Attachment 5 Regional State Groups NOFO Document Templates.pdf

Request for Proposal

Regional State Groups NOFO DE-FOA-0003617

DOE Provided Templates

Per NOFO Part 1, Application Content Requirement—Required Application Documents, the following templates, forms, and documents are being provided for the administrative convenience of the applicant as part of this funding opportunity package. See attached.

Any additional templates, forms, and documents stated as a requirement in NOFO Part 1, Application Content Requirement—Required Application Documents can be downloaded from various sites as indicated in each of their sections in NOFO Part 2.

It is the applicant's responsibility to ensure that all requirements for application submissions align with NOFO Part 1 & 2.

1. SF-424 Application for Federal Assistance

2. Project Management Plan

3. Budget Justification – Applicant (same document to be used for prime and sub-recipients)

4. Budget Information - Non Construction Programs

5. Current and Pending Support

6. Location(s) of Work

7. Disclosure of Lobbing Activities

8. Certification Regarding Lobbing

9. Summary for Public Release

OMB Number: 4040-0004 Expiration Date: 11/30/2025

Application for Federal Assistance SF-424

*1. Type of Submission:

Preapplication

Application

Changed/Corrected Application

*2. Type of Application

New

Continuation

Revision

* If Revision, select appropriate letter(s):

* Other (Specify)

*3. Date Received: 4. Applicant Identifier:

5a. Federal Entity Identifier: *5b. Federal Award Identifier:

State Use Only:

6. Date Received by State: 7. State Application Identifier:

8. APPLICANT INFORMATION:

*a. Legal Name:

*b. Employer/Taxpayer Identification Number (EIN/TIN): *c. UEI:

d. Address:

*Street 1:

Street 2:

*City:

County/Parish:

*State:

*Province:

*Country:

*Zip / Postal Code

e. Organizational Unit:

Department Name: Division Name:

f. Name and contact information of person to be contacted on matters involving this application:

Prefix: *First Name:

Middle Name:

*Last Name:

Suffix:

Title:

Organizational Affiliation:

*Telephone Number: Fax Number:

*Email:

*9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

*Other (Specify)

*10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

*12. Funding Opportunity Number:

*Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

*15. Descriptive Title of Applicant’s Project:

Attach supporting documents as specified in agency instructions.

16. Congressional Districts Of:

*a. Applicant: *b. Program/Project:

Attach an additional list of Program/Project Congressional Districts if needed.

17. Proposed Project:

*a. Start Date: *b. End Date:

18. Estimated Funding ($):

*a. Federal

*b. Applicant

*c. State

*d. Local

*e. Other *f. Program Income *g. TOTAL

*19. Is Application Subject to Review By State Under Executive Order 12372 Process?

a. This application was made available to the State under the Executive Order 12372 Process for review on

b. Program is subject to E.O. 12372 but has not been selected by the State for review.

c. Program is not covered by E.O. 12372.

*20. Is the Applicant Delinquent On Any Federal Debt?

Yes No

If “Yes”, explain:

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U. S. Code, Title 218, Section 1001)

** I AGREE

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

Authorized Representative:

Prefix: *First Name:

Middle Name:

*Last Name:

Suffix:

*Title:

*Telephone Number: Fax Number:

* Email:

*Signature of Authorized Representative: *Date Signed:

Federal Award Identifier:

Applicant Identifier Field:

Federal Entity Identifier Field:

FundingTite:

CDFAtitle: Airport Improvement Program

FundFedShare: 0

FundApplicant: 0

FundTotal: 0

FundState: 0

FundLocal: 0

FundOther: 0

FundPgmIncome: 0

SubmisisonType: Off

LegalName:

AppType: Off

TypeAppRevLetters:

AppTypeOther:

DateStateRcv:

StateAppnID:

EINTIN:

Street2:

City:

County:

State:

Province:

Country: USA: United States

ApplicantOther:

CatalogNum: 20.106

FedAgencyName: Federal Aviation Administration

FundOpportunityNum:

CompetitionIDNum:

