ATTACHMENT E

AFFIDAVIT FORM

Name of Regional Consortium (Consortium): ____________________________________

My name is ____________________________. I am ___________________________ [Title] of _____________________________ [Name of local agency/town acting as Fiscal Agent], which is the Fiscal Agent for _______________________________ [Name of Consortium].

Pursuant to Rule 1.11 of the California Public Utilities Commission's Rules of Practice and Procedure, I am an officer, agent, or employee of ______________________________ [Name of local agency/town acting as Fiscal Agent].

I swear or affirm that I have personal knowledge of the facts stated in this Application for Consortium Grant Account funding under the provisions of the California Advanced Services Fund, I am competent to testify to them, and I have the authority to make this Application on behalf of and to bind the Consortium.

I further swear or affirm that _______________________________ [Name of Consortium] agrees to comply with all federal and state statutes, rules, and regulations covering broadband services and state contractual rules and regulations, if granted Consortium Grant Account funding from the California Advanced Services Fund.

I further swear or affirm that no member, officer, director, or partner of ______________________________ [Name of Consortium or its Fiscal Agent] has: 1) filed for bankruptcy; 2) was sanctioned by the Federal Communications Commission or any state regulatory agency for failure to comply with any regulatory statute, rule, or order; nor 3) has been found either civilly or criminally liable by a court of appropriate jurisdiction for violation of Section 1700 et. seq. of the California Business and Professions Code, or for any action which involved misrepresentation to consumers, nor is currently under investigation for similar violations.

I swear or affirm, under penalty of perjury, and under Rule 1.1 of the California Public Utilities Commission's Rules of Practice and Procedure, that, to the best of my knowledge, all of the statements and representations made in this Application are true and correct.

___________________________

Signature and Title

___________________________

__________ Type or Print Name and Title

SUBSCRIBED AND SWORN to before me on the _____ day of ____, 20____.

Notary Public In and For the State of __________________

My Commission expires: ______________________

(END OF ATTACHMENT E)

ATTACHMENT F

CASF CONSORTIA APPLICATION CHECKLIST

(Required for application)

To assist the Commission in verifying the completeness of your application, mark the box to the left of each item submitted with your application. Any unchecked items will automatically result in the disqualification of your proposal.

	1. Name of Applicant
	2. Key Contact Information1
		First Name
		Last Name
		Address Line 1
		Address Line 2
		City
		State
		ZIP Code
		Email Address
		Phone Number
	3.	Name of Fiscal Agent
		Letter from a public institution, e.g. city, county, academic institution, tribal government, etc., stating its willingness to act as a Fiscal Agent for the community including an understanding of the rights, duties, and responsibilities of the Fiscal Agent
		First Name Last Name
		Address Line 1
		Address Line 2
		City
		State
		ZIP Code
		Email Address
		Phone Number
		Contact Person
		First Name
		Last Name
		Address Line 1
		Address Line 2
		City
		State
		ZIP Code
		Email Address
		Phone Number
	4. Consortium Members2 (to be provided for each consortium member)
		Phone Number
		Address Line 1
		Address line 2
		City
		State
		ZIP Code
		Contact Person
		First Name
		Last Name
		Address Line 1
		Address Line 2
		City
		State
		ZIP Code
		Email Address
		Phone Number
	5. Governing Board Structure
	6. Description of Geographical Region, e.g. maps, Census Block Groups, and ZIP codes
	7. Proposed Broadband Project Description
	8. Endorsements from regional government entities, e.g. county boards of supervisors, etc., which demonstrate substantial support for consortium by letters and/or resolutions
	9. Endorsements from public, non-profit, and/or for-profit organizations, e.g. community-based organizations, associations, schools, health care organizations, libraries, businesses, consumers, etc., which demonstrate substantial support for consortium by letters and/or resolutions
	10. Action Plan3
	11. Work Plan4
		Work Plan Year 1
		Work Plan Year 2
		Work Plan Year 3
	12. Proposed Budget5
		Expected cost breakdown based on Work Plan with explanation of source of matching funds
		Budget Year 1
		Budget Year 2
		Budget Year 3
	13.	Notarized Affidavit [Attachment E to be signed by Fiscal Agent)

(END OF ATTACHMENT F)

