2024-ttpsf-application-form-all-categories.pdf

TTP Safety Fund Application Form FY2024 Page 1

2024 TRIBAL TRANSPORTATION PROGRAM SAFETY FUND

APPLICATION FORM

INSTRUCTIONS

FHWA prefers this form is completed electronically.

Submit this application form along with all supporting documentation by following further instructions online at: https://highways.dot.gov/federal-lands/programs-tribal/safety/funds

This is an interactive form in the Adobe Acrobat (.pdf) format. To ensure full functionality, download a free copy of Acrobat Reader if you do not already have it installed on your computer.

Viewing the form in a web browser or other PDF viewers may result in an inability to use interactive features and may not allow the user to save content entered into the form.

If you have questions about the TTPSF please send an email to TTPSF@dot.gov or call Adam Larsen at 360-619-2601.

STEP 1. SELECT CATEGORY

Please review the Notice of Funding Opportunity and the Application Guide to identify the most appropriate for your application. Please check the box corresponding to funding category for this application.

STEP 2. ENTER APPLICANT INFORMATION

Applicant Identifier Find your six-character code here.

Unique Entity Identifier (UEI) Must be registered at www.sam.gov

Official Name of Tribe

Street Address

City

State

Zip Code

Safety Plan

Data Assessment, Improvement, and Analysis

Systemic Roadway Departure Countermeasures

Infrastructure Improvement https://highways.dot.gov/federal-lands/programs-tribal/six-codes http://www.sam.gov/ https://highways.dot.gov/federal-lands/programs-tribal/safety/funds http://get.adobe.com/reader

TTP Safety Fund Application Form FY2024 Page 2

Contact Person for this Project

Full Name

Title

Organizational Affiliation (Department)

Telephone Number

Email Address

Additional Email Address This optional field can be used to list an additional email address that may be contacted about this project.

Status of Prior TTPSF Awards Describe the status of projects funded by TTPSF awards in prior years. For completed projects please provide an evaluation of the project’s success in improving transportation safety. Include an additional page if needed.

Project Abstract In a maximum of five sentences, summarize project work that would be completed under the project, the hazardous road location or feature or the highway safety problem that the project would address, and whether the project is a complete project or part of a larger project with prior investment. The project abstract must succinctly describe how this specific request for TTPSF would be used to complete the project.

STEP 3. ENTER PROJECT INFORMATION

Project Title

STEP 4. PROJECT NARRATIVE

Unless applying for funding to develop a transportation safety plan, applications must include a project narrative as described in the Notice of Funding Opportunity. Applicants are encouraged to use the recommended project narrative outline provided in the Application Guide on the program web page. The project narrative must address the selection criteria for the appropriate category. Supporting documentation may be attached to an application but the project narrative should summarize supporting documents and their relevance.

TTP Safety Fund Application Form FY2024

STEP 5. Project Funding

TTPSF Grant Request

Tribal Match (includes TTP Shares)

Other Federal Funds

State/Local Public Agency

Project Total

Other Funding Source

Describe Matching Contributions Describe other funding sources or leveraged resources anticipated to be part of this project, if any.

Is the applicant delinquent on any Federal debt?

If yes, include an explanation as supporting documentation when uploading this application.

Will the applicant accept partial funding?

If yes, describe independent components of the proposed project that could be accomplished with various funding packages in the project narrative.

TTP Safety Fund Application Form FY2024

TTP Safety Fund Application Form FY2024 Page 5

STEP 6. Facility Inventory and Ownership - Only required for applications to the "Infrastructure Improvement" and "Data Assessment, Improvement, and Analysis" Categories.

Include the route’s common name, ownership, and route/section numbers from the National Tribal Transportation Facilities Inventory (NTTFI). If inventory information is not provided in this form, the application may be considered not qualified. For roadways not owned by the BIA or a Tribe, a letter from the owner acknowledging the project is required. If the project will impact more than nine routes, attach a separate document listing all project routes. More information about the NTTFI is available at

Data Assessment and Improvement projects that are not specific to a route do not require route information.

https://itims.bia.gov

TTP Safety Fund Application Form FY2024 Page 6

STEP 7. AUTHORIZATION

Authorized Representative (Person who authorized the application to be submitted)

Full Name

Title

Telephone Number

Email Address

Authorized Signature Certification: By signing this report, I certify to the best of my knowledge and belief that the information in this application is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and intent set forth in the award documents. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)

X________________________________________________________________________________________

If the authorized representative is unable to sign using an electronic signature, please submit this electronic form without the signature and also provide an image of the signed form as supporting documentation.