Section 5310 Capital Grant Application

for Private Non-Profit Corporations

to Enhance Mobility Transportation

FY-2026

Private Non-Profit Organization Governmental Entity

General Information

Legal Name of Applicant Organization:
Unique Entity ID (UEI):
Address (include city, state, and zip code):
Name of Project Director or Supervisor:	Phone No.:	Email Address:
Name of Person Preparing this Application:	Phone No.:	Email Address:
Services Generally Provided by Applicant:

Demographics

Ethnicity of Clientele	Service Area Population	Percent of Total Service Area Population	Age Groups Served	Service Area Population	Percent
Black or African American	%	Under 5 years of age	%
Hispanic or Latino	%	5 to 19 years of age	%
Native Hawaiian or other Pacific Islander	%	20 to 44 years of age	%
Asian	%	45 to 59 years of age	%
Native American or Alaska Native	%	60 to 74 years of age	%
Non-Minority	%	Over 75 years of age	%
Total	%	Total	%

Transportation Project

Identify the Geographical Areas to be Served: (Include all towns, cities, counties)
Intended Use: (Check one) Replacement Expansion
Specific by Clientele Category: (the number of individuals that will be transported with the requested vehicle(s)
Elderly:
Mental Disability:
Physical Disability (requiring wheelchair lift or ramp):
Other: (specify i.e. visually impaired, etc.)
Total Number of Clientele:

Capital Assistance Vehicle(s) Requested

Prioritize Vehicle(s) Requested (1, 2, 3)	Vehicle	No. of Units	Vehicle Cost	Total Cost
Ford Transit Conversion Van	$98,000	$
Small Bus	$125,000	$
Lowered Floor Minivan	$77,000	$
*Requires Certification of Equivalent Service
Total Costs:	$
Total federal funds requested (80% of total costs)	$
Local share (20% difference between federal funds requested and total costs)	$

PLEASE NOTE: If you applied for and received a 5310 award from NDOT for a vehicle from a previous fiscal year, NDOT intends to procure the vehicle as supply chain and contract issues allow. You can apply for an additional vehicle(s) during the current round of applications (due August 1 thru October 31, 2025) only if you intend to replace another vehicle or expand service. If you are unclear about pending applications from previous cycles, please contact Carly Grutel at carly.grutel@nebraska.gov.

Number of passenger boardings last year for vehicle(s) being replaced:
Projected number of passenger boardings for vehicle(s) requested (per year):
Projected number of days per month the new vehicle(s) will be used:

Maintenance of Vehicles

To assure that vehicles acquired with Federal Transit Assistance funds are maintained in optimal operating condition, it is required that they be maintained in accordance with the vehicle manufacturer’s recommended maintenance schedule. Applicants must verify by certifying below.

Maintenance Certification

certifies that vehicles purchased under Section 5310 will be
maintained in accordance with detailed maintenance and inspection schedule provided by the manufacturer.

(printed name of person signing)	(Title)

(signature of authorized representative)	(Date)

Vehicle Being Replaced

This vehicle will be taken out of regular service (can be used as backup).

Year of Vehicle Being Replaced:
(vehicle must have been in service for at least four years or has a minimum of 100,000 miles)
Make:
Model:
Vehicle Identification No.:
Mileage:
Vehicle Condition:

Is this vehicle an FTA funded vehicle?

Yes	No

Identify which vehicle requested will replace the vehicle listed above.

Small bus	Ford transit	Lowered floor minivan

Project Justification (please add numerical data when possible)

A.	Describe benefits to be derived from the project to the elderly or disabled user:

B.	Identify shortcomings of existing services and how your project will overcome them:

C.	Describe in detail reason for expansion of vehicle fleet:

D.	Describe any plans to combine previously described transportation services and how this project will coordinate with existing transportation services. (Attach purchase of service and interagency agreements, or documentation of unsuccessful coordination efforts.)

E.	Will your agency use the vehicle for incidental use (e.g., meal or prescription medication delivery)?

Yes No

If yes, approximately how many miles per month will the vehicle travel to provide incidental services?

Local Governmental Authority Certification

(for governmental entities only)

As the authorized representative of	,
I certify that there are no nonprofit organizations readily available in the area to provide the service as described in the 5310 application.

(printed name of person signing)	(title)

(signature)	(date)

COMPLETE THE APPLICATION BY SIGNING BELOW.

CERTIFICATION: I hereby certify the information in this application is accurate and, as the authorized official for this project, hereby agree to comply with all provisions of the grant program and all other applicable state and federal laws.

(applicant’s authorized representative)	(title)	(date)

FTA FISCAL YEAR 2025 CERTIFICATIONS AND ASSURANCES

FEDERAL FISCAL YEAR 2025 FTA CERTIFICATIONS AND ASSURANCES SIGNATURE PAGE

(Required of all Applicants for federal assistance to be awarded by FTA in FY 2025)

AFFIRMATION OF APPLICANT

Name of the Applicant:
Name and Relationship of the Authorized Representative:

BY SIGNING BELOW, on behalf of the Applicant, I declare that is has duly authorized me to make these Certifications and Assurances and bind its compliance. Thus, it agrees to comply with all federal laws, regulations, and requirements, follow applicable federal guidance, and comply with the Certifications and Assurances as indicated on the foregoing page applicable to each application its Authorized Representative makes to the Federal Transit Administration (FTA) in federal fiscal year, irrespective of whether the individual that acted on his or her Applicant’s behalf continues to represent it.

