RESTORE Act Grant Application Forms

RESTORE ACT Direct Component Multiyear Plan Matrix — Department of the Treasury
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
2b. DATE OF LAST MULTIYEAR
ACCEPTANCE (mm/dd/yyyy):
PLAN ACCEPTANCE:
4. TOTAL ALLOCATIONS PLUS KNOWN FUNDS NOT YET
DEPOSITED IN TRUST FUND FOR DIRECT COMPONENT:

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)

8. Estimated Total Funding Contributions For Proposed
Activity(ies) (refer to Instructions)
8a. Direct
8b. Other
8c. Other
8d. Total
Component
RESTORE
Third-Party
Contribution
Contribution Act
Contribution
Contribution

9. Proposed
Start Date
mm/dd/yyyy

10. Proposed
End Date
mm/dd/yyyy

11. Status (refer
to Instructions)

Please note: Grant awards may reflect non12. ESTIMATED TOTAL FUNDING
material changes in proposed dates and
CONTRIBUTIONS FOR ACTIVITY(IES)
(refer to Instructions)
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
1
2a
2b
3

4

5

6
7
8
8a.

8b.

8c.
8d.

9
10
11

12
12a.

12b.
12c.
12d.

Instructions
Multiyear Plan Version - Indicate whether the version is the initial multiyear plan submittal or an amendment to an existing
Treasury- accepted multiyear plan. For example, the first amendment to the plan would be "amendment #1."
Date of Initial Multiyear Plan Acceptance - If this is the initial multiyear plan, put N/A. If this is an amendment to a Treasuryaccepted multiyear plan, provide the date of initial acceptance.
Date of Last Multiyear Plan Acceptance - Provide the date of the last multiyear plan amendment acceptance.
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 availab le to
Applicant can be found on Treasury's RESTORE Act website.
Total Direct Component Allocations Plus Known Funds Not Yet Deposited in Trust Fund - All Trust Fund current allocation(s) and
not-yet- deposited 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
Activity Title is assigned by the applicant for the activity/project/program.
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)
Total Funding Contributions for Proposed Activity(ies) - List the total funds the applicant will use for the proposed activity.
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.
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.
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 Fi nancial
Assistance Application.
Total Contribution is the total amount from all funding sources including the Direct Component funds allocated by Treasury and the
not-yet-deposited 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.
Proposed End Date is provided by the applicant. This is an estimated end date based on the anticipated project period of
performance.
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 i n scope, change
in eligible activity, completed activity, deleted activity, etc.).
Estimated Total Funding Contributions for Activity(ies) - The totals should include activities listed on any additional pages.
Total Funding of Direct Component Contributions include both the portion of the allocation issued by Treasury and the not -yetdeposited funds that represent known future allocations from the Trust Fund’s Direct Component portion that the applicant pla ns 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.
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.
Total Funding of all Other Third-Party Contributions for all proposed activities listed on the Matrix.
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 3

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:

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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:

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NARRATIVE DESCRIPTION:
1. A description of each activity that includes the need, purpose, objective(s), milestones and location. Include map showing the
location of each activity.

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2. How the applicant made the multiyear plan available for 45 days for public review and comment, in a manner calcu lated 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 su bmit
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).

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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 ho w each
activity qualifies for at least one of the eligible activities under the RESTORE Act.

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

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

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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 th e RESTORE Act Direct
Component.

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SUPPORTING DOCUMENTATION:
7. MYP Public Comment Documentation: Documentation proving that all of the following were made available for public comment
for a period of at least 45 days: the MYP Narrative, MYP Matrix, and MYP Map. In addition, if a more detailed MYP was prepared,
per #9 below, this must be made available for public comment. This documentation typically includes copies of all public notices,
agendas/presentations/minutes from public meetings to discuss the plan, notifications to Indian Tribes, etc. It should include a copy
of all public comments received.

8. Letter Adopting MYP: A signed letter from the Authorizing Official formally adopting the MYP submitted to Treasury. This letter
should be dated after the submission and consideration of public comments and uploaded as an attachment.

9. More Detailed MYP Information (optional): If a more detailed plan has been prepared beyond the information included in the
sections above, please upload the file(s) here.

10. Comprehensive Land Use Plan Certification (Louisiana entities only): You must upload a Comprehensive Land Use Plan
certification.

Page 2

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
1. Applicant Name:
2. Descriptive Title of the Project (refer to SF-424):
3. Activity Title from Multiyear Plan Matrix, column #6:
Statutory Questions
4. Select the Primary Qualifying Eligible Activity:
a. Restoration and protection of the natural resources, ecosystems, fisheries, marine and
wildlife habitats, beaches and coastal wetlands of the Gulf Coast Region
b. Mitigation of damage to fish, wildlife and natural resources
c. Implementation of a federally approved marine, coastal, or comprehensive conservation
management plan, including fisheries monitoring
d. Workforce development and job creation
e. Improvements to or on State parks located in coastal areas affected by the Deepwater
Horizon oil spill
f. Infrastructure projects benefitting the economy or ecological resources, including port
infrastructure
g. Coastal flood protection and related infrastructure
h. Planning assistance
i. Promotion of tourism in the Gulf Coast Region, including recreational fishing
j. Promotion of the consumption of seafood harvested from the Gulf Coast Region
5. Select all other eligible activities that apply:
 Restoration and protection of the natural resources, ecosystems, fisheries, marine and
wildlife habitats, beaches and coastal wetlands of the Gulf Coast Region
 Mitigation of damage to fish, wildlife and natural resources
 Implementation of a federally approved marine, coastal, or comprehensive conservation
management plan, including fisheries monitoring
 Workforce development and job creation
 Improvements to or on State parks located in coastal areas affected by the Deepwater
Horizon oil spill
 Infrastructure projects benefitting the economy or ecological resources, including port
infrastructure
 Coastal flood protection and related infrastructure
 Planning assistance
 Promotion of tourism in the Gulf Coast Region, including recreational fishing
 Promotion of the consumption of seafood harvested from the Gulf Coast Region

6. Was the Proposed activity included in any claim for compensation paid out by the Oil Spill
Liability Trust Fund after July 6, 2012? If “Yes,” this activity is not eligible for a Direct Component
grant.
 Yes
 No
Project Location
7. Location/primary place of performance. Please provide the actual location for the activity.
a. Street Address:
b. City/Town:
c. County/Parish:
d. State:
e. Zip code:
8. If there is more than one location for the activity, please include a list of the additional locations.
a. Street Address:
b. City/Town:
c. County/Parish:
d. State:
e. Zip code:
9. If available, provide latitude/longitude(s) or GPS coordinates for the location(s) of the project.
10. Attach a map showing the project location in the Gulf Coast Region.
11. Is a GIS shape file available?
 No.
 Yes. If yes, please provide a point of contact (name and email address) from whom the file
may be obtained.
Proposed Scope of Work
The applicant must provide a detailed scope of work that fully describes the project or program for
which funding is requested, including all the questions below.
12. Key Personnel
a. Applicant’s Authorizing Official authorized to sign the grant application and award:
Name
Email
Phone
b. Project Director responsible for the project:
Name
Email
Phone
c. Financial Officer responsible for maintaining accounting and financial records of the grant:
Name
Email
Phone

13. Project or Program Description:
a. Need:
b. Purpose:
c. Objectives that clearly identify with the eligible activity(ies)
14. Identify how the proposed project activity will be carried out in the Gulf Coast Region as defined
in 31 CFR 34.2. (select appropriate response)
 In Gulf Coast States, the coastal zones defined under section 304 of the CZMA that border
the Gulf
 Land within coastal zones held in trust by the Federal Government
 Any adjacent land, water, and watersheds within 25 miles of coastal zone
 All federal waters of the Gulf of Mexico
 The eligible activity is exempt from being located in the Gulf Coast Region. If the eligible
activity is exempt, provide the reason for exemption:
15. Describe possible material risks in implementing and maintaining the proposed activity, e.g.,
operational, legal, regulatory, budgetary, or ecological risks, and include 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.
16. 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 exist, make an
affirmative statement as to their consistency.
Best Available Science
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.)
17. Is the proposed activity a restoration or natural resource project or does the proposed project
include restoration or natural resource objectives?
 No
 Yes. If yes, a detailed response must be included with the application and supporting
documentation may be required. In your responses cite and describe peer reviewed
literature or publicly available data. For each source cited, the applicant must provide
sufficient citations, including title; journal in which the literature source appeared, if
applicable; publication date; author(s); and URL if downloaded or available online.
a. Provide a response with the following:
• an explanation of how the project’s natural resource protection and/or
restoration objectives and proposed methods are based on best available
science
• a summary of any risks or uncertainties associated with the project and explain
how these risks will be mitigated

•

a description of the peer-reviewed information that justifies the proposed
objectives, including methods used for the proposed activity.
• a description of the literature sources’ conclusions and any uncertainties or risks
in the scientific basis that would apply to the proposed activity.
• if the information supporting the proposed activity does not directly pertain to
the Gulf Coast Region, an explanation on how the applicant’s methods
reasonably support and are adaptable to that geographic area.
• an evaluation of uncertainties and risks in achieving the project’s best available
science objectives over the longer term.
b. To support the Best Available Science determination, provide copies of 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.
Budget Justification
18. 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 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.)
19. If indirect costs are requested, the applicant must select the appropriate response below and
provide relevant supporting documentation:
 Indirect costs are based on a grant-by-grant method and do not exceed 3% of award amount
 Indirect costs are based on the Aggregate Method and do not exceed 3% of the total
Administrative Cost Pool available.
a. If requesting the aggregate method, provide a table of administrative costs requested to
date and the available funds in the recipient’s administrative indirect cost pool. (We
recommend using the worksheet from the Aggregate Method Administrative Cost Tool.)
b. Indirect costs must be supported by either a current federally approved Indirect Cost Rate
Agreement or an election to use the de minimis indirect cost rate. Applicants electing to use
the de minimis rate should upload a letter or other similar document, signed by their Chief
Financial Officer or other senior official. Applicants electing to use a federally approved
Indirect Cost Rate Agreement (Negotiated Indirect Cost Rate Agreement, NICRA) should
upload the current NICRA.
20. Does the project include Other Funding Sources?
 No.
 Yes. If yes, provide documentation of proof of availability of other funds needed for
completion of project activities. (See relevant Funding Opportunity Announcement for a
complete description of what Treasury accepts as documentation as proof of available other
funds).

Direct Component Funds to Satisfy Non-Federal Cost Share
Treasury’s RESTORE Act regulations at 31 CFR § 34.200(b) allow eligible applicants to use funds under
the Direct Component to satisfy the non-Federal cost-share of an activity that is eligible for funding
under 31 CFR § 34.201 and authorized by Federal law. Applicants seeking to use Direct Component
funding to cover the non-Federal cost-share of another federally funded project or program which is a
Direct Component eligible activity must include documentation in its application. 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. (See relevant Funding Opportunity Announcement for a complete description of what must be
provided.)
21. Will the proposed activity use Direct Component funding to cover the non-Federal cost-share of
another federally funded project or program which is a Direct Component eligible activity?
 No.
 Yes.
a. If yes, has the other Federal agency approved the activity?
 No. If no, the applicant must provide the additional information as follows.
i. The project description/scope of work and performance metric.
ii. A narrative describing the activity’s status and the approximate timeline for the
Federal agency to approve or decline the activity.
iii. A letter of commitment from that agency or other documentation that indicates
the applicant will receive funding.
 Yes. If yes, the applicant must upload a copy of the grant agreement or other
approval document as part of this Direct Component application.
Contractor
22. Does the applicant plan to contract out any work described in the Scope of Work and included in
the Budget Justification (do not include subrecipient’s contractors)?
 No.
 Yes.
a. Describe the expected number of contracts, method of procurement, and the applicant’s
plan for monitoring contractor performance and compliance.
b. Has a contractor already been selected?
 No.
 Yes. If yes, provide information for each contractor.
i. Name:
ii. Unique Entity ID (SAM):
iii. Date the applicant executed contract:
iv. Amount of contract awarded:

Subrecipient
23. Does the proposed project include a subaward?
 No.
 Yes. If yes, provide a separate, clearly defined scope of work and budget for the
subrecipient(s).
a. Has a subrecipient already been selected?
 No. If no, describe how the applicant 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.
 Yes. If yes, provide information for each subrecipient.
i. Name:
ii. Unique Entity ID (SAM):
iii. Date of applicant selection of subrecipient:
iv. Amount of funds to be provided to subrecipient:
v. Describe how the applicant selected the subrecipient; the applicant’s plan for
monitoring the subrecipient’s performance and compliance, and the means by
which the applicant assessed the subrecipient’s level of risk.
Land Acquisition, Construction, and Relocation Assistance
24. Will land, or an interest in land, be acquired?
 No.
 Yes. If yes, answer the questions below. Based on the applicant’s responses to the following
questions, the applicant may be required to upload supporting documentation.
a. What are the legal rights that will be acquired?
 Fee simple title
 Less-Than Fee Simple Title (e.g., easement)
b. If an easement, what is the life of the easement?
c. If known, what is the tax parcel number(s)? If tax parcel known, provide a copy of the
legal description of the property.
d. Will the applicant (or subrecipient) hold title to the land?
 No. If no, please provide a brief explanation for ownership of the property including
how access to property for the project will be obtained.
 Yes. If obtained, provide a copy of the title opinion or certificate.
e. If known, what is the total acreage of the proposed property interest to be acquired?
f. Are the property boundaries known for the project site?
 No.
 Yes. If yes, provide a map of the area in which the real property to be acquired will
be located, with the boundaries of the project site clearly delineated and provide a
Federal Emergency Management Agency (FEMA) floodplain map of the area in
which the real property to be acquired will be located with the boundaries of the
site clearly delineated.

