1994-159-RES WHEREAS, TEXAS SURPLUS PROPERTY AGENCY WAS ABOLISHED BY THE TEXAS LEGISLATURE
RESOLUTION NO. q4- 1 ~q
WHEREAS, the Texas Surplus Property Agency was abolished by the Texas legislature
effective September, 1993, and, since that date, the General Services Commission has operated
the Federal Surplus Property Program; and,
WHEREAS, the Federal Surplus Property Program is the City's primary source for
surplus property; and,
WHEREAS, in order to continue participation in the Federal Surplus Property Program,
it is necessary for the City of Paris to submit an Application for Eligibility, along with related
documents; and,
WHEREAS, the forms of the Application for Eligibility and the related documents,
attached hereto as Exhibit A, should, in all things, be approved, and the City Manager, Michael
E. Malone, should be authorized to execute the same; NOW, THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, that the
forms of the Application for Eligibility and the related documents, attached hereto as Exhibit A,
be, and the same are hereby, approved; and,
BE IT FURTHER RESOLVED, that the City Manager, Michael E. Malone, be, and
he is hereby, authorized and directed to execute on behalf of the City of Paris the Application
for Eligibility and all related documents in the forms shown in Exhibit A, attached hereto.
PASSED AND ADOPTED this 12th day of December, 1994.
ATTEST:
~~I.~~~O
Mattie Cunningham, CIty Clerk
TO FORM:
~
-
GENERAL SERVICES COMMISSION
INTER-GOVERNMENTAL PROGRAMS
FEDERAL SURPLUS PROPERTY PROGRAM
APPLICATION FOR ELIGIBILITY
To Receive Federal Surplus Property (41 CFR 101-44,207)
I I. LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION:
'lame of OrganlzaClon i=eaeral Tax ID#
Streee AddresS/Location
,\1alling Address (P. 0. Box #. Slreet C;ty & Slate, (9 Dlgl/ Zip Coae)
:ounty -:-eleonone 11
'I. APPLICANT STATIJS (CHECK ONE):
D Public Agency including Public SchOOlS (evidence must be provided I Fiscal Year Ending
Date:
I D Nonprofit. tax-exempt Organization
III. TYPE OR PURPOSE OF ORGANIZATION:
D Slale D COllecJtOf UnIY,",slty D Ch,ld Car. CantIN' D Tralnlnq Center D '.~ec1lCalln.tlIVtIOn
D County D 5econoarv SchOOl D SChOOllQf Hen(llcaopftO 0 RadlClfTV StatIOn D ";OSO'''I
D Citv 0 Elementary School 0 School lor AetaroeG 0 L......, 0 HeallhCem..
I D Sch0Q40istnc:1 D PrncnOOI D '-4uMum 0 Shell.eo Worltsnoo Tralnlnq Proqrams
0 Program for Old., InclMCIuala 0 P1'OY1der ol.........nc.IO HomeleSS InCllYIduata 0 ::,I"IIC
0 Oth.,IIDeClfyl
I rv. SOURCES OF FUNDING (Attach Supporting Documentation);
0 Tu SUDOQt1eo 0 Grant 0 Con"""",," o OtherrSptICltv)
V. HAS THE ORGANIZATION BEEN APPROVED, ACCREDITED, OR
LICENSED? (COPY REQUIRED) BY WHAT AUTHORITY?
r:ff' NON-PROFIT ORGANIZATIONS INCLUDING VOLUNTEER FIRE DEPARTMENTS COMPLETE PARTS VI AND VI/,
VI. PROVIDE A WRITTEN DESCRIPTION OF PROGRAM OR SERVICES
OFFERED, INCLUDING A DESCRIPTION OF FACILITIES OPERATED (REQUIRED)
VII. HAS THE ORGANIZATION BEEN DETERMINED TO BE TAX EXEMPT UNDER SECTION
501 OF THE INTERNAL REVENUE CODE OF 1954: (COPY REQUIRED)
VIII.
Date Printea Name of Aulhoflzea Official Signature of AuthonzeC1 Official
FOR STATE AGENCY USE ONLY
The applicant has been aelerrnlned 0 eligible D ineligible
a. 0 a public agency, 0 nonprofit education, 0 nonprofit heaJth
Eligibility expIres Account #
Date EXHBI A Director
~
MAIL COMPLETED FORMS TO:
II
II rz::neaAI ellon...~ n",...ru-~ ",n,......"
SECTION I:
SECTION II:
SECTION III:
SECTION IV:
SECTION V:
SECTION VI:
SECTION VII:
SECTION VIII:
",TE:
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ELIGIBILITY FORM
(Please type or pnnt in blue or biack ink oniy)
Provide the full legal name of your organization on the first line of this section" Provide the mailing address of your
organization as recognized by the U.S, PosIal Service. Include Zip Code, ProVide the street address If different
form mailing address. or provide directions If 10caIed on a rural route or other remote area, list the county in which
the organization IS actually 10caIed and a business telephone number wIth area code,
Check the appropnate box which descnbes your organization, {If you are unaole to oetermlne which status to
check. please contact this office for assistance. I
Check the appropriate box or boxes (check as many as apply) WhIch indicates the type or ourpose of your organi-
zation. (Definitions have been proVided on the reverse side ot the application to aSSist in making this determina-
tion.)
Check the appropriate box which indicates the organlzatrons sources of funding. Suoportrng documentation indi-
cating the types and amounts of funding must be suomltted with the completed application.