ATTACHMENT G

CASF Rural and Urban Regional Broadband Consortia Grant Account

Consortium Scoring Criteria

- Total Maximum Points Available: 100 -

- Minimum Points Needed To Be Considered For Funding: 70 -

Criterion Maximum Points

1. Regional Consortium Representation and Endorsements 15

· Consortium is representative of organizations,

including, but not limited to, local and regional

government, public safety, K-12 education,

health care, libraries, higher education, community-based

organizations, tourism, parks and recreation, agricultural,

and business (up to 10 points)

· Endorsed by regional government entities (such as

City and county government), and non-profit/for-profit

organizations (such as community-based organizations,

associations, schools, health care organizations, libraries,

businesses, consumers, etc.) by letters or resolutions

(up to 5 points)

2. Regional Consortium's / Members Experience 35

· Experience working with community groups (up to 5 points)

· Prior successes in achieving broadband adoption, access

and deployment, particularly in areas where CASF-funded

broadband deployment projects are underway or completed

(up to 10 points)

· Demonstrated success building regional, multi-party collaborative

efforts focused on broadband or broadband-related issues that

achieved results (up to 10 points)

· Experience managing the deployment of broadband services

(if using a contractor to deploy or operate the broadband facilities,

demonstrated experience of consortium members managing

contractors) (up to 5 points)

· Proven track record of working successfully with culturally

and linguistically diverse communities (up to 5 points)

3. Action Plan 20

· Submission of a completed, detailed Action Plan that

includes deliverables, expected outcomes, timelines, and

core responsibilities as listed in Attachment A

(up to 20 points)

4. Work Plan 20

· Submission of a completed, detailed Work Plan that includes

timelines and activities designed to implement the

Action Plan as listed in Attachment A

(up to 20 points)

5. Budget 10

· A budget that is clear, detailed, comprehensive,

cost-effective and easily traceable to the goals and

activities referenced in the Action Plan and Work Plan

(up to 10 points)

(END OF ATTACHMENT G)

ATTACHMENT H

CONSENT FORM

Name of Regional Consortium (Consortium): __________________________________________________________________

____________________________________________________________________________________________________________________________________

Members of Consortium: __________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

(include additional pages if necessary)

Commission Resolution awarding grant from the California Advanced Services Fund (CASF) Rural and Urban Regional Consortia Grant Account (Consortia Grant Account): Resolution T-_____________, dated ________________, 20 __.

The Consortium identified above hereby agrees to comply with all grant terms, conditions, and requirements set forth in Commission Decision ______________ and

Commission Resolution T-_____________. Undersigned representative of

__________________________________ [Name of Member of Consortium] is duly authorized to execute this Consent Form on behalf of the Consortium and to bind the Consortium to the terms, conditions, and requirements set forth in Commission Decision _______________ and Commission Resolution T-_____________.

Dated this _____ day of ______________________, 20___.

________________________________

Signature

________________________________

Printed Name

________________________________

Title

________________________________

Organization (Name of Member of Consortium)

__________________________________________________________________

Business Address (include street address, suite/apt. number, city, state, and ZIP Code)

________________________________

Telephone Number (include area code)

________________________________

Email Address

(END OF ATTACHMENT H)

ATTACHMENT I

Sample of Quarterly Report Format

[Name of Regional Consortium]

[Name of Project]

QUARTERLY REPORT

Start Date: ____/____/2011

Quarter (circle one): 1Q 2Q 3Q 4Q

Date Report Submitted: ____/____/2011

Goals/ Objectives (as stated in the Action Plan)	Activity(ies) (as stated in the Work Plan)	Performance Measures	Estimated Completion Date	Revised Estimated Completion Date	Date Completed	Actual Performance Results	Comments (e.g. reason why actual results not meeting planned performance measures)
Goal A	Convened meetings with community-based organiza-tions (CBOs)	· Conducted four (4) meetings · Conducted seven (7) conference calls	2/14/11		2/14/11	2 meetings conducted 3 conference calls conducted	Reason why perforamce measure was not met

(END OF ATTACHMENT I)

¹ For applications involving sub-regional consortia, include key contact information for each sub-regional consortium.

² For applications involving sub-regional consortia, include consortium members for each sub-regional consortium.

³ For applications involving sub-regional consortia, include Action Plan for each sub-regional consortium.

⁴ For applications involving sub-regional consortia, include Work Plan for each sub-regional consortium.

⁵ For applications involving sub-regional consortia, include yearly budget for each sub-regional consortium.