Form Dtmb 292 – Fill Out and Use This PDF

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ELIGIBILITY FORM

(Please type or print in blue or black ink only)

SECTION I 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 US Postal Service. Include ZIP Code. Provide the street address if different from mailing address or provide directions if located on a rural route or other remote area. List the county in which the organization is actually located and a business telephone number with area code.

SECTION II Check the appropriate box which describes your organization. If you are a public agency check the appropriate box in section III then skip to section VIII. If you are unable to determine which status to check, please call 517-373-8622.

SECTION III Check the appropriate box or boxes (check as many as apply) which indicates the type or purpose of your organization.

SECTION IV A comprehensive written description of all programs and/or services provided is required. A description of the operational facilities should also be included. Be sure to include information on staff and staff qualifications, hours of operation, services and programs offered, population of enrollment, fees charged, etc. Include samples of pamphlets, catalogs, brochures or posters. If incorporated, include complete copy of Articles of Incorporation with all filing certificates and amendments, and a copy of your current By-Laws.

SECTION V Check the appropriate box which indicates the organization’s sources of funding. Supporting documentation indicating the types and amounts of funding must be submitted with the completed application.

SECTION VI All applicants making application as “Nonprofit, tax-exempt organizations” must provide a copy of the IRS determination letter indicating tax exemption under Section 501 of the IRS Code of 1986. The name of the organization on this IRS letter must match the name provided in Section 1 of this application, if not, include sufficient evidence such as amendments to Articles of Incorporation, or Assumed Name filing certificate to establish an “audit trail” of names showing the legal connection.

SECTION VII Applicants making application as “Nonprofit, tax-exempt organization” are required to submit evidence that the applicant is currently approved, accredited, or licensed. Programs for older individuals must include evidence of funding under the Older Americans Act of 1965; Titles IV or XX of the Social Security Act; Titles VIII or X of the Economic Development Act of 1964; or the Community Services Block Grant Act. Providers of assistance to homeless individuals must include a letter from the mayor, county judge, city or county health officer or comparable authority which certifies that the applicant is a “provider of assistance to the homeless”. The certification must identify the service or assistance being provided and the number of individuals receiving such assistance.

SECTION VIII Annotate date and provide an original signature of applicant’s Authorized Official (President, Chairman of the Board, Mayor, City Manager, Executive Director, Administrator, Fire Chief, or other comparable authorized official). Photocopied, rubber stamped, machine produced, carbon, or other facsimile type signatures are not acceptable.

NOTE: INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. USE THIS INSTRUCTION SHEET AS YOUR CHECK LIST TO ASSURE ALL REQUIRED INFORMATION AND DOCUMENTATION IS PROVIDED. IF YOU HAVE A QUESTION OR NEED ASSISTANCE CALL (517) 373-8622 OR (517) 241-3860.

MAIL OR FAX APPLICATION TO:

Department of Technology, Management and Budget, Federal Surplus Program,

3111 W. St. Joseph Street, Lansing, MI 48917

Fax: (517) 334-8262

This form can be made available in accessible formats upon request to qualified individuals with disabilities.

2

AUTHORIZED REPRESENTATIVES

(See definitions)

I.LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION:

Name of Organization

Mailing Address (PO Box #, Street, City & State)			ZIP Code+4
Street Address/Location (if different from mailing address)
	(	)	(	)
County	Telephone #		Fax #
Organization Web Address			Organization E-Mail Address

II.THE FOLLOWING REPRESENTATIVES ARE DESIGNATED TO:

A.Represent Donee Organization as its authorized agent; and

B.Acquire Federal surplus property on behalf of the Donee Organization; and

C.Obligate necessary Donee Organization funds for this purpose; and

D.Execute Distribution Documents binding the Donee Organization to the terms, conditions, reservations, and restrictions applying to Property obtained through the agency.

III.	__________ NEW DESIGNATIONS	__________ ADDITIONAL DESIGNATIONS ONLY
	(Delete all previous authorizations)		(Add to previous authorizations)
IV.	REPRESENTATIVES:
	Name	Title	Signature

Email Address (required)

Email Address (required)

Email Address (required)

_

Email Address (required)

_

V.CERTIFICATION

Date	Signature of Authorized Official (see definitions)
	Printed Name & Title of Authorized Official

This form can be made available in accessible formats upon request to qualified individuals with disabilities.

