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Grant Funding Application The following owner information is required to receive grant funds: Owner Information: SAM 2, Dam Name: I jr i! —�= tai+lf, , * / 277 Dam Owner's Representative: OP, /, Legal Name of Dam Owner: WA 4k .l Mailing Address of Owner: / ;:4 1 0 �� ,�/T 9424 • Phone#: 49.3495s• ` 3 Fax#: • c. 5 E-mail: AM*"erS• Federal Employer Identification Number(FEIN): In order for money to be disbursed by the State of Colorado, a taxpayer I.D. is required. This number is included on the W-9 or Form 147C from the IRS. In many cases the dam owner is already in the State's system and the above information is not necessary. Upon receipt of the application you will be notified if the FEIN number or W-9 is required. D-U-N-S Number: For an entity to receive federal funds as a direct recipient or subrecipient (as in this case), a D-U-N-S number is required. The D-U-N-S number can be easily obtained by accessing the following website: http://fedgov.dnb.com/webform . Provide documentation of the DUNS number with the application. Office of Management and Budget(OMB)Audit: For your information, the Federal pass-through funds you will receive as part of this grant could be subject to an Audit in Accordance with the OMB Circular A-133. . To comply with this Audit, the Department of Natural Resources (DNR) will contact you requesting certification that your entity has not received over $500,000 is Federal funding within the fiscal year, or is in compliance with Circular A-133. If the entity received less than $500,000 in Federal funding in the fiscal year you are not subject to the requirements of Circular A-133 and the certification requires a simple check box and signature. You will be contacted following the completion of the project. Contact John Batka with questions related to this audit at 970-352-8712 x1251. Colorado Dam Safety Branch December 20, 2012 inundation Mapping Grant Program Guidelines Page 2 of 2