Hamilton County Public Health Communities Putting Prevention to Work

Funding Opportunity Announcement Overview Hamilton County Public Health (HCPH) announces the availability of WeTHRIVE! SM grants offering technical assistance and funding for Hamilton County communities to develop policy and environmental changes that will promote or sustain health promotion initiatives. Communities funded will build or expand existing health coalitions; create and implement wellness resolutions; and develop and begin to implement sustainable plans for increasing physical activity and improved nutrition, ultimately decreasing obesity rates in their community. Funding for this project is available through Communities Putting Prevention to Work (CPPW), a two-year project funded by the American Recovery & Reinvestment Act of 2009 through the Centers for Disease Control and Prevention (CDC). HCPH is one of 44 grant-awarded communities charged with implementing strategies for improved nutrition, increased physical activity and reduced obesity. WeTHRIVE! is a county-wide movement focused on changing social norms by creating policy, systems and environmental changes with the ultimate goal of reducing obesity and other chronic diseases. More information can be found at WatchUsThrive.org. Priority will be given to communities that demonstrate early readiness and serve underserved populations. Projects will begin November 21, 2011 and must be completed by February 29, 2011. Hamilton County Public Health will hold two conference calls to review this funding announcement and answer questions. Communities may choose to participate on one of the following dates: Tuesday, November 1, 2011 from 10:30-11:00 a.m. and Wednesday, November 2, 2011 from 6:00-6:30 p.m. Call attendance is not required. To participate, simply dial: 1- 877-768-0032. When prompted, enter the room number: *9219613* (you must enter the asterisks). FUNDING Communities will be awarded up to $24,000 (up to $7,000 for successful completion of planning phase and up to $17,000 for successful completion of implementation phase).

ELIGIBILITY Hamilton County communities:

Local governments (cities, townships, villages) Chartered Neighborhood Community Councils Priority will be given to communities who have not received CDC/Healthy Communities Program funding for similar programs, such as Steps, Pioneering Healthier Communities, ACHIEVE or Strategic Alliance for Health. Applicants must be willing to serve as the fiscal agent for the project and have the capacity to receive and expend approved grant budgets. Applicants must be willing to enter into an agreement with HCPH for use of grant funds. EXPECTATIONS Expectations of Funded Communities/Neighborhoods:

• Planning Phase Expectations o Adopt a Community Wellness Resolution (see Appendix B) o Complete the Community Health Assessment and Group Evaluation (CHANGE)

Tool o Complete a Shared Use Assessment o Use CHANGE tool findings to develop a physical activity and nutrition policy,

systems or environmental change Action Plan • Implementation Phase Expectations

o Adopt at least one Shared Use agreement o Select and implement at least one approved policy, systems or environmental

change strategy o Submit final report to HCPH no later than February 29, 2012.

• Administrative Expectations o Attend kick-off meeting o Attend monthly conference call with other grantee communities (coordinated by

HCPH) o Meet/communicate with HCPH regularly o Participate in WeTHRIVE! SM! marketing efforts

Hamilton County Public Health will:

• Provide assessment tools and instructions • Provide technical assistance throughout the project period via training, conference calls,

site visits, and educational resources • Coordinate monthly conference calls • Assist communities with development of Action Plans • Help to promote efforts within grantee’s community and throughout Hamilton County

PROJECT TIMELINE Proposal due: November 14, 2011 Awards announced: November 21, 2011 Kick-off Meeting & Working Session (required): November 29, 2011 Final report due: February 29, 2012 REIMBURSEMENT Completion of Planning phase = $7,000 Completion of Implementation phase = up to $17,000

• Participants must complete the planning phase by December 31, 2011 in order to be eligible to receive the implementation dollars.

• After the planning phase is complete, the grantee will submit implementation budget and justification to support identified implementation strategy. Once budget is approved by HCPH, spending can begin.

• HCPH will work with communities to develop their community action plans. These plans will vary by community based on the community needs identified in the planning phase. Examples of potential implementation strategies could include:

1. Infrastructure enhancements to the built environment to increase safe physical

activity opportunities (e.g. Par Course/fitness equipment, lighting, benches, bike racks, sidewalks, walking/biking trails, etc.)

2. Healthy retail initiatives to improve access to affordable fresh produce and other healthy foods. Utilize the corner or convenience stores that will have the greatest impact on these types of communities to provide affordable fresh produce and other healthy food options.

