Attachment 1 - App Template - NOFO 693JJ324NF00025.docx

FY 2023 – FY 2026 National Culvert Removal, Replacement, and Restoration Grant Program (Culvert AOP Program) ATTACHMENT 1 – Application Template

The U.S. Department of Transportation (DOT) provides this National Culvert Removal, Replacement, and Restoration Grant Program (Culvert Aquatic Organism Passage (AOP) Program) Application Template to assist project sponsors who intend to apply for a Culvert AOP Program grant. Interested eligible applicants should read the FY 2023 – FY 2026 Culvert AOP Notice of Funding Opportunity (NOFO) in its entirety, and especially where noted in this application template, to submit eligible and competitive applications.

Submission of this Application Template alone is not sufficient to constitute a complete application. Applicants should review Section D of the NOFO to determine which documents must and should be submitted.

I. Basic Project Information Description - Provide a narrative for the below items on basic details pertinent to the overall application and any individual projects, including the application name, description of all projects, location(s), involved parties, etc. Items in this section will be used to determine grant program eligibility as detailed in Section C of the NOFO.

Eligibility Criteria

Provide a concise description of the project(s) based on the directions in provided in D.2.a.I

(Name and identify which Eligible Applicant category applies. Select from the below statutory Eligible Applicants) ☐ State ☐ Unit of local government ☐ Indian Tribe

☐ Culvert ☐ Weir

Additional Project Information

☐ Yes ☐ No

Other Public and Private Parties

II. Grant Funds, Sources and Uses of all Project Funding Project Costs – Provide information detailing the costs associated with the project. These costs will be used to determine eligible award amount, how the project supports financial goals of the program, and other factors. More information on this section can be found in Section D.2.ii of the NOFO.

Estimate in year-of-expenditure dollars: $____________

Amount:_____________________________, and repeat for each source)

(Identify each source of non-Federal funding and estimated amount, e.g.

Source:_____________________________ Amount:_____________________________, and repeat for each source)

Estimate in year-of-expenditure dollars: $____________

Estimate in year-of-expenditure dollars: $____________

Estimate in year-of-expenditure dollars: $____________

☐ This is attached separately. The file is named:

Expenditure: Cost:

Expenditure: Cost:

Expenditure: Cost:

Expenditure: Cost:

Expenditure: Cost:

Expenditure: Cost:

☐ A detailed budget is attached separately. The file is named:

(Please select one) ☐ Yes ☐ No

If Yes, explain the intended benefits of project bundling, and detail here or in a detailed budget attachment the cost (in year of expenditure dollars) for each project if bundled and if not bundled.

☐ A detailed budget is attached separately. The file is named:

III. Statutorily Required Project Selection Priorities Project Selection Priorities—Please check which of the project selection priorities listed below, and at Section E of the NOFO, apply to the project(s) in your application.

☐ Anadromous fish listed as endangered or threatened under the Endangered Species Act.

☐ Anadromous fish identified by NMFS or USFWS that could reasonably become listed as a federally endangered species or a threatened species.

☐ Anadromous fish identified by NMFS or USFWS as prey for endangered species, threatened species, or protected species.

☐ Anadromous fish identified by NMFS or USFWS as climate resilient stock. See Section H.

☐ Project that opens up more than 200 meters of upstream habitat for anadromous fish before the end of the natural habitat.

IV. Project Selection Criteria Project Selection Criteria – Provide narrative response on how the project responds to the selection criteria in Section E.1.a of the NOFO. In responding to Project Selection Criteria, refer to statutory selection priorities included in Section E of the NOFO and address them in the appropriate Project Selection Criteria.

This project contributes to the Conservation Benefits to Anadromous Fish criterion by…

This project contributes to the Regional Watershed Context criterion by…

This project contributes to the Ecosystem Benefits criterion by…

This project contributes to the Project Design, Monitoring and Evaluation criterion by…

What are the proposed design standards and specifications for ensuring resulting infrastructure provides for the safety of the traveling public over the service life of that infrastructure?

This project contributes to the Climate Change, Sustainability, and Resilience criterion by…

This project contributes to the Equity and Barriers of Opportunity criterion by…

V. Project Readiness and Environmental Risk Submit the requested information in Section D.2.b.v. This information will be used to evaluate the application on Project Readiness as described in E.1.b. for DOT to conduct a review of the project readiness and environmental review and permitting risk criteria for the project and provide a summary. If project includes multiple culverts or weirs, indicate the information for each structure included in the application and what impact would occur on the timeframes if the project were unbundled.

Technical Feasibility

Project Schedule

Date: Project Milestone:

Date: Project Milestone:

Date: Project Milestone:

Date: Project Milestone:

Date: Project Milestone:

☐ This is attached separately. The file is named:

Planned or Actual Completion of Preliminary Design Date: __________ Planned or Actual Start of Final Design Date: ____________ Planned or Actual Completion of Final Design Date: ____________

Required Approvals

Planned or Actual Start of NEPA Date: ____________ Planned or Actual Completion of NEPA Date: ____________ Final NEPA Determination or current status of NEPA process:

☐ No

☐ No

Assessment of Project Risks and Mitigation Strategies

☐ No ☐ Not Applicable

If Yes, Planned or Actual Start of Right-of-Way Acquisition Date: ____________

Planned or Actual Completion of Right-of-Way Acquisition Date: ____________

· Would right-of-way acquisition require relocation of any people or businesses?

☐ Yes ☐ No

· If Yes, are people or businesses being relocated members of traditionally underserved and underrepresented populations (underserved communities)?

· If Yes, please describe the required relocation of any people or businesses.

Lead Applicant Evaluation