K-4 - Matching Grant Funds for DNR Grant - Fire Department

USFS FEDERAL FINANCIAL ASSISTANCE Provided through the VOLUNTEER FIRE ASSISTANCE (VFA) PROGRAM COOPERATIVE FORESTRY ASSISTANCE ACT OF 1978. Distributed through an agreement with the State Forester of Iowa DNR Forestry. Volunteer Fire Assistance (VFA) APPLICATION - Application Deadline: OCTOBER 16, 2023 1. FED TAX ID#: ________________________________ DUNS #: ________________________________ Name of City/Township of Agency: ______________________________________________________ Name of Fire Department: _____________________________________________________________ Mailing Address: ______________________________________________________________________ City: __________________________________________ State: Iowa Zip: _______________________ 2. Estimated TOTAL project cost: ______________________ 3. Date of Application (MM/DD/YYYY): __________________________ County: __________________ 4. Is the requesting community under 10,000 population? [ ] Yes [ ] No 5. Is the local 50% cost share available? [ ] Yes [ ] No 6. How many acres of state owned land are you protecting? _______ acres 7. Is the local agency registered with the State Fire Marshall’s office? [ ] Yes [ ] No 8. Has the local agency provided Iowa Wildland Fire Reports during 2022/23? [ ] Yes [ ] No 9. Has the local agency participated in Wildland Fire training? [ ] Yes [ ] No 10. Does the local agency use wildland fire PPE on wildland fires? [ ] Yes [ ] No 11. Is the completed W-9 Federal Tax ID form attached? [ ] Yes [ ] No 12. Please list the communities that this department has Mutual Aid agreements with: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ The applicant certifies, as a condition of this grant application, that no one within their organization will engage in the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance in conducting any activity with this grant. The applicant further certifies that to the best of his/her knowledge and belief, the information in this application is true and correct and that he/she will comply with the Cooperative Forestry Assistance Act of 1978 and its administration guidelines if the grant is received. Head of Local Government: __________________________ Signature: __________________________ (or Financial Officer) Name (please print): ________________________________________________ Title: ________________________________________________________________________________ Day and Evening Phone: ______________________________________________________________ Email Address: _______________________________________________________________________ Fire Chief: __________________________ Signature: __________________________ Name (please print): _________________________________________________________________ Day and Evening Phone: ______________________________________________________________ Email Address: ______________________________________________________________________