ApplicanIs making application as "Nonorofit. tax-exempt organization"' are reqUIred to suomit eVidence that the
applicant IS currently aoproved. accreditee. or licensed. Programs for older mdividuals must include eVidence of
funding under the Older Americans Act of 1965: Titles IV of XX of the SOCial Security Act: Titles VIII of X of the
eCOnOmiC Development Act of 1964: or the Community Service BlOCK Grant Act. PrOViders of assistance to home-
less Individuals must Include a letter from the mayor. county Judge. or county health officer or comparable authonty
which certifies that aoplicant is a "provider of assistance to the homeless.'. The CertIfication must identify the
selVlces or assistance oeing prOVided ana the numoer of individuals receiving such assistance.
A comorehenslve written descnption of aU programs or services proVided is reqUired. A deSCription of the opera-
tionai faCilities shOUld also be included. Be sure to Include InformaIlon of staff and staff qualifications. hours of
operation services and programs offered. population or enrollment. fees charged etc.. Include samples of pam-
phlets, catalogs. brochures or posters, If inco'1loration With all filing certificates and amendments. and a copy of
your current By-Laws.
All applicants making application as "Nonprofit. tax-exempI organizations" must provided a cooy of the IRS deter-
mination letter indicaIing tax exemption under Section 501 of the I.R.S. Code of 1954, The name of the organiza-
tion on this IRS letter must maIch the name provided in Section I of this application. If not. Include sufficient
eVidence such as amendments to Articles of Incorporation. or Assumed Name filing certificates to establish an
"audit trail" of names shoeing the legal connection,
Annotate date and oravlde an onginaJ signature of applicant's Authorized Official (Presloent. Chairman of the
Board. County Judge, Mayer. City Manager. ExecuIive Director. AdministraIor. Fire cnief, or other comparaOle
authOrized official.) PhotocopIes. rubber stamped. machine produced. cartlon. or other faCSimile type signatures
are not acceptable. Also, pnntlhe name of authOrized officiat on the line proVided.
INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. USE THIS INSTRUCTION SHEET AS YOUR CHECK
L1STTO ASSURETHAT ALL REQUIRED INFORMATION AND DOCUMENTATION IS PROVIDED. IFYOU HAVE A
QUESTION OR NEED ASSISTANCE CALL: 512/463.{)493. 5121463-8902. 512/463-5286.
..
03.3o.t:10402 (8JI4)
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
FOR COVERED CONTRACTS
Federal Executive Order 12549 requires the General SSMess CommiSSion to screen eacn ApPlicant Organtzatlon to cetermine wl181her the
appllcam has a rlgnt 10 obtain finanClal &sslstanc8IPropeny In acccraance with feaera! regulations on aebarment. susoenSlon. ineligibility and
vOluntary exClusion. Each applicant organazatlcnlc0V8reo contractor must alSO screen eacn of its coverea succontractars. In this C8rtlficallon
q:ontractor" reters 10 both contraaor ana SUbcontractOr. "contract" reters to bOth contract ana SUOCOmract.
3y sIgning and SUbmitting this CBniticallOn II1S Applicam OrganrzaIion acceots Ihe follOWing terms:
- 1. The certification herein beiow is "mateoal representation of fact upon wnich reliance was olacea woen thiS comract was emlll1H:l into. It
II is later determrneo that the OrganlZ8IIOn renoerea an erroneous cenlficauan, In addition 10 otner remeale, available to Ihe teoera. govern.
ment, the General Services CommiSSIon. the United States General Services Administration or OIner teaeral depanmenr or agency may pur-
sue avaIlable remeaies. Induding SuspenSion anaJcr debarment.
2. The Organization shaJl PRMdelmmeai818 wnnen notice to the Agency to wnich this centticauon IS SUDmltted if at any time the Organazatlon
iearns that the Csntfication was erroneous wnen SUDmmed or has become erroneous oy reason at changea Circumstances.
3. The wores "C0V8l1Ki contract." "debarrea." "suspenaeci." "inaligible:' "panlcio8m." ".,erson;' ";Jrinoo81:' "proposcu:' and '"Voluntarily ex.
cludBCI:' as usea in Ihis cendieanon have meaMlngs Da.seo upon matenaJ in tne Oetinnrons and Coverage Sections at feoeral rules Imptement.
Ing ExecutIve Order 12549.
4 The OrganIzation agrees by submming this csnlficatlon thaI. ShOUld eligibility 10 aCQUire orooerty De granted. it shall not knOWIngly enler
IntO any SUDCOmraa wllh a person who IS oeDarrea. susoenOed. declareo Ineligible. or vOiuntanly eXCluoBQ tram panlCloauon In Ihis COWtntc:2
'ransamon. Unless autnonzea by the Genenu SeMC8S CommISSIOn. Ihe Unrtea States Generar SeMCSS Admlnlstranon or Clner federal deQllrtmem
:r agency.
The Organization further agrees Dy SUbmlnlnq this certlficanon tnal It Will inclUde thiS certificatIon lltled "Certification Aegarainq Cebar-
-am. Susoenslon. IneligIbility, ana Voluntarv ExclUSion 10r Coverea ContraCtS" WllOOUt moadicanon, In aU Coverea sUbcontraClS In SOIlcuaUon
'or all COV8r8Q SubCOntractS.