3

NONDISCRIMINATION ASSURANCE

LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION:

Name of Organization

Mailing Address (PO Box #, Street, City, State)

ZIP Code+4

Street Address/Location (if different from mailing address)

	(	)	(	)
County	Telephone #		Fax #
Organization Web Address			Organization E-Mail Address

, the donee,

(Name of Organization)

agrees that the program for or in connection with which any property is donated to the donee will be conducted in compliance with, and the donee will comply with and will require any other person (any legal entity) who through contractual or other arrangements with the donee is authorized to provide services or benefits under said program to comply with all requirements imposed by or pursuant to the General Services Administration (41 CFR 101-6.2 and 101-8) issued under the provisions of Title VI of the Civil Rights Act of 1964, as amended, section 606 of Title VI of the Federal Property and Administrative Services Act of 1949, as amended, section 504 of the Rehabilitation Act of 1973, as amended, Title IX of the Education Amendments of 1972, as amended, section 303 of the Age Discrimination Act of 1975, and the Civil Rights Restoration Act of 1987, to the end that no person in the United States shall on the ground of race, color, national origin, sex or age, or that no otherwise qualified handicapped person shall solely by reason of the handicap, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity for which the donee received Federal assistance from the General Services Administration; and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement.

The donee further agrees (1) that this agreement shall be subject in all respects to the provisions of said Federal statutes and regulations, (2) that this agreement obligates the donee for the period during which it retains ownership or possession of the property, (3) that the United States shall have the right to seek judicial enforcement of this agreement, and (4) that this agreement shall be binding upon any successor in interest of the donee and the word “donee” as used herein includes any such successor in interest.

__

Date	Signature of Authorized Official

This form can be made available in accessible formats upon request to qualified individuals with disabilities.

4

DEFINITIONS

Authorized Official – Means the President, Chairman of the Board, Mayor, City Manager, Superintendent, Executive Director, Administrator, Fire/Police Chief, or other comparable official.

Authorized Representative – Means the person(s) who is/are certified by the Authorized Official to represent the Donee Organization as its authorized agent; and is authorized to screen/acquire Federal surplus property on behalf of the Donee Organization; and obligate necessary Donee Organization funds for this purpose; and execute distribution documents binding the Donee Organization to the terms, conditions, reservations, and restrictions applying to property obtained through the agency.

APPROVED - Recognition and approval by the State department of education, State department of health, or other appropriate authority where no recognized accrediting board, association, or other authority exists for the purpose of making an accreditation. For an educational institution or an educational program, approval must relate to academic or instructional standards established by the appropriate authority. For a public health institution or program, approval must relate to the medical requirements and standards for the professional and technical services of the institution established by the appropriate authority.

ACCREDITED - Approved by a recognized accrediting board or association, at a regional, State or national level such as a State board of education or health; the American Hospital Association; a regional or national accrediting association for universities, colleges, or secondary schools; or another recognized accrediting association.

ACCREDITATION – Means the status of public recognition that an accrediting agency grants to an institution or program that meets the agency’s standards and requirements.

CHILD CARE CENTER - A public or nonprofit facility where educational, social, health, and nutritional services are provided to children through age 14 or as prescribed by State Law, and that is approved or licensed by the State or other appropriate authority as a child day care center or child care center.

CLINIC – Means an approved public or nonprofit facility organized and operated for the primary purpose of providing outpatient public health services, and includes customary related services such as laboratories and treatment rooms.

COLLEGE - Means an approved or accredited public or nonprofit institution of higher learning offering organized study courses and credits leading to a baccalaureate or higher degree.

CONSERVATION – Means a program or programs carried out or promoted by a public agency for public purposes involving directly or indirectly the protection, maintenance, development, and restoration of the natural resources of a given political area. These resources include but are not limited to the air; land; forests; water; rivers; streams; lakes and ponds; minerals; and animals, fish and other wildlife.

DRUG ABUSE OR ALCOHOL TREATMENT CENTER – Means a clinic or medical institution that provides for the diagnosis, treatment, or rehabilitation of alcoholics or drug addicts. These centers must have on their staffs, or available on a regular visiting basis, qualified professionals in the fields of medicine, psychology, psychiatry, or rehabilitation.

ECONOMIC DEVELOPMENT – Means a program(s) carried out or promoted by a public agency for public purposes to improve the opportunities of a given political area for the establishment or expansion of industrial, commercial, or agricultural plants or facilities and which otherwise assists in the creation of long term employment opportunities in the area or primarily benefits the unemployed or those with low incomes.

