RESTORE Act Direct Component & Centers of Excellence Research Grants Program

RESTORE ACT Direct Component Multiyear Plan Matrix — Department of the Treasury

OMB Approval No. 1505-0250

Applicant Name:

1. MULTIYEAR PLAN VERSION (INITIAL OR AMENDMENT NUMBER):

2a. DATE OF INITIAL MULTIYEAR PLAN ACCEPTANCE (mm/dd/yyyy):

3. CUMULATIVE DIRECT COMPONENT ALLOCATION AVAILABLE FOR DISTRIBUTION TO APPLICANT:
5. Primary Direct Component Eligible
Activity Further Described in Application
(Static Field)

6. Activity Title (Static Field)

7. Location (Static Field)

2b. DATE OF LAST MULTIYEAR PLAN ACCEPTANCE:

4. TOTAL ALLOCATIONS PLUS KNOWN FUNDS NOT YET DEPOSITED IN TRUST FUND FOR DIRECT COMPONENT:
8. Estimated Total Funding Contributions For Proposed Activity(ies)(refer to Instructions)
8a. Direct Component
Contribution

8b. Other RESTORE Act
Contribution

8c. Other Third Party
Contribution

8d. Total Contribution

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

9. Proposed Start Date
mm/dd/yyyy

10. Proposed End Date
mm/dd/yyyy

11. Status (refer to Instructions)

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

12. ESTIMATED TOTAL FUNDING CONTRIBUTIONS FOR ACTIVITY(IES) (refer to
Instructions)

$0.00

$0.00

$0.00

Please note: Grant awards may reflect non-material changes in proposed dates and

$0.00 estimated funding.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to complete this information collection, including the time
to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

Instructions for Completing the Multiyear Implementation Plan Matrix
Note: the term ”static field” means that the information in the field will not change when the applicant amends the Multiyear Plan.
Box or
column
number

Instructions

1

Multiyear Plan Version Indicate whether the version is the initial multiyear plan submittal or an amendment to an existing Treasuryaccepted multiyear plan. For example, the first amendment to the plan would be "amendment #1."

2a

Date of Initial Multiyear Plan Acceptance If this is the initial multiyear plan, put N/A. If this is an amendment to a Treasury-accepted
multiyear plan, provide the date of initial acceptance.

2b

Date of Last Multiyear Plan Acceptance Provide the date of the last multiyear plan amendment acceptance.

3

Cumulative Direct Component Allocation Available For Distribution to Applicant Total amount of funds that Treasury allocated to the
applicant under the Direct Component portion of the RESTORE Act Gulf Coast Restoration Trust Fund, the allocation available to Applicant
can be found on Treasury's RESTORE Act website.

4

5

Total Direct Component Allocations Plus Known Funds Not Yet Deposited in Trust Fund All Trust Fund current allocation(s) and not-yetdeposited funds that represent known future allocations from the Trust Fund that the applicant plans to apply to the activities it proposes in
its multiyear plan. The reference to the "not-yet-deposited funds that represent known future allocations from the Trust Fund" means future
payments into the Trust Fund expected from a final court decree or settlement agreement .
Primary Direct Component Eligible Activity From the drop-down menu, choose the primary qualifying Direct Component eligible activity
from the RESTORE Act: 1) Restoration and protection of the natural resources, ecosystems, fisheries, marine and wildlife habitats, beaches,
and coastal wetlands of the Gulf Coast Region; 2) Mitigation of damage to fish, wildlife, and natural resources; 3) Implementation of a
federally approved marine, coastal, or comprehensive conservation management plan, including fisheries monitoring; 4) Workforce
development and job creation; 5) Improvements to or on State parks located in coastal areas affected by the Deepwater Horizon oil spill; 6)
Infrastructure projects benefitting the economy or ecological resources, including port infrastructure; 7) Coastal flood protection and related
infrastructure; 8) Planning assistance; 9) Promotion of tourism in the Gulf Coast Region, including recreational fishing; and 10) Promotion of
the consumption of seafood harvested from the Gulf Coast Region The applicant will list any other applicable proposed eligible activities in

6

Activity Title is assigned by the applicant for the activity/project/program.

7

Location - If county-wide or state-wide activity, list the specific municipality(ies) where the activity shown on the accompanying map will
occur. (Static Field)

8

Total Funding Contributions for Proposed Activity(ies) List the total funds the applicant will use for the proposed activity.

8a.

Direct Component Contribution may include both the portion of the allocation issued by Treasury and the not-yet-deposited funds that
represent known future allocations from the Trust Fund’s Direct Component scope of work portion that the applicant plans to use for the
proposed activity.

8b.

Other RESTORE Act Contribution includes the total amount of other RESTORE Act funding that the applicant will rely on to complete the
proposed activity. For example, the Spill Impact Component (or other RESTORE Act Component) may include both the portion of the current
allocation(s) and the not-yet-deposited funds that represent known future allocations from the Trust Fund that the applicant plans to use for
the proposed activity. The applicant will list specific RESTORE Act source of funds in the Direct Component Federal Financial Assistance
Application.

8c.

Other Third Party Contribution includes in-kind, for profit and nonprofit, federal, state, or local funding that the applicant will rely upon to
complete the proposed activity. The applicant will list specific sources of funds in the Direct Component Federal Financial Assistance
Application.

8d.

9

Total Contribution is the total amount from all funding sources including the Direct Component funds allocated by Treasury and the not-yetdeposited funds that represent known future allocations from the Trust Fund’s Direct Component; other current RESTORE Act allocation(s)
and not-yet-deposited funds that represent known future allocations from the Trust Fund; and other third party funds that the applicant
plans to use for a proposed activity.
Proposed Start Date is provided by the applicant. This is an estimated start date that is anticipated by the applicant. It must not be earlier
than the project grant award anticipated date.

10

Proposed End Date is provided by the applicant. This is an estimated end date based on the anticipated project period of performance.

11

Status Leave blank for initial multiyear plan. If this submission is an amendment to a previously Treasury-accepted multiyear plan, state the
current status of the activity(ies) included in the previously accepted plan(s) (e.g., activity funded, change in scope, change in eligible activity,
completed activity, deleted activity, etc.).

12

Estimated Total Funding Contributions for Activity (ies) The totals should include activities listed on any additional pages.

12a.

Total Funding of Direct Component Contributions include both the portion of the allocation issued by Treasury and the not-yet-deposited
funds that represent known future allocations from the Trust Fund’s Direct Component portion that the applicant plans to use for the Direct
Component's scope of work of its proposed activity, which cannot exceed the combined total of allocated and known to-be-allocated funds,
for all proposed activities listed on the Matrix.

12b.

Total Funding of All Other RESTORE Act Contributions for all proposed activities listed on the Matrix that may include the other current
allocation(s) and not-yet-deposited funds that represent known future allocations from the Trust Fund.

12c.

Total Funding of all Other Third Party Contributions for all proposed activities listed on the Matrix.

12d.

Total Funding Contributions for all Proposed Activities listed on the Matrix that may include Direct Component; other current allocations and
not-yet-deposited funds that represent know future allocations from the Trust Fund; and other third party funds.

Page 2

RESTORE ACT Direct Component Multiyear Plan Narrative 

Department of the Treasury 

OMB Approval No. 1505-0250

Directions:  Use this form for the Initial Multiyear Plan and any subsequent amendments to an 
accepted Multiyear Plan.  For amendments, include only new and/or materially modified activities. 
Multiyear Plan Version (Initial or Amendment Number):
Date of Initial Multiyear Plan Acceptance:
Date of Last Multiyear Plan Acceptance:
Eligible Applicant Name:
Name and Contact Information of the Person to be contacted (POC) on matters concerning this Multiyear Implementation Plan:

POC Name:
POC Title:
POC Email:
POC Phone:
NARRATIVE DESCRIPTION:
1. A description of each activity, including the need, purpose, objective(s), milestones and location. Include map showing the location of
each activity.

2. How the applicant made the multiyear plan available for 45 days for public review and comment, in a manner calculated to obtain
broad-based participation from individuals, businesses, Indian tribes, and non-profit organizations, such as through public meetings,
presentations in languages other than English, and postings on the Internet. The applicant will need to submit documentation (e.g., a
copy of public notices) to demonstrate that it made its multiyear plan available to the public for at least 45 days. In addition, describe
how each activity in the multiyear plan was approved after consideration of all meaningful input from the public and submit
documentation (e.g., a letter from the applicant's leadership approving submission of the multiyear plan to Treasury or a resolution
approving the applicant's multiyear plan).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time
required to complete this Information collection, including the time to review instructions, search existing data resources, gathering and
maintaining the data needed, and completing and reviewing the collection of information, should be directed to the Department of the
Treasury, Office of Gulf Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

3. How each activity included in the applicant's multiyear plan narrative meets all the requirements under the RESTORE Act, including a
description of how each activity is eligible for funding based on the geographic location of each activity and how each activity qualifies
for at least one of the eligible activities under the RESTORE Act.

4. Criteria the applicant will use to measure the success of the activities included in the multiyear plan narrative in helping to restore and
protect the Gulf Coast Region impacted by the Deepwater Horizon oil spill.

5. How the activities included in the multiyear plan narrative were prioritized and list the criteria used to establish the priorities.

6. If applicable, describe the amount and current status of funding from other sources (e.g., other RESTORE Act contribution, other
third party contribution) and provide a description of the specific portion of the project to be funded by the RESTORE Act Direct
Component.

RESTORE Act Direct Component Application Narrative
Department of the Treasury
OMB Approval No. 1505-0250

The Direct Component Funding Opportunity Announcements describe in detail the content and information required for your
application submission. This application form must be included with your application, along with the separate Direct
Component Application Narrative Supplement (i.e., project and budget narratives) and other documentation as required by
the relevant Funding Opportunity Announcement.
GENERAL INFORMATION: (This section must be completed)
Applicant:
Applicant Name:
Descriptive Title of Project:
(refer to SF-424)

Project Title:

Activity Title from Multiyear Plan (MYP) Matrix:
Column #6

MYP Activity Title:

A. STATUTORY QUESTIONS
1. Qualifying eligible activity:
Please select the primary eligible activity in the
first column, and select all other eligible
activities that apply in the second column.

Select
Primary
Activity

Select All
Others
That
Apply
☐

☐

☐
☐
☐

☐
☐
☐
☐
☐
2. Was this proposed activity included in any claim for
compensation paid out by the Oil Spill Liability Trust Fund after
July 6, 2012?

Yes

Qualifying Eligible Activity

1. Restoration and protection of the natural
resources, ecosystems, fisheries, marine and
wildlife habitats, beaches and coastal wetlands
of the Gulf Coast Region
2. Mitigation of damage to fish, wildlife and
natural resources
3. Implementation of a federally approved
marine, coastal, or comprehensive conservation
management plan, including fisheries
monitoring
4. Workforce development and job creation
5. Improvements to or on State parks located in
coastal areas affected by the Deepwater
Horizon oil spill
6. Infrastructure projects benefitting the
economy or ecological resources, including port
infrastructure
7. Coastal flood protection and related
infrastructure
8. Planning assistance
9. Promotion of tourism in the Gulf Coast
Region, including recreational fishing
10. Promotion of the consumption of seafood
harvested from the Gulf Coast Region
No

If “Yes,” this activity is not eligible for a Direct Component
grant.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to
complete this information collection, including the time to review instructions, search existing data resources, gathering and maintaining the
data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf
Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

Page 1

3. Location/Primary Place of Performance
(a) Please provide the actual location for the
activity as street address, nearest
intersection, and note boundaries on a
submitted map. If there is more than one
location for the activity, include a list of
the additional locations, city/town,
county/parish, state, and zip code in the
Direct Component Application Narrative
Supplement.

Location:

City/Town:
County/Parish:
State:
Zip code:

(b) If available, provide latitude/longitude(s)
or GPS coordinates for the location(s) of
the project.
(c) If a GIS shape file is available, please
provide a point of contact (name and
email address) from whom the file may
be obtained.

B.

DISCUSSION OF SPECIFIC ACTIVITY (This information will supplement the Direct Component Application Narrative
Supplement.)

1. Best Available Science, if applicable
The RESTORE Act requires activities designed to protect or restore natural resources to be based on the ‘best available science,’
which is defined in the Act as science that (a) maximizes the quality, objectivity, and integrity of information, including statistical
information; (b) uses peer-reviewed and publicly available data; and (c) clearly documents risks and uncertainties in the scientific
basis for such projects.
Is the proposed activity designed to protect or restore natural resources? (If yes, a detailed response must be included with the
Direct Component Application Narrative Supplement.)
Yes

No

2. Permits
Directions: Answer the following items concerning permits, if applicable.
(a) Permits
Does the proposed activity require any federal, tribal, state, or other permits? (For potential federal environmental permits,
see Environmental Checklist and Environmental Checklist Reference Guidance.)
Yes

No

If yes, a list of the specific federal, tribal, state, or other permits required for this project and the status of the permits
must be included with the Direct Component Application Narrative Supplement.
3. Land Acquisition, Construction, and Relocation Assistance
Directions: Answer the following items concerning land acquisition, construction, and relocation assistance, if applicable, and
provide the appropriate supporting documentation.
(a) Land Acquisition Activities
Will land or interest in land be acquired?

Page 2

Yes

No

If yes, answer questions i - vii:
i. What are the legal rights that will be acquired?
Fee Simple Title

Less-Than-Fee Simple Title (e.g., easement)

ii. If an easement, what is the life of the easement?
iii. What is the tax parcel number(s)? __________________ (Include the legal description of the property with the Direct
Component Application Narrative Supplement.)
iv. Will the applicant (or subrecipient) hold title to the land? Yes

No

v. What is the total acreage of the proposed property interest to be acquired?
vi. Has the applicant (or subrecipient) obtained a recent certified appraisal of the property?

Yes

No

If yes, attach a copy of the appraisal with the Direct Component Application Narrative Upload.
vii. Has the applicant (or subrecipient) obtained a title opinion or certificate?

Yes

No

If yes, attach a copy of the title opinion or certificate with the Direct Component Application Narrative Supplement.
viii. Has the applicant (or subrecipient) obtained a signed statement from the seller(s) that he/she is a willing seller and has
not been coerced into selling or conveying the property interest?

Yes

No

If yes, attach a copy of the signed willing seller statement with the Direct Component Application Narrative Supplement.
(b) Construction
Does the project include construction?
If yes, answer questions i-iii:

Yes

No

i. Will or does the applicant (or subrecipient) hold title to the property to be improved? Yes

No

ii. What is the tax parcel number(s) of the property? __________________ (Include the legal description of the property with
the Direct Component Application Narrative Supplement.)
iii. Has the applicant (or subrecipient) obtained a recent certified appraisal of the property?

Yes

No

If yes, attach a copy of the appraisal with the Direct Component Application Narrative Supplement.
(c) Relocation Assistance
Will the proposed project cause the displacement of any persons, businesses, or farm operations?

Yes

No

If yes, as required by Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970,
explain: the number of displaced persons, including businesses and farm operations; what fair and reasonable relocation
payments and advisory services will be provided to any displaced persons; and what provisions will be made to ensure that
safe, decent, and sanitary replacement dwellings will be available to such persons within a reasonable period of time prior to
displacement.

Page 3

Direct Component Narrative Supplement
All applicants must provide a narrative supplement including the following information with the
application as an upload in GrantSolutions.gov. The information is required unless it is not
applicable to the project, program, or activity. Applicants should review the applicable funding
opportunity announcement and Treasury guidance for a complete list and explanation of
requirements.
1. Applicant Name
2. Descriptive Project Title (refer to SF-424)
3. Additional Locations (not included in the Direct Component Application Narrative form,
if applicable)
4. Proposed Scope of Work - A detailed scope of work that fully describes the project or
program for which funding is requested, including:
a. Project or Program Description
b. Need
c. Purpose
d. Objectives that clearly identify with the eligible activity(ies)
e. How the proposed project activity will be carried out in the Gulf Coast Region as
defined in 31 CFR 34.2. Attach a map showing the project location in the Gulf
Coast Region.
f. Possible material risks in implementing and maintaining the proposed activity,
e.g., operational, legal, regulatory, budgetary, or ecological risks, with a brief
discussion of mitigation strategies that the applicant may need to address in order
to implement and/or maintain the proposed activity. If the applicant determines
that there are no material risks, then include a statement summarizing the
determination.
g. Key Personnel, including name and contact information for the following:
i. The applicant’s Authorizing Official who is authorized to sign the grant
application and award,
ii. The Project Director who is responsible for the project, and
iii. The Financial Officer who is responsible for maintaining the accounting
and financial records of the grant.
h. A description of all funding sources included on the SF‐424.
5. Budget Justification – Provide a detailed budget that supports the proposed scope of
work. The budget justification should relate each budget category listed in the SF‐424A
and SF‐424C (see below) to the specific tasks identified in the proposed scope of work,
including any third party funding. The budget justification should provide specific
justification for all budget categories that apply; including an explanation of the
necessity, allowability, reasonableness, and allocability of proposed costs. (See relevant
Funding Opportunity Announcement for a complete description of the budget categories.)
a. Total Budget
b. Amount of Total Budget incurred pre-award
c. Personnel (Salaries and Fringe)

d. Travel
e. Equipment
f. Supplies
g. Contractual
h. Subawards
i. Construction
j. Other
k. Indirect Costs
6. Identification of Other Funding Sources (if applicable) - Some Direct Component
projects will require additional funds to cover the full cost of the project (“other funds”),
which may include local government funds, state funds, or other federal funds. Treasury
requires documentation of proof of availability of other funds needed for completion of
project activities. Treasury will not award funds for the non-federal share of a project
receiving funding from another Federal agency until the other Federal agency has
approved the activity and Treasury receives documentation of the approval.
7. Contractor (if applicable) – Indicate if the applicant plans to contract out any work
described in the Scope of Work and included in the Budget Justification above (do not
include subrecipient’s contractors). Describe the expected number of contracts, method of
procurement, and the applicant’s plan for monitoring contractor performance and
compliance. If a contractor has already been selected include the following:
a. Name of each contractor;
b. DUNS number of each contractor;
c. Date the applicant executed each contract; and
d. Amount of each contract awarded.
8. Subrecipient (if applicable) - If the proposed project includes a subaward, include a
separate, clearly defined scope of work and budget for the subrecipient. Describe how the
applicant selected or plans to select subrecipient(s), the applicant’s plan for monitoring
the subrecipient(s) performance and compliance, and the means by which the applicant
will assess each subrecipient’s level of risk. If a subrecipient has already been selected
include the following:
a. Name of each subrecipient;
b. DUNS number of each subrecipient;
c. Date of applicant selection of each subrecipient; and
d. Amount of funds to be provided to each subrecipient
9. Milestones – List the milestones and the estimated timeframe for completion (i.e.,
performance period start date + number of months to completion)
10. Performance Measures – include the following (see illustrative list of performance
measures on Treasury’s RESTORE Act website):
a. Measure: An indicator of success toward reaching a goal. The measure should
reflect how the applicant will evaluate success from the narrative of the accepted
multiyear plan.
b. Baseline: The starting point of the measure. It is the status quo without the grant
award.

