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 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 the applicable evidence of title/rights documentation 

pursuant to the Treasury’s guidance at Treasury’s RESTORE Act Direct Component 

Resources website.

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 the applicable evidence of title/rights documentation 

pursuant to the Treasury’s guidance at Treasury’s RESTORE Act Direct Component 

Resources website.

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 the applicable evidence of title/rights documentation 

pursuant to the Treasury’s guidance at Treasury’s RESTORE Act Direct Component 

Resources website.

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.
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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.
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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 2

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 3

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 4

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 5

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 6

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 7

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 8

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 9

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 10

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 11

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 12

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 13

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 14

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 15

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 16

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 17

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 18

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 19

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 20

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.
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
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 thisinformation 

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, 1500Pennsylvania Ave.,

NW, Washington,DC 20220.

RESTORE Act Direct Component Applicant Certifications

Department of the Treasury

OMB Approval No. 1505-0250

Directions: These certifications are required by federal law and Department of the Treasury (Treasury) regulations to be submitted with each application 

to Treasury for financial assistance under the RESTORE Act Direct Component. The certifications must be signed by an authorized senior official of the 

Applicant who can legally bind the entity and has oversight for the administration and use of the Direct Component funds.

A. RESTORE Act Certification

1. Pursuant to the RESTORE Act, I certify that for any 

award agreement resulting from this application:

(a) Each activity funded under this agreement has been primarily 

designed to plan for or undertake activities to restore and protect one 

or more of the following: the natural resources, ecosystems, fisheries, 

marine and wildlife habitats, beaches, coastal wetlands, or economy of 

the Gulf Coast region.

(b) Each activity funded under this agreement is designed to carry out 

one or more of the eligible activities for the Direct Component.

(c) Each activity funded under this agreement was selected after 

consideration of all meaningful input from the public, including broadbased participation from individuals, businesses, Indian tribes, and 

nonprofit organizations, as described in the grant application. The 

certification in this paragraph (1)(c) does not apply to planning 

assistance funds to prepare and amend the Multiyear Implementation 

Plan.

(d) Each activity funded under this agreement that protects or restores 

natural resources is based on the best available science, as that term 

is defined in 31 C.F.R. Part 34.

(e) The Applicant has procedures in place for procuring property and 

services under this award that are consistent with the procurement 

standards applying to Federal grants. The Applicant will not request 

funds under this award for any contract unless this certification remains 

true and accurate.

(f) Pursuant to 2 C.F.R. § 200.303, the Applicant will establish and 

maintain effective internal control over all award agreements resulting 

from this application, and provide reasonable assurance that the 

Applicant will manage the award in compliance with Federal statutes, 

regulations, and the terms and conditions of the award. The Applicant 

knows of no material deficiencies in its internal controls.

(g) A conflict of interest policy consistent with 2 C.F.R. § 200.318(c) is 

in effect and covering each activity funded under this Agreement.

(h) The Applicant will comply with Title VI of the Civil Rights Act of 

1964, the Rehabilitation Act of 1973, and all other applicable federal 

laws and regulations concerning anti-discrimination.

2. I make each of these certifications based on my personal knowledge 

and belief after reasonable and diligent inquiry, and I affirm that the 

Applicant maintains written documentation sufficient to support each 

certification made above, and that the Applicant’s compliance with 

each of these certifications is a condition of the Applicant’s initial and 

continuing receipt and use of the funds provided under this Agreement.

B. Certification Regarding Debarment, Suspension, 

and Other Responsibility Matters -- Primary

Covered Transactions: Instructions for 

Certification

1. By signing and submitting this Application, the prospective primary 

participant (the Applicant) is providing the certification set out below.

2. The inability of an Applicant to provide the certification required below 

will not necessarily result in the denial of participation in this covered 

transaction. The prospective Applicant shall submit an explanation of 

why it cannot provide the certification set out below. The certification or 

explanation will be considered in connection with Treasury’s approval of 

the proposed application. However, failure of

the Applicant to furnish a certification or an explanation shall disqualify 

such person/entity from participation in this transaction.

3. This certification is a material representation of fact upon which 

reliance is placed when Treasury determines to enter into this 

transaction. If it is later determined that the Applicant knowingly 

rendered an erroneous certification, in addition to other remedies 

available to the Federal government, Treasury may terminate this 

transaction for cause or default.

4. The Applicant shall provide immediate written notice to Treasury if at 

any time the Applicant learns that its certification was erroneous when 

submitted or has become erroneous by reason of changed 

circumstances.

5. The terms “covered transactions,” “debarred,” “suspended,” 

“ineligible,” “lower tier covered transaction,” “participant,” “person,” 

“primary covered transaction,” “principal,” “proposal”, and “voluntarily 

excluded,” as used in this clause (certification), have the meanings set 

out in the Definitions and Coverage sections of the rules implementing 

Executive Order 12549. You may contact Treasury for assistance in 

obtaining a copy of those regulations (31 C.F.R. Part 19).

6. The Applicant agrees by submitting this Application that, should the 

proposed covered transaction be entered into, it shall not knowingly 

enter into any lower tier covered transaction with a person who is 

debarred, suspended, declared ineligible, or voluntarily excluded from 

participation in this covered transaction, unless authorized by Treasury.

7. The Applicant further agrees by submitting this Application that it will 

not award any contract or subaward to any entity on the governmentwide Excluded Parties List System (see 31 C.F.R. Part 19, Appendix).

8. A participant in a covered transaction may rely upon a certification of 

a prospective participant in a lower tier covered transaction that it is not 

debarred, suspended, ineligible, or voluntarily excluded from the 

covered transaction, unless it knows that the certification is erroneous. 

A participant may decide the method and frequency by which it 

determines the eligibility of its principals. Each participant may, but is 

not required to, check the Nonprocurement List.

9. Nothing contained in the foregoing shall be construed to require 

establishment of a system of records in order to render in good faith the 

certification required by this clause. The knowledge and 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 thisinformation 

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, 1500Pennsylvania 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.
Page 3

Signature of Authorized Senior Official:

Name: Date:

Title: Organization: