Download:
pdf |
pdfOMB Control Number=2035.NEW, Expiration Date =mm/dd/yyyy
D
R
FT
The use of this provided template is optional. EPA will not penalize or withhold a benefit from the respondent for providing the requested information in another format.
1
2
T
AF
Thriving Communities
Environmental
Protection Agency Grant - n t al Form
AF
Organization Name *
T
I. Organization Information
If Fiscally Sponsored please list your Fiscal Sponsor and the name of your project
D
R
Brief Description of Applicant Organization
Provide a brief description (100 words or less) of the applicant organization, including
its mission and key ongoing projects and activities in which it is involved
Mailing Address
Country
Select...
Address
3
5/24/24, 2:12 PM
Initial Form Designer
Address Line 2 (optional)
City
State, Province, or Region
Zip or Postal Code
Site Address (if different from above)
T
Country
Address
AF
Select...
D
R
Address Line 2 (optional)
City
State, Province, or Region
Zip or Postal Code
Organization Phone Number
Organization Website
example.com
4
Employer Identification Number
AF
T
XX-XXXXXXX
D
R
Organization Annual Budget
Choose File
Upload a file. No files have been attached yet.
Acceptable file types: .csv, .doc, .docx, .odt, .pdf, .rtf, .txt, .wpd, .wpf, .gif, .jpg, .jpeg,
.png, .svg, .tif, .tiff, .epub, .key, .mobi, .mus, .musx, .ppt, .pptx, .sib, .xls, .xlsx, .zip
Provide Income Statement for most recently completed fiscal year
Choose File
Upload a file. No files have been attached yet.
Acceptable file types: .csv, .doc, .docx, .odt, .pdf, .rtf, .txt, .wpd, .wpf, .gif, .jpg, .jpeg,
.png, .svg, .tif, .tiff, .epub, .key, .mobi, .mus, .musx, .ppt, .pptx, .sib, .xls, .xlsx, .zip
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
5
5/24/24, 2:12 PM
Initial Form Designer
Year Organization Founded
AF
II. Contact Information
T
How many full-time equivalent employees (FTE) does your
organization employ?
Primary Contact Name
D
R
First Name
Last Name
Individual will be responsible for ongoing reporting and administration of this grant
Primary Contact Title
Primary Contact Phone Number
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
6
5/24/24, 2:12 PM
Initial Form Designer
Primary Contact Email
email@example.com
Authorized Person Contact Name
First Name
Individual with signatory authority
T
Last Name
AF
Authorized Contact Phone Number
Authorized Contact Email
D
R
email@example.com
Other Contact Information
III. Project Phase
Which Project Phase are you applying for?
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
7
5/24/24, 2:12 PM
Initial Form Designer
Phase I - Assessment for up to $150,000 for a one-year project period
PHASE II - Planning for up to $250,000 for a one to two-year project period
PHASE III - Development for up to $350,000 for a two-year project period
PHASE I - Noncompetitive Fixed Amount Subaward
T
I . Environmental Justice Issue(s) to Be Addressed
D
R
Other
AF
What are the local environmental/public health issue(s) that your
project seeks to assess (Phase I) or address (Phase II and III)?
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
8
Initial Form Designer
AF
Other (please describe)
T
5/24/24, 2:12 PM
V. Project Plan, Goals, Outputs, and Outcomes
D
R
Project Plan, Goals, Outputs, and Outcomes
9
| File Type | application/pdf |
| File Title | Initial Form Designer |
| Author | Taylor Bayless |
| File Modified | 2024-06-27 |
| File Created | 2024-05-24 |