Proposer's Name

Bureau of Outdoor Recreation Boating Division

Attachment C

RFP 2027 Federal Clean Vessel Act Grant Solicitation Number:

Federal Clean Vessel Act Grant Application Form

All applicants must complete the entire application with the exception of Parts V, VI and VII. Complete Part V for funding of Operation and Maintenance Costs Associated with a Land-Based MSDF, complete Part VI for Operation and Maintenance Costs Associated with a Pumpout Vessel, and complete Part VII for Construction/Purchase/Installation of a New MSDF or Repair or Upgrade of an Existing MSDF (including purchase or repair/upgrade of a Pumpout Vessel).

Part I: Application Information

Part II: Eligibility & Application Type

1. Eligibility Checklist

a. Will the MSDF be available for use by all recreational vessels in need of such facilities?

Yes No If No, your project is not eligible to receive funding, with the exception of Pumpout Vessel off loading stations which are eligible to receive funding.

b. Will the use of the MSDF be offered for free?

If No, your project is not eligible to receive funding.

Yes No

c. Is the installation of a proposed MSDF, a result of a state or federal enforcement action?

If Yes, your project is not eligible to receive funding.

2. Application Types-Check all that apply:

Operations and Maintenance Costs Associated with a Land Based MSDF Operations and Maintenance Costs Associated with a Pumpout Vessel

Yes No

Construction/Purchase/Installation of a New MSDF or Repair or Upgrade of an Existing MSDF (including purchase or repair/upgrade of a Pumpout Vessel)

Page 1 Rev 2/23

Proposer's Name:

Contact Person:

Mailing Address:

Town:

Business Phone:

State:

E-mail:

Zip Code:

Federal Employer Identification or Social Security No.:

Part III: Facility Information

1. Facility Name (if different from proposer's name):

Location Address:

Town: State: Zip Code:

2. Latitude: Longitude:

3. Name of Waterbody Location(s) Served (i.e. Long Island Sound, CT River, etc.)

4. Does the facility currently have operational MSDFs?

If yes, specify the types and number of each MSDF facility:

Yes No

Stationary No. Cart-Style No. Vessel No.

Central Vacuum System: No. Dump Station No.

Other (specify type and number): No.

5. Provide an estimate of how many pumpouts will be conducted by the existing and/or proposed MSDF in a calendar year. (estimate should be based on prior year's data, if available)

6. If the proposer is seeking funding for Operations & Maintenance or repair/upgrade of an existing MSDF, Please provide a description of the existing facility or pumpout vessel (include age and condition; include photographs as Exhibit E)

Rev 2/23

Part IV: Proposal Information

1. Operating months, days, and hours of MSDF- Please be specific.

The information will be posted on the DEEP website and printed in the Boater's Guide. (i.e. May 15 through October 30, 7 days per week, 7am to 7pm)

2. If the applicant is seeking funding for both Operation and Maintenance and Construction/Purchase/ Installation of a New MSDF or Repair or Upgrade of an Existing MSDF (including purchase or repair/ upgrade of a Pumpout Vessel) funding, describe the planned start and end date for this phase of the project. (Example: March 1 through April 15)

3. Specify the type and number of MSDFs for which you are requesting Operation and Maintenance funding:

Stationary No. Cart-Style No. Vessel No.

Central Vacuum System No. Dump Station No.

Other (specify type and number):

4. Does the facility have a fuel dock? Yes No If yes, is the MSDF located on the fuel dock? Yes No

No.

5. What is the proximity of the MSDF to the dock-mounted fuel dispenser, in feet:

6. At the location of the MSDF, what is the approximate depth of water, in feet, during low tide, in relation to the mean low water elevation:

7. Identify the proximity, in feet or nautical miles, of the MSDF closest to the nearest Federal Navigational Channel or Fairway:

8. Provide the following for boaters to contact the MSDF:

a. Hailing Frequency (VHF Channel):

b. Phone Number:

c. Website address:

Part V. Budget Information for Operations & Maintenance Costs Associated with a Land-Based MSDF

Please complete this section:

1. Personnel Types Hourly Rates Estimated Time Total

Administration $ $

Program $ $

Program $ $

Program $ $

2. Contractual $

3. Operating $

4. Equipment (including repairs & upgrades/purchases) $

5. Sewage Waste Removal $

6. Supplies $

7. Other (specify below)* $

8. Total Eligible O & M Costs $

9. Funding Requested= 75% of Total O & M Costs (multiply line 8 x 0.75) $

*Specify Other

Attach additional sheets if needed.

Part VI. Budget Information for Operations & Maintenance Costs Associated with a Pumpout Vessel

Please complete this section:

*Specify Other

Note:Total funding requested cannot exceed $45,000 per vessel.

For pumpout vessel programs with detailed budgets and costs, please attach a separate spreadsheet to document anticipated expenses and label “Exhibit C”.

