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COMMONWEALTH OF PENNSYLVANIA
Pennsylvania Fish and Boat CommissionErie Access Improvement Program
GRANT APPLICATION FORM
/SECTION I - IDENTIFICATION OF APPLICANT AND PROJECT COORDINATOR
Legal Name of Applicant: Federal ID Number: County / Federal ID Number / SAP Number / County
Mailing Address (Street/P.O. Box, City/Town):
(Zip Code) / (Telephone Number)
Local Project Coordinator (Person in Charge of Project): Title:
Mailing Address (Street/P.O. Box, City/Town):
(Zip Code) / (Telephone N
mber)
Email Address: FAX Number:
Applicant Classification: Municipality County Land Trust Other ______
Name and Title of Chief Elected Official or Executive Officer:
SECTION II – GENERAL PROJECT INFORMATION
Project Title:
Project Address / Location (if located in more than one County, Township, etc., please list all)
County / Borough, City, Town or Township
Is Project Property Leased? Yes No. Project Property is Owned By:
Project Type (Check One) / Acquisition / Technical Assistance
Access Improvement / Other
Category (Check One) / Acquisition – Fee Simple / Acquisition – Easement / Access Improvement
Technical Assistance / Other
SECTION III – PROPOSED PROJECT BUDGET
To accurately estimate a project’s eligible costs, applicants should thoroughly review program materials and/or contact the PFBC. PFBC will help you develop a realistic / eligible scope of work, qualifications, and verify ADA access and other requirements.$ Total Project Cost
— $ (minus) Grant Amount Requested
(50% maximum)
= $ ______Local Match*
ALL COST FIGURES SHOULD BE ROUNDED TO NEAREST $100
*For all projects, list all Public and Private cash and/or non-cash matching contributions that comprise the local match indicated above.MATCH SOURCES / CASH AMOUNT / PENDING / SECURED / NON-CASH VALUE
SECTION IV – PROJECT DESCRIPTION
Applicants are encouraged to discuss proposed projects, project scope of work, etc., with the Commission prior to submission of the application.Project Type: Check the appropriate box and provide the scope of work for your project below.
Acquisition – See Below
Access Improvement – See Below
Technical Assistance – See Below
Other
Describe the scope of work for your above checked project type in the space provided below.
Acquisition – Describe the area to be acquired in terms of size, number of parcels, natural and man-made features, nature of surrounding land use, existing uses, relation to existing public parkland, trails, conservation areas, and future proposed facilities. Indicate interest to be acquired if other than fee simple.
Access Improvement – Describe your project scope of work in terms of facilities to be developed/rehabilitated, their existing and proposed uses and capacity, and their relation to fishing and/or boating opportunities.
Technical Assistance – Describe your project scope of work/technical assistance request. Identify the nature of your project and what assistance you are requesting from the Commission; planning, administration, design, etc.
Provide the scope of work for your proposed project in this space –
attach additional sheets as necessary.
Did you discuss your project with the PFBC? Yes NoIf yes, please indicate with whom.
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SECTION V – PROJECT SELECTION CRITERIA
Legal Name of Applicant: Project Title:PFBC uses the criteria below to evaluate, rate, and rank grant applications for funding consideration. Each of the criteria has a statement and a commentary to further explain the statement and provide guidance to help the applicant give a concise response to each statement. Use the space provided on this form; attach additional pages if necessary.
1. Needs and Benefits Assessment – Points: Maximum of 20. Criterion: List and describe the fishing, conservation and general access need that exists at the proposed project site, in the community, region, or county that makes this project an important priority. Further, list and describe the immediate and future long-term benefits that will be realized if the proposed project is completed. Attach additional pages if necessary.
2. Partnerships / Intergovernmental Cooperation – Points: Maximum of 20. Criterion: Describe how the project involves partnership efforts among governmental, nonprofit or other public and private organizations. Describe in detail the commitments (monetary and otherwise) project partners have made. Attach supporting documents and additional pages as necessary. Priority will be given to those projects that identify the most match.
3. PFBC Erie Access Improvement Program Priorities – Points: Maximum of 20. Criterion: Describe how the proposed project addresses PFBC Erie Access Improvement Priorities. Attach additional pages if necessary.
4. Planning – Points: Maximum of 20. NOTE: This Criterion has 3 parts.
Part A – Describe how the project is generally consistent with local or county comprehensive planning and zoning by answering the following questions:
1. Does this project involve the funding of infrastructure or facilities? Yes No
2. Is there a Comprehensive Plan?
Local Yes No
County Yes No
Multi-municipal / Regional Yes No
3. Date of Comprehensive Plan(s)
4. If yes, is the project generally consistent with a Comprehensive Plan?
Local Yes No N/A
County Yes No N/A
Multi-municipal / Regional Yes No N/A
5. Is there a zoning ordinance?
Local Yes No
County Yes No
What is the property zoned?
Is the project consistent with local zoning? Yes No
6. Does the Municipality have zoning with riparian setbacks? Yes No
Part B – Also describe how the project is consistent with other local, regional, state, or federal plans or will implement actions recommended in other local, state or federal plans. Attach additional pages if necessary.
Part C – Describe the status of discussions/interactions that have taken place on the project thus far. Attach additional pages if necessary.
5. Site Compatibility – Points: Maximum of 15. Criterion: Discuss the reasons how and why the proposed site was identified and why is it appropriate for the proposed project. Discuss the impact of the proposed project on the existing environmental conditions of the site (wetlands, waters, etc). Attach additional pages if necessary.
6. Other – Points: Maximum of 5. Criterion: Discuss other factors that you wish the Commission to consider in its evaluation of your project. For example, does the project involve the permanent securing of prime fishing waters, involve rehabilitation of existing facilities, imposition of user fees to support the long-term viability of the facility, etc.
SECTION VI – CERTIFICATION
By signing this grant application, I certify that to the best of my knowledge, information and belief, the above information provided on this form and related attachments is true, correct and that:1. Any property to be acquired/developed has not been used for storage/disposal of toxic chemicals/waste and is not affected by such a site.
2. Any wetland areas located on the property to be acquired/developed have been identified and will be protected in accordance with applicable state/federal laws and regulations.
3. The applicant is not under suspension or debarment by the Commonwealth or any governmental entity, instrumentality, or authority.
4. The applicant it is not delinquent in the payment of any Commonwealth obligation, including taxes.
5. The applicant has assessed what administrative, cash, and/or non-cash needs will be required to provide the local match for the requested grant and affirms that the match is available and the applicant has the capacity to proceed with the project.
6. If in-kind services are used as a portion of the required match, the in-kind service rates do not exceed the applicant’s normal billing rates and do not include food, drinks, gifts, and other hospitality items related to the general promotion of the applicant or the promotion of any projects that the applicant is involved in; or, costs related to fund raising and/or lobbying government officials for the benefit of the applicant in general or for any projects that the applicant is involved in.
7. All statements made in this application and supporting materials are true.
Signature ______Date ______
SECTION VII – ACCEPTANCE OF FEDERAL FUNDING IF AVAILABLE
The applicant understands that when federal funds are utilized, there are additional requirements that apply beyond those required by the Commission. If a project is funded, in whole or in part, with federal funds, the local match cannot come from another federal source. The Commission will require additional documentation if federal funds are to be used to support the project.I will accept federal funding for this project. I will not accept federal funding for this project.
SECTION VIII –VERIFICATION OF 501 (c)(3) STATUS (to be completed by 501(c)(3) organizations) only)
By program definition, eligible applicants include 501(c)(3) entities involved in restoration, rehabilitation, acquisition, development or other activities that furthers the Commonwealth’s recreation resources. The organization must be involved in these activities and be both tax exempt under Section 501 (c)(3) of the Internal Revenue Code and registered with the Pennsylvania Department of State, Bureau of Charitable Organizations. In order for the Commission to verify your status and eligibility, please complete the following two questions in their entirety (this section does not apply to Municipalities) and attach a copy of each approval letter to your application:1. Please print your organization’s name exactly as it appears on your approval letter from the Internal Revenue Service, provide the date of approval.
ORGANIZATION NAME: _, and DATE:
2. Please print your charitable organization’s name at it appears on the Pennsylvania Department of State, Bureau of Charitable Organizations Certificate of Registration, provide the registration number and the date of certificate expiration. Registration with the Department of State, Bureau of Charitable/Nonprofit Organizations is required for the PFBC’s funding of non-profit organizations.
ORGANIZATION NAME: _, REGISTRATION NO: _
DATE OF CERTIFICATE EXPIRATION:
Please attach additional sheets if necessary.
ACQUISITION
Detailed Budget Form
Applicant: ______Project Title: ______
Date Prepared: ______
ITEM / WORK ITEM / TOTAL COST
Use additional sheets if necessary.
DEVELOPMENT
Detailed Budget Form
Applicant: ______Project Title: ______
Date Prepared: ______
ITEM NUMBER / WORK ITEM / NO. OF UNITS / UNIT COST / TOTAL COST
TOTALS
Use additional sheets if necessary.
SUMMARY COST ESTIMATE FORM – (ALL PROJECTS)
Use Development and Acquisition Worksheets to complete the table below.
Your cost categories should reflect your project description and correspond with your Project Scope of Work. The Grand Total – Project Cost, located in the lower right box should match the Total on your Detailed Budget Form.
SUBMIT: All applicable elements of the Detailed Budget Forms.
SELECT ONLY ONEProject Type: / CASH COSTS / NON-CASH
In Kind Services / NON-CASH
Equipment Use / NON-CASH
Volunteer Services / NON-CASH
Donated Services Materials or Land / SUB-TOTALS
Acquisition Projects
Land Costs
Lump Sum Total – other Items
Development Project
Construction, Materials, Labor& Equipment
Design/Engineering Services
Use/Rental of Equipment
Lump Sum Total – other Items
Planning Project
Consultant Services
Lump Sum Total – other Items
SUB-TOTALS
GRAND TOTAL – PROJECT COST
Instructions for the Signature and Resolution Pages: For use of Government/Municipal applicants
Erie Access Improvement Program
Grant Application Manual and Forms
SIGNATURE PAGE FOR GRANT APPLICATION AND GRANT AGREEMENT
(All signatures must be original; a hand stamp, FAX, or photocopy is not acceptable)
Name of Applicant/Grantee ______
Federal I.D. No. ______
SAP Vendor No. ______
WITNESS: GRANTEE:
WITNESS: GRANTEE:
Signature Signature
Date:
(typed or printed)
#7
Title:
Date:
PFBC USE ONLYProject Number:
RESOLUTION
WHEREAS, ______(“applicant”) desires to undertake the following project [project title]______
______; and
WHEREAS, the applicant desires to apply to the PA Fish and Boat Commission (“Commission”) for a grant for the purpose of carrying out this project; and
WHEREAS, the application package includes a document entitled “Signature Page for Grant Application and Grant Agreement”; and
WHEREAS, the applicant understands that, by signing the “Signature Page for Grant Application and Grant Agreement” and submitting it to the Commission as part of the grant application, the applicant agrees to the terms and conditions of the grant and will be bound by the Grant Agreement if the Commission awards a grant;
NOW THEREFORE, it is resolved that:
1 The “Signature Page for Grant Application and Grant Agreement” may be signed on behalf of the applicant by the official who, at the time of signing, has the title of .
2. If this official signed the “Signature Page for Grant application and Grant Agreement” prior to the passage of this Resolution, this grant of authority applies retroactively to the date of signing.
3. If the applicant is awarded a grant, the “Signature Page for Grant Application and Grant Agreement,” signed by the above official, will become the applicant/grantee’s executed signature page for the Grant Agreement, and the applicant/grantee will be bound by the Grant Agreement.
4. Any amendment to the Grant Agreement may be signed on behalf of the grantee by the official who, at the time of signing of the amendment, has the title specified in paragraph 1 and the grantee will be bound by the amendment.
I hereby certify that this Resolution was adopted by the [identify the governing body of the applicant, e.g. city council, borough council, board of supervisors, board of directors] ------ this day of , .
Secretary
PFBC USE ONLYProject Number:
SIGNATURE PAGE FOR GRANT APPLICATION AND GRANT AGREEMENT
(All signatures must be original (please sign in ink); a hand stamp, FAX, or photocopy is not acceptable)
Name of Applicant/Grantee
Federal I.D. No.
SAP Vendor No.
WITNESS: GRANTEE:
Signature Signature
Date:
(typed or printed)
Title:
Date:
PFBC USE ONLYProject Number:
RESOLUTION
WHEREAS, ______(“applicant”) desires to undertake the following project