kristin 121 N Rouse Ave Bozeman MT 59715 406-582-2318 kdonald@bozeman.net Kristin Donald Jeff Mihelich Chris Mehl Finance Director City Manager Mayor 6/12/20 6/12/20 6/12/20 DocuSign Envelope ID: E3481E24-9DD2-445B-A430-95C32BDDB70A 132 6/12/2020 5 Expense Category Expense Description Actual Non- FEMA-eligible Costs through May 31 Actual Presumptively FEMA-eligible Costs through May 31 Have Costs Been Paid For with Other Federal Funds? (Y/N) Supporting Documentation Included (Y/N) Estimated Future Costs Jun 1 - Dec 30 Total Costs (Actual Costs + Estimated Costs) Provide Clarification or Justification for ALL Costs. FEMA costs must include a narrative with "who, what, where, why, and when." 1 (FEMA-eligible)Additional EOC /Emergency Protective Measures temp hire (regular time, OT, and benefits)-$ Provide payroll reports/timesheets listing employee, job title, hours worked, and salary information (payroll and overtime policies required for FEMA-eligible costs) 2 (FEMA-eligible)Existing staff OT EOC/Emergency protective measures regular time, OT, and benefits -$ Provide payroll reports/timesheets listing employee, job title, hours worked, and salary information (payroll and overtime policies required for FEMA-eligible costs) 3 Additional EMS, LE, and public health hired on or after March 12 (including regular and overtime pay, not benefits)-$ Provide payroll reports listing employee, job title, hours worked, and salary information (timesheets not required) 4 POLICE & FIREFIGHTERS Existing EMS, LE, and public health hired before March 12 (including regular and overtime pay, not benefits) $ 1,430,289 N Y 1,430,289$ A- Provide payroll reports listing employee, job title, hours worked, and salary information (timesheets not required) 5 Additional other staff hired after March 1 -$ Provide payroll reports/timesheets listing employee, job title, hours worked, and salary information 6 OTHER STAFF (2/3 TIME SPENT ON COVID-19)Existing repurposed staff hired before March 1 (regular time pay, not benefits) $ 66,795 N Y 66,795$ B Provide payroll reports/timesheets listing employee, job title, hours worked, and salary information 7 Existing other staff OT could apply to an employee not substantially dedicated (per 2/3 requirement) covering for an employee out due to COVID-19 -$ Provide payroll reports/timesheets listing employee, job title, hours worked, and salary information 8 (FEMA-eligible)Cleaning and Disinfecting supplies- medical supplies and commodities $ 497 N Y 497$ C -Justification may include: itemized invoices, receipts, and vouchers with valid dates 9 (FEMA-eligible)Cleaning and Disinfecting additional staff or contractors to conduct increased sanitation and cleaning of equipment, facilities, vehicles -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 10 Cleaning and Disinfecting decontamination equipment $ 1,892 N Y 1,892$ D Justification may include: itemized invoices, receipts, and vouchers with valid dates 11 (FEMA-eligible)Distributing Public Information EOC dissemination of information to the public -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 12 Distributing Information signs for closures, social distancing requirements -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 13 Distributing Information publication costs for posting notices related to closures, social distancing requirements $ 4,010 N Y 4,010$ E Justification may include: itemized invoices, receipts, and vouchers with valid dates FEMA may provide funding to eligible Applicants for: costs related to emergency protective measures conducted as a result of the COVID-19 pandemic. Emergency protective measures are activities conducted to address immediate threats to life, public health, and safety. In general, costs related to the continuity of government may be eligible under CARES Act reimbursement; whereas, costs related to emergency operation centers (EOC) may be eligible for FEMA reimbursement. NON-PAYROLL expenses (MEDICAL/PUBLIC HEALTH/COMPLIANCE - including contracted staffing related to COVID-19) Local Government Entity (LGE) COVID - 19 Reimbursement Form The CARES Act provides that payments may only be used to cover costs that: 1. are necessary expenditures incurred due to the public health emergency with respect to the Coronavirus Disease 2019 (COVID–19); 2. were not accounted for in the budget most recently approved as of March 27, 2020 (the date of enactment of the CARES Act) for the State or government; and 3. were incurred during the period that begins on March 1, 2020, and ends on December 30, 2020. Reimbursement Category PAYROLL EXPENSES for employees whose services are substantially dedicated to mitigating or responding to COVID-19 CERTIFICATION SIGNATURE DATE:REIMBURSEMENT REQUEST FOR COSTS INCURRED FROM MARCH 1, 2020 THROUGH MAY 31, 2020 Medical Expenses Such As: •COVID-19-related expenses of public hospitals, clinics, and similar facilities. •Expenses of establishing temporary public medical facilities and other measures to increase COVID-19 treatment capacity, including related construction costs. •Costs of providing COVID-19 testing, including serological testing. •Emergency medical response expenses, including emergency medical transportation, related to COVID-19.•Expenses for establishing and operating public telemedicine capabilities for COVID-19-related treatment. Public Health Expenses Such As: •Expenses for communication and enforcement by State, territorial, local, and Tribal governments of public health orders related to COVID-19.