Allowable Costs

A. Supplies: (Examples include meeting materials such as pens, flip charts, paper, etc.)

B. Equipment: (Equipment is tangible, non-expendable property having a useful life of more than one year. Equipment costs must be less than $5,000 per unit. Successful applicants are requested to make every attempt to buy American-made products, when possible. Examples include park benches, bike racks, outdoor fitness/par course equipment, etc.). C. Other: (This category contains items not included in the previous budget categories. Examples include printing costs, signage, stipends, personnel, etc.)

Unallowable Costs

• Construction • Lobbying • Research • Land or building acquisition

• Reimbursement of pre-award costs • Supplanting federal, state or local funds

HCPH reserves the right to request an amendment to or deny requested funding that does not meet approved criteria or does not match the scope of work proposed.

APPLICATION INSTRUCTIONS

1. Complete and submit the Application Form (Appendix A). 2. Answer the following questions. Each question should have a response of 500 words or

less.

a. Who will be the main point(s) of contact for the project? For each contact person, list their current role or position within the government or neighborhood council and indicate whether they are paid or volunteer. Describe how consistency within the project will be maintained in the event of personnel changes due to upcoming elections or unforeseen events.

b. Is there a coalition/committee in place that will be involved in implementing the

activities described in this proposal?

i. If YES: When was the coalition/committee established and what the mission? How often do they meet? Can the they meet more frequently if necessary? List the current members and each member’s role.

ii. If NO: Do you plan to develop a community health coalition/committee? What role would the coalition/committee play in implementing the activities described in this proposal? Who would you recruit to join the coalition/committee?

c. Describe existing community partnerships (including partnership with

WeTHRIVE! SM) and the scope of these partnerships. Describe potential new partners that may assist with implementing the strategies outlined in this proposal.

d. Describe recent successes as they relate to improving the health of your

community. How did these successes occur? Who was involved? What was the community impact?

e. Describe the demographics of the proposed intervention area (race/ethnicity,

population size, socioeconomic status, etc).

f. Describe the health status of your community. If applicable, provide data on the existing burden of chronic disease (diabetes, obesity, and cardiovascular disease) and health risk behaviors (physical inactivity, poor nutrition, smoking rates) for the proposed target intervention area.

g. Has your community completed a community health assessment? What were the

results of the assessment? How have you used these findings to address changes in your community’s health?

h. Describe your community’s vision and ideas for building a healthy community. If

your community has a written plan to address health, physical activity and/or healthy eating, provide a copy of the plan.

i. Does your community have an existing wellness resolution?

i. If YES: When was it adopted? Please provide a signed copy. How was

the resolution communicated to the residents within the community? ii. If NO: What steps will you take to draft such a resolution? Who will be

responsible? How will the resolution be communicated to residents within the community?

3. Submit Letter of Commitment outlining the lead agent’s commitment to this project. 4. Complete and submit the Vendor Registration Form (Appendix C).

5. Optional: Additional documents to support application submission (e.g., articles,

previous successes, coalition membership rosters, letters of support, etc.). SUBMISSION The deadline for submission is 4:00 p.m. on Monday, November 14, 2011. Electronic submission should be sent to tonya.key@hamilton-co.org and must be received by 4:00 p.m. on Monday, November 14, 2011. Hard Copies will not be accepted. Late submissions will not be considered. For questions regarding this grant proposal, please contact Tonya Key at tonya.key@hamilton-co.org.

PROJECT DEFINITIONS

Community Health Assessment and Group Evaluation (CHANGE) Tool: An assessment and evaluation tool that helps community teams (such as coalitions) develop a community health action plan. This tool walks community team members through the assessment process and helps define and prioritize possible areas of improvement. Using this information as a guide, team members can develop a course for improving community health by implementing policies to make positive and sustainable changes. This tool can be used annually to assess current policy, systems, and environmental change strategies and offer new priorities for future efforts.

Environmental Change: Interventions that impact physical changes to the economic, social, or physical environment.

Policy Change: A shift in formal operations of organizations and/or governmental institutions that allows new or different activities to occur and thrive. These shifts may arise in the form of information-sharing, community participation, professional input, compromise, and consensus-building and are usually the result of effective advocacy. These are interventions that impact law, ordinances, resolutions, mandates, regulations, or rules (formal or informal). Shared Use: Two or more entities entering into an agreement to share spaces like athletic fields, playgrounds and gymnasiums to create safe spaces to play and be physically active. This allows communities to maximize facilities as well as financial and human resources.

Sustainability: Ensuring an effort or change lasts. Note: sustainability is often misunderstood as securing further or ongoing funding for a program that would otherwise end. It is important to understand that sustainability can be achieved without ongoing funding, by changing policies, norms, attitudes, etc. Systems Change: A permanent change to policies, practices, and decisions of related organizations or institutions in the public and/or private sector. These are interventions that impact all elements of an organization, institution, or system.

Underserved Populations: In the context of this project, individuals with limited access to affordable, healthy food or affordable, safe places for physical activity. These are also vulnerable populations identified to be at-risk for health disparities as defined by race/ethnicity, socio-economic status, geography, gender, age or disability status.

APPENDIX A

HAMILTON COUNTY PUBLIC HEALTH

Communities Putting Prevention to Work

Application

Applicant Agency/Organization:

Applicant Agency Address:

Primary Applicant Agency Contact Person/Title:

Telephone Number: ( ) Email:

Municipality/Neighborhood Population Size:

Appendix B

Wellness Resolution

****Please Read ****

Comment: This document is a guide to assist municipal and local government officials in

tailoring a Wellness Resolution that is appropriate for your city, township, or village. This model

plan serves as a template for communities to use to develop their own resolution. Please be

advised that changes and/or modifications to this document are allowed where appropriate. Be

sure to work with your WeTHRIVE! technical assistance team when considering changes and/or

modifications. The legal information provided in this document does not constitute legal advice

or legal representation. For legal advice, consult your respective legal representative.

Resolution No. ___ Committing [Municipality] to WeTHRIVE!SM

Community Wellness in

Action (Wellness Resolution)

PREAMBLE

WHEREAS, in Hamilton County 57 percent of adults are overweight or obese, 31.7 percent of third

graders are overweight or obese, 80 percent of children who are overweight at age 10 will be obese as

an adult, and over the past 40 years childhood obesity has increased more than fourfold in those ages 6

to 11 years;

WHEREAS, overweight children and adults are at greater risk for numerous adverse health

consequences, including type 2 diabetes, heart disease, stroke, high blood pressure, high cholesterol,

certain cancers, asthma, low self-esteem, depression and other debilitating diseases;

WHEREAS, the cost of obesity in Ohio is $3.3 billion each year;

WHEREAS, good nutrition is a central part of any obesity prevention effort as healthier diets could save

at least $71 billion per year in medical costs, lost productivity and lost lives in the U.S.;

WHEREAS, only 7.2 percent of Ohio students (grades 9-12) report eating the recommended servings of

fruits and vegetables per day; and in Hamilton County, only 25 percent of adults consume the

recommended servings of fruits and vegetables per day.

WHEREAS, infants who are breastfed are less likely to become obese children or adults;

WHEREAS, most Americans are failing to meet the Centers for Disease Control and Prevention’s

recommendations of at least 30 minutes of moderate physical activity at least five days a week for

adults, and at least 60 minutes of moderate to vigorous intensity physical activity for children every day;

and Ohio students in Grades K-8 receive an average of 72.7 minutes of physical education/week, well

below the national recommendation of 150 minutes/week for elementary school children and 225

minutes/week for middle school students;

WHEREAS, research shows that not only does Hamilton County have a high rate for childhood obesity,

but specific populations including African-American, Hispanic and low-income families are

disproportionately affected;

WHEREAS, in many communities, families have limited access to full-service supermarkets and no safe

places to play;

WHEREAS, low-income communities are less likely to have places where people can be physically active,

such as parks, green spaces, and bike paths and lanes;

WHEREAS, children in rural areas and towns have less access to places to play than children in urban

areas and suburbs;

WHEREAS, improvements to the “built environment” – including, bike and pedestrian friendly streets,

adequate public transportation, access to healthy food retailers, access to parks, trails and grocery

stores, or the lack thereof – have a significant impact on obesity rates;

WHEREAS, individual effort alone is insufficient to combat the rise of obesity and significant societal and

environmental changes are needed to support individual efforts to make healthier choices;

WHEREAS, tobacco use remains the single largest preventable cause of disease, disability, and death in

the U.S., where almost 1 in 5 adults smoke;

WHEREAS, 443,000 Americans die of smoking or exposure to secondhand smoke each year;

WHEREAS, 29% of adults in Hamilton County smoke cigarettes and 22% percent of twelfth graders

report tobacco use in the past 30 days.