CompetitionTitle:

AffectedAreas:

CongDistrictOfc:

CongDistrictApt:

DelinquentExplain:

AppnStateRvw: Off

AppnEO: Off

AppnNoEO: Off

StateAppnRvwDate:

AuthRepNamePrefix: [ ]

AuthRepNameSuffix: [ ]

AuthRepFirstName:

AuthRepMidName:

AuthRepLastName:

AuthRepTitle:

AuthRepPhoneNum:

AuthRepFaxNum:

AuthRepEmail:

AuthRepSignDate:

AppnDelinquent: New

CertAgree: Off

ZIPcode:

RcvDate:

ProjStartDate:

ProjEndDate:

DeptName:

DivName:

NamePrefix: [ ]

POCFirstName:

POCMiddleName:

POCLastName:

NameSuffix: [ ]

POCTitle:

POCOrgAffiliatn:

POCphone:

POCFAX:

POCEmail:

Street1:

TitleDescript:

ApplicantType1: [Pick an applicant type]

ApplicantType2: [Pick an applicant type]

ApplicantType3: [Pick an applicant type]

UEI - Unique Entity ID:

Project Management Plan

Sample Template

Title of the Project:

Topic Area:

Lead PI/Project Coordinator:

Collaborators:

*Note: Project Management Plan will need to address the criterion identified in NOFO Part 1, Technical Criteria on pg. 29.

Provide a summary-level description of the project, including but not limited to elements such as:

1. Technical Scope Summary (divided by budget periods).

2. Proposed Go/No-Go Decision Points for budget period.

3. Work Breakdown Structure (WBS).

4. Integrated Project Schedule (IPS) showing critical path for the entire project, and including task and subtask durations, milestones, Community Benefits Plan, and Go/No-Go decision.

5. Task Description Summary:

a. A concise description of the specific activities to be conducted over the life of the project (including project construction and operations) for each task/subtask. This should include identification of the anticipated Federal, state, and local codes, regulations, and permitting requirements applicable to siting, construction, and operation of the proposed project.

6. Buy America Buy America (BABA) Requirements for Infrastructure Projects:

a. The workplan must, include a short statement on whether the project will involve the construction, alteration, and/or repair of infrastructure in the United States. Build America, Buy America | Department of Energy for applicable definitions and other information to inform this statement.

7. Milestone Summary.

8. A summary of the End of Project Goal(s).

9. Process for making decisions on scientific/technical direction:

a. Discuss the process for deviations from the technical direction outlined in the scope and how final decisions regarding technical direction will be made.

10. Publications:

a. Discuss anticipated publications from the research, how publication decisions will be made, and who will be responsible for defining who participated in any given publication.

11. Intellectual Property Issues:

a. Discuss any intellectual property issues and how they will be resolved between different entities.

12. Communication Plans:

a. Discuss plans for communications and how groups will coordinate and collaborate on the project. Discuss communication strategies that will enable project success.

13. Procedures for resolving conflicts:

a. Describe the process for resolving competing hypotheses, differences of professional opinion, and other potential conflicts between team members.

14. PIs’ roles and administrative, technical, and scientific responsibilities for the project:

a. Describe each PI and collaborator’s role in the project including administrative, technical, and scientific responsibilities.

Budget Justification

The budget is the financial plan for the proposed project. Following selection of applications for award consideration, but prior to award being made, The Department of Energy (DOE) will perform a budget review to determine whether the proposed activities are supported by adequate resources in this plan, as well as to verify cost data, including that specific elements of the proposed budget are allowable, allocable, reasonable and are consistently treated in accordance with Generally Accepted Accounting Principles (GAAP) and applicable cost principles. Both the applicant’s budget, as well as subrecipients’ budgets (over $250,000) will be reviewed from both a technical and cost perspective. This evaluation will provide a comparison between the budget and the project narrative.

In addition to completing the budget on the appropriate form as specified in the Funding Opportunity Announcement (FOA), the applicant should verify that all costs proposed are:

-In accordance with any limitations, exclusions or special conditions set forth in the FOA.

-In accordance with GAAP and the applicable cost principles, and also that the costs are reasonable, allocable, and allowable.

In order for DOE to accomplish the budget review of the application, applicants are to provide a budget justification, including supporting information. Applicants are encouraged to provide any information necessary to justify their budget request. To facilitate DOE’s budget review, it is recommended that applicants provide the following for each Object Class Category/Cost Classification category for each separate budget (i.e., budget for each budget year of the project period and a cumulative overall project budget).

1. Personnel (Section A&B from the Budget Form).

a. Skill Mix/Hours. Identify key individuals and/or positions (titles/personnel categories); describe the levels of key personnel (experience/skill/education, etc.), and state time commitments in hours for individuals and/or positions.

The time commitment should be consistent with the number of months included on the budget sheet.

b. Labor Rates. State labor rates/compensation (in dollars) to be paid to the individuals or positions listed. Explain how the rates are established. Identify and provide justification for any escalation to the labor rates during the proposed project. The labor rate is the base rate paid to the employee and does not include any adders, benefits, or fee.

c. Fringe Benefits. Specify rates used and how they are applied. Identify any escalation to the fringe rates with justification. Provide details on how rates are determined; if rates are part of the applicants approved rate agreement with their cognizant Federal agency, specify this and provide a copy of the rate agreement.

2. Equipment* (Section C on the Budget Form). If proposed, provide the following:

a. Identify clearly what the equipment is (e.g., description, manufacturer part number, etc., if known)

b. Explain how the proposed equipment meets the definition of “equipment” at 2 CFR 200.33, as opposed to items of supply.

c. Explain the need for the equipment to accomplish the project.

d. Indicate the unit cost and quantity for each item to be purchased.

e. Explain how the cost estimates for equipment purchases are established, are determined to be fair and reasonable, and are consistent with your established procurement procedures. Include available supporting documents such as quotes or catalog pricing for the proposed equipment.

3. Travel (Section D on the Budget Form). If travel is proposed, provide the following:

a. Identify each of the proposed trips, including number of travelers, and their positions, departure/destination location, duration (number of travel days), purpose of the trip, and justification for why the identified people need to travel. Include travel cost detail such as airfare, lodging, per diem, ground transportation, and registration fees. An example table is provided below.

b. Include a copy of the relevant portions of the travel policy or specify where DOE can access the travel policy. Explain how the proposed travel costs are consistent with your established travel policy.

Travel Table

Purpose Depart From

Destination Duration of trip

Ground Transportation

Airfare Hotel Daily Rate

Daily Per-diem Rate

Registration Fees

Total

Name/Position

4. Participant/Trainee Support Costs (Section E from the Budget Form). Participant support costs means direct costs for items such as stipends or subsistence allowance, travel allowances, and registration fees paid to or on behalf of participants or trainees (but not employees) in connection with conferences, or training projects.

5. Other Direct Costs (Section F, from the Budget Form).

a. Materials and Supplies* (Section F, 1.). If proposed, provide the following:

i. A summary description the materials and supplies, quantity, unit cost, extended cost, and basis of estimate (i.e. vendor quote or catalog pricing) for each item/category. An example table is below.

Description Quantity Unit Cost Extended Cost

Basis

Total $

ii. Specify how these materials/supplies meet the definition of “supplies” at 2

CFR 200.94 (as opposed to “equipment”), and the purpose/necessity for the items.

iii. Explain how the proposed materials/supplies costs are consistent with your established procurement procedures. Include an explanation of how the cost estimate for the materials/supplies was established and how you determined it to be reasonable.

b. Publication Costs (Section F, 2.). If proposed, provide the following:

i. The necessity for the amount requested with a basis for the amount.

c. Consultant Services (Section F, 3.). If proposed, provide the following:

i. Explanation of why the services are necessary for the project, and the basis for the cost. Explain how cost was determined to be reasonable.

ii. Explanation of how the consultant services costs are consistent with your established procurement policy.

d. ADP/Computer Services (Section F, 4.). If proposed, provide the following:

i. Explanation of why the costs are necessary for the project, and explanation of how the costs are consistent with your established procurement policy. Explain how the cost was determined to be reasonable.

e. Subawards/Consortium/Contractual Costs* (Section F, 5.). If proposed, provide the following:

i. Determination if receiving entity is a contractor or a subrecipient.

Guidance for making determinations is found at 2 CFR 200.330 Subrecipient and Contractor Determinations, 2 CFR 200.23 Contractor, and 2 CFR 200.92 Subaward.

ii. For each subaward proposed, identify the subrecipient; verify the subrecipient has a current SAM registration and a DUNs. For any subawards greater than $250,000 or 50% of the total work effort (whichever is less), a separate cumulative SF-424 budget form for the subrecipient must be provided with budget justification (Section J, fee is not allowed on with subrecipients either). Provide a copy of the subrecipient’s approved indirect rate agreement with the subrecipient’s cognizant Federal agency in accordance with 2 CFR

200.19. Describe the work to be accomplished by each subrecipient and how it supports the project objectives.

iii. For each Contract proposed provide a description of the goods or services to be acquired by contract and how it supports the project objectives. Provide your rationale/determination for how this is considered a contract vs. a subaward. Explain how the proposed contractual costs are consistent with your established procurement procedures, including how the costs are justified as reasonable.

f. Equipment or Facility Rental/User Fees (Section F, 6.). If proposed provide the following:

i. Provide a detailed listing of the estimated amount of time for equipment rental or facility use and the corresponding rate. Provide published rate schedules or websites to the rates.

ii. Explain how the acquisition of proposed rentals/user fees are consistent with your established procurement procedures.

g. Alterations and Renovations (Section F, 7.). If proposed provide the following:

i. Provide a basis for the cost and why it is necessary for the project.

h. Other 1, 2, & 3. (Section F, 8. 9. & 10.) List all other direct cost categories not included in the above categories for this section. Specify the type of direct cost and basis for the cost. Cost type examples: Tuition or Federally Funded Research and Development Center (FFRDC).

i. Tuition. Provide details on how the total amount requested was calculated (number of semesters for how many students, etc.); include supporting documents or website for published tuition rates. Identify any escalation to the budgeted amount and provide justification for the escalation rate. Specify how the effort proposed by the applicant to be performed by undergraduate/graduate students is justified, consistent with the project narrative, and necessary to accomplish the project objective.

ii. Federally Funded Research and Development Center (FFRDC). If proposed, provide the dollar amount to go to the FFRDC. This amount should be consistent with the amount included on the approved Field Work Proposal. As a reminder, the amount going directly to the FFRDC cannot be included in calculating indirect costs.

6. Indirect Costs (Section H from the Budget Form).

a. Specify whether your proposed indirect rates have been audited and approved; include a copy of the rate agreement from the applicant’s cognizant Federal agency. Explain how the indirect cost budgeted amount is calculated (how the rate was properly applied to what base, use of modified total direct costs, etc.).

7. Fee (Section J from the Budget Form).

a. Fee in the budget sheet must be left blank. In accordance with 2 CFR 200.400

(g) payment of profit or fee is unallowable under federal financial assistance (i.e.

grants and cooperative agreements).

* If you propose to purchase equipment, materials/supplies, and/or have subrecipients or contractors, then provide a copy of your purchasing procedures (or relevant part(s) of those procedures) or where DOE can access. Include how those procedures are in compliance with the procurement standards specified at 2 CFR 200.17-200.326.

CURRENT AND PENDING (OTHER) SUPPORT COMMON FORM

November 1, 2023

The individual agrees to update this disclosure at the request of the Federal research funding agency prior to the award of support and at any subsequent time the agency determines appropriate during the term of the award. (Refer to the Federal research funding agency’s policy on updating award support).

Instructions for Submission of the Current and Pending (Other) Support Common Form

Current and pending (other) support information is used to assess the capacity or any conflicts of commitment that may impact the ability of the individual to carry out the research effort as proposed. The information also helps assess any potential scientific and budgetary overlap/duplication with the project being proposed.