EDUCATION – Means a program or programs to develop and promote the training, general knowledge, or academic, technical, and vocational skills and cultural attainments of individuals in a community or other given political area. Public educational programs may include public school systems and supporting facilities such as centralized administrative or service facilities.

EDUCATIONAL INSTITUTION – Means an approved, accredited, or licensed public or nonprofit institution, facility, entity, or organization conducting educational programs or research for educational purposes, such as a child care center, school, college, university, school for the mentally or physically disabled, or an educational radio or television station.

EDUCATIONAL RADIO OR TELEVISION STATION – Means a public or nonprofit radio or television station licensed by the Federal Communications Commission and operated exclusively for noncommercial educational purposes.

HEALTH CENTER – Means an approved public or nonprofit facility that provides public health services, including related facilities such as diagnostic and laboratory facilities and clinics and clinics.

HISTORIC LIGHT STATION – Means a historic light station as defined under section 308(e)(2) of the National Historic Preservation Act 16 U.S.C. 470w-7(e)(2), including a historic light station conveyed under subsection (b) of that section, notwithstanding the number of hours that the historic light station is open to the public.

HOMELESS INDIVIDUAL – Means:

(1)An individual who lacks a fixed, regular, and adequate nighttime residence, or who has a primary nighttime residence that is:

(i)A supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill);

(ii)An institution that provides a temporary residence for individuals intended to be institutionalized; or

(iii)A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

(2)For purposes of this regulation, the term does not include any individual imprisoned or otherwise detained pursuant to an Act of the Congress or State Law.

HOSPITAL – Means an approved or accredited public or nonprofit institution providing public health services primarily for inpatient medical or surgical care of the sick and injured and includes related facilities such as laboratories, outpatient departments, training facilities, and staff offices.

LIBRARY - A public or nonprofit facility providing library services free to all residents of a community, district, State or region.

This form can be made available in accessible formats upon request to qualified individuals with disabilities.

7

LICENSED – Mean recognition and approval by the appropriate State or local authority approving institutions or programs in specialized areas. Licensing generally relates to established minimum public standards of safety, sanitation, staffing, and equipment as they relate to the construction, maintenance, and operation of a health or educational facility, rather than to the academic, instructional, or medical standards for these institutions.

MEDICAL INSTITUTION – Means an approved, accredited, or licensed public or nonprofit institution, facility, or organization the primary function of which is the furnishing of public health and medical services to the public at large or promoting public health through the conduct of research, experiments, training, or demonstrations related to cause, prevention, and methods of diagnosis and treatment of diseases and injuries. The term includes but is not limited to hospitals, clinics, alcoholic and drug abuse treatment centers, public health or treatment centers, research and health centers, geriatric centers, laboratories, medical schools, dental schools, nursing schools, and similar institutions. The term does not include institutions primarily engaged in domiciliary care although a separate medical facility within such a domiciliary institution may qualify as a “medical institution”.

MUSEUM – Means a public or nonprofit institution which is organized on a permanent basis essentially for educational or esthetic purposes and which, using a professional staff, owns or uses tangible objects, whether animate of inanimate; cares for these objects; and exhibits them to the public on a regular basis (at least 1000 hour per year). As used in the Donation Program, the term “museum” includes, but is not limited to, the following institutions if they satisfy all other provisions of FPMR 101-44.207: aquariums and zoological parks; botanical gardens and arboretums; nature centers; museums relating to art, history (including historical buildings), natural history, science, and technology; and planetariums. For the purposes of this definition, an institution uses a professional staff if it employs at least one qualified full time staff member or the equivalent, whether paid or unpaid, primarily engaged in the acquisition, care, or public exhibition of objects owned or used by the institution. This definition of “museum” does not include any institution that exhibits object to the public if they display or use of the objects is only incidental to the primary function of the institution. For example, an institution which is engaged primarily in the sale of antiques, objects d’art, or other artifacts and which incidentally provided displays to the public of animate of inanimate objects, either free or at a nominal charge, does not qualify as a museum.

NATIONALLY RECOGNIZED ACCREDITING AGENCY – Means an accredited agency that the Department of Education recognizes under 34 CFR par 600. (For a list of accredited agencies, see the Department’s web site at http://www.ed.gov/offices/OPE/accreditation/index.html .

NONPROFIT – Means not organized for profit and exempt from Federal income tax under section 501 of the Internal Revenue Code (26 U.S.C. 501).