c. Target: The anticipated result of the measure. It is the anticipated new status with
the grant award.
11. MYP Consistency - Describe whether the proposed scope of work differs from the
corresponding project/program identified in the applicant’s Multiyear Plan accepted by
Treasury. If no differences exits, make an affirmative statement as to their consistency.
12. Best Available Science (if applicable) - The RESTORE Act requires activities designed
to protect or restore natural resources to be based on the 'best available science,' which is
defined in the Act as science that (a) maximizes the quality, objectivity, and integrity of
information, including statistical information; (b) uses peer-reviewed and publicly
available data; and (c) clearly documents risks and uncertainties in the scientific basis for
such projects. The applicant must make a determination that a project designed to protect
or restore natural resources is based on the best available science. (See Direct Component
FAQs on Treasury’s RESTORE Act website.) In order to support this determination, the
applicant must:
a. Explain how the project’s natural resource protection and/or restoration objectives
and proposed methods are based on best available science;
b. Summarize any risks or uncertainties associated with the project and explain how
these risks will be mitigated;
c. Cite and describe peer reviewed literature or publicly available data. For each
source cited, the applicant must provide sufficient citations, including:
i. Title;
ii. Journal in which the literature source appeared, if applicable;
iii. Publication date;
iv. Author(s); and
v. Web address if downloaded or available online.
d. Upload any cited planning documents, internal reports and/or other
documentation of site conditions that are not part of peer-reviewed literature
and/or are not publicly available with the application.
e. Summarize the following:
i. The peer-reviewed information that justifies the proposed objectives,
including methods used for the proposed activity.
ii. The literature sources’ conclusions and any uncertainties or risks in the
scientific basis that would apply to the proposed activity.
iii. How, if the information supporting the proposed activity does not directly
pertain to the Gulf Coast Region, the applicant’s methods reasonably
support and are adaptable to that geographic area.
iv. An evaluation of uncertainties and risks in achieving the project’s best
available science objectives over the longer term.
13. Permits or Authorizations (if applicable) – Provide a list of the specific federal, tribal,
state, or other permits or authorizations required for the project and their status. If permits
or authorizations have already been obtained, include them with the application. (For
federal environmental requirements, see Environmental Checklist and Environmental
Checklist Reference Guidance.)

14. Construction and Land Acquisition Projects (if applicable) – Projects that include
construction and/or land acquisition may require additional supporting documentation
including the following:
a. Legal description of the property and tax parcel number;
b. Title Opinion or certificate;
c. A signed statement from the seller(s) that he/she is a willing seller and has not
been coerced into selling or conveying the property interest;
d. Certified appraisal
e. Construction drawings

RESTORE Act Direct Component Applicant Certifications
Department of the Treasury
OMB Approval No. 1505-0250
Directions: These certifications are required by federal law and Department of the Treasury (Treasury) regulations to be submitted with each application
to Treasury for financial assistance under the RESTORE Act Direct Component. The certifications must be signed by an authorized senior official of the
Applicant who can legally bind the entity and has oversight for the administration and use of the Direct Component funds.

A. RESTORE Act Certification
1. Pursuant to the RESTORE Act, I certify that for any award
agreement resulting from this application:
(a) Each activity funded under this agreement has been primarily
designed to plan for or undertake activities to restore and protect one
or more of the following: the natural resources, ecosystems, fisheries,
marine and wildlife habitats, beaches, coastal wetlands, or economy of
the Gulf Coast region.
(b) Each activity funded under this agreement is designed to carry out
one or more of the eligible activities for the Direct Component.
(c) Each activity funded under this agreement was selected after
consideration of all meaningful input from the public, including broadbased participation from individuals, businesses, Indian tribes, and
nonprofit organizations, as described in the grant application. The
certification in this paragraph (1)(c) does not apply to planning
assistance funds to prepare and amend the Multiyear Implementation
Plan.
(d) Each activity funded under this agreement that protects or restores
natural resources is based on the best available science, as that term
is defined in 31 C.F.R. Part 34.
(e) The Applicant has procedures in place for procuring property and
services under this award that are consistent with the procurement
standards applying to Federal grants. The Applicant will not request
funds under this award for any contract unless this certification remains
true and accurate.
(f) Pursuant to 2 C.F.R. § 200.303, the Applicant will establish and
maintain effective internal control over all award agreements resulting
from this application, and provide reasonable assurance that the
Applicant will manage the award in compliance with Federal statutes,
regulations, and the terms and conditions of the award. The Applicant
knows of no material deficiencies in its internal controls.
(g) A conflict of interest policy consistent with 2 C.F.R. § 200.318(c) is
in effect and covering each activity funded under this Agreement.
(h) The Applicant will comply with Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, and all other applicable federal
laws and regulations concerning anti-discrimination.
2. I make each of these certifications based on my personal knowledge
and belief after reasonable and diligent inquiry, and I affirm that the
Applicant maintains written documentation sufficient to support each
certification made above, and that the Applicant’s compliance with
each of these certifications is a condition of the Applicant’s initial and
continuing receipt and use of the funds provided under this Agreement.

B. Certification Regarding Debarment, Suspension,
and Other Responsibility Matters -- Primary Covered
Transactions: Instructions for Certification
1. By signing and submitting this Application, the prospective primary
participant (the Applicant) is providing the certification set out below.
2. The inability of an Applicant to provide the certification required
below will not necessarily result in the denial of participation in this
covered transaction. The prospective Applicant shall submit an
explanation of why it cannot provide the certification set out below.
The certification or explanation will be considered in connection with
Treasury’s approval of the proposed application. However, failure of
the Applicant to furnish a certification or an explanation shall disqualify
such person/entity from participation in this transaction.
3. This certification is a material representation of fact upon which
reliance is placed when Treasury determines to enter into this
transaction. If it is later determined that the Applicant knowingly
rendered an erroneous certification, in addition to other remedies
available to the Federal government, Treasury may terminate this
transaction for cause or default.
4. The Applicant shall provide immediate written notice to Treasury if at
any time the Applicant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed
circumstances.
5. The terms “covered transactions,” “debarred,” “suspended,”
“ineligible,” “lower tier covered transaction,” “participant,” “person,”
“primary covered transaction,” “principal,” “proposal”, and “voluntarily
excluded,” as used in this clause (certification), have the meanings set
out in the Definitions and Coverage sections of the rules implementing
Executive Order 12549. You may contact Treasury for assistance in
obtaining a copy of those regulations (31 C.F.R. Part 19).
6. The Applicant agrees by submitting this Application that, should the
proposed covered transaction be entered into, it shall not knowingly
enter into any lower tier covered transaction with a person who is
debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by
Treasury.
7. The Applicant further agrees by submitting this Application that it will
not award any contract or subaward to any entity on the governmentwide Excluded Parties List System (see 31 C.F.R. Part 19, Appendix).
8. A participant in a covered transaction may rely upon a certification of
a prospective participant in a lower tier covered transaction that it is not
debarred, suspended, ineligible, or voluntarily excluded from the
covered transaction, unless it knows that the certification is erroneous.
A participant may decide the method and frequency by which it
determines the eligibility of its principals. Each participant may, but is
not required to, check the Nonprocurement List.
9. Nothing contained in the foregoing shall be construed to require
establishment of a system of records in order to render in good faith
the certification required by this clause. The knowledge and

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to complete this
information collection, including the time to review instructions, search existing data resources, gathering and maintaining the data needed, and
completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf Coast Restoration, 1500
Pennsylvania Ave., NW, Washington, DC 20220.

Page 2
information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of
business dealings.
10. Except for transactions authorized under paragraph 6 of these
instructions, if a participant in a covered transaction knowingly enters
into a lower tier covered transaction with a person who is suspended,
debarred, ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal
government, Treasury may terminate this transaction for cause or
default.

C. Certification Regarding Debarment, Suspension,
and Other Responsibility Matters -- Primary Covered
Transactions
1.The prospective primary participant (the Applicant) certifies to the
best of its knowledge and belief, that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from covered transactions
by any Federal department or agency;
(b) Have not within a three-year period preceding this Application been
convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or local)
transaction or contract under a public transaction; violation of Federal
or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly
charged by a governmental entity (Federal, State or local) with
commission of any of the offenses enumerated in paragraph (1)(b) of
this certification; and
(d) Have not within a three-year period preceding this Application had
one or more public transactions (Federal, State or local) terminated for
cause or default.
2. Where the Applicant is unable to certify to any of the statements in
this certification, such Applicant shall attach an explanation to this
proposal.

D. Certification Regarding Drug-Free Workplace
Requirements
1. The Applicant certifies that it will provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful
manufacture, distribution, dispensing, possession, or use of a
controlled substance is prohibited in the Applicant’s workplace and
specifying the actions that will be taken against the employee for
violations of such prohibition;
(b) Establishing a drug-free awareness program to inform employees
about:
(i) The dangers of drug abuse in the workplace;
(ii) The Applicant’s policy of maintaining a drug-free workplace;
(iii) Any available drug counseling, rehabilitation, and employee
assistance program; and
(iv) The penalties that may be imposed upon employees for drug
abuse violations occurring in the workplace.

(c) Making it a requirement that each employee to be engaged in the
performance of the award be given a copy of the statement required by
paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a)
that, as a condition of employment in such grant, the employee will:
(i) Abide by the terms of the statement; and
(ii) Notify the employer of any criminal drug use statute conviction
for a violation occurring in the workplace no later than five
calendar days after such conviction;
(e) Notifying the granting agency in writing, within ten calendar days
after receiving notice of a conviction under paragraph (d)(ii) from an
employee or otherwise receiving actual notice of such conviction;
(f) Taking one of the following actions, within 30 days of receiving
notice under paragraph (d)(ii) , with respect to any employee who is so
convicted:
(i) Taking appropriate personnel action against such an
employee, up to and including termination, consistent with the
requirements of the Rehabilitation Act of 1973, as amended; or
(ii) Requiring such employee to participate satisfactorily in a drug
abuse assistance or rehabilitation program approved for such
purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency; and
(g) Making a good faith effort to continue to maintain a drug-free
workplace through implementation of paragraphs (a) through (f).

E. Certification Regarding Lobbying
1.The Applicant certifies, to the best of its knowledge and belief, that:
(a) No Federal appropriated funds have been paid or will be paid, by or
on behalf of the Applicant, to any person for influencing or attempting
to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement.
(b) If any funds other than Federal appropriated funds have been paid
or will be paid to any person for influencing or attempting to influence
an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of
Congress in connection with this Application, the undersigned shall
complete and submit Standard Form-LLL, ‘‘Disclosure Form to Report
Lobbying,’’ in accordance with its instructions.
(c) The Applicant shall require that the language of this certification be
included in the award documents for all subawards at all tiers
(including subcontracts, subgrants, and contracts under grants, loans,
and cooperative agreements) and that all sub-recipients shall certify
and disclose accordingly.
2. This certification is a material representation of fact upon which
reliance is placed when this transaction is made or entered into.
Submission of this certification is a prerequisite for making or entering
into this transaction imposed by title 31 U.S. Code section 1352. Any
person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.

Signature of Authorized Senior Official:

Name:

Date:

Title:

Organization:

RESTORE Act Environmental Checklist
Department of the Treasury

OMB Approval Number 1505‐0250

Directions: The following questions will aid the applicant in identifying the environmental laws that may
apply to the eligible activity and the environmental documents that should be submitted with the application.
If a response of “Yes” is recorded to any of the following questions, the applicant should summarize the status
of any actions taken in the table located on the last page of the checklist. Treasury will use submitted
documents to record the applicant’s assertion that it has complied with applicable environmental laws. For
projects that will be implemented by a subrecipient, applicants may submit an Environmental Checklist
completed by an authorized representative employed by the subrecipient. A statement from the applicant
attesting to its review of the subrecipient’s Environmental Checklist must be submitted with the application.
Please note: More information, references, and links to all the laws and executive orders can be found in
the Environmental Checklist Reference Guide on Treasury’s RESTORE Act website.

PROPOSED PROJECT NAME:
APPLICANT NAME:
INFORMATION PROVIDED BY:

1)

NAME:

DATE:

TITLE:

ORGANIZATION:

__

NATIONAL ENVIRONMENTAL POLICY ACT (NEPA): Will the proposed activity be subject to any
federal permitting authority, subject to any federal regulatory decision or approval, and/or receive
federal assistance of any federal agency (other than RESTORE Act funding associated with this
application)?
Yes

No

Uncertain

If yes, list the federal agency(ies): ________________________________________
Has a NEPA or NEPA-like review been prepared for this proposed eligible activity or is a NEPA review
underway? (NEPA documentation may include a Categorical Exclusion (CE), Environmental
Assessment (EA)/Finding of No Significant Impact, or an Environmental Impact Statement (EIS), or a
1

state or tribal equivalent, or the issuance of or a public notice of intent to issue a federal permit,
such as a USACE Section 404/10 permit).
Yes

No

If yes, list the document(s) and federal agency(ies): ________________________________________

Upload a copy of the environmental review document with your application.

2)

COASTAL ZONE MANAGEMENT ACT (CZMA): If the activity will occur in or near the state’s
designated coastal zone, and therefore in the Gulf Coast Region as defined in Treasury’s regulations
at 31 CFR 34.2, is the activity likely to have reasonably foreseeable effects on any land or water use
or natural resource of the designated coastal zone?
Yes

No

If yes, a federal consistency determination or certification pursuant to Section 307 of the CZMA may
be required, from the state agency responsible for CZMA consistency.

3)

NATIONAL MARINE SANCTUARIES ACT: Is the proposed activity located in a National Oceanic and
Atmospheric Administration (NOAA) National Marine Sanctuary?
Yes

No

If yes, identity the National Marine Sanctuary: ____________________________
A permit or other authorization may be required from NOAA.

4)

MAGNUSON – STEVENS FISHERY CONSERVATION AND MANAGEMENT ACT: Will the proposed
activity occur in proximity to an Essential Fish Habitat (EFH) as identified by NOAA’s National Marine
Fisheries Service (NMFS)?
Yes

No

If yes, identity the EFH types: ____________________________
If yes, consultation with NMFS Habitat Conservation Division may be required.

2

5)

MARINE MAMMAL PROTECTION ACT (MMPA) (NMFS): Will the proposed activity occur in
proximity to any known marine mammals under the jurisdiction of the NMFS?
Yes

No

Will the proposed activity likely result in the take of a marine mammal? “Take” as defined under the
MMPA means "to harass, hunt, capture, or kill, or attempt to harass, hunt, capture, or kill any
marine mammal" (16 U.S.C. 1362).
Yes

No

Uncertain

If yes, identify the marine mammal(s): ___________________________________
A consultation and/or permit from the NMFS may be required.
6)

MARINE MAMMAL PROTECTION ACT (USFWS): Will the proposed activity occur in proximity to
any known marine mammals under the jurisdiction of the U.S. Fish and Wildlife Service (USFWS)?
Yes

No

Will the proposed activity likely result in the take of a marine mammal?
Yes

No

Uncertain

If yes, identify the marine mammal(s): ___________________________________
A consultation and/or permit from the USFWS may be required.

7)

ENDANGERED SPECIES ACT (ESA) (USFWS): Will the proposed activity occur in proximity to
threatened or endangered species or critical habitat as defined by the ESA and under the jurisdiction
of the USFWS?
Yes

No

Will the proposed activity potentially affect threatened or endangered species or critical
habitat as defined by the ESA and under the jurisdiction of the USFWS?
Yes

No

Uncertain

If yes, list the species: __________________________________________

3

8)

ENDANGERED SPECIES ACT (NMFS): Will the proposed activity occur in proximity to threatened or
endangered species or critical habitat as defined by the ESA and under the jurisdiction of the NMFS?
Yes

No

Will the proposed activity potentially affect threatened or endangered species or critical
habitat as defined by the ESA and under the jurisdiction of the NMFS?
Yes

No

Uncertain

If yes, list the species: __________________________________________
A consultation and/or permit from the USFWS and/or NMFS may be required.

9)

COASTAL BARRIER RESOURCES ACT (CBRA): Is the proposed activity located in or adjacent
to a unit of the Coastal Barrier Resources System (CBRS)?
Yes

No

If yes, indicate the CBRS unit(s): __________________________
If yes, the federal funding for the activity may be prohibited. Treasury may be required to make a
determination regarding CBRA compliance.

10)

MIGRATORY BIRD TREATY ACT: Will the proposed activity affect any migratory bird species
protected by the Migratory Bird Treaty Act?
Yes

No

If yes, list the migratory bird species: __________________________
A consultation and/or permit from the USFWS may be required.

4

11)

BALD AND GOLDEN EAGLE PROTECTION ACT
Will the proposed activity affect any bald or golden eagles protected by the Bald and Golden
Eagle Protection Act?
Yes

No

If yes, a consultation and/or permit from the USFWS may be required.

12)

WILD AND SCENIC RIVER ACT: Is the proposed activity located on a designated Wild and Scenic
River?
Yes

No

If yes, list the river: ________________________________
Will the proposed activity located on a designated Wild and Scenic River harm the free-flowing
condition, water quality, or outstanding resource values of the river?
Yes

No

If yes, the activity may be prohibited. Contact the USFWS.

13)

NATIONAL HISTORIC PRESERVATION ACT (NHPA) AND THE ARCHAEOLOGICAL AND HISTORIC
PRESERVATION ACT (AHPA): Will the proposed activity occur either near property listed or eligible
for listing in the National Register of Historic Places or near property otherwise protected by section
106 of the NHPA or a similar State Preservation Act?
Yes

No

Will the proposed activity adversely affect either a property listed or eligible for listing in the
National Register of Historic Places or near property otherwise protected by section 106 of the NHPA
or a similar State Preservation Act?
Yes

No

If yes, the activity may be prohibited or require mitigation from the State Historic Preservation
Officer or Tribal Historic Preservation Officer.

5

14)

RIVERS and HARBORS ACT - SECTION 10 (and SECTION 408 if applicable): Will the proposed
activity involve any work (including structures) that will occur in, over or under navigable waters
of the United States?
Yes

No

If yes, a Section 10 permit may be required from the USACE. (In cases of use or alteration of a
federal civil works project, a Section 408 consultation with the USACE may be required.)

15)

CLEAN WATER ACT (CWA), SECTION 404: Will the proposed activity result in any discharge of
dredge or fill material to the nation’s waters or wetlands?
Yes

No

If yes, a Section 404 permit may be required from the USACE.

16)

CLEAN WATER ACT (CWA), SECTIONS 401 and 402: Will the proposed activity result in any discharge
of a pollutant to the nation’s waters or wetlands?
Yes

No

If yes, a Section 401 Water Quality Certification and/or 402 National Pollutant Discharge Elimination
System (NPDES) permit may be required from the Environmental Protection Agency (EPA) or a State
or local agency authorized by EPA to administer the NPDES permitting program under State law.

17)

MARINE PROTECTION, RESEARCH, AND SANCTUARIES ACT (MPRSA): Does the proposed activity
involve the transportation of materials from the US for the purpose of ocean dumping covered by
the MPRSA?
Yes

No

If yes, a permit may be required from the EPA or, for dredged materials, the USACE.

6

18)

CLEAN AIR ACT (CAA): Will the proposed activity result in any emissions of pollutants to the air
within a non-attainment area or maintenance area?
Yes

No

If yes, the activity may require compliance with the CAA including obtaining a permit in some
circumstances from EPA or a delegated state agency.

19)

RESOURCE CONSERVATION AND RECOVERY ACT (RCRA): Will the proposed activity include
the treatment, storage, or disposal of hazardous waste or involve underground storage tanks?
Yes

No

If yes, RCRA hazardous waste storage tank requirements may apply.