0, The Organlzauon may rety upon a cenlficauon at a pOIamlal SUDComractor tnal IS nor debarrea. susoenOed. ineligible. or vOluntanty axclud-
.;0 from lOe coverea COntracl. unless II knows tnatlne certification IS erroneous. A OrganlZ8llon must. at a minImum OOtalO cenlficabone from
lIS covered subcontraaors upon 8ach suDcontracfs innialion and upon eacn renewal.
7. Nothing contalnea In all Ihe fOregolng snall be construea to reqUIre estaDlishmem Of a system of recoras In order 10 render in good faith
the cenlficallOn required by this cenrficarlon dQCume,... The knowtedge and Informallon of a comractor IS not requlrea to eXCMd tnII Whtch
IS normally posseasea by . prudent person In the oralnary course of bUSiness dealings.
a ExcePl for ContraClS aulhonzea Uncler paragraph 4 of these lemus. It an OrganlzalJOn In a coverea comract knOWingly enters IntO . CCMmtd
'5ubCOmraa: with a person who IS luaQenGBd. d8batred. ineUgible. or votuntanly excluded from panlciPAUon In this Iran.sacIion. in addttion
:.1 other remediel avaJlablelO Ih. federaJ government. the Uniled Sla1el GeneraJ SeMce. Administration. or otner tederal deaanm8nl or .gen.
cy, as appllCaDle. andJQr Ihe Genetal S8Mces CommiSSIOn may pursue available remeales. inCluding susoenSlon anoJor deOalllwW.
CEflTIFlCATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOWNTARY
EXCWSION FOR COVERED CONTRACTS
YOU MUST CHECK THE BOX WHICH APPLIES TO YOUR ORGANIZATION OR'
THIS FORM IS INCOMPLETE.
~
----: The App41C8n1 OR)anlDbon canities. by subrl'nSSlOn of this CenIficanon. that nBlther If nor lis onnctDalS is Dresemty detlamtd. ~~.
~tOoos8Cl for clebarmenl. declareo Ineligible or VOluntanly excluded from panlClpallon 1M this Contract by any federal deoanme" or agency
or Dy the Slale of Texas.
I I ..
~ The ApPlicant OrganlZabOn IS unable 10 candy 10 one or more of the terms In tn,s cenlticauon. and the Applicanl OrgarllZlllOn ~Ult
lllaCn an explanation for eactl of the at)Qw terms to whICh he IS unaoJe to make cenlficallon. AnaCh tn. eJCplanatlon(s' to thll C81aftc:1tion.
Name of Applicant OrglllUZlWOn
Printed Name at Aulhanzea OfflciaJ
Dale
SignarureiTiUe af Autnonzaa OfficiaJ
MAlL COUPlETED FORMS TO; GENERAL SERVtCES COMMISSION. FEDERAL SURPLUS PROPERTY PROGRAM.
P.O."SOX 130C7.AUS11N. TX 7B7'ff.3OQ
CERTIFICATIONS AND AGREEMENTS
al THE DONEE CERTIFIES THAT:
oJ Ills a aUQlIe agenc... or a nenoram lnSIttutJon or orgamzatlon. exemot from laxallon unaer seetle" 501 ct tr.e Internal Revenue Cooe 011954:
~Ilmn me meamng Of section 203lj} at the Feaeral Prooeny ana Aamlnlstratlve Services ACI or 1949. as amenoea. anOlor tne raoulauons 01 the General
ServIces AdminiStration cGSA\ -
2) II a Duelle agencY. lne orocen:v 15 neeCleo ano will oe usee 0',1 the ree10lent Tor carrvlng OUI or cromatlng fer me reSlcenlS ot a given Donllcal
:.,ea one or more DUDlIe outcases. or IT a nonorom tax.exemot Instltuto" or organization. !ne orocertv IS neeaeo lor ana Will be usee ov tne reclDl8n1
":r eoucauonal or DUDlle "eanh QUrDoses. IncruDlng researCh for any sue" outClase. or Tor orograms lor Older InclvloualS. The oroo8ny IS not bemg
",COUlreo tor any otner use or ouroose. or tor sale or otner Q1StrfOutlon: or tor permanent use QUISICe Ine :Slate. exceol wlm onor acproval ot Ine
:tal8 agency ana GSA.
]) Funes are avallaDle 10 cay all casts ana cnarqes InClaent 10 donallon.
.:oj This transacllon snail be SUOlect to In& nonOISCrlmtnauon regulatiOnS governmg lne oonallon 01 SUOIUS oersonal Drooenv Issuea unaer Title
., at me CiVil Rignls Act at 1964. Tille VI Sec1Ion 606 at the Feaeral Prooenv ana AamlnlStrallve Services ACt or '949. as amenaea. ana section
:04 at me renaDllilatlon Act of 1973. as amenoeo. Tille IX at the Education Amenoments 01 1972. as amencea. ana SectIon 303 or the Age Oiscnmma-
. :1O Act or 1975.
01 THE DONEE AGREES TO THE FOllOWING FEDERAL CONDITIONS:
1) AUllems ot orooenv snail be ctacea In use for Ine ourposelsllor wnrcn aCQUlreo Wllhln one vear ot reCelot ana snail be ccntlnuea In use tor
sucn our oases tor one year Hom the oate Ihe orocenv was claceo In use. In Ihe event Ihe crocenv IS nOt SO Olaceo In use. or cantlnuea in use.