FTA intends that the Certifications and Assurances the Applicant selects on the other side of this document should apply to each Award for which it now seeks, or may later seek federal assistance to be awarded during federal fiscal year 2025.

The applicant affirms the truthfulness and accuracy of the Certifications and Assurances it has selected in the statements submitted with this document and any other submission made to FTA, and acknowledges that the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. § 3801 et seq., and implementing U.S. DOT Regulations, “Program Fraud Civil Remedies,” 49 CFR part 31, apply to any certification, assurance or submission made to FTA. The criminal provisions of 18 U.S.C. § 1001 apply to any certification, assurance, or submission made in connection with a federal public transportation program authorized by 49 U.S.C. Chapter 53 or any other statute.

In signing this document, I declare under penalties of perjury that the foregoing Certifications and Assurances, and any other statements made by me on behalf of the Applicant are true and accurate.

Signature:	Date:
Name:
authorized representative of applicant

FEDERAL FISCAL YEAR 26-27 CERTIFICATIONS AND ASSURANCES

FOR FTA ASSISTANCE PROGRAMS

(Signature pages alternative to providing Certifications and Assurances in TrAMS)

Name of applicant:

The applicant certifies to the applicable provisions of all categories: (check here):

OR

The applicant certifies to the applicable provisions of the categories it has selected:

Category	Description
01.	Certifications and Assurances Required of Every Applicant
02.	Public Transportation Agency Safety Plans
03.	Tax Liability and Felony Convictions
04.	Lobbying
05.	Private Sector Protections
06.	Transit Asset Management Plan
07.	Rolling Stock Buy America Reviews and Bus Testing
08.	Urbanized Area Formula Grants Program
09.	Formula Grants for Rural Areas
10.	Fixed Guideway Capital Investment Grants and the Expedited Project Delivery for Capital Investment Grants Pilot Program
11.	Grants for Buses and Bus Facilities and Low or No Emission Vehicle Deployment Grant Programs
12.	Enhanced Mobility of Seniors and Individuals with Disabilities Programs
13.	State of Good Repair Grants
14.	Infrastructure Finance Programs
15.	Alcohol and Controlled Substances Testing
16.	Rail Safety Training and Oversight
17.	Demand Responsive Service
18.	Interest and Financing Costs
19.	Cybersecurity Certification for Rail Rolling Stock and Operations
20.	Tribal Transit Programs
21.	Emergency Relief Program

CERTIFICATIONS AND ASSURANCES SIGNATURE PAGE

AFFIRMATION OF APPLICANT

Name of the Applicant:

BY SIGNING BELOW, on behalf of the Applicant, I declare that it has duly authorized me to make these Certifications and Assurances and bind its compliance. Thus, it agrees to comply with all federal laws, regulations, and requirements, follow applicable federal guidance, and comply with the Certifications and Assurances as indicated on the foregoing page applicable to each application its Authorized Representative makes to the Federal Transit Administration (FTA) in the federal fiscal year, irrespective of whether the individual that acted on his or her Applicant’s behalf continues to represent it.

The Certifications and Assurances the Applicant selects apply to each Award for which it now seeks, or may later seek federal assistance to be awarded by FTA during the federal fiscal year.

The Applicant affirms the truthfulness and accuracy of the Certifications and Assurances it has selected in the statements submitted with this document and any other submission made to FTA, and acknowledges that the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. § 3801 et seq., and implementing U.S. DOT regulations, “Program Fraud Civil Remedies,” 49 CFR part 31, apply to any certification, assurance or submission made to FTA. The criminal provisions of 18 U.S.C. § 1001 apply to any certification, assurance, or submission made in connection with a federal public transportation program authorized by 49 U.S.C. chapter 53 or any other statute

In signing this document, I declare under penalties of perjury that the foregoing Certifications and Assurances, and any other statements made by me on behalf of the Applicant are true and accurate.

Signature	Date

Authorized Representative of Applicant

AFFIRMATION OF APPLICANT’S ATTORNEY

Name of the Applicant:

As the undersigned Attorney for the above-named Applicant, I hereby affirm to the Applicant that it has authority under state, local, or tribal government law, as applicable, to make and comply with the Certifications and Assurances as indicated on the foregoing pages. I further affirm that, in my opinion, the Certifications and Assurances have been legally made and constitute legal and binding obligations on it.

I further affirm that, to the best of my knowledge, there is no legislation or litigation pending or imminent that might adversely affect the validity of these Certifications and Assurances, or of the performance of its FTA assisted Award.

Signature	Date

Attorney for Applicant

Each Applicant for federal assistance to be awarded by FTA must provide an Affirmation of Applicant’s Attorney pertaining to the Applicant’s legal capacity. The Applicant may enter its electronic signature in lieu of the Attorney’s signature within TrAMS, provided the Applicant has on file and uploaded to TrAMS this hard-copy Affirmation, signed by the attorney and dated this federal fiscal year.