WHEREAS, there is no risk-free level of contact with secondhand smoke; even brief exposure can be

harmful to the health of children and adults.

WHEREAS, smoking costs the US about $96 billion each year in direct medical costs and $97 billion from

productivity losses due to premature death;

NOW, THEREFORE, LET IT BE RESOLVED, that [Municipality / Adopting body] hereby recognizes that

obesity and tobacco use are serious public health threats to the health and wellbeing of adults, children,

and families in [Municipality]. And in light of the foregoing considerations, [Municipality] commits to the

WeTHRIVE! Community Wellness in Action Movement and to do all it can to decrease the rate of obesity,

overweight, and tobacco use in its communities; and to implementing the necessary laws or policies to

create work, school, and neighborhood environments conducive to healthier eating, increased physical

activity and decreased tobacco use and exposure to second-hand smoke among residents.

I. Built Environment

BE IT FURTHER RESOLVED that [Municipality / Adopting body] directs all staff responsible for the design,

approval, and construction of neighborhoods, streets, and business areas, including planners, engineers,

public works staff, and community economic development and redevelopment personnel, to make

every effort to:

• Prioritize capital improvement projects that increase opportunities for physical activity in

existing areas;

• Plan and construct a built environment that encourages regular walking, biking, public

transportation use, and other forms of physical activity by encouraging compact development,

mixed land use within neighborhoods, and complete streets that are safe and welcoming for

pedestrians, bicyclists, public transportation riders, and people of all ages and abilities; and

• Increase the number of grocery stores in underserved communities and take other actions to

increase these communities’ access to healthy food, including fresh fruits and vegetables.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] directs the [Planning Department Director

/ City Manager] to review comprehensive plans, zoning ordinances, subdivision regulations, and other

plans, codes, and regulations, and report to the [Adopting body] with a draft of proposed revisions that

could increase access to healthy foods, decrease access to unhealthy food retail outlets, and increase

opportunities for physical activity within [insert appropriate period]. In conducting the aforementioned

review and report, the [Planning Department Director / City Manager] shall also consider implementing

zoning restrictions on unhealthy food retail outlets, such as fast food restaurants. The report shall also

include an examination of racial, ethnic, and socio-economic disparities in access to healthy foods and

physical activity facilities or resources, and proposed strategies to remedy these inequities.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] recommends that the [Planning

Department Director / City Manager] procure a Health Impact Assessment from the [Local Health

Department] to evaluate any new large-scale planning and development project.

II. Access to Healthy Food

BE IT FURTHER RESOLVED that in an effort to support community gardens, markets, and food systems

change, [Municipality / Adopting body] directs the [Department of Public Works / Department of Real

Estate / other appropriate agency] to inventory property owned by [Municipality] and determine where

there is unused land that [Municipality] could provide to the public for community gardening.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] directs the [Department of Public Works /

Department of Real Estate / other appropriate agency] to review and revise all laws and policies that

might erect unnecessary barriers to community gardening, farmers’ markets, or related activities. The

director of the [Department of Public Works / Department of Real Estate / other appropriate agency]

shall report its findings to the [Adopting body] within [insert appropriate period] of the date this

resolution is adopted.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] directs the [Community and Economic

Development Department / other appropriate agency] to identify any transportation barriers to

accessing supermarkets, farmers’ markets, or other healthy food retailers and determine where there

are opportunities to increase access to healthy food through public transportation, such as expanded

bus lines, light rail, subway, or shuttle routes. The director of the [Community and Economic

Development Department / other appropriate agency] shall report to the [Adopting body] with its

findings within [insert appropriate period] of the date this resolution is adopted.