"'e aonee snail Immealal81y nouty the State agency, ana althe oonee s exoense. relurn sucn orooertv to the Slate agency. cr otnerwlse maKe Ihe
:rooenv avallaDle lor transTer or Clner olsoosa; ov the State agency. provloea the orooenv IS Stilt usaore as aetermlneo bv (he State agency.
'2) Sucn soeClal hanollng or use limitations as are Imooseo bv General Services Aamlnlstratlon IGSAl on any IlemlS) or cfooeny liSted hereon.
'3\ In me event Ihe orooenv IS nor usee or nanoled as reOUlreD ov 10)(1) ana 121. :llle ana nont 10 lne cosseSSlon 01 SUCh ::rooeny snail at the
:::)IIon aT GSA reven to tne Unllec States 01 Amertca ana ueon aemana Ihe conee snail release suen orocenv 10 sucn oerson as GSA or ItS aeslgnee
~nall direct.
':1 THE DONEE AGREES m THE FOLLOWING CONDITIONS IMPOSED BY THE STATE ,A,GENCY. APP!..!CASLE -:0 )TP.~S WITH A UNIT AC-
:UISITJON CCST CF ::5.000 OR MORE AND PA.SSENGER MOTOR VEHICLES. :=iEGAADLESS CF ACQUISITION COST. :::XCE?T VESSELS 50
':ET CR MORE IN LENGTH AND AIRCRAFT FOREIGN GIFTS, OR OTHER ITEMS OF P~OPERTY ~EQUIRING SPECIAL "ANDLlNG OR USE
_.~,1ITATIONS, REGARDLESS CF THE ACQUISITION COST OR PURPOSE FOR WHICH ACQUIRED:
'} The orooenv snail oe useo only lor Itle ourooselsl for wnlch acaUlrea ana tor no omer ourooselS!.
2\ T~ere snail be a certoo 01 restrlCIlOn wnlcn Will eXOlre aner sucn orooeny nas ceen usea lOr me ourooselsl lor wmcn aCOUlreo for a cerloo
18 montns Tram tne aate tne orooeny IS Olacea In use.
:;j In me event Ihe orocertY IS not usea as reoulreo bv lCl(') ana (2) ana Federal reStrlctlons 101(1), !bl(2) ana In have exolrec Ihen rlgnlto Ihe
:~SseSSlon or sucn oroceny Shall at the oOllon or lhe Slate agenCY reven to the Slale or Texas ana Ine oonee snail release sucn orooeny 10 sucn
:erson iiS me Slate aQencv snail direct.
01 THE DONEE AGREES TO THE FOllOWING TERMS. RESERVATIONS, AND RESTRICTIONS:
'n From Ine oate It receives me orooeny hsteo hereon anc througn penoo/sl of time lhe conaltlons tmooseo bv rbl. (el. ana III remain In effect.
~ oonee snail not sell, Irace. ~eaS8. lena. ball. canmDallze. encumoer. or olherwls8 dlsOQse at sucn orooeny. or remove II oermanemty. tor use
'Slce tne Slate. WtlnOU( the onor aoproval of GSA unoer 10) ana If). or the Slate agency unaer Icl ana /fl. The oroceeos tram any sale. lraQe. lease.
.in. oallment. encumorance or other alSPOsal at the crooeny. wnen sucn action IS autnorlzed by GSA or oy the Slate agencv, Shall be remltlea
.Jromouy OV lne aonee 10 GSA or the State agency. as Ihe case may be.
,2) In the event any ollhe orooertV hst8CI tlereon IS SOld. Iraaeo. teaseo. loanea, balled, canmcallzea. encumoerea. or otherwise OJSDOsea oi bv
'!"Ie oonee Tram the oate II receIves tne Qrooenv tnrougn Ihe oenOd/S) at tIme the concltlons Imoosea oy ICI. IC) ana It) rematn In eHect. wllnOut
:Hlor aooroval ot GSA or lI1e Stale agency, the oonee. al the ootlon of GSA or the Slate aeencv snail oay to GSA or Ine Slale aeeney. as the case
. ...,av oe. lne oroceeos Of lI1e Olsoosal or lne talt marKet value or Ihe lair rental value 01 !tie orooertv at Ihe lime or sucn clso0sal. as oetermtnea
:'1 GSA or me State aeencv.
3) If at any lIme. tram me oale II reCBlves tne orooenv Ihraugn the cenco(s} 01 tIme !he canOlllons Imooseo ov lbl. (Cl ana In remain In eHect.
3nv Of me arooenv Ilsteo hereon IS no longer sUllable. usaole. or turther neeaed bv the conee lor the curooselsl tor wnlcn acoulreo. Ihe aonee
;:na1l Drom011v nOtify tne Slate aQencv. ana Shall. as OIrecteo ov lhe Slate agenCY. return the orocertv to Ine Stale agenCY. retease lhe aropenv to
;,namer aonee or anotner Slale agency. a oeoanmem or agency Of Ihe Umteo St~tes. sell or otherwise olsDose 01 We prooenv. ine proceeGs from
:.ny sale snail be remllleo oromauy oy tne aonee to Ine Slate agency.
~l The conee snail maKe reoons to tne Slate agency on the use. canaltion. ana location at the orooertv IIsteo hereon. ana on other penlnenl
"'aners as may 08 reoulrea Irom time to time by the Slale agenCY.