This document provides instructions on submission of current and pending (other) support information for each individual identified as a senior/key person on a Federally funded research project.1

A separate submission must be provided for each proposal and active project, as well as in-kind contributions using the instructions and format specified below. Note that there is no page limitation for this section of the application, though some fields have character limitations for consistency and equity.

Consulting activities must be disclosed under the proposals and active projects section of the form when any of the following scenarios apply:

• The consulting activity will require the senior/key person to perform research as part of the consulting activity;

• The consulting activity does not involve performing research, but is related to the senior/key person’s research portfolio and may have the ability to impact funding, alter time or effort commitments, or otherwise impact scientific integrity; or

• The consulting entity has provided a contract that requires the senior/key person to conceal or withhold confidential financial or other ties between the senior/key person and the entity, irrespective of the duration of the engagement.

Consistent with NSPM-33, individuals are required to disclose contracts associated with participation in programs sponsored by foreign governments, instrumentalities, or entities, including foreign government-sponsored talent recruitment programs. Further, if individuals receive direct or indirect support that is funded by a foreign government-sponsored talent recruitment program, even where the support is provided through an intermediary and does not require membership in the foreign government-sponsored talent recruitment program, that support must be disclosed. Individuals must also report other foreign government sponsored or affiliated activities. In accordance with 42 USC § 19232, individuals are prohibited from being a party in a malign foreign talent recruitment program.

1In accordance with the NSPM-33 Implementation Guidance, senior/key persons typically do not include graduate students.

https://www.nsf.gov/bfa/dias/policy/researchprotection/nspm33definitions.pdf https://www.nsf.gov/bfa/dias/policy/researchprotection/nspm33definitions.pdf https://www.nsf.gov/bfa/dias/policy/researchprotection/nspm33definitions.pdf https://www.nsf.gov/bfa/dias/policy/researchprotection/nspm33definitions.pdf#page=2 https://www.nsf.gov/bfa/dias/policy/researchprotection/nspm33definitions.pdf#page=3

A table entitled, NSPM-33 Implementation Guidance Pre- and Post-award Disclosures Relating to the Biographical Sketch and Current and Pending (Other) Support2 has been created to provide helpful reference information regarding pre-award and post-award disclosures. The table includes the types of activities to be reported, where such activities must be reported in the application, as well as when updates are required in the application and award lifecycle. A final column identifies activities that are not required to be reported.

Individuals are reminded not to submit any personal information in the current and pending (other) support. This includes items such as: home address; home telephone, fax, or cell phone numbers; home e-mail address; driver’s license number; marital status; personal hobbies; and the like. Such personal information is not appropriate for the current and pending (other) support template and is not relevant to the merits of the proposal. The Federal research funding agency is not responsible or in any way liable for the release of such material.

The format for submission of the two types of support: (a) proposals and active projects; and (b) in-kind contributions is provided below.

* = required

Identifying Information

*Name: Enter the name of the senior/key person (Last Name, First Name, and Middle Name, including any applicable suffix).

Persistent Identifier (PID) of the Senior/Key Person: Enter the PID of the senior key person.

The PID is a unique, open digital identifier that distinguishes the individual from every other researcher with the same or a similar name.

*Position Title: Enter the current position title of the senior/key person.

Organization and Location

*Name: Enter the name of the primary organization of the senior/key person.

*Location: Enter the City, State/Province, and Country where the primary organization is located. If the State/Province is not applicable, enter N/A.

a. Proposals and Active Projects

In this section, disclose ALL proposals and active projects in accordance with the definition for current and pending (other) support.