•Expenses for acquisition and distribution of medical and protective supplies, including sanitizing products and personal protective equipment, for medical personnel, police officers, social workers child protection services, and child welfare officers, direct service providers for older adults and individuals with disabilities in community settings and other public health or safety workers in connection with the COVID-19 public health emergency. •Expenses for disinfection of public areas and other facilities, e.g., nursing homes, in response to the COVID-19 public health emergency. •Expenses for technical assistance to local authorities or other entities on mitigation of COVID-19 related threats to public health and safety.•Expenses for public safety measures undertaken in response to COVID-19.•Expenses for quarantining individuals. Compliance Expenses Such As: •Expenses for food delivery to residents, including, for example, senior citizens and other vulnerable populations, to enable compliance with COVID-19 public health precautions. •Expenses to improve telework capabilities for public employees to enable compliance with COVID-19 public health precautions. •COVID-19 related expenses of maintaining state prisons and county jails, including as relates to sanitation and improvement of social distancing measures, to enable compliance with COVID-19 public health precautions. •Reasonableexpenses for care for homeless populations provided to mitigate COVID-19 effects and enable compliance with COVID-19 public health precautions. Payroll Expenses Such As: •all regular and overtime pay (not benefits) for first responder, public safety, and public health personnel for the duration of the declared State of Emergency throught the Phase 1 re-opening (March 12 -May 31, 2020); •other employees, regular and overtime hours substantially dedicated to mitigating or responding to the COVID-19 public health emergency; substantially dedicatedmeans the employee dedicated at least 2/3 of regular time to mitigating or responding to COVID-19, since March 1, 2020; Examples of IneligibleExpenditures: •Expenses for the State share of Medicaid •Damages covered by insurance•Payroll or benefits expenses for employees whose work duties are not substantially dedicated to mitigating or responding to the COVID-19 public health emergency. •Expenses that have been or will be reimbursed under any federal program, such as the reimbursement by the federal government pursuant to the CARES Act of contributions by States to State unemployment funds. •Reimbursement to donors for donated items or services. •Workforce bonuses and hazard pay. •Severance pay. •Legal settlements. •All costs related to primary elections (including mail-in ballots, postage, etc.) •Paid leave to keep non-essential employees on payroll •Interoperability •Costs associated with funding the entire law enforcement outside of May 12 -May 31•Costs already reimbursed with federal funds (other than FEMA) Federal Emergency Management Agency (FEMA) eligible expenses such as: •Emergency operations center activities (EOC)•Training•Facility disinfection •Technical assistance on emergency management •Dissemination of information to the public to provide warnings and guidance •Pre-positioning or movement of supplies, equipment, or other resources•Purchase and distribution of food, water, or ice •Purchase and distribution of other commodities •Security, law enforcement, barricading and patrolling •Storage of human remains or mass mortuary services DocuSign Envelope ID: E3481E24-9DD2-445B-A430-95C32BDDB70A 133 Expense Category Expense Description Actual Non- FEMA-eligible Costs through May 31 Actual Presumptively FEMA-eligible Costs through May 31 Have Costs Been Paid For with Other Federal Funds? (Y/N) Supporting Documentation Included (Y/N) Estimated Future Costs Jun 1 - Dec 30 Total Costs (Actual Costs + Estimated Costs) Provide Clarification or Justification for ALL Costs. FEMA costs must include a narrative with "who, what, where, why, and when."Reimbursement Category 14 Distributing Information marketing efforts -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 15 Distributing Information call center operations -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 16 Increased Administrative Costs increased workers' compensation rates -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 17 Increased Administrative Costs increased health insurance rates -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 18 Increased Administrative Costs increased liability claims and insurance rates -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 19 Increased Administrative Costs covering credit card fees -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 20 Increased Administrative Costs conducting health assessments -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 21 Increased Administrative Costs modifications for physical distancing of staff -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 22 (FEMA-eligible)Personal Protective Equipment (PPE) additional for EMS and law enforcement/ First responders doing EPMs $ 5,476 N Y 5,476$ F- Justification may include: itemized invoices, receipts, and vouchers with valid dates 23 Personal Protective Equipment (PPE) non-EMS and LE employees $ 3,478 N Y 3,478$ G Justification may include: itemized invoices, receipts, and vouchers with valid dates 24 Personal Protective Equipment (PPE) residents -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 