5) AI the ootlon of the Slate agency. the aonee may aDrogate the State conditions set lonh In IC) ana the Slate lerms. reservations. and reSlnctlons
:emnem Ihereto In Id) by paymem of any amoum as defermlned by Ihe State aoency.
el THE DONEE AGREES TO THE FOllOWING CONDITIONS, APPLICABLE TO ALL ITEMS OF PROPERTY LISTED HEREON:
1} The orooertV aCCUlreo bV lne donee IS on an "as IS. wnere IS" baSIS. WlltlOut warrantv 01 any KlhO. ana the Government 01 the Unnea States
:! Amenca. lne Slate 01 Texas. ;~s aoenCles or aSSlens. ana emOlovees thereot Will be nBld harmless Irom anv or all aeots, 'a.ollllles. luagmenlS.
:~SIS. cemanas. SUIlS. aCllons. cr cliums Of any nal.ure anSlho tram or InClaent 10 the conation of tne oroaenv. ItS use. or r:t'1al olspaSlUon.
r 21 Where a oonee carnes Insurance against damages to or ioss of propeny due to fire or omer nazaras ana wners lOSS or or aamage to donatea
::rooenv With unexglfeQ terms. conditions. reservauons or reSlnClIOns occurs. GSA or the State agency. as tne case may oe. Will be enlltlea to retm.
~ursement tram Ihe aonee out aT the Insurance Qroceeas. at any amount equal to the unamonlzea Damon or Ine fair marKet value 01 the damagea
:lr oestrovea conatea lIems.
.~ THE DONEE AGREES TO THE FOllOWING ADDITIONAL TERMS AND CONDITIONS APPLICABLE TO THE DONATION OF AIRCRAFT AND
-SSElS ISO FEET OR MORE IN lENGTHl HAVING AN ACQUISITION COST OF S5.000 OR MORE. AND FOREIGN GIFTS OR OTHER ITEMS
. "ROPEATY REQUIRING SPECIAL HANDLING OR USE LIMITATIONS. REGARDLESS OF THE ACQUISTION COST OR THE PURPOSE FOR
rllCH ACQUIRED:
11) The oonallon snail be SUblect to the additional saeclal terms. conditions. reservations. ana restnetlons set fonh In ttle Conaltlonal Transfer Docu-
"'8nl or Olher agreement ex8CUl80 by tne authorlzea donee reoresentatlve.
;9) THE DONEE CERTIFIES Ihat nellner It nor lIS Qrlncloles are cresently debarred. susoenaeo. oroooseo for cebarment. ceclared Ineligible. or
'/olunlaruy eXCludea trom oanlCI03l10n In thiS transaction oy any Federal depanment or agency pursuant to Executive Order 12549 ana 34 CFA Pan
35. See, 85.510
Ih) THE DONEE UNDERSTANDS that by execullon of this document. it is ccmuderea a subrSCIOlem of federal financlai aSSistance pursua"uo the
Single Auan Act at 1984 ana runner agrees to OfOVloethe Slats agency with a copy of the Bualt reaUlrea by OMS CirCUlar A-128 or A-l33 as 8Q~lC8ble.
~CC::UNT#
"AME OF ORGANIZATION <DONEE)
=R1NTED NAME OF AUTHORIZED OFFICIAL
OATE
Account #
GENERAL SERVICES COMMISSION
INTER-GOVERNMENTAL PROGRAMS
FEDERAL SURPLUS PROPERTY PROGRAM
, NONDISCRIMINATION ASSURANCE I
LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION:
Name of Organization
Sueel AddresS/Location
Met/Ing Address fP. O. Box .. Slreel. City & Statel
(9 digit ZIp Codel
I
County
Teleonone "
(Name 01 OrganlZal/On)
, the donee.
agrees that the program for or In connection with which any propeny is donaIed to the donee will
be conducted in compliance with. and the donee will comply with and will require any other per-
son (any legal enIlty) who througn contractual or other arrangements w,th the donee IS authorized
10 provide servIces or benefits under said program to comply wIth all requirements Imposeo by or
pursuant to the regulations of the General Services AdmlnlSIraIlon 141 C.F.R. 101-6.2 ana 101-8)
issued under Ihe provIsions of Tille VI of the Civil Rights Act of 1964. as amended. section 606 of
Tille VI of the Federal Propeny and AdmlnlStraI,ve ServIces Act of 1949. as amenoed. section 504
of the RehabilitaIion Act of 1973. as amended. Tille IX of the Education Amenoments Of 1972. as
amended. section 303 at the Age Discnmlnatlon Act of 1975. ana the Civil Right Restoration Act ot
1987. to the end thaI no person In the United SlaIes shall on the ground of race. color. nallonal
orrgln. sex. or age. or Ihat no otherwise qualified handicllllped person shall soiely by reason of
the handicap. be excluded from panlcipation in. be denied beneflls of. or be suolected to
discnmination under any program or activity 10r which the donee received Federal assistance trom
the General Services Administration: and hereby gives assurance that II will immediately take any
measures necessary to effectuate this agreement.
The aonee funher agrees II) that this agreement shall be subject In all respeclS to the orovlslons
of saId Federal staIutes and reguJatlons (2) that this agreemenI obligates the donee for the oerlod
dUring which it retaIns ownershio or possessIon of the propeny. (3) thaI the United Stales snail
have the nghI to seek Judicial enforcement of this agreement. and (4) thaI thiS agreement shall be
binding upon any successor In Interest at the donee and the wore "donee' as used herein in-
cludes any such successor In Interest.