2 This table supersedes in its entirety, Table 2a and Paragraph 7 of the Disclosure Requirements and Standardization Section of the NSPM-33 Implementation Guidance.

https://www.nsf.gov/bfa/dias/policy/nspm_disclosuretable/nspm33_disclosuretable_sept2022.pdf https://www.nsf.gov/bfa/dias/policy/nspm_disclosuretable/nspm33_disclosuretable_sept2022.pdf https://www.nsf.gov/bfa/dias/policy/nspm_disclosuretable/nspm33_disclosuretable_sept2022.pdf https://www.nsf.gov/bfa/dias/policy/nspm_disclosuretable/nspm33_disclosuretable_sept2022.pdf https://www.nsf.gov/bfa/dias/policy/nspm_disclosuretable/nspm33_disclosuretable_sept2022.pdf https://www.nsf.gov/bfa/dias/policy/nspm_disclosuretable/nspm33_disclosuretable_sept2022.pdf https://www.nsf.gov/bfa/dias/policy/researchprotection/nspm33definitions.pdf#page=2

*Proposals and Active Projects

*Title: Enter the title of each proposal/active project being reported.

*Status of Support: Select the appropriate status type as defined below:

• Current – all active projects, or projects with ongoing obligations, from whatever source irrespective of whether such support is provided through the proposing organization or is provided directly to the individual.

• Pending – any proposal that is being considered for funding from a potential funding organization (including this proposal) irrespective of whether such support is provided through the proposing organization or is provided directly to the individual.

Proposal/Active Project Award Number (if available): Enter the applicable proposal/active project award number for each proposal and/or active project, if available.

*Source of Support: Identify the entity for each proposal and/or active project that is providing the support. Include all Federal, State, Tribal, territorial, local, foreign, public or private foundations, non-profit organizations, industrial or other commercial organizations, or internal funds allocated toward specific projects.

*Primary Place of Performance: Identify the primary location where the proposal and/or active project is being executed. Enter the City, State/Province, and Country where the organization is located. If the State/Province is not applicable, enter N/A.

*Proposal/Active Project Start Date: Indicate the start date (MM/YYYY) of the project, as proposed/awarded.

*Proposal/Active Project End Date: Indicate the end date (MM/YYYY) of the project, as proposed/awarded.

*Total Anticipated Proposal/Project Amount: Enter the total award amount for the entire period of performance, inclusive of indirect costs, rounded to the nearest dollar. If the dollar value is not readily ascertainable, a reasonable estimate should be provided. If the support is in a foreign country’s currency, convert to US dollars at time of submission.

*Person-Month(s) (or Partial Person-Months) Per Year Devoted to the Proposal/Active Project: Enter how much time the individual anticipates is necessary to complete the scope of work on the proposal and/or active project. Enter the number of person-months (even if unsalaried) for the current budget period and enter the proposed person-months for each subsequent budget period. If the time commitment is not readily ascertainable, a reasonable estimate should be provided.

*Overall Objectives: Provide a brief statement of the overall objectives of the proposal/active project. This field is limited to 1500 characters.

*Statement of Potential Overlap: Enter a description of the potential overlap with any pending proposal or active foreign or domestic project and this proposal in terms of scope, budget, or person-months planned or devoted to the project by the individual. If there is no potential overlap, enter “none” in this field.

b. In-Kind Contributions

In this section, disclose all in-kind contributions with an estimated dollar value of $5000 or more and that require a commitment of the individual’s time. An in-kind contribution is a non-cash contribution provided by an external entity that directly supports the individuals’ research and development efforts. An in-kind contribution may include but is not limited to: real property;

laboratory space; equipment; data or data sets; supplies; other expendable property; goods and services; employee or student resources. In-kind contributions with an estimated value of less than $5000 need not be reported.

*Status of Support: Select the appropriate status type as defined below:

• Current – all in-kind contributions obligated from whatever source irrespective of whether such support is provided through the proposing organization or is provided directly to the individual.

• Pending – all in-kind contributions currently under consideration from potential funding organizations irrespective of whether such support is provided through the proposing organization or is provided directly to the individual.

*Receipt (or Anticipated Receipt) Date of In-Kind Contribution: Enter the receipt date (or anticipated receipt date) of the in-kind contribution.

*Source of Support: Identify the entity (entities) that is providing the in-kind contribution.