III. Schools

BE IT FURTHER RESOLVED that [Municipality] pledges to support schools’ efforts to promote physical

activity and good nutrition by:

• Working with school districts, parent-teacher organizations, student organizations, and

community groups to expand youth and community opportunities for physical activity through

after school, weekend, and summer programs and by implementing joint use agreements and

other cooperative arrangements;

• Supporting schools’ efforts to cultivate school gardens;

• Supporting schools’ efforts to implement farm-to-school programs;

• Supporting school’s efforts to implement competitive food policies;

• Supporting school’s efforts to implement tobacco-free school policies;

• Collaborating with school districts to facilitate the location of schools within walking and biking

distance of the neighborhoods they serve; and

• Supporting school districts’ efforts to establish and implement “safe routes to school” programs.

BE IT FURTHER RESOLVED that [Municipality] recognizes that community gardens can improve nutrition,

physical activity, community engagement, safety, and economic vitality for a neighborhood and its

residents, and provide environmental benefits to the community at large. Therefore, [Municipality /

Adopting body] supports efforts to establish community gardens and encourages businesses, housing

providers, faith-based organizations, private citizens, and government agencies to donate or otherwise

provide land to communities for gardening.

BE IT FURTHER RESOLVED that [Municipality] pledges to support community efforts to establish and

maintain farmers’ markets, recognizing that farmers’ markets provide fresh produce to community

residents, support small farmers, and build community.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] strongly encourages farmers’ markets,

grocery stores, and other food retailers to accept EBT (electronic benefit transfer) cards and WIC

(Special Supplemental Nutrition Program for Women, Infants, and Children) vouchers to increase access

to healthy food for low-income families.

IV. Parks and Recreation

BE IT FURTHER RESOLVED that [Municipality / Adopting body / Department of Parks and Recreation]

shall review existing beverage and snack vending machine contracts, and upon renewal, revise these

contracts to eliminate [all / at least 75% of] sugar-sweetened beverages and snacks high in sugar and fat,

and replace them with snacks and beverages that support good health and nutrition, by [insert

appropriate date].

BE IT FURTHER RESOLVED that [Municipality / Adopting Body] encourages residents to use local parks

and hereby directs the Director of the [Department of Parks and Recreation] to create and publish a

“Family Resource Guide to Programs, Parks and Activities.” This guide shall be available to the public on

the municipal website, at parks and recreation offices, and at community centers within [3 months / 6

months / one year] of the date this resolution is adopted. The guide shall include recommendations for

being more physically active, as well as a list and descriptions of all public parks, playgrounds, and

community programs involving physical activity within the municipality.

BE IT FURTHER RESOLVED that [Municipality/Adopting Body] recognizes that tobacco use and exposure

to secondhand smoke is both a health and environmental issue. Therefore, [Municipality/Adopting

Body] directs the governing body to draft and vote on a resolution that all park and recreation facilities

owned by [Municipality / Adopting body], both indoor and outdoor, shall be 100% tobacco-free.

V. Community and Day Care Centers

BE IT FURTHER RESOLVED that [Municipality / Adopting body] strongly encourages community centers,

day care centers, after-school programs, and other youth-centered organizations to:

• Serve foods and beverages in accordance with the [USDA Dietary Guidelines for Americans /

Institute of Medicine’s Nutrition Standards for Foods in School] while eliminating foods and

beverages of minimal nutritional value;

• Expand opportunities for children and families to engage in physical activity wherever practical;

and

• Integrate the promotion of healthy eating and active living into their program activities.

• Implement tobacco-free policies for community and day care centers to create indoor and

outdoor areas that are 100% tobacco-free..

* Model after-school and childcare policies are being developed

VI. Food and Beverage Industry (Retailers)

BE IT FURTHER RESOLVED that [Municipality / Adopting body] encourages all restaurants doing business

in [Municipality] to support the health of our communities by offering and clearly identifying healthier

options on their menus.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] encourages all grocery stores, corner

stores, restaurants, and other food and beverage retailers doing business in [Municipality] to support

the health of our communities by increasing advertising of healthy items and decreasing

marketing/advertising of unhealthy items.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] encourages all restaurants doing business

in [Municipality] to support the health of our communities by placing all tobacco products behind the

counter and out of reach/eyesight from children under 18.