(Dale)
(Prinrea Name of Authonzea Officlai)
(Signature of Aulhonzed Official)
MAIL COMPlETED FORMS 10: GENERAL SERVICES COMMISSION. FEOERAL SURPLUS PROPERTY PROGRAM.
? O. BOX 13OD. AlI!:T1N TY "1R'7t1_"VW.7
DEFINITIONS
Hospital. An approveo or accredited puclie or nanproHt institution provloing puclie health servIces Primarily for Inoatient medical
Jr surgical care oj the SICK ana Inlurea. lnclulding related facuities suen as laooratones. outpatient deoanment. training faCilities.
ana staff offices.
'Library. A pUOlic or nonprofit faCIlity providing library services tree to all reSidents of a community. CIStrlCt, State or region.
Licensed. Recognition and aoproval by the appropnate Slate or local aumonty approving institutions or orograms In speclaliz-
eo areas, LicenSing generally rel?'eS to established minimum public standards of satety, sanitation, statfing, and equipment
as may relate to the construction 1amtenance, and operaLon of a health or educational faCility, raIner man 10 the academiC.
'nstructlon. or eaucatlonal or PUL..JC health orograms suer. as occupatIOnal training, phYSical or mental heanh rehabilitation
servIces. or nursing care. Licenses frequently must be renewed at penoaic Intervals.
Local Government _ A government. or administration Cj a locality. Within a State or a possession ot the United Slates.
Medical InsIitutlon . An approved, acc,edited, or Iicen,d pUblic or nonorotit institution. facliity, entlN. or organization the
:mmary function ot Wnlctl is the furmsnmg of puolic health and medical servIces to the PUblic at large or oromotlng puolic
health through the conduct or research for any SUCh purposes. expenments. training, or aemonstratlons relateD to cause. preven-
tion. ana methOdS of diagnOSIs and treatment of diseases and injuries. The term includes but IS not limned to hOSpitals. clinics.
alconollc ana drug aouse treatment centers. pUblic health or treatment centers. research and health centers. genafnc centers.
laboratones. medical SChools. dental scnools. nursing SChOOlS. and similar Institutions. The term ooes not InClude Institutions
DnmarllV engaged in domiciliary care although a separate medical faCility within such as domiciliary institutIon may qualify
as a' meOlcal InstitUtiOn."
Museum _ A pubhc or DrlVate nonorotlt Instltutlon wnlcn IS organlzea on a oermanent baSIS essentlallv for eaucatlonal or esthetic
:urooses ana Wnlcn. uSing a prOfeSSional start. owns or uses tanglOle OOlects. wnether animate or inanimate: cares tor tnese
oo!ects: ana eXhibits tnem to the puOtlC on a regUlar oasIs either tree or at a nominal Charge. p"g used In the DonatIon Program.
'.he term "museum" includes. but IS not l1mltea to. tne followmg inStitutions If they satisfy all other prOVISIons ot FPMR 101-44.207:
.::.Quarlums ana ZOOlogical parKS: bOtanical gardens ana aooretums: museums relating to an. history. natural hIstory. sCience.
3nd tecnnology: ana olanetarlums. For the purposes of this program. an Institution uses a profeSSional statf If It emplOYS full
::me at least one qualified staff memoer WhO devotes hIS or ner time Orlmamy 10 the acaUIsltlOn. care. or puellC eXOIbition OT
COlects owned or useO by the Institution. This definltlon of museum ooes not Include any institutIon which eXnlbits oblectS to
the pucllC If the display or use of the OOlects 15 OnlY incidental to the primary function of the institution. For example. an Instltu-
lion wnlch is engaged primarily in the sale of antiQues. oblets d' art. or other amfacts and which InCidentally prOVides displays
to the public of animate or Inanimate Objects. either free or at a nommal charge. does not qualify as a museum.
Nonprofit Tax..Exempt Activity .. An institution or organization, no pan of the net earnmgs of which inures or may lawfully
Inure to the benefit of any prlVaIe shareholder or Individual. and which has been held to be tax exempt unaer the provIsions
of section 501 ot the Interanl Revenue Code of 1954,
Program for Older Individuals. Any State or local government agency or any nonprofit, tax-exempt activity which receives
funas aoproprlated for programs for older Individuals under the Older Americans ACI ot 1965. as amended. under tlUe IV or
!ltle XX ot the SOCIal Security Act. or under titles VIII and X of Ihe Economic OpportUnity Act of 1964 and the Communlly Ser-
vices Block. Grant Act.
Provider of Assiatance to Homeless Individuals. A public or a nonprofit. tax-exempt inSIIIution or organlzalJon that ooerates
a orogram wnlch prOVides assistance such as food. shelter. or other services to homeless Individuais. as defined above. Pro-
peny acqUired through the donation program by such inSIIIuIlons or organlzaIlons musI be used exclUSively In their programlsl
for prOViding assistance to homeiess Individuals.
Public Health In~tltutlon _ An approved. accredited. or licensed public or nonprofit institution, faCility, entity. or organlzaIlon
conouctlng a public health program or program such as hospital. clinic. health center. or medical institution. Including research
lor any such program, the services of which are available 10 the pubiic at large,
School (except schools for Ihe mentally reIarded and schoois for the physically handicapped) . A Duohc or nonorofit aD-
provea or accreolted organizatiOnal entity devoted primarilY to approved academiC. vOCatiOnal, or prOfeSSIonal stuay and In-
structlon which operates primarily for educational purposes on a full-time basis for a minimum school year and employs a
full.lime staft of qualified instructors.