Include, for example, Federal, State, Tribal, territorial, local, foreign, public or private foundations, non-profit organizations, industrial or other commercial organizations, or internal funds allocated toward specific projects.

*Summary of In-Kind Contribution(s): Enter a summary of the in-kind contribution not intended for use on the proposal/active project.

*Person-Month(s) (or Partial Person-Months) Per Year Devoted to the In-Kind Contribution: Enter how much time the individual anticipates is necessary to complete the scope of work associated with use of the in-kind contribution. Enter the number of person-months (even if unsalaried) for the current budget period and enter the proposed person-months for each subsequent budget period. If there is no associated time commitment, the in-kind contribution need not be reported.

*US Dollar Value of In-Kind Contribution: Enter the US dollar value of the in-kind contribution with an estimated value of $5000 or more. If the dollar value is not readily ascertainable, a reasonable estimate should be provided. If the support is in a foreign country’s currency, convert to US dollars at time of submission, rounded to the nearest dollar.

*Overall Objectives: Provide a brief statement of the overall objectives of the in-kind contribution(s). This field is limited to 1500 characters.

*Statement of Potential Overlap: Enter a description of the potential overlap with any current or pending foreign or domestic in-kind contribution and this proposal in terms of scope, budget, or person-months planned or devoted to the project by the individual. If there is no overlap, enter “none” in the field.

*Certification

Each senior/key person is required to complete the following certifications regarding the information provided in their Current and Pending (Other) Support:

I certify that the information provided is current, accurate, and complete. This includes, but is not limited to, information related to current, pending, and other support (both foreign and domestic) as defined in 42 U.S.C. §6605.

I also certify that, at the time of submission, I am not a party in a malign foreign talent recruitment program.

Misrepresentations and/or omissions may be subject to prosecution and liability pursuant to, but not limited to, 18 U.S.C. §§287, 1001, 1031 and 31 U.S.C. §§3729-3733 and 3802.

Signature3:

Date:

Note: A Privacy Act and Burden Statement must appear on the Current and Pending (Other) Support Common Form. Each Federal research funding agency that elects to use these forms must replace the following language and incorporate their specific System of Records Notice in their PRA common forms request submitted to OMB/OIRA for clearance.

*Privacy Act and Burden Statement:

The information requested on this form is solicited under the authority of the National Science Foundation Act of 1950, as amended. The information on this form will be used in connection with the selection of qualified proposals. The information requested may be disclosed to qualified reviewers and staff assistants as part of the proposal review process; to proposer institutions/grantees to provide or obtain data regarding the proposal review process, award decisions, or the administration of awards; to government contractors, experts, volunteers and researchers and educators as necessary to complete assigned work; to other government agencies or other entities needing information regarding Proposers or nominees as part of a joint application review process, or in order to coordinate programs or policy; and to another Federal agency, court, or party in a court or Federal administrative proceeding if the government is a party. Information about Principal Investigators may be added to the Reviewer file and used to select potential candidates to serve as peer reviewers or advisory committee members. See Systems of Records, NSF-50, "Principal Investigator/Proposal File and Associated Records,” 79 Federal Register 76398 (December 22, 2014), and NSF-51, "Reviewer/Proposal File and Associated Records," 79 Federal Register 76398 (December 22, 2014). Submission of the

3 To be acceptable to the Federal research funding agency, the date of the signature must be within the past 12 months from when the document is submitted to the federal research funding agency.

information is voluntary. Failure to provide full and complete information, however, may reduce the possibility of receiving an award.

An agency may not conduct or sponsor, and a person is not required to respond to, an information collection unless it displays a valid OMB control number. The OMB control number for this collection is 3145-0279. Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions. Send comments regarding the burden estimate and any other aspect of this collection of information, including suggestions for reducing this burden, to:

Reports Clearance Officer Policy Office, Division of Institution and Award Support Office of Budget, Finance, and Award Management National Science Foundation Alexandria, VA 22314

Location(s) of Work

Location(s) of Work yes

Recipient Name: Agreement # (CID):

Reporