Preaward Compliance Review Report For All Applicants Requesting Federal Financial Assistance Form

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FORM Approved

United States Environmental Protection Agency

OMB No. 2090-0014

Washington, DC 20460

Expires 2-28-03

Preaward Compliance Review Report For

All Applicants Requesting Federal Financial Assistance

Note: Read instructions on reverse side before completing form.

(Name, City, State)

I. A. Applicant

B. Recipient

C. EPA Project No.

II. Brief description of proposed project, program or activity.

III. Are any civil rights lawsuits or complaints pending against applicant and/or recipient?

Yes

If “Yes”, list those complaints and the disposition of each complaint.

IV. Have any civil rights compliance reviews of the applicant and/or recipient been conducted by any Federal Agency

Yes

during the two years prior to this application for activities which would receive EPA Assistance?

If “Yes”, list those compliance reviews and status of each review.

V. Is any other Federal financial assistance being applied for or is any other Federal financial assistance being applied

Yes

to any portion of this project, program or activity?

If “Yes”, list the other Federal Agency(s), describe the associated work and the dollar amount of assistance.

VI. If entire community under the applicant’s jurisdiction is not served under the existing facilities/services, or will not be served under the proposed plan, give reasons why.

Population Characteristics

VII.

Number of People

1. A. Population of Entire Service Area

B. Minority Population of Entire Service Area

2. A. Population Currently Being Served

B. Minority Population Currently Being Served

3. A. Population to be Served by Project, Program or Activity

B. Minority Population to be Served by Project, Program or Activity

4. A. Population to Remain Without Service

B. Minority Population to Remain Without Service

VIII. Will all new facilities or alterations to existing facilities financed by these funds be designed

Yes

and constructed to be readily accessible to and useable by handicapped persons?

If “No”, explain how a regulatory exception (40 CFR 7.70) applies.

IX. Give the schedule for future projects, programs or activities (or of future plans), by which service will be provided to all beneficiaries within applicant’s jurisdiction. If there is no

schedule, explain why.

X. I certify that the statements I have made on this form and all attachments thereto are true, accurate and complete. I acknowledge that any knowingly false or misleading statement may

be punishable by fine or imprisonment or both under applicable law.

A. Signature of Authorized Official

B. Title of Authorized Official

C. Date

For the U.S. Environmental Protection Agency

Authorized EPA Official

Date

Approved

Disapproved

Previous editions are obsolete

EPA Form 4700-4 (Rev. 1/90)