School for the Mentally Retarded _ A facility or insIltution operaIed orimarily 10 provide specialized instruction to sIudents
of limited menIal capacity. It must be public or nonprofiI and must operate on a full.Iime basis for Ihe equivalent of a minimum
schOOl year preSCribed for public school instruction of the mentally retarded. have a staff of qualified instructors. and demonstrate
that the tacility meets the health ana safety stanaaras at tne State or local govermental body.
School for Ihe Physically Handicapped _ A school organized primarily to provide speclaiized instruction to students whose
pnyslcal handicaps necesslIaIe IndiVidual or group InstrUCtion, The scnools musI be public or nonprofit and ooerate on a full.
lime oasIs for the eqUivalent of a minimum school year preSCribed for public SChooi Instruction tor the phYSically handicapped.
have a sIaft of qualified instructors. and demonstraIe thaIIhe facility meets the healIh and safety sIandaros of the Slate or
local governmenIal body.
Univenlity . A public or nonprofit approved or accrediIed institution for Instruction and stUdy in the higher branches of learning
and empowered to confer In specIal depanmenIs or colleges.
~1M4'
ACCOUnlrt
GENERAL SERVICES COMMISSION
INTER-GOVERNMENTAL PROGRAMS
FEDERAL SURPLUS PROPERTY PROGRAM
, AUTHORIZED REPRESENTATIVES f
LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION:
.Vame Of OrganlZ8DDn
.:J'1reer Addms$
'.fs///m; Adc1rsss (p.Q Box If, S/rser. '-~N" Sls/l"
(9 DigIt ZI" C""el
";~unty
7eleonone "
THE FOLLOWING REPRESENTATIVES ARE DESIGNATED TO:
4. Ae,JreS8nr Oonse Organization as IS ItS aultJorlzea agent: ana
3. ACQUIre Federal surD/US Drooerry on behalf of the Donee Orgamzatlon: and
C. Obligate nec&ssaJy Donee OrgantzaIlon (unas (or /hIS PUrpose: ana
O. ExflCute Distnbu/Jon Documents bmamg /he Donee Organ/ZJJ/lon 10 me lerms. conaltlons. reservstlOflS.
and resrnctians applying 10 Property obtamea througn Ihe agancy.
~ NEW DESIGNATIONS
(De/8'" 81/ PnMOUS 8UlhOllZJlllOnl
OR
.= ADDITIONAL DESIGNATIONS ONLY
(Add to DfW10Us 8uthonz8DOnJ
IV, REPRESENTAnVES:
Name
iitlll
TB/8pnOlle
Signarurs
V. CERTTFICATION (Don.. amnns that nama a,.. cummt/comH:t).
D6IW
PnnMt1 N_ at ~ 0Ifft:JW
Tille
~ at AutI1ak-. 0Ifft:JW
DEFINITIONS
APPROVED _ Recognition ana approval cv the Slate oecanment at eaucatlon. State aecanment ot nealm. or Clner aooroDnate
a.utnomv woere no reccgntzea accrealling coara. aSSOCiation. or Clner aumanN eXIsts TOr me ourcose aT maKing an accrealta.
:Ion. Rlr an eaucatlonaJ InstItUtIon or an educauon3.1 orogram. approval muSt relate to acaaemlc or Instructional stanuaras
--:staOlIsnea by me aoproonate authority. An eaucatlonat Institution or program may 09 consloerea aoprovea If its InSUUC:lon
.no creolts tnerelor are aceemea by tnree accreortea or StaltHoproved instlIUIlons. or If iI ml!i!IS tne acaoemlc cr InStruction
stanaaros orescnoeo tor cuche senODIS In the state: I.B.. the organizational entity or program IS aevatea PrlmarllV to aoprov80
acacemlc. '/ocauonal (inClueing tecnmca1 or occupallona.tl. or profeSSional StUCV and instruction Wnlcn acerates onmanlv for
,oueatlonal purooses on a full-time OasiS for a minimum senocl year as preserloea by tne Stale ano emolovs a IUII.llme ..tt
01 ouanlleo Instructcrs. For a puelic ne81Ih InstrtulJon cr program. approval must relale Ie me mealeal recUlrements ano, In-
cares TOr me prmesslonas ana teer""caJ services at the instItution estaDllsnea by tnB approonate autnornv. A heaun Instltutlon
cr orogram may De conslC8AlCl as approvea wilen a SlallI Dcdy haYl/lg autl10nty unoer law 10 estaClisn stanoarcs ano nlOUuamems
lor auelle nBaJth InStitUtiOns renOar..s aoproval thereto wneU1er oy accreaitation oroceaures or OV licenSing ar suen emsr mMnoa
preserlOea by State law. In the apsence of an official Stale approving autnOrllV tor a pUOlle Mann Instltutlcn cr crcgram or
eaucauonat Instnutlon or cmgram. the awaraing at researcn grants to the Institution or organizatiOn OVa reccgnlZ80 authority
suen as tnB Nauonallnsntute of Healtn. the National Institute at Education. or oy Similar nauonal aaVI$orv counclis or organlza.
;\0"5 may constduta approva1 of the ,"smullon or - -- '"ram provldec1 all otner crnena are met.