g. Has the applicant (or subrecipient) obtained a recent certified appraisal of the property?
 No.
 Yes. If obtained, provide a copy of the recent certified appraisal. If the appraisal is
older than one year from the date of the grant application, please provide a written
justification.
h. Has the applicant (or subrecipient) obtained a title opinion or certificate?
 No
 Yes. If obtained, provide a copy of the title opinion or certificate.
i. 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?
 No.
 Yes. If obtained, provide a copy of the signed willing seller statement.
25. Does the project include construction?
 No.
 Yes. If yes, answer the questions below. Based on the applicant’s responses to the following
questions, the applicant may be required to upload supporting documentation.
a. Will or does the applicant (or subrecipient) hold title to the property to be improved?
 No. If no, please provide a brief explanation of the ownership of the property
including how access to property for the project will be obtained.
 Yes. If obtained, provide a copy of the title opinion or certificate.
b. If known, what is the tax parcel number(s) of the property? If tax parcel known, provide
a copy of the legal description of the property.
c. Are the property boundaries known for the project site?
 No.
 Yes. If property boundaries known, provide a map of the area in which the
construction project will be located, with the boundaries of the project site clearly
delineated and a Federal Emergency Management Agency (FEMA) floodplain map of
the area in which the construction project will be located with the boundaries of the
site clearly delineated.
d. Has the applicant (or subrecipient) obtained a recent certified appraisal of the property?
 No.
 Yes. If obtained, provide a copy of the recent certified appraisal. If the appraisal is
older than one year from the date of the grant application, please provide a written
justification.
e. Has the applicant (or subrecipient) obtained construction drawings for the project?
 No.
 Yes. If obtained, provide a copy of the construction drawings for the project.
f. Is the applicant proposing an Estimated Useful Life for the construction activity?
 No.
 Yes. If yes, provide a proposed Estimated Useful Life for infrastructure (in years) and
provide a description of the method used to determine the Estimated Useful Life of
the project.

26. Relocation Assistance: Will the proposed project cause the displacement of any persons,
businesses, or farm operations?
 No.
 Yes. 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.

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 subm itted with each application
to Treasury for financial assistance under the RESTORE Act Direct Compone nt. 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 Applica tion that it will
not award any contract or subaward to any entity on the government wide 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 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.

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 Restorati on, 1500 Pennsylvania Ave.,
NW, Washington, DC 20220.

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.

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 Restorati on, 1500 Pennsylvania Ave.,
NW, Washington, DC 20220.

Signature of Authorized Senior Official:
Name:

Date:

Title:

Organization:

Page 3

RESTORE Act Environmental Compliance Form - Department of the Treasury
OMB Approval Number 1505‐0250

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 to implement the requirements of the law. If a response of ‘No’ is recorded to any of
the following questions, the applicant has the option to summarize their analysis and conclusion regarding
the non-applicability of the environmental law. 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 RESTORE Act Environmental Compliance Form
completed by the subrecipient’s authorized representative. A signed statement from the applicant attesting
to its review of the subrecipient’s RESTORE Act Environmental Compliance Form must be included 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.
A. FORM INTAKE
1) Please offer the following details about who provided the information to complete this form.
Name:
Title:
Organization:
Date:
2) For projects that do not involve construction activities, has the applicant identified any
environmental laws that may apply to the eligible activity?
□ Yes. If yes, the applicant will proceed to question 3.
□ No.
□ Not applicable. The project includes construction activities.
3) Will the project be implemented by a subrecipient?
□ Yes. If yes, provide the subrecipient organization:
□ No. If no, proceed to Section B.
4) Has the subrecipient’s authorized representative completed and certified the Environmental
Compliance Form?
□ Yes. If the subrecipient has completed and certified the Environmental Compliance Form at time
of application, the applicant should upload the certified form and any supporting
documentation.
□ No. If the subrecipient has not completed and certified the Environmental Compliance Form
Page 1

review at time of application, please provide a brief explanation (for example, the subrecipient
agreement has not been executed and the applicant will require the subrecipient to submit a
completed and certified Environmental Compliance Form prior to commencing construction
activities within the scope of work.)
5) Certification of Review
If the Environmental Compliance Form is completed and certified by the subrecipient, the applicant
must complete the following statement attesting to review of the subrecipient’s Environmental
Compliance Form.
The Applicant certifies that it has reviewed the subrecipient’s RESTORE Act Environmental
Compliance Form and attest to its accuracy.
Signature of Applicant’s Authorized Senior Official:
Name:
Date:
Title:
Organization:
B. ASSESSMENT OF APPLICABILITY OF ENVIRONMENTAL LAWS
If the project will be implemented by the recipient, the following questions must be completed by the
applicant.
1) NATIONAL ENVIRONMENTAL POLICY ACT (NEPA)
An Environmental Review may be required based on the answers to the following questions:
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)?
If the answer to any of these questions is “yes,” contact the relevant federal agency or agencies for
further guidance on environmental compliance.
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 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 ☐ Uncertain ☐
If yes, list the document(s) and federal agency(ies): _______________________________________
Page 2

If no, briefly summarize your entity's determination that a NEPA or NEPA-like review will not be
required for this proposed eligible activity. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of the environmental review, correspondence with the relevant
federal agency(ies), or copy of a public notice of intent to issue a federal permit.
2) COASTAL ZONE MANAGEMENT ACT (CZMA)
A federal consistency determination or certification pursuant to Section 307 of the Coastal Zone
Management Act may be required from the state coastal zone management program, based on the
answers to the following questions:
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 ☐ Uncertain ☐
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.
If no, briefly summarize your entity's determination that the activity will not be likely to have
reasonably foreseeable effects on any land or water use or natural resource of the designated
coastal zone. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include correspondence with relevant State Coastal Zone Management
Program regarding CZMA applicability and requirements, a copy of a federal consistency
Page 3

determination, or copy of a certificate. In cases of joint reviews, documentation of CZMA compliance
may include a copy of a state permit. In Florida, documentation may include a copy of a clearance
letter from the state Clearinghouse.

3) NATIONAL MARINE SANCTUARIES ACT
A permit or other authorization may be required from the National Oceanic and Atmospheric
Administration (NOAA) based on the answer to the following question:
Is the proposed activity located in a National Oceanic and Atmospheric Administration (NOAA)
National Marine Sanctuary?
If the answer to this question is “yes” or “uncertain” contact the nearest Regional Office of NOAA’s
National Marine Sanctuaries Program for further guidance.
Yes ☐ No ☐ Uncertain ☐
If yes, identity the National Marine Sanctuary: ____________________________
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a state or federal permit, copy of a consultation, or
correspondence with a Regional Office of NOAA's National Marine Sanctuaries Program to
determine whether a permit and/or consultation or further coordination is required.
4) MAGNUSON – STEVENS FISHERY CONSERVATION AND MANAGEMENT ACT
Consultation with the NMFS may be required if Essential Fish Habitat (EFH) is present and based on
the answers to the following questions:
Will the proposed activity occur in proximity to an Essential Fish Habitat (EFH) as identified by
NOAA’s National Marine Fisheries Service (NMFS)?
If yes, consultation with NMFS Habitat Conservation Division may be required.
Yes ☐ No ☐ Uncertain ☐
If yes, identity the EFH types: ____________________________
If no, briefly summarize your entity's determination that EFH is not present: (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
Page 4

coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a state or federal permit, copy of a consultation, or
correspondence with NOAA NMFS to determine whether a permit and/or consultation or further
coordination is required.
5) MARINE MAMMAL PROTECTION ACT (MMPA) (NMFS)
A permit may be required if an activity will result in the “take” of a marine mammal, based on the
answers to the following questions. “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).
Permits for most marine mammals are issued by NMFS.

If the answer to either of these questions is “yes” or you are unsure, contact NMFS.
Will the proposed activity occur in proximity to any known marine mammals under the jurisdiction
of the NMFS?
Yes ☐ No ☐ Uncertain ☐
If no, briefly summarize your entity's determination that the proposed activity will not occur in
proximity to any known marine mammals under the jurisdiction of NMFS. (optional)
Will the proposed activity likely result in the take of a marine mammal?
Yes ☐ No ☐ Uncertain ☐
If yes, identify the marine mammal(s): ___________________________________
If no, briefly summarize your entity's determination that the proposed activity will not likely result
in the take of a marine mammal. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with NMFS. This may
include correspondence leading to a determination that further coordination, permits, certifications,
consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a state or federal permit, copy of a consultation, or
correspondence with a NMFS Field Office to determine whether a permit and/or consultation or
further coordination is required.
Page 5

6) MARINE MAMMAL PROTECTION ACT (USFWS)
A permit may be required if an activity will result in the “take” of a marine mammal, based on the
answers to the following questions. "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).
Manatees, polar bears, sea otters, walruses, and dugongs are under the jurisdiction of the USFWS.
If the answer to either of these questions is “yes” or you are unsure, contact the appropriate USFWS
ecological services office to determine if a permit is required.
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 ☐ Uncertain ☐
If no, briefly summarize your entity's determination that the proposed activity will not occur in
proximity to any known marine mammals under the jurisdiction of USFWS. (optional)
Will the proposed activity likely result in the take of a marine mammal?
Yes ☐ No ☐ Uncertain ☐
If yes, identify the marine mammal(s): ___________________________________
If no, briefly summarize your entity's determination that the proposed activity will not likely
result in the take of a marine mammal. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a state or federal permit, copy of a consultation, or
correspondence with a USFWS Field Office to determine whether a permit and/or consultation or
further coordination is required.
7) ENDANGERED SPECIES ACT (ESA) (USFWS)
A consultation pursuant to Section 7 or 10 of the Endangered Species Act and/or a permit and
conservation plan pursuant to Section 10 may be required based on the answers to the following
questions:
If the answer to either of these questions is “yes,” or you are unsure, contact the appropriate
ecological services field office of the USFWS and/or the Office of Protected Resources Program of the
NMFS to determine if consultation is required. Most consultations are conducted informally with the
Page 6

federal agency or a designated non‐federal representative.
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 ☐ Uncertain ☐
If no, briefly summarize your entity's determination that the proposed activity will not occur in
proximity to threatened or endangered species or critical habitat as defined by the ESA and under
the jurisdiction of USFWS. (optional)
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: __________________________________________
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a consultation pursuant to Section 7 of the ESA and/or a copy
of a Section 10 permit and conservation plan. Documentation may include correspondence with the
appropriate USFWS Field Office to determine if consultation is required.
8) ENDANGERED SPECIES ACT (NMFS)
A consultation pursuant to Section 10 of the Endangered Species Act and/or a permit and
conservation plan pursuant to Section 10 may be required based on the answers to the following
questions:
If the answer to either of these questions is “yes,” or you are unsure, contact the Office of Protected
Resources Program of NMFS to determine if consultation is required. Most consultations are
conducted informally with the federal agency or a designated non‐federal representative.
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 ☐ Uncertain ☐
If no, briefly summarize your entity's determination that the proposed activity will not occur in
proximity to threatened or endangered species or critical habitat as defined by the ESA and under
the jurisdiction of NMFS. (optional)
Will the proposed activity potentially affect threatened or endangered species or critical
Page 7

habitat as defined by the ESA and under the jurisdiction of the NMFS?
Yes ☐ No ☐ Uncertain ☐
If yes, list the species: __________________________________________
If no, briefly summarize your entity's determination that the proposed activity will not occur in
proximity to threatened or endangered species or critical habitat as defined by the ESA and under
the jurisdiction of NMFS. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a consultation pursuant to Section 7 of the ESA and/or a copy
of a permit and conservation plan pursuant to Section 10. Documentation may include
correspondence with the appropriate NMFS Office to determine if consultation is required.
9) COASTAL BARRIER RESOURCES ACT (CBRA)
Federal funding may be prohibited for projects that occur on certain designated coastal barriers,
based on the answer to the following question:
Is the proposed activity located in or adjacent to a unit of the Coastal Barrier Resources
System (CBRS)?
If yes, the federal funding for the activity may be prohibited. Treasury may be required to
make a determination regarding CBRA compliance. If the answer to this question is “yes,”
contact the appropriate USFWS ecological services office for further guidance. If yes, the
federal funding for the activity may be prohibited.
Yes ☐ No ☐
If yes, indicate the CBRS unit(s): __________________________
If no, briefly summarize your entity's determination that the proposed activity is not located in or
adjacent to a unit of the CBRS. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Page 8

Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of an exception to meeting CBRA, correspondence with the
appropriate USFWS Field Office, and/or a CBRS Mapper image that demonstrates the project is not
located in or adjacent to a unit of CBRA.
10) MIGRATORY BIRD TREATY ACT
The migratory bird species protected by the Act are listed in 50 C.F.R. 10.13. A consultation with
USFWS may be required based on the answers to the following question:
Will the proposed activity affect any migratory bird species protected by the Migratory Bird
Treaty Act?
Yes ☐ No ☐ Uncertain ☐
If the answer is “yes” or you are unsure, contact the appropriate ecological services field office of the
USFWS. More information can be found at FWS Migratory Bird Treaty Act. A consultation and/or
permit from the USFWS may be required.
If yes, list the migratory bird species: __________________________
If no, briefly summarize your entity's determination that the proposed activity will not affect any
migratory bird species protected by the Migratory Bird Treaty Act. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a permit, a copy of a consultation, or correspondence with the
appropriate USFWS Field Office to determine whether a permit, and/or consultation or further
coordination is required.
11) BALD AND GOLDEN EAGLE PROTECTION ACT
A permit may be required based on the answers to the following questions:
Will the proposed activity affect any bald or golden eagles protected by the Bald and Golden
Eagle Protection Act?
Yes ☐ No ☐ Uncertain ☐
If no, briefly summarize your entity's determination that the proposed activity will not affect any
bald or golden eagles protected by the Bald and Golden Eagle Protection Act. (optional)

Page 9

Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a permit, a copy of a consultation, or correspondence with the
appropriate USFWS Field Office to determine whether a permit, and/or consultation or further
coordination is required.
12) WILD AND SCENIC RIVER ACT
There are designated Wild and Scenic rivers in the Gulf Coast States and the Act may apply based on
the answer to the following question:
Is the proposed activity located on a designated Wild and Scenic River?
If the answer to this question is “yes,” contact the appropriate USFWS ecological services office for
further guidance.
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.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include correspondence with the appropriate USFWS ecological service office
for further guidance and any necessary mitigation requirements.
13) NATIONAL HISTORIC PRESERVATION ACT (NHPA) AND THE ARCHAEOLOGICAL AND HISTORIC
PRESERVATION ACT (AHPA)
Page 10

If the answer to this question is “yes,” or you are unsure, contact your state historic preservation
office for further guidance concerning compliance requirements.
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 ☐ Uncertain ☐
If no, briefly summarize your entity's determination that the proposed activity will not occur 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. (optional)
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 ☐ Uncertain ☐
If yes, the activity may be prohibited or require mitigation from the State Historic Preservation
Officer or Tribal Historic Preservation Officer.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a description of special conditions required on the project, or
correspondence with the appropriate state historic preservation office or tribal historic preservation
office for further guidance concerning any compliance requirements.
14) RIVERS and HARBORS ACT - SECTION 10 (and SECTION 408 if applicable)
A permit may be required from the USACE based on the answer to the following question:
Will the proposed activity involve any work (including structures) that will occur in, over or under
navigable waters of the United States?
Yes ☐ No ☐ Uncertain ☐
In cases of use or alteration of a federal civil works project, a Section 408 consultation with the
USACE may be required. If the answer to this question is “yes” or you are unsure, contact the
Regulatory Program of the nearest District Office of the USACE for further guidance on Section 10
permits. If yes, a Section 10 permit may be required from the USACE.

Page 11

If no, briefly summarize your entity's determination that the proposed activity will not occur in,
over, or under navigable waters of the United States. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a Section 10 permit from USACE (standard individual permit,
letter-of-permission, nationwide permit, or regional permit), a Section 408 consultation with USACE,
or correspondence with USACE to determine whether a permit, and/or consultation or further
coordination is needed.
15) CLEAN WATER ACT (CWA), SECTION 404
A permit may be required based on the answer to the following question:
Will the proposed activity result in any discharge of dredge or fill material to the nation’s
waters or wetlands?
If the answer to this question is “yes” or you are unsure, contact the Regulatory Program of the
nearest District Office of the USACE for further guidance on Section 404 permits. If yes, a
Section 404 permit may be required from the USACE.
Yes ☐ No ☐ Uncertain ☐
If no, briefly summarize your entity's determination that the proposed activity will not result in any
discharge of dredge or fill material in the Nation's waters or wetlands. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a CWA Section 404 permit from USACE or delegated state
agency, or evidence of exemption from permit requirements. Documentation may include
correspondence with USACE or delegated state agency to determine whether a permit or further
Page 12

coordination is needed.
16) CLEAN WATER ACT (CWA), SECTIONS 401 and 402
A National Pollution Discharge Elimination System (NPDES) permit may be required based on the
answer to the following question:
Will the proposed activity result in any discharge of a pollutant to the nation’s waters or wetlands?
Yes ☐ No ☐ Uncertain ☐
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. If
the answer to this question is “yes,” or you are unsure, contact your state water quality agency for
additional guidance.
If no, briefly summarize your entity's determination that the proposed activity will not result in any
discharge of pollutants to the Nation's waters or wetlands. (optional)
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a CWA Water Quality Certification (Section 401) or a copy of a
National Pollution Discharge Elimination System (NPDES) permit for discharges. Documentation may
include correspondence with the relevant state water quality agency with guidance concerning any
Section 401 or NPDES requirements.
17) MARINE PROTECTION, RESEARCH, AND SANCTUARIES ACT (MPRSA)
A permit may be required based on the answer to the following question:
Does the proposed activity involve the transportation of materials from the US for the purpose of
ocean dumping covered by the MPRSA?
Yes ☐ No ☐ Uncertain ☐
If the answer to this question is “yes” or you are unsure, contact the Environmental Protection
Agency’s (EPA) Office of Wetlands, Oceans, and Watersheds/Oceans and Coastal Protection Division
for further guidance.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
Page 13

coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a state or federal permit, or correspondence with EPA to
determine whether a permit and/or consultation or further coordination is required.
18) CLEAN AIR ACT (CAA)
Special conditions may be required on projects that could affect air quality, based on the answer to
the following question:
Will the proposed activity result in any emissions of pollutants to the air within a non-attainment
area or maintenance area?
Yes ☐ No ☐ Uncertain ☐
If the answer to this question is “yes” or you are unsure, contact the nearest state air quality agency
for further guidance on determining conformity with the state implementation plan. If yes, the
activity may require compliance with the CAA including obtaining a permit in some circumstances
from EPA or a delegated state agency.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a CAA permit from EPA or a delegated state agency, or
correspondence with the EPA or delegated state agency to determine conformity with the relevant
state implementation plan.
19) RESOURCE CONSERVATION AND RECOVERY ACT (RCRA)
A RCRA permit may be required from the EPA or designated state agency based on the answer to
the following question:
Will the proposed activity include the treatment, storage, or disposal of hazardous waste or
involve underground storage tanks?
Yes ☐ No ☐ Uncertain ☐
If the answer to this question is “yes” or you are unsure, contact the nearest RCRA Regional Office of
Page 14

the EPA or state authorized agency for further guidance on RCRA compliance. If yes, RCRA
hazardous waste storage tank requirements may apply.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a permit, or correspondence from EPA or authorized state
agency with further guidance on RCRA compliance.
20) COMPREHENSIVE ENVIRONMENTAL RESPONSE, COMPENSATION, AND LIABILITY ACT (CERCLA)
Special provisions and requirements may apply based on the answer to the following question:
Will the proposed activity involve a Superfund site?
Yes ☐ No ☐ Uncertain ☐
If the answer to this question is “yes” or you are unsure, contact the nearest Regional Office of the
EPA for further guidance on CERCLA requirements. If yes, the activity requires coordination with EPA.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a permit, or correspondence from EPA or authorized state
agency with further guidance on CERCLA compliance, including any special provisions and
requirements that may apply.
21) SAFE DRINKING WATER ACT (SDWA)
A permit may be required if the proposed activity will involve underground injection which may
impact drinking water sources and based on the answer to the following question:
Will the proposed activity involve underground injection, which may impact drinking water
sources?
Page 15

Yes ☐ No ☐ Uncertain ☐
If yes, a SDWA permit may be required from EPA or a state with an EPA-approved primacy program.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a permit, or correspondence from EPA or state drinking water
or underground injection control program with further guidance on SDWA compliance, including any
special provisions and requirements that may apply.
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.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a correspondence with the local office of the Natural Resources
Conservation Service with further guidance on FPPA requirements and any applicable permits or
mitigation steps.
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 ☐ Uncertain ☐
If yes, the purchase of Federal Flood Insurance may be required.
Do you have anything to report on environmental compliance status for this law?
Page 16

Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a map image that demonstrates the project is not located in a Special
Flood Hazard Area on a NFIP map. Documentation may include a record of the eight-step process to
be followed for projects that may have potential impacts to or within floodplains, or correspondence
with the nearest Regional Office of FEMA with further guidance.
24) E.O. 11988 and E.O. 12148 – FLOOD MANAGEMENT
Is the proposed activity located in a Special Flood Hazard Area on a National Flood Insurance
Program map?
Yes ☐ No ☐ Uncertain ☐
If yes, a public notice may be required.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a map image that demonstrates the project is not located in a Special
Flood Hazard Area on a NFIP map. Documentation may include a record of the eight-step process to
be followed for projects that may have potential impacts to or within floodplains, or correspondence
with the nearest Regional Office of FEMA with further guidance.
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 ☐ Uncertain ☐
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.
If no, briefly summarize your entity's determination that the project is not proposing a new
construction activity in wetlands. (optional)

Page 17

Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a determination that there is no practicable alternative to the
construction, and/or the proposed action includes all practicable measures to minimize harm to
wetlands. Documentation may include correspondence with the appropriate USFWS Field Office to
determine whether consultation or further coordination is necessary. Documentation may include a
Wetlands Mapper image depicting the project location and proximity to wetlands.
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 ☐ Uncertain ☐
If yes, the activity may require mitigation.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include further guidance from the Council on Environmental Quality regarding
the incorporation of EJ into environmental reviews.
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.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
Page 18

N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a copy of a permit, or correspondence with NOAA Coral Reef Program
to determine with a permit, and/or consultation or further coordination is required.
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 ☐ Uncertain ☐
If yes, action to prevent the introduction of invasive species may be required.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
Documentation may include a description of actions necessary to prevent the introduction of
invasive species, or correspondence with the USDA to determine whether further coordination or
guidance is 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 ☐ Uncertain ☐
If yes, the activity may be prohibited or require mitigation from the USFWS.
Do you have anything to report on environmental compliance status for this law?
Please select 'yes' to report any coordination that your entity has conducted with the relevant
federal agency(ies). This may include correspondence leading to a determination that further
coordination, permits, certifications, consultations, or mitigation is not required for this project.
N/A ☐ Yes ☐ No ☐
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Page 19

Upload supporting documents.
Documentation may include a description of mitigation actions or correspondence with the
appropriate USFWS Field Office to determine whether further coordination or guidance is required.
C. OTHER PERMITS AND CERTIFICATIONS
Does the applicant anticipate that the proposed activity will require any other federal, tribal, state, or
local permits or certifications that have not yet been addressed?
Yes ☐ No ☐ Uncertain ☐
If yes, please provide the following information for any additional permits or certifications.
Name of responsible agency/tribe:
Permit, certification, determination mitigation required:
Date of contact or permission obtained:
Status:
Upload supporting documents.
D. Certification
Please select the statement that most accurately reflects the status of the information provided on the
Environmental Compliance Form submitted with this application.
☐ The information provided on this form is preliminary. The Applicant will complete and submit to
Treasury an updated Environmental Compliance form, certified by the Applicant’s Authorized Official
(and subrecipient, if applicable), prior to or with its written request to Treasury for permission to
commence construction or to initiate other project implementation activities that require prior
approval. (This option may be appropriate when the proposed scope of work includes an initial
planning and design phase during which any applicable environmental laws will be identified, and all
required permits, certifications or authorizations will be identified and acquired.)
☐ The information provided on this form is final, to the best of the Applicant’s knowledge, and the
Applicant’s Authorized Official certifies to its accuracy and completeness.

Page 20

RESTORE Act Application Milestones and Performance Measures – Department of the
Treasury
OMB Approval No. 1505-0250
A. Milestones:
Provide the milestones and the estimated timeframe for completion (Number of Months
After Performance Period Start Date).
B. Performance Measures:
Include the following information. For guidance, 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.

Page 1

RESTORE Act Milestones Report
RESTORE Act Milestones Report — Department of the Treasury

OMB Approval No. 1505-0250

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

-CEstimated
Completion
Timeframe of
Milestone
(Format: award
+ # of months)

-DIs milestone
contingent upon
completion of
another
milestone
(Y/N)?
If yes, which
milestone is it
contingent 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
ERROR!
ERROR!
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 contr ol 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 d irected to the Department of the Treasury, Office of Gulf Coast
Restoration, 1500 Pennsylvania Ave., NW, Washington, DC 20220.