PARKS AND RECREATION – Means a program(s) carried out or promoted by a public agency for public purposes which involve directly or indirectly the acquisition, development, improvement, maintenance, and protection of park and recreational facilities for the residents of a give political area.

PROGRAM FOR OLDER INDIVIDUALS – Means a conducted by a State or local government agency or any nonprofit activity that receives funds appropriated for services or programs for older individuals under the Older Americans Act of 1965, as amended, under title IV or title XX of the Social Security Act (42 U.S.C. 601 et seq.), or under titles VIII and X of the Economic Opportunity Act of 1964 (42 U.S.C. 2991 et seq.) and the Community Services Block Grant Act (42 U.S.C. 9901 et seq.).

PROVIDER OF ASSISTANCE TO HOMELESS INDIVIDUALS – Means a public agency or a nonprofit institution or organization that operates a program which provides assistance such as food, shelter, or other services to homeless individuals.

PROVIDER OF ASSISTANCE TO IMPOVERISHED FAMILIES AND INDIVIDUALS – Means a public or nonprofit organization whose primary function is to provide money, goods, or services to families or individuals whose annual incomes are below the poverty line (as defined in section 673 of the Community Services Block Grant Act)(42 U.S.C. 9902). Providers include food banks, self-help housing groups, and organizations providing services such as the following: Health care; medical transportation; scholarships and tuition assistance; tutoring and literacy instruction; job training and placement; employment counseling; child care assistance; meals or other nutritional support, clothing distribution; home construction or repairs; utility or rental assistance; and legal counsel.

PUBLIC AGENCY- Means any State; political subdivision thereof, including any unit of local government or economic development district; any department, agency, or instrumentality thereof, including instrumentalities created by compact or other agreement between States or political subdivisions; multijurisdictional substate districts established by or pursuant to State law; or any Indian tribe, band, group, pueblo, or community located on a State reservation.

PUBLIC HEALTH – Means a program(s) to promote, maintain, and conserve the public’s health by providing health services to individuals and/or by conducting research, investigations, examinations, training, and demonstrations. Public health services may include but are not limited to the control of communicable diseases, immunization, maternal and child health programs, sanitary engineering, sewage treatment and disposal, sanitation inspection and supervision, water purification and distribution, air pollution control, garbage and trash disposal, and the control and elimination of disease-carrying animals and insects.

PUBLIC HEALTH INSTITUTION – Means an approved, accredited, or licensed public or nonprofit institution, facility, or organization conducting a public health program(s) such as a hospital, clinic, health center, or medical institution, including research for any such programs, the services of which are available to the public.

PUBLIC PURPOSE – Means a program(s) carried out by a public agency which are legally authorized in accordance with the laws of the State or political subdivision thereof and for which public funds may be expended. Public purposes include but are not limited to programs such as conservation, economic development, education, parks and recreation, public health and public safety, programs of assistance to the homeless or impoverished, and programs for older individuals.

PUBLIC SAFETY – Means a program(s) carried out or promoted by a public agency for public purposes involving, directly or indirectly, the protection, safety, law enforcement activities, and criminal justice system of a given political area. Public safety programs may include but are not limited to those carried out by: public police departments; sheriff’s offices; the courts; penal and correctional institutions and including juvenile facilities; State and civil defense organizations; and fire departments and rescue squads including volunteer fire departments and rescue squads supported in whole or in part with public funds.

SCHOOL (EXCEPT SCHOOLS FOR THE MENTALLY OR PHYSICALLY DISABLED) - Means a public or nonprofit approved or accredited organizational entity devoted primarily to approved academic, vocational, or professional study and instruction, that operates primarily for educational purposes on a full-time basis for minimum school year and employs a full-time staff of qualified instructors.

SCHOOL FOR THE MENTALLY OR PHYSICALLY DISABLED – Means a facility or institution operated primarily to provide specialized instruction to students of limited mental or physical capacity. It must be public or nonprofit and must operate on a full-time basis for the equivalent of a minimum school year prescribed for public school instruction of the mentally or physically disabled, have a staff of qualified instructors, and demonstrate that the facility meets the health and safety standards of the State or local government.

UNIVERSITY – Means a public or nonprofit approved or accredited institution for instruction and study in the higher branches of learning and empowered to confer degrees in special departments or colleges.

This form can be made available in accessible formats upon request to qualified individuals with disabilities.

8