VII. [City / County] Hospitals (Healthcare Providers)

BE IT FURTHER RESOLVED that the [Municipality / Adopting body] urges the [Chief Executive Officers /

other appropriate hospital administrators] of [insert the names of city and/or county hospitals (health

care providers)] to review all existing beverage and snack vending machine contracts, and upon renewal,

revise these contracts to eliminate [all / at least 75% of] sugar-sweetened beverages and snacks high in

sugar and fat, and replace them with snacks and beverages that support good health and nutrition.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] urges the [Chief Executive Officers / other

appropriate hospital administrators] of [insert the names of city and/or county hospitals] to revise

cafeteria menus to comply with the current standards set forth in the USDA Dietary Guidelines for

Americans.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] urges the [Chief Executive Officers / other

appropriate hospital administrators] of [insert the names of city and/or county hospitals] to adopt

practices consistent with the UNICEF/WHO Baby-Friendly Hospital Initiative USA, to promote, protect

and support breastfeeding.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] urges the [Chief Executive Officers / other

appropriate hospital administrators] of [insert the names of city and/or county hospitals] to adopt

systems changes and practices that support BMI surveillance and patient education related to healthy

weight, physical activity, and nutrition.

VIII. Employee Wellness

BE IT FURTHER RESOLVED that in order to promote employee wellness within [Municipality], and to set

an example for other businesses, [Municipality / Adopting body] hereby directs the director of [the

Department of Human Resources / other appropriate department or agency] to work with key

stakeholders, including management municipal employees, and union representatives to draft a plan for

[implementing / enhancing] a municipal employee wellness program. In addition to the proposed

wellness policy, the plan shall include estimated program costs and estimated potential savings from

improved employee health and wellbeing. The director of [the Department of Human Resources / other

appropriate agency] shall present the plan for the municipal employee wellness program to the

[Adopting body] within [insert appropriate period] of the date this resolution is adopted. The wellness

policy shall include support of the tobacco-free municipality and offer smoking cessation programs

and/or incentives to employees.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] strongly encourages private employers to

adopt and implement employee wellness programs to promote physical activity and healthier eating.

BE IT FURTHER RESOLVED that [Municipality / Adopting body] strongly encourages private employers to

adopt and implement tobacco-free campus policies and to offer smoking cessation programs and/or

incentives to employees.

IX. Tobacco-Free Community

BE IT FURTHER RESOLVED that [Municipality / Adopting body] directs the governing body to draft and

vote on a resolution that all property and facilities owned by [Municipality / Adopting body], both

indoor and outdoor, shall be 100% tobacco-free.

X. Implementation

BE IT FURTHER RESOLVED that the head of each affected agency or department, including the [Director

of Community and Economic Development, Director of Parks and Recreation, City Manager’s Office,

Director of Public Works / Department of Real Estate / insert relevant departments] shall report back to

the [Adopting body] [annually / within one year of the date of Resolution’s adoption] regarding steps

taken to implement this Resolution, additional steps planned, and any desired actions that would need

to be taken by [Adopting body] or other agencies or departments to implement the steps taken or

planned.

APPENDIX C

VENDOR REGISTRATION FORM (Substitute Form W-9 )

PLEASE SUBMIT THIS FORM TO THE AGENCY WITH WHICH YOU DO BUSINESS

VENDOR NUMBER_________________

(County use only)

VENDOR INFORMATION - PLEASE PRINT

Company Name:_______________________Individual’s Name:__________________ (If Sole Proprietor):___________________Date of Birth_________________________ Taxpayer ID: FEIN: SSN:

Mailing Address (Street/P.O. Box, City, State & Zip): Contact Name: Phone #( ) Fax #( )

Remittance Address (If different than above): Contact Name: Phone #( ) Fax #( )

Type of ( )Agency ( )Corporation ( )Employee ( )Federal Agency Business: ( )State Agency ( )Local Government ( )Partnership ( )Proprietorship ( )Self ( )Other (PleaseExplain)

Small Business? ( )Yes ( )No Small Disadvantaged Business? ( )Yes ( )No Minority or Female Owned? ( )MBE ( )FBE Certified By:_________________________________ (i.e. - Federal SBA, State/Local Agency, Regional NMSDC Affliate)

I hereby certify that the information supplied herein is true and correct and I am a U.S. person (including a U.S. resident alien). ________________________________ _____________________ Signature of person filling out this form Date

FOR COUNTY USE ONLY This Vendor should be added to Hamilton County’s list of authorized vendors. ______________________ ___________ _____________________ Authorized Signature Department Number Date