A.ccreaited .. Aoprovea by a recognized accreoltm ;rd or assocatlon. at a regional. state or nauonallevel suen as a State
::loam ot eaucatlon or hearth: the Amencan HOSDltaI NsOClatlOn: a regional or national accrealtlng aSSOCiation for umversltles.
-:olleges. or seconaary scnoots: or anCltnei recognizee accreDiting aSSOCiation.
.:..dutt Dav Care .. ~ orogram of services crOVlaea unDer nealtn leaaersnlo In an amOulatorv care senlnq tor.acults wno 00
-Ot reOUlre 24 hour Institutional care ana vet. oue to onVSlcaJ anOlor mental ImOalrment. are not caoaCle OT lull-time Inaeoen-
:ent living. ?amclcants In the aav care orogram are rf!ferreo to me orogram cy Inelr anenamq pnVS1Clan or C" some omer
;,ocroonatB sauce sue" an an institutional dlscnaI'Q8 planning program. a weltare agencY. etc. The essential elementS or a
:av care orogram ars alfect80 toware meeting thS nSalth maintenance ana restorauve n&eOS of pamclcants. riowtlWll'. tnere
are SOCializatiOn elements In tne crogram wnlcn. OV overcoming the isolatiOn so otten assOClatea with lUness In thS aged ana
:lsaolsa. are conslDereo Vital for tne purcose of foStenng ana mamtalnlng the maximum 00551018 state or healtn ana well-beIng.
Chlld Care canter.. A cuche or nonproTlt facIlity wnere educational. SOCial. health. ana nutntlonal services are cRMded to
cmldren Inrougn age 14 cr as presenbea Dy Stale law. ana wnlcn IS approved or llcanseo by tne Stale or olner apPlOlln8Ie
autnontv as a cnlld day care center or cnild care center.
Clinic. An apprcvea puDlic or noneroflt facility organlZ8d and operaIed for Ins pnmary purpose of provlOlng OUlOaII8I1l public
oealIh seMC8S. Incluaing CUSlDmary relatea seMcn auch as laDCr8IOnea ana lraaun&m rcems.
Collega _ An approved or accredited puDUe cr nonprofit inS1JlUIIOn cf nignsr leamlng oHerlng orgamzec stuoy courses ano
creallS leaalng to a DaccaJauralll8 or nlgner aegree.
Economic OevekJpment. A OrograrrtCs) earned out or cremoted bv a puoHe agency for cuche purcoses wnlch InvotYeS. direct.
, or inDirectlY. effortS to ImpC'0Y8 ,ne ODPDnUnltleS Of a given areator tns successrut eSlaDhshment or exoanslon 01 industnal.
:ommerclal. or agncultural PlantS or facdties ana wnlcn OU'1elWlH asslStS In tne creano" of long term emPlovment opportUnitieS
n tl"1s area or cnmanty beI~ib tMe unemOloyed or tnose with low Incomes. For puohe agency use may not ael as a conoun
'or tne transter or proPertY.
EducatlonallnaUlutlan . An approvea. accrealted. cr licensed puohe cr nonprofit InStlIUtlOn. facility. enlllY. cr crganlZlWOn
::onoucung e<l1JClIIIllMl progr8IIlS InclUOtng rnun:n 1Cr any sucn programs. sucn as a child care cemer. senCCl. COIlegtt.lUlIWllIIlV.
sencel for tne mematly _ed. scncel lcr the pnysu:aJly handll:appea. cr an eaucatlon81 raolCllelevlslon _.
Educatlona' Radio Station _ A (aOIO station IIcenseo bv tl"1e Federal Communications C,Jmmlsslon ana ocerateo exctuslvelv
!or noncommencal e<1ucanonal purposes ana wnlch IS puolic or nonprofit ana tax..exemOt unaer section 501 or tnB tnternal
Revenue Coda of 1954.
EducaUon Talevialon Slatlon . A lei_alan S18IlOn licensed by Ine Federal Communications CommiSSion ana o~ ex-
clusIVelY lor noncommancal educallon81 purposaa and wIIiclI is public or nonprofit ana taX-exempt unoer secuon 501 of Ine
I ntemal Revenue COde of 1954.
Heallh Center. "'n aopnMlO puollc or nonorcflt faclllty UIlllzea ey a nealIn unrt for tne proviSion of cuDlle h.81th S8MCes.
'neluolng relalaCl taediliaa SUCh as olagnostlc ana labonIIDrY faCIlities ana clinicS.
Homala.. Indlvldual. An individual wno lacks a fixed. regular and adeauate nlghtlime reSidence or wno has a cnmlllY n.gnl-
:Ime reSidence Inalls: (1) a SUpeMaeG pueliely or pl1Y8l8ly openWIO aII.'UIl' aeugnea 10 pl'O\lld. IemocralV liVIng a....omoaa.
:Ions I Including ~are nOllllL congregate shallars. and tranarlional nOUSlng fDr the memally ill): (2) an Inst_thaI pnMdes
a IemocralV r8lldence lor lnaivlduala lIlI.naed 10 be InsutulJonaliZeCl: or (3) a puelic or pnv1118 plaCll oesl9neo tor. or ortltnanly
"sed as. a ragwar s--.J KCOIlIOCIaIian for human betngL For puroceM at \his raguIaIIan. the I8fTl1 aoes IlOlIrlClUde any
,naiYldual i",..._NIlI or _lIlI_ _ned p~ ID an N:t of tne eongraa or a 511II8 laW.
),1.11 ....