RESTORE Act Status of Performance Report
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
toward
target
(reporting
period)

Progress
toward
target
(cumulative)

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 number for
this information collection is 1505-0250. Comments concerning the time required to complete this information collection, including the time to review instruction s, search existing data resources,
gathering and maintaining the data needed, and completing a nd 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

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 Excell ence (COE)
discipline (i.e., measuring success, rather than listing milestones or tasks). Please focus on a discrete number of pri ority 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 COE number 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
Restoration and protection of the natural resources, ecosystems,
Coastal and deltaic sustainability, restoration and protection, including
DC ‐ 1
COE ‐ 1 solutions and technology that allow citizens to live in a safe and
fisheries, marine and wildlife habitats, beaches, and coastal wetlands of
the Gulf Coast region.
sustainable manner in a coastal delta in the Gulf Coast Region.
Coastal fisheries and wildlife ecosystem research and monitoring in the
DC ‐ 2
COE ‐ 2
Mitigation of damage to fish, wildlife, and natural resources.
Gulf Coast Region.
DC ‐ 3
Implementation of a federally approved marine, coastal, or
COE ‐ 3 Offshore energy development, including research and technology to
comprehensive conservation management plan, including fisheries
improve the sustainable and safe development of energy resources in
monitoring.
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.
Improvements to or on State parks located in coastal areas affected by
DC ‐ 5
COE ‐ 5 Comprehensive observation, monitoring, and mapping of the Gulf of
the Deepwater Horizon oil spill.
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 harvested 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 narrat ive 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 number for
this information collection is 1505-0250. Comments concerning the time required to complete this information collection, including the time to review instruction s, 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 3

Civil Rights Act of 1964 Title VI Narrative for RESTORE Act - Direct Component and
Centers of Excellence Research Grants Applicants – Department of the Treasury
OMB Approval No. 1505-0250

All applicants must provide a Title VI Narrative as an upload in their applications. 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. 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.

5. 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).
6. A list of all Federal agencies providing federal financial assistance.
7. 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.
8. A copy of the applicant’s plan for providing language assistance to persons with limited
English proficiency, based on the Treasury LEP Guidance.

Page 3

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 (If yes, complete Sections A, C, D, and E)
☐ New/Additional Center(s) of Excellence (If yes, complete Sections B, C, D, and E)
☐ Both Existing and New/Additional Center(s) of Excellence (If yes, complete Sections A , B, C,
D, and E)
A. EXISTING CENTER(S) OF EXCELLENCE:
1.
Selection Process and Public Input
a. List existing Center(s) and the corresponding grant number(s) under which it
was first established, thereby incorporating previous responses by
reference.
b. 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).
B. NEW/ADDITIONAL CENTER(S) OF EXCELLENCE:
1.
Selection Process – New/Additional Center(s) of Excellence
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 cross- section 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

2.

requirements.
Public Input – New/Additional Center(s) of Excellence
Explain the process the applicant has engaged in or will engage in to provide 45day 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 (required for all applications):
1.
Subaward Management
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.
D. CENTER OF EXCELLENCE INFORMATION (required for all applications):
1.
Contact Information
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.
a. Name of Center of Excellence:
b. Name of Subrecipient:
c. Street address:
d. City:
e. County/Parish:
f. State:
g. Zip code:
h. UEI Number
i. PI Name:
j. PI Phone Number:
k. PI Email Address:
2.

Eligible Disciplines
Select the applicable eligible disciplines that each Center will be focusing on as
part of this grant request. (Select all that apply)
☐ 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
☐ Offshore energy development, including research and technology to improve
the sustainable and safe development of energy resources in the Gulf of
Mexico
☐ Sustainable and resilient growth and economic and commercial development
in the Gulf Coast Region
☐ Comprehensive observation, monitoring, and mapping of the Gulf of Mexico
3.

Center Details
Provide more information on each Center, including what type of entity it is and
whether it is a consortium.
a. Type of Entity (Institution of higher education, corporation, etc.):
b. Is the Center of Excellence a consortium?
□ No.
□ Yes. If yes, list all member organizations and addresses:

4.

Minority-Serving Institutions
Select whether there is a Minority-Serving Institution(s) and name the entity and
type of MSI if applicable.
☐ No.
☐ Yes. 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.

5.

Location
Is the Center of Excellence located in the Gulf Coast Region, as defined at 31 CFR
§ 34.2? Explain or upload a map if necessary.
☐ No.
☐ Yes.

E. PROGRAM DETAILS (required for all applications):
1.
Proposed Scope of Work
A detailed scope of work that fully describes the program for which funding is
requested, including:
a. Key Personnel. Include the name and contact information for the following:
i. Applicant’s Authorizing Official authorized to sign the grant application
and award:
Name
Email
Phone

ii. Project Director responsible for the project:

Name
Email
Phone

iii. Financial Officer responsible for maintaining accounting and financial
records of the grant:
Name
Email
Phone

b. Program Description. The Program Description must include the following:
Need:
Purpose:
Objectives, including how they are designed to contribute to
establishing/maintaining the Center(s) and monitoring the subrecipient(s)
Science, technology, and monitoring activities and how these activities relate
to the eligible discipline(s):
c. Subrecipient Scope of Work. Include a separate, clearly defined scope of
work for the subrecipient(s) and a detailed subrecipient budget.
2.

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 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. Indirect costs must be supported by a current federally approved Indirect
Cost Rate. Applicants electing to use a federally approved Negotiated Indirect
Cost Rate Agreement should upload the current agreement. Please contact
Treasury if the applicant does not have an indirect cost rate from its
cognizant federal agency and wishes to include indirect costs in the proposed
budget.

3.

Permits
Do the Center’s proposed activities require any federal, tribal, state, or other
permits?
☐ No.
☐ Yes. If yes, 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 - Reference Guidance on the
RESTORE Act Centers of Excellence Resources webpage.)

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 CFR § 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 Federa l 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 CFR § 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 CFR 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 government wide Excluded Parties List System (see 31 CFR 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 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 Fede ral
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.

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 tie rs (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 sub ject to a civil
penalty of not less than $10,000 and not more than $100,000 for each
such failure.

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.

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
f ederal 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 thereaf ter. 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 las t
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 f orm contains three parts:
o

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.

o

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.
o

Certif ication of the Applicant's Authorized Representative
Identif y the individual who has the authority to commit the organization to the Council's grant management
requirements and who can certify the accuracy of the statements made in the form. As noted above, the signed
certif ication 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

Phone
number

Email

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 2

Self-Assessment Questions
Environment
Please respond
“Y” or “N”

Questions
1. Does management promote open communications
throughout the organization and effectively provide
inf ormation to employees and other stakeholders?
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?
3. Do policies, procedures and processes for managing
f ederal grant funds meet the requirements of OMB 2 CFR
Chapter I and Chapter II, Unif orm 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 Accounting 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 f unds?
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 f or employees to confidentially report suspected
violations of policies and or suspected instances of fraud or
other criminal activity, including specifically those related to
f ederal 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. Notif y the appropriate federal agency in cases of
conf irmed fraud related to federal funds
12. Does the organization have a written grants management
manual or standard operating procedures?

Page 3

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y
Y
Y
Y

N
N
N
N

Y

N

Comments

Risk Assessment
Please respond
“Y” or “N”

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?

Y

N

14. Does the organization have a documented risk assessment
and compliance monitoring process in place specifically for
f ederal grant programs?

Y

N

Comments

Objectives
Please respond
“Y” or “N”

Questions
15. Allowable / Unallowable Activities & Costs – Does an
ef f ective system of internal controls exists to provide
reasonable assurance that federal awards are expended
only f or 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
f ederal 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
f ederal 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 f ederal 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 f ederal awarding agency is appropriately
compensated for its share of any property sold or
converted to non-federal use
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?

Page 4

Y

N

Y

N

Y

N

Y

N

Y

N

Y
Y

N
N

Y

N

Y

N

Y

N

Comments

Objectives (Continued)
Please respond
“Y” or “N”

Questions
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
f or all f unds, 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 reasonable assurance that:
a. Federal award inf ormation 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?

Page 5

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y
Y
Y

N
N
N

Y

N

Comments

Information & Communication
Please respond
“Y” or “N”

Questions
28. Are external and internal Communication channels
established between organization and (1) f ederal agency, (2)
state agencies, (3) sub-recipients and (4) contractors and
vendors and (5) other stakeholders?
29. Is inf ormation 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
f ederal and grant specific program requirements, including
reporting and record retention requirements?
31. Do inf ormation systems policies and procedures exist for the
saf eguarding of data, including personally identifiable
inf ormation (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?

Y

N

Y

N

Y

N

Y

N

Y

N

Comments

Monitoring
Please respond
“Y” or “N”

Questions
33. Are the associated grant fund operations regularly assessed
by an internal auditor, Inspector General and/or external audit
f unction (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
f ederal grant programs to ensure that guidelines and
requirements are being met?

Y

N

Page 6

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)

Page 7

RESTORE Act Permission to Commence with Construction Checklist – Department of the Treasury
OMB Approval No. 1505-0250
The recipient must not commence construction prior to the date of the Award. The recipient must make a
written request to Treasury for permission to commence with construction after the construction contractor
has been selected and at least 30 days prior to construction. No construction funds may be drawn from
ASAP without Treasury’s written permission. If the recipient commences construction prior to Treasury’s
determination, the recipient proceeds at its own risk.
Directions: The following questions will aid the applicant’s request for permission to commence with
construction. Treasury will use submitted documents to determine that the award of all contracts with
associated costs are in compliance with the scope of the project and all terms and conditions of this award,
and that all necessary permits have been or will be obtained, all Special Award Conditions tied to the
commencement of construction have been satisfied, and the federal interest is secure.
REQUIREMENTS
Based on the recipient’s responses to the following, supporting documentation may be requested.
1. Upload a written request for permission to commence construction. Permission to commence
construction should be requested after the construction contractor has been selected and at least 30
days prior to the anticipated construction start date.
2. Has a good and merchantable title free of all mortgages, foreclosable liens, or encumbrances, to all
land, rights of way and easements necessary for completion of the project been acquired?
□ No.
□ Yes. If yes, upload the appropriate supporting documentation. Examples of appropriate
documentation may include recent title opinion, deed, clear site certification, etc.
3. Have all federal, state, and local permits necessary for the completion of the project been obtained?
□ No.
□ Yes. If yes, provide a list of all required permits, or an updated Environmental Compliance
Form. Note status of permits and the expiration date of any existing permits. Upload any
supporting documentation.
4. Has the federal interest been recorded on the property?
□ No.
□ Yes. If yes, provide documentation of the recorded federal interest. Recipients must record a
“Covenant of Purpose, Use of Ownership” in real property records in the jurisdiction in which
the real property is located. The covenant should be filed prior to the initiation of construction.
□ N/A. If not applicable, please provide an explanation.
5. Has an Estimated Useful Life for the project been established for the project?
□ No.
□ Yes. If yes, provide the EUL (in years).

6. Are all contracts awarded with associated costs in compliance with award terms & conditions?
□ No.
□ Yes. If yes, please upload relevant contracts.
7. Do Davis-Bacon Act Provisions apply to this award?
□ No.
□ Yes.
a. If yes, was a copy of DOL’s prevailing wage determination included in each solicitation?
□ No.
□ Yes. If yes, please upload supporting documentation, as appropriate.
□ N/A. Please provide an explanation.
8. Are all subawards in compliance with award terms & conditions?
□ No. All relevant subaward agreements must be signed and in place prior to commencement of
construction.
□ Yes.
□ N/A.
9. Has a performance bond and payment bond on the part of the contractor been agreed to?
□ No. A performance bond and payment bond on the part of the contractor for 100% of the
contract price are required.
□ Yes. If yes, please upload supporting documentation, as appropriate.
10. Have Floodplain Notice requirements been met? The Floodplain Notice is only required when the
action will be in or affecting a designated 100-year floodplain and will have potential to adversely
affect the designated 100-year floodplain. Agencies are allowed to use their environmental review
process (e.g., Categorical Exclusion determination, Findings of No Significant Impact, and
Environmental Impact Statement) as a vehicle to satisfy this requirement.
□ No.
□ Yes. If yes, please upload supporting documentation, as appropriate.
□ N/A.
11. Have Floodplain Protection and Floodplain Insurance requirements been met? The National Flood
Insurance Program requirement only applies to structures which are defined as a walled and roofed
building, including a gas or liquid storage tank that is principally above ground, as well as a
manufactured home. A residential building built in a floodplain must be elevated above the Base
Flood Elevation (BFE). Non-residential buildings may be elevated or flood proofed.
□ No.
□ Yes. If yes, please upload supporting documentation, as appropriate.
□ N/A
12. Have all Special Award Conditions (SAC’s) associated with commencement of construction been
addressed?
□ No. If no, please provide an explanation.
□ Yes. If yes, please list SACs addressed.
□ N/A.