25 Public Health increased testing - equipment, contracted staffing, facilities -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 26 Public Health contract tracing - equipment, contracted staffing -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 27 Public Health COVID testing of wastewater system -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 28 (FEMA-eligible)Social Distancing supplies and equipment if performing EPMs -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 29 Social Distancing plexiglass at service windows $ 1,389 N Y 1,389$ H Justification may include: itemized invoices, receipts, and vouchers with valid dates 30 Social Distancing physical remodeling for separation of public where necessary -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 31 Social Distancing hand-washing stations and sanitizer in public locations -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 32 Social Distancing postage for additional mailing expenses -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 33 Social Distancing supplies and equipment $ 877 N Y 877$ I Justification may include: itemized invoices, receipts, and vouchers with valid dates 34 (FEMA-eligible)Social services non-congregate sheltering (NCS) all costs -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 35 Social services congregate emergency sheltering -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 36 Social services senior and disability services -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 37 Social services mental health services -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 38 (FEMA-eligible)Technology security systems -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 39 (FEMA-eligible)Technology incident command structure -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 40 Technology remote communication systems and software -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 41 Technology cameras and other hardware -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 42 Technology subscriptions to video conferencing systems -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 43 Technology setting up and operating electronic payment systems -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 44 Telework equipment -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 45 Telework supplies -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 46 Training hazard training -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 47 Training civil disturbance response training -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 48 Training social distancing training -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 49 Training contract tracing training -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 50 Other FEMA-eligible Costs Facility Security/screening contracting for additional security, medical, etc.-$ Justification may include: itemized invoices, receipts, and vouchers with valid dates DocuSign Envelope ID: E3481E24-9DD2-445B-A430-95C32BDDB70A 134 Expense Category Expense Description Actual Non- FEMA-eligible Costs through May 31 Actual Presumptively FEMA-eligible Costs through May 31 Have Costs Been Paid For with Other Federal Funds? (Y/N) Supporting Documentation Included (Y/N) Estimated Future Costs Jun 1 - Dec 30 Total Costs (Actual Costs + Estimated Costs) Provide Clarification or Justification for ALL Costs. FEMA costs must include a narrative with "who, what, where, why, and when."Reimbursement Category 51 Other FEMA-eligible Costs Temporary Facilities screening or alternate care sites -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 52 Other FEMA-eligible Costs Temporary Facilities medical care and Transport (uninsured costs)-$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 53 Other FEMA-eligible Costs Temporary Facilities mass mortuary/storage -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 54 Other Other Costs Directly Related to Covid-19 Cell Phone Overages $ 697 N Y 697$ J- Justification may include: itemized invoices, receipts, and vouchers with valid dates 55 Other Other Costs Directly Related to Covid-19 Emergency Supplies for Fire Stations $ 1,410 N Y 1,410$ K Justification may include: itemized invoices, receipts, and vouchers with valid dates 56 Other Other Costs Directly Related to Covid-19 EOC supplies $ 81 N Y 81$ L Justification may include: itemized invoices, receipts, and vouchers with valid dates 57 Other Other Costs Directly Related to Covid-19 Cleaning Services $ 2,180 N Y 2,180$ M Justification may include: itemized invoices, receipts, and vouchers with valid dates 58 Other Other Costs Directly Related to Covid-19 -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 59 Other Other Costs Directly Related to Covid-19 -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 60 Other Other Costs Directly Related to Covid-19 -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 61 Other Other Costs Directly Related to Covid-19 -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 62 Other Other Costs Directly Related to Covid-19 -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates 63 Other Other Costs Directly Related to Covid-19 -$ Justification may include: itemized invoices, receipts, and vouchers with valid dates TOTAL $ 1,513,098 $ 5,972 $ - $ 1,519,071 Justification may include: itemized invoices, receipts, and vouchers with valid dates DocuSign Envelope ID: E3481E24-9DD2-445B-A430-95C32BDDB70A 135