Attach additional sheets if needed Rev 2/23

1. Personnel Types Hourly Rates Estimated Time Total

Administration $ $

Program $ $

Program $ $

Program $ $

2. Contractual $

3. Operating $

4. Vessel Expenses $

5. Equipment (including repairs & upgrades/purchases) $

6. Sewage Waste Removal $

7. Supplies $

8. Other (Specify Below)* $

9. Total Eligible O & M Costs $

10. Funding Requested= 75% of Total O & M Costs (multiply line 9 x 0.75) $

Part VII. Budget Information for Construction/Purchase/Installation of a New MSDF or Repair or Upgrade of an Existing MSDF (Including purchase or repair/upgrade of a Pumpout Vessel)

Please complete this section:

Description Total

1. Equipment Upgrade/Purchase (specify) $

2. Construction/Installation Costs include Plumbing, Electrical and Site Work (specify)

3. Supplies (specify) $

4. Total Construction/Purchase/Installation/Repair Upgrade (Total line 1 through 3) $

5. Funding Requested= 75% of Total Costs (multiply line 4 x 0.75) $

Attach additional sheets if needed.

Part VIII. Total Budget Information

Part IX. Supporting Documents

Check the applicable box below for each Exhibit being submitted with this application form. When submitting any supporting documents, please label the documents as indicated in this part (e.g., Exhibit A, B, etc.) and be sure to include the proposer's name as indicated on this application form.

Rev 2/23

Total Costs: $

(Part V, line 8 + Part VI, line 9 + Part VII, line 4)

Funding Requested(75% of Total Costs): $

(Part V, line 9 + Part VI, line 10 + Part VII, line 5)

Match (Dollar Value) to be Provided by Proposer (25% of Total Costs): $

(Total Costs X 0.25)

Projects which provide more than 25% match will be more competitive.

Exhibit A*-Applicant Compliance Information Form (DEEP-APP-002)

Exhibit B-For Construction/Purchase/Installation of a New MSDF or Repair or Upgrade of an Existing MSDF, submit as Exhibit B, the design of the proposed or existing MSDF which contains specific design or upgrade components -see Attachment D of the RFP. The guide can be found at https://portal.ct.gov/DEEP/Boating/CVA/ CVA-Grant-Program-Information.

Exhibit C-Mobile Pumpout Vessel Operation and Maintenance Budget: Submit as Exhibit C a Mobile Pumpout Vessel Operation and Maintenance Budget, if applicable, as identified under Part VI of this Application form.

Exhibit D-If you are not currently a vendor registered with the State Of Connecticut Comptroller's office you must also include a completed Agency Vendor Form. This form may be downloaded at:

www.das.state.ct.us/Purchase/Info/Vendor_Profile_Form_(SP- 26NB).pdf. You may download the W9 form and instructions at: www.irs.gov/pub/irs- pdf/fw9.pdf.

Exhibit E*-Photographs of Existing MSDFs or Pumpout Vessels; digital color prints only.

* Required for all applications.

Exhibit F-Buy America, Build America Certification http://www.das.state.ct.us/Purchase/Info/Vendor_Profile_Form_(SP-http://www.irs.gov/pub/irs-

Part X. Applicant Certification

The applicant and the individual(s) responsible for actually preparing the application must sign this part. An application will be considered incomplete unless all required signatures are provided. If the applicant is the preparer, please mark N/A in the spaces provided for the preparer.

Funding provided through this grant program is provided by the U.S. Fish and Wildlife Service, Clean Vessel Act Program and is administered through Connecticut's Department of Energy and Environmental Protection - Boating Division. Funds awarded through this grant application process are to be used solely for allowable costs and expenses as identified within the application instructions and any contract between the grantee and the State of Connecticut.

Any funding provided through any subsequent State Contract is subject to audit and investigation by the U.S.

Office of the Inspector General (OIG) and the State of Connecticut Attorney General's Office (AG), as well as Connecticut's Department of Energy and Environmental Protection (DEEP). Any instances of potential fraud, waste, theft or abuse will be reported by DEEP to the OIG and the AG's office for investigation and prosecution.

False statement(s) in the submitted information is punishable as a criminal offense pursuant to section 53a-157b of the General Statutes, and in accordance with any other applicable statute or regulation.

“I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that based on reasonable investigation, including my inquiry of the individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief.

I understand that a false statement in the submitted information is punishable as a criminal offense, pursuant to section 53a-157b of the General Statutes, and in accordance with any other applicable statute or regulation.

I certify that this application is on complete and accurate forms as prescribed by the commissioner without alteration of the text.

I further certify, upon submission of this application, all of the following:

a) The application form and associated materials are complete and accurate;

b) All requested costs and expenses shall be used solely for allowable costs and expenses;

c) All requested costs and expenses shall be supported with original receipts, invoices or other supporting documentation; and

d) There shall be no instances of fraud, theft, waste, abuse, mismanagement or misconduct regarding the funds provided through this grant application process.”

Signature of Applicant Date

Printed Name of Applicant Title (if applicable)

Signature of Preparer Date

Printed Name of Preparer Title (if applicable)

Check here if additional signatures are required. If so, please reproduce this sheet and attach signed copies to this sheet.

You must include signatures of any person preparing any report or parts thereof required in this application (i.e., marine architects, professional engineers, surveyors, consultants, etc.)