20)

COMPREHENSIVE ENVIRONMENTAL RESPONSE, COMPENSATION, AND LIABILITY ACT (CERCLA):
Will the proposed activity involve a Superfund site?
Yes

No

If yes, the activity requires coordination with EPA.

21)

SAFE DRINKING WATER ACT (SDWA): Will the proposed activity involve underground injection,
which may impact drinking water sources?
Yes

No

If yes, a SDWA permit may be required from EPA or a state with an EPA-approved primacy program.

22)

FARMLAND PROTECTION POLICY ACT (FPPA): Will the proposed activity irreversibly convert
farmland (directly or indirectly) to nonagricultural use?
Yes

No

If yes, the project may be subject to U.S. Department of Agriculture FPPA requirements.

7

23)

FLOOD DISASTER PROTECTION ACT OF 1973: Is the proposed activity located in a Special Flood
Hazard Area on a National Flood Insurance Program map?
Yes

No

If yes, the purchase of Federal Flood Insurance may be required.

24)

E.O. 11988 and E.O. 12148 – FLOODPLAIN MANAGEMENT: Is the proposed activity located in a
Special Flood Hazard Area on a National Flood Insurance Program map?
Yes

No

If yes, a public notice may be required.

25)

E.O 11990 and E.O 12608 – WETLAND PROTECTION: Is any portion of the project proposing a new
construction activity in wetlands?
Yes

No

If yes, action to minimize the destruction, loss or degradation of wetlands, and to preserve and
enhance the natural and beneficial values of wetlands may be required.

26)

E.O. 12898 ENVIRONMENTAL JUSTICE: Will the proposed activity have disproportionately high and
adverse human health or environmental effects on minority or low‐income populations?
Yes

No

If yes, the activity may require mitigation.

27)

E.O. 13089 – CORAL REEF PROTECTION: Will the proposed activity involve a coral reef ecosystem or
National Marine Sanctuary?
Yes

No

If yes, the activity should not degrade the condition of coral reef ecosystems.

8

28)

E.O. 13112 – INVASIVE SPECIES: Will the proposed activity have the potential to introduce or cause
the spread of an invasive species?
Yes

No

If yes, action to prevent the introduction of invasive species may be required.

29)

E.O. 13186 – RESPONSIBILITIES OF FEDERAL AGENCIES TO PROTECT MIGRATORY BIRDS. Is the
proposed activity likely to occur during a time of the year when migrating birds are in the vicinity?
Yes

No

If yes, the activity may be prohibited or require mitigation from the USFWS.

Environmental Compliance Status
Report the status of your contact with required agencies/tribes or date permission obtained on the table
below which coincides with the environmental laws and executive orders outlined in the checklist. If none,
state so. Upload completed environmental compliance documentation (e.g., NEPA documents, permits)
Federal law or EO Name of
listed in checklist responsible
agency/tribe

Permit, certification,
determination or
mitigation required

Date agency/tribe
Status (complete/
contact or date
in process/ not
permission obtained required)

9

Document
Upload

OMB Approval No. 1505-0250

RESTORE Act Milestones Report — Department of the Treasury
Applicant/Grantee:
Title:
Reporting Period Ending (Options: initial report, Mar 31, Sept 30), 20XX

INSTRUCTIONS FOR COMPLETING FORM
Please complete Columns B-E in the initial report submitted as part of an application package. After a grant is awarded, complete Columns G-H for each milestone as applicable and submit as part of the performance reports described in the Standard Terms and
Conditions. Columns E and H will calculate automatically, and will show an error message unless the values in each column total 100%. These milestones should reflect what is in the applicant's scope of work as described in the applicable RESTORE Act Direct
Component or Centers of Excellence Application Narrative.

TO COMPLETE

-AMilestone
Number

-BMilestone Description
Provide a brief description of the significant steps that comprise the scope of work

-D-CIs milestone contingent
Estimated Completion
upon completion of
Timeframe of Milestone
another milestone (Y/N)?
(Format: award + # of
If yes, which milestone is
months)
it contigent upon (# from
Column A)?

-EWhat percentage of the
Scope of Work is
estimated to be
completed with this
milestone?

-GActual Completion Date
of Milestone
(Format: Month-Year)

-HEstimated percentage of
budget for the awarded
Scope of Work spent on
milestone

1

0%

0%

2

0%

0%

3

0%

0%

4

0%

0%

5

0%

0%

6

0%

0%

7

0%

0%

8

0%

0%

9

0%

0%

10

0%

0%

TOTAL
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the
time required to complete this information collection, including the time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information, should be directed to the
Department of the Treasury, Office of Gulf Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

RESTORE Act Status of Performance Report  — Department of the Treasury                                                                                                        

OMB Approval No. 1505‐0250

Applicant/Grantee:
Title:
Reporting Period Ending (Options: initial report, Mar 31, 
Sept 30)
Goal(s):
Eligible 
Activity/ 
Discipline #

Measure #

Measure

Baseline

Target

Target Date 
(month/
year)

Progress  Progress 
toward  toward target 
(cumulative)
target 
(reporting 
period)

Status/Next Steps

-

-

-

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control numberfor this information collection is 1505-0250. Comments concerning the time required to complete this information collection, including the
time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

RESTORE Act Status of Performance Report  — Department of the Treasury                                                                                                        

OMB Approval No. 1505‐0250

Instructions for Completing Form
The purpose of this form is to report the status of progress toward reaching priority goals of the eligible Direct Component (DC) activity/Centers of Excellence (COE) discipline (i.e., measuring success, rather than listing milestones or 
tasks).  Please focus on a discrete number of priority goals (1‐3) and the
corresponding performance measures (1‐5).  Complete boxes shaded in blue.
Goal(s): Anticipated result(s). State the priority goal(s) to be achieved with the grant award. Priority goal(s) should clearly identify with the eligible DC activity/COE discipline.
Eligible Activity/Discipline #: For a DC grant, select the DC number from the drop‐down list that corresponds to the DC Eligible Activity associated with that measure. For a (COE)grant, select the COEnumber from the drop down list that 
corresponds to the COE Eligible Discipline associated with that measure.
The DC numbers and COE numbers, along with the corresponding Eligible Activities and Disciplines, are listed directly below.
Direct Component (DC) Eligible Activities

Centers of Excellence (COE) Eligible Disciplines

DC ‐ 1

Restoration and protection of the natural resources, ecosystems, fisheries, marine and wildlife 
habitats, beaches, and coastal wetlands of the Gulf Coast region.

COE ‐ 1

Coastal and deltaic sustainability, restoration and protection, including solutions and technology 
that allow citizens to live in a safe and sustainable manner in a coastal delta in the Gulf Coast 
Region.

DC ‐ 2

Mitigation of damage to fish, wildlife, and natural resources.

COE ‐ 2

Coastal fisheries and wildlife ecosystem research and monitoring in the Gulf Coast Region.

DC ‐ 3

Implementation of a federally approved marine, coastal, or comprehensive conservation 
management plan, including fisheries monitoring.

COE ‐ 3

Offshore energy development, including research and technology to improve the sustainable and 
safe development of energy resources in the Gulf of Mexico.

DC ‐ 4

Workforce development and job creation.

COE ‐ 4

Sustainable and resilient growth, economic and commercial development in the Gulf Coast Region.

DC ‐ 5

Improvements to or on State parks located in coastal areas affected by the Deepwater Horizon oil 
spill.

COE ‐ 5

Comprehensive observation, monitoring, and mapping of the Gulf of Mexico.

DC ‐ 6

Infrastructure projects benefitting the economy or ecological resources, including port 
infrastructure.

DC ‐ 7

Coastal flood protection and related infrastructure.

DC ‐ 8

Planning assistance.

DC ‐ 9

Promotion of tourism in the Gulf Coast Region, including recreational fishing

DC ‐ 10

Promotion of consumption of seafood hravested from the Gulf Coast Region

Measure #: Starting with 1, number each performance measure.
Measure:  An indicator of success toward reaching a goal. This should reflect "how the applicant will evaluate success" from the narrative of an accepted multiyear plan.
Baseline: The starting point of the measure. It is the status quo without the grant award.
Target:  The anticipated result of the measure. It is the anticipated new status with the grant award.
Target Date: It is the anticipated date for reaching the target.
Progress toward target (reporting period/cumulative): Leave blank on the initial report. For subsequent reports, record progress made during the reporting period  and the progress made from the start date of the grant award through the 
current reporting period.
Status/Next Steps: Briefly describe specific progress and/or challenges related to the measure.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control numberfor this information collection is 1505-0250. Comments concerning the time required to
complete this information collection, including the time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf Coast
Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

Civil Rights Act of 1964 Title VI Narrative for RESTORE Act Direct Component and
Centers of Excellence Research Grants Applicants
All applicants must provide a Title VI Narrative as an upload in GrantSolutions.gov. The Title
VI Narrative must be approved by the applicant’s board of directors or appropriate governing
entity or official(s) responsible for policy decisions prior to submission to Treasury. Applicants
must submit a copy of the board resolution, meeting minutes, or similar documentation with the
Title VI Narrative as evidence that the board of directors or appropriate governing entity or
official(s) has approved the Title VI Narrative.
The Title VI Narrative, submitted with the application, shall include the information listed
below. Treasury will accept a Title VI compliance form recently prepared and submitted to
another Federal agency. If any information required by Treasury is not included in the other
agency’s Title VI compliance form, the missing information must be submitted with the
application for the Title VI Narrative to be considered a complete response. If any item listed
below is not relevant to the project for which federal financial assistance is requested, the
information should be marked as “not applicable.” The Title VI Narrative should include:
1. A statement that the Title VI notice to the public is posted in a prominent place or places,
and the type of postings being used (i.e., in the recipient’s place(s) of business, in written
communications to the beneficiaries, or on the recipient’s website).
2. A list of any pending Title VI investigations, complaints, or lawsuits filed with the applicant.
This list should include those investigations, complaints, or lawsuits that pertain to
allegations of discrimination on the basis of race, color, and/or national origin that pertain to
the applicant submitting the narrative.
3. Information regarding the applicant’s Title VI compliance history if it has previously
received funding from another federal agency. The information shall include a copy of any
Title VI compliance review reports issued by such other federal agency in the previous two
years. The information shall include:
a. The purpose or reason for the review.
b. The name of the agency or organization that performed the review.
c. A summary of the findings and recommendations of the review.
d. A report on the status and/or disposition of such findings and recommendations.
4. A copy of the applicant’s plan for providing language assistance to persons with limited
English proficiency, based on the Treasury LEP Guidance.
5. Applicants that have program-related, non-elected planning boards, advisory councils or
committees, or similar bodies, the membership of which is selected by the applicant, must
provide a table depicting the racial breakdown of the membership of those committees, and a
description of efforts made to encourage the participation of minorities on such committees
or councils.

6. A description of the location of existing or proposed facilities connected with the proposed
project, program, or activity, and whether the location has or will have the effect of
unnecessarily denying access to any persons on the basis of prohibited discrimination (race,
color or national origin).
7. A list of the applicant’s pending applications for federal financial assistance and existing
assistance. (A download file from USAspending.gov is acceptable for existing federal
financial assistance.)
8. A description of the procedures the applicant will use to ensure subrecipients comply with
Title VI and a proposed schedule of Title VI Narrative submissions from the subrecipient for
this project or program.

RESTORE Act Centers of Excellence Research Grant Program Application Narrative
Department of the Treasury

OMB Approval No. 1505-0250

The Centers of Excellence Research Grants Program Funding Opportunity Announcement describes in detail the content and
information required for your application submission. This application form must be included with your application, along with the
separate Centers of Excellence Application Narrative Supplement (i.e., project and budget narratives) and other documentation as
required by the relevant Funding Opportunity Announcement.
GENERAL INFORMATION:
Applicant Name:
Federal Funding Opportunity Announcement #:
Is this application to fund the establishment of a
new/additional Center(s) of Excellence and/or an existing
Center(s) of Excellence?

Existing Center(s) of Excellence (complete Section A)
New/Additional Center(s) of Excellence (complete Section B)
Both Existing and New/Additional Center(s) of Excellence
(complete Sections A and B)

A. EXISTING CENTER(s) OF EXCELLENCE:
1. Selection Process and Public Input
(a) Directions: List existing Center(s) and the corresponding grant number(s) under which it was first established, thereby
incorporating previous responses by reference.

(b) Directions: Provide a description of any modifications to the rules and policies that were approved after consideration of
meaningful input from the public made since the selection of the existing Center(s).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to
complete this information collection, including the time to review instructions, search existing data resources, gathering and maintaining the
data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf
Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

B. NEW/ADDITIONAL CENTER(s) OF EXCELLENCE:
1. Selection Process – New/Additional Center(s) of Excellence
Directions: Describe the competitive review process that the applicant used, or will use, to select a new/additional Center(s) of
Excellence, including: a) the qualifications for entities and consortia; b) the criteria for selection and how those criteria have been/will be
applied; c) how priority has been/will be given to entities and consortia that demonstrate the ability to organize the broadest crosssection of participants with interest and expertise in the discipline(s) on which this application is focused, including participation by
minority-serving institutions; d) timeframe of selection process; and e) any other selection factors. As appropriate, provide references to
existing state statutory or regulatory requirements.

2. Public Input – New/Additional Center(s) of Excellence
Directions: Explain the process the applicant has engaged in or will engage in to provide 45-day minimum public review and comment on
its rules and policies, including the competitive selection process, and the consideration of meaningful input from the public, including
broad-based participation from individuals, businesses, Indian tribes, and non-profit organizations. Provide links to public comments,
newspaper articles, transcripts, or minutes of meetings, etc. If these are not available on the Internet, please attach relevant documents
to the application package.

C.

RECIPIENT INFORMATION
1. Subaward Management
Directions: Describe how the applicant will manage the subaward(s) to the Center(s), including the applicant’s policies and procedures for
issuing subawards; the process to guard against conflicts of interest; the process for selecting science, technology, or monitoring projects;
and monitoring subrecipient’s performance and compliance, including the subrecipient’s oversight of lower tier subrecipients.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to
complete this information collection, including the time to review instructions, search existing data resources, gathering and maintaining the
data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf
Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

D.

CENTER OF EXCELLENCE INFORMATION:
1. Please provide the name of the
Center(s) of Excellence and the
name and address for each entity
selected to operate the Center(s)
of Excellence as a subrecipient of
the applicant; attach more pages
as needed. Also, provide the
Principal Investigator’s (PI)
contact information.

Name of Center of Excellence:
Name of Subrecipient:
Street address:
City:
County/Parish:
State:
Zip code:
DUNS Number:
PI Name:
PI Phone Number:
PI Email Address:

2.

Select the applicable eligible
disciplines that each Center will
be focusing on as part of this grant
request.

Select all that apply

Eligible Discipline
A.

☐

B.
☐
C.

Offshore energy development,
including research and technology
to improve the sustainable and
safe development of energy
resources in the Gulf of Mexico

D.

Sustainable and resilient growth
and economic and commercial
development in the Gulf Coast
Region

E.

Comprehensive observation,
monitoring, and mapping of the
Gulf of Mexico

☐

☐

☐

Coastal and deltaic sustainability,
restoration and protection,
including solutions and technology
that allow citizens to live in a safe
and sustainable manner in a coastal
delta in the Gulf Coast Region
Coastal fisheries and wildlife
ecosystem research and
monitoring in the Gulf Coast
Region

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to
complete this information collection, including the time to review instructions, search existing data resources, gathering and maintaining the
data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf
Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

3.

Provide more information on each
Center, including what type of
entity it is and whether it is a
consortium.

Type of Entity (Institution of higher
education, corporation, etc.)
Is the Center of Excellence a
consortium?

yes

no

If yes, list all member organizations and
addresses:

4.

Select whether there is a
Minority-Serving Institution(s),
and name the entity and type of
MSI if applicable.

5.

Select whether the Center is
located in the Gulf Coast Region.

8.

Permits

Minority-Serving Institution(s)
included?

yes

no

If yes, name and type of institution(s): (e.g.,
Historically Black College or University or
Hispanic Serving Institution – see definition
of Minority Institution and list of
institutions at
http://www2.ed.gov/about/offices/list/ocr
/edlite-minorityinst.html

Is the Center of Excellence located in the Gulf Coast Region, as defined at 31 C.F.R. §
34.2? Explain or attach a map if necessary.
yes

no

Does the Center’s proposed activities require any federal, tribal, state, or other permits? (For potential federal environmental permits
see Environmental Checklist and Environmental Checklist Reference Guidance.)
Yes

No

If yes, a list of the federal, tribal, state, or other permits required for the Center’s proposed activities and the status of the permits must
be included with the Centers of Excellence Application Narrative Supplement.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to
complete this information collection, including the time to review instructions, search existing data resources, gathering and maintaining the
data needed, and completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf
Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

Centers of Excellence Application Narrative Supplement
All applicants must provide a narrative including the following information with the application
as an upload in GrantSolutions.gov. The information is required unless it is not applicable to the
project, program, or activity. Applicants should review the applicable funding opportunity
announcement and Treasury guidance for a complete list and explanation of requirements.
1. Applicant Name
2. Proposed Scope of Work - A detailed scope of work that fully describes the program for
which funding is requested, including:
a. Program Description
b. Need
c. Purpose
d. Objectives, including how they are designed to contribute to
establishing/maintaining the Center(s) and monitoring the subrecipient(s)
e. Science, technology, and monitoring activities and how these activities relate to
the eligible discipline(s)
f. Key Personnel, including:
i. The applicant’s Authorizing Official who is authorized to sign the grant
application and award,
ii. The Project Director who is responsible for the program,
iii. The Financial Officer who is responsible for maintaining the accounting
and financial records of the grant, and
iv. The Principal Investigator(s) leading the Center(s).
g. A description of all funding sources included on the SF‐424.
3. Subrecipient Scope of Work - Include a separate, clearly defined scope of work for the
subrecipient(s) and a detailed subrecipient budget
4. Milestones – List the milestones and the estimated timeframe for completion (i.e.,
performance period start date + number of months to completion)
5. Performance Measures – include the following:
a. Measure: An indicator of success toward reaching a goal. The measure should
reflect how the applicant will evaluate success from the narrative of the accepted
multiyear plan.
b. Baseline: The starting point of the measure. It is the status quo without the grant
award.
c. Target: The anticipated result of the measure. It is the anticipated new status with
the grant award.
6. Budget Justification - Explain in detail how the proposed budget supports the proposed
scope of work. The budget justification should relate each budget category listed in the
SF‐424A (see below) to the specific tasks identified in the proposed scope of work. The
budget justification should provide specific justification for all budget categories that
apply; including an explanation of the necessity, allowability, reasonableness, and
allocability of proposed costs. (See the Centers of Excellence Research Grants Program
Funding Opportunity Announcement for a complete description of the budget categories.)

a. Total Budget
b. Amount of Total Budget incurred pre-award
c. Personnel (Salaries and Fringe)
d. Travel
e. Equipment
f. Supplies
g. Contractual
h. Subawards (including a detailed subaward budget by object class category)
i. Other
j. Indirect Costs
7. Permits or Authorizations (if applicable): Provide a list of specific federal, tribal, state, or
other permits or authorizations required for science, technology, and monitoring activities
in this program and their status. If permits or authorizations have been obtained, include
them with the application. (For federal environmental requirements, see Environmental
Checklist and Environmental Checklist Reference Guidance.)

RESTORE Act Centers of Excellence Applicant Certifications
Department of the Treasury
OMB Approval No. 1505-0250
Directions: These certifications are required by federal law and Department of the Treasury (Treasury) regulations to be submitted with each application
to Treasury for financial assistance under the RESTORE Act Centers of Excellence Research Grants program. The certifications must be signed by an
authorized senior official of the Applicant who can legally bind the entity and has oversight for the administration and use of the Centers of Excellence
Research Grants program funds.

A. RESTORE Act Certification
1. Pursuant to the RESTORE Act, I certify that for any award
agreement resulting from this application:
(a) Funds will be used to award competitive grants for the
establishment of Centers of Excellence that focus on science,
technology, and monitoring in at least one of the following disciplines:
(i) Coastal and deltaic sustainability, restoration, and protection,
including solutions and technology that allow citizens to live in a
safe and sustainable manner in a coastal delta in the Gulf Coast
region;
(ii) Coastal fisheries and wildlife ecosystem research and
monitoring in the Gulf Coast Region;
(iii) Offshore energy development, including research and
technology to improve the sustainable and safe development of
energy resources in the Gulf of Mexico;
(iv) Sustainable and resilient growth and economic and commercial
development in the Gulf Coast Region; and
(v) Comprehensive observation, monitoring, and mapping of the
Gulf of Mexico.
(b) Rules and policies for Centers of Excellence Research Grants,
including the competitive selection process and measures to guard
against conflicts of interest, were published and available for public
review and comment for a minimum of 45 days, and that they were
adopted after consideration of all meaningful input from the public,
including broad-based participation from individuals, businesses,
Indian tribes, and non-profit organizations. The certification in this
paragraph (1)(b) does not apply in instances where state statutes and
regulations or policies addressing this issue were in effect prior to
August 15, 2014.
(c) The Applicant has procedures in place for procuring property and
services under this award that are consistent with the procurement
standards applying to Federal grants. The Applicant will not request
funds under this award for any contract unless this certification remains
true and accurate.
(d) Pursuant to 2 C.F.R. § 200.303, the Applicant will establish and
maintain effective internal control over all award agreements resulting
from this application, and provide reasonable assurance that the
Applicant will manage the award in compliance with Federal statutes,
regulations, and the terms and conditions of the award. The Applicant
knows of no material deficiencies in its internal controls.
(e) A conflict of interest policy consistent with 2 C.F.R. § 200.318(c) is
in effect and covering each Center of Excellence funded under this
Agreement.
(f) The Applicant will comply with Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, and all other applicable federal
laws and regulations concerning anti-discrimination.
2. I make each of these certifications based on my personal knowledge
and belief after reasonable and diligent inquiry, and I affirm that the
Applicant maintains written documentation sufficient to support each
certification made above, and that the Applicant’s compliance with
each of these certifications is a condition of the Applicant’s initial and
continuing receipt and use of the funds provided under an award
Agreement.

B. Certification Regarding Debarment, Suspension,
and Other Responsibility Matters -- Primary Covered
Transactions: Instructions for Certification
1. By signing and submitting this Application, the prospective primary
participant (the Applicant) is providing the certification set out below.
2. The inability of an Applicant to provide the certification required
below will not necessarily result in the denial of participation in this
covered transaction. The prospective Applicant shall submit an
explanation of why it cannot provide the certification set out below.
The certification or explanation will be considered in connection with
Treasury’s approval of the proposed application. However, failure of
the Applicant to furnish a certification or an explanation shall disqualify
such person/entity from participation in this transaction.
3. This certification is a material representation of fact upon which
reliance is placed when Treasury determines to enter into this
transaction. If it is later determined that the Applicant knowingly
rendered an erroneous certification, in addition to other remedies
available to the Federal government, Treasury may terminate this
transaction for cause or default.
4. The Applicant shall provide immediate written notice to Treasury if at
any time the Applicant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed
circumstances.
5. The terms “covered transactions,” “debarred,” “suspended,”
“ineligible,” “lower tier covered transaction,” “participant,” “person,”
“primary covered transaction,” “principal,” “proposal”, and “voluntarily
excluded,” as used in this clause (certification), have the meanings set
out in the Definitions and Coverage sections of the rules implementing
Executive Order 12549. You may contact Treasury for assistance in
obtaining a copy of those regulations (31 C.F.R. Part 19).
6. The Applicant agrees by submitting this Application that, should the
proposed covered transaction be entered into, it shall not knowingly
enter into any lower tier covered transaction with a person who is
debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by
Treasury.
7. The Applicant further agrees by submitting this Application that it will
not award any contract or subaward to any entity on the governmentwide Excluded Parties List System (see 31 C.F.R. Part 19, Appendix).
8. A participant in a covered transaction may rely upon a certification of
a prospective participant in a lower tier covered transaction that it is not
debarred, suspended, ineligible, or voluntarily excluded from the
covered transaction, unless it knows that the certification is erroneous.
A participant may decide the method and frequency by which it
determines the eligibility of its principals. Each participant may, but is
not required to, check the Nonprocurement List.
9. Nothing contained in the foregoing shall be construed to require
establishment of a system of records in order to render in good faith
the certification required by this clause. The knowledge and

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time required to complete this
information collection, including the time to review instructions, search existing data resources, gathering and maintaining the data needed, and
completing and reviewing the collection of information, should be directed to the Department of the Treasury, Office of Gulf Coast Restoration, 1500
Pennsylvania Ave., NW, Washington, DC 20220.

Page 2
information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of
business dealings.
10. Except for transactions authorized under paragraph 6 of these
instructions, if a participant in a covered transaction knowingly enters
into a lower tier covered transaction with a person who is suspended,
debarred, ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal
government, Treasury may terminate this transaction for cause or
default.

(c) Making it a requirement that each employee to be engaged in the
performance of the award be given a copy of the statement required by
paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a)
that, as a condition of employment in such grant, the employee will:
(i) Abide by the terms of the statement; and
(ii) Notify the employer of any criminal drug use statute conviction
for a violation occurring in the workplace no later than five
calendar days after such conviction;
(e) Notifying the granting agency in writing, within ten calendar days
after receiving notice of a conviction under paragraph (d)(ii) from an
employee or otherwise receiving actual notice of such conviction;
(f) Taking one of the following actions, within 30 days of receiving
notice under paragraph (d)(ii), with respect to any employee who is so
convicted:
(i) Taking appropriate personnel action against such an
employee, up to and including termination, consistent with the
requirements of the Rehabilitation Act of 1973, as amended; or
(ii) Requiring such employee to participate satisfactorily in a drug
abuse assistance or rehabilitation program approved for such
purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency; and
(g) Making a good faith effort to continue to maintain a drug-free
workplace through implementation of paragraphs (a) through (f).

C. Certification Regarding Debarment, Suspension,
and Other Responsibility Matters -- Primary Covered
Transactions
1. The prospective primary participant (the Applicant) certifies to the
best of its knowledge and belief, that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from covered transactions
by any Federal department or agency;
(b) Have not within a three-year period preceding this Application
been convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or local)
transaction or contract under a public transaction; violation of Federal
or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly
charged by a governmental entity (Federal, State or local) with
commission of any of the offenses enumerated in paragraph (1)(b) of
this certification; and
(d) Have not within a three-year period preceding this Application had
one or more public transactions (Federal, State or local) terminated for
cause or default.

E. Certification Regarding Lobbying
1. The Applicant certifies, to the best of its knowledge and belief, that:
(a) No Federal appropriated funds have been paid or will be paid, by or
on behalf of the Applicant, to any person for influencing or attempting
to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement.
(b) If any funds other than Federal appropriated funds have been paid
or will be paid to any person for influencing or attempting to influence
an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of
Congress in connection with this Application, the undersigned shall
complete and submit Standard Form-LLL, ‘‘Disclosure Form to Report
Lobbying,’’ in accordance with its instructions.
(c) The Applicant shall require that the language of this certification be
included in the award documents for all subawards at all tiers
(including subcontracts, subgrants, and contracts under grants, loans,
and cooperative agreements) and that all sub-recipients shall certify
and disclose accordingly.

2. Where the Applicant is unable to certify to any of the statements in
this certification, such Applicant shall attach an explanation to this
proposal.

D. Certification Regarding Drug-Free Workplace
Requirements
1. The Applicant certifies that it will provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful
manufacture, distribution, dispensing, possession, or use of a
controlled substance is prohibited in the Applicant’s workplace and
specifying the actions that will be taken against the employee for
violations of such prohibition;
(b) Establishing a drug-free awareness program to inform employees
about:
(i) The dangers of drug abuse in the workplace;
(ii) The Applicant’s policy of maintaining a drug-free workplace;
(iii) Any available drug counseling, rehabilitation, and employee
assistance program; and
(iv) The penalties that may be imposed upon employees for drug
abuse violations occurring in the workplace.

2. This certification is a material representation of fact upon which
reliance is placed when this transaction is made or entered into.
Submission of this certification is a prerequisite for making or entering
into this transaction imposed by title 31 U.S. Code section 1352. Any
person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.

Signature of Authorized Senior Official:

Name:

Date:

Title:

Organization:

Treasury Office of Gulf Coast Restoration
RESTORE Act Eligible Entity
OPERATIONAL SELF-ASSESSMENT (OSA)

OSA Instructions

On July 6, 2012, the President signed the Resources and Ecosystems Sustainability, Tourist Opportunities, and
Revived Economies of the Gulf Coast States Act of 2012 (RESTORE Act) into law. The Act establishes a Trust
Fund in the Treasury of the United States, known as the Gulf Coast Restoration Trust Fund. Under the Act,
amounts in the Trust Fund are available for programs, projects, and activities that restore and protect the
environment and economy of the Gulf Coast region. For the Direct Component and Centers of Excellence
Research Grants Program, Treasury is responsible for determining eligibility and monitoring compliance with
requirements in the RESTORE Act and other federal laws and policies on grants.
Treasury’s RESTORE Act guidance requires that all eligible entities under the Direct Component and the Centers of
Excellence Research Grants Program complete an Operational Self-Assessment (OSA) prior to receiving funding
and once a year thereafter. The OSA focuses on operational internal control areas and will be used, in part, to
assist Treasury in determining an appropriate compliance monitoring protocol. The OSA is not intended to provide
guidance regarding compliance or audit requirements, but simply as a data gathering tool.
Please complete the OSA form electronically. Once you have entered the required information, please print the
last page and have the OSA signed by the individual who has the authority to commit your organization to
Treasury's grant management requirements. Please scan and include the signature pages with your electronic
submission.
The completed OSA form should be submitted via email to restoreact@treasury.gov.
The OSA form contains three parts:
• Organization Contact information
Enter the required descriptive information about the recipient organization and identify the name, title and contact
information of the individual who is responsible for completing this form. The contact person who completes the
form may be different from the individual, described above, who has the authority to commit the organization to
the requirements. Be sure to include the date on which the form was completed.
• Operational Self-Assessment Questions
The OSA questions are organized by the five components of internal control consistent with the Government
Accountability Office (GAO) Standards for Internal Control in the Federal Government (known as the Green Book):
control environment, risk assessment, control activities, information and communication, and monitoring.
Please click on the "Y" to answer Yes or the "N" to answer No for each question in the OSA. Provide any
additional comments pertinent to your answers. The Comment spaces are set so that the text will wrap when
you type.
• Certification of the Applicant's Authorized Representative
Identify the individual who has the authority to commit the organization to the Treasury's grant management
requirements and who can certify the accuracy of the statements made in the form. As noted above, the
signed certification page is required.

Treasury Office of Gulf Coast Restoration
RESTORE Act Eligible Entity
OPERATIONAL SELF-ASSESSMENT (OSA)

Organization Contact Information
Entity Name
OSA Completed By
Job Title
Contact Details

Email

Phone
number

Entity Address
Date OSA Completed
Comments

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 1505-0250. Comments concerning the time
required to complete this information collection, including the time to review instructions, search existing data resources, gathering and
maintaining the data needed, and completing and reviewing the collection of information, should be directed to the Department of the
Treasury, Office of Gulf Coast Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

Page | 1

Self-Assessment Questions
Environment
Questions

Please respond
“Y” or “N”

1. Does management promote open communications
throughout the organization and effectively provide
information to employees and other stakeholders?

Y

N

2. Does management provide adequate training and
supervisory oversight to all employees to ensure that the
organization effectively carries out its programs and
activities, including employees working on federal grant
programs?

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

3. Do policies, procedures and processes for managing
federal grant funds meet the requirements of OMB 2
CFR Chapter I and Chapter II, Uniform Administrative
Requirements, Cost Principles and Audit Requirements
for Federal Awards?
4. Are the organization’s internal controls in compliance
with guidance in the ‘‘Standards for Internal Control in
the Federal Government’’ issued by the United States
Government Accountability Office?
5. Does management regularly create, review and update
policies, procedures and processes to ensure that the
organization effectively carries out its programs and
activities, including updates that may be needed for
federal grant funds?
6. Does management periodically assess and maintain
proper segregation of duties?
7. Does management have a written code of conduct or
ethics policy that is reviewed and signed off by
employees at least annually?
8. Does management have a written conflict of interest
policy that is reviewed and signed off by employees at
least annually?
9. Do management and employees attend anti-fraud
awareness training at least annually and is that training
evidenced by attendance sheets or other mechanisms?
10. Does management have written policies and procedures
in place for employees to confidentially report suspected
violations of policies and or suspected instances of fraud
or other criminal activity, including specifically those
related to federal grant programs?
11. Does management perform the following:
a. Address breaches of the code of conduct or ethics
policy
b. Address instances of fraud or other criminal activity
c. Take remedial actions to prevent future violations
d. Notify the appropriate federal agency in cases of
confirmed fraud related to federal funds
12. Does the organization have a written grants
management manual or standard operating procedures?

Page | 2

Comments

Risk Assessment
Questions
13. Does the organization have a documented internal control
program and risk assessment methodology for managing
and monitoring operational, financial and regulatory
compliance risks that is periodically reviewed and updated
as needed?
14. Does the organization have a documented risk
assessment and compliance monitoring process in place
specifically for federal grant programs?
Objectives
Questions
15. Allowable / Unallowable Activities & Costs – Does an
effective system of internal controls exists to provide
reasonable assurance that federal awards are expended
only for allowable activities and that the costs of goods
and services charged to federal awards are allowable and
in accordance with the applicable cost principles?
16. Cash – Does an effective system of internal controls
exists to provide reasonable assurance that the (1)
drawdown of federal cash is only for immediate needs, (2)
reimbursement is requested only after costs have been
incurred, (3) entities comply with applicable Treasury
agreements, and (4)recipients limit payments to
subrecipients to immediate cash needs?
17. Davis-Bacon Act – Does an effective system of internal
controls exists to provide reasonable assurance that
contractors and subcontractors were properly notified of
the Davis-Bacon Act requirements and the required
certified payrolls were submitted to the non-federal entity?
18. Eligibility – Does an effective system of internal controls
exists to provide reasonable assurance that only eligible
individuals and organizations receive assistance under
federal award programs and that subawards are made
only to eligible subrecipients?
19. Equipment & Real Property – Does an effective system of
internal controls exists to provide reasonable assurance
that:
a. Proper records are maintained for equipment acquired
with federal awards
b. Equipment is adequately safeguarded and maintained
c. Disposition or encumbrance of any equipment or real
property is in accordance with federal requirements
d. A physical inventory and reconciliation of property is
conducted at least every two years
e. The federal awarding agency is appropriately
compensated for its share of any property sold or
converted to non-federal use

Page | 3

Please respond
“Y” or “N”
Y

N

Y

N

Comments

Please respond
Comments
“Y” or “N”
Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Objectives (Continued)
Questions
20. Real Property Acquisition & Relocation – Does an effective
system of internal controls exists to provide reasonable
assurance of compliance with the real property acquisition,
appraisal, negotiation, and relocation requirements?
21. Matching, Level of Effort, Earmarking – Does an effective
system of internal controls exists to provide reasonable
assurance that matching, level of effort, or earmarking
requirements are met using only allowable funds or costs
which are properly calculated and valued?
22. Financial Management – Does a financial management
system provide for effective control over and accountability
for all funds, property and other assets, including ensuring
that all such assets are used solely for authorized
purposed and activities that are allowable in accordance
with the applicable cost principles and are only used during
the authorized period of availability?
23. Procurement, Suspension & Debarment – Does an
effective system of internal controls (including written
procurement procedures) exists to provide reasonable
assurance that procurement of goods and services are
made in compliance with the provisions of 2 CFR 200 and
that covered transactions are not made with a debarred or
suspended party?
24. Program Income – Does an effective system of internal
controls exists to provide reasonable assurance that
program income is correctly earned, recorded, and used in
accordance with the program requirements?
25. Reporting – Does an effective system of internal controls
exists to provide reasonable assurance that reports of
federal awards submitted to the federal awarding agency
include all activity of the reporting period, are supported by
underlying accounting or performance records, and are
fairly presented in accordance with program requirements?
26. Subrecipient Monitoring – Does an effective system of
internal controls exists to provide reasonableassurance
that:
a. Federal award information and compliance
requirements are communicated to subrecipients
b. Subrecipient performance is monitored
c. Subrecipient audit findings are resolved, and the
impact of any subrecipient noncompliance on the
pass- through entity is evaluated
d. A risk assessment of the subrecipient is performed
e. Subrecipient eligibility is assessed
27. Time-keeping – Does an effective personnel time system
exists which has the capability to create periodic reports of
activities and time of each employee whose compensation
is charged to a project that employee works on, including
each Federal assistance program?

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Please respond
“Y” or “N”
Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Comments

Information & Communication
Questions
28. Are external and internal Communication channels
established between organization and (1) federal agency,
(2) state agencies, (3) sub-recipients, (4) contractors and
vendors, and (5) other stakeholders?
29. Is information related specifically to federal fund awards
(including grant agreements, program guidelines, legal
requirements, required reporting and other requirements),
communicated to relevant internal and external
stakeholders?
30. Does the organization have management, information and
accounting systems in place that are designed to meet all
federal and grant specific program requirements, including
reporting and record retention requirements?
31. Do information systems policies and procedures exist for
the safeguarding of data, including personally identifiable
information (PII), authorization and addition of system
users, termination of user rights, information back-up and
recovery, and retention and destruction of data?
32. Is access to data, including PII, protected against
unauthorized access and limited to appropriate individuals
based on job functions?

Please respond
“Y” or “N”
Y

N

Y

N

Y

N

Y

N

Y

N

Comments

Monitoring
Questions

Please respond
“Y” or “N”

33. Are the associated grant fund operations regularly
assessed by an internal auditor, Inspector General and/or
external audit function (Uniform Guidance audit)?

Y

N

34. Does the organization formally respond to all internal audit,
Inspector General and external audit findings in writing and
make timely remedial actions/corrections?

Y

N

35. Does management periodically review all reports,
deliverables, expenditures, and other requirements related
to federal grant programs to ensure that guidelines and
requirements are being met?

Y

N

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Comments

Treasury Office of Gulf Coast Restoration
RESTORE Act Eligible Entity
OPERATIONAL SELF-ASSESSMENT (OSA)

CERTIFICATION OF APPLICANT'S AUTHORIZED OFFICIAL (REQUIRED)
I certify that the statements made on this form are true, accurate, and complete. I acknowledge that
any knowingly false or misleading statement may be punishable by fine or imprisonment or both
under the applicable law.
Name of Authorized Official

Title of Authorized Official

Signature

Date Signed (mm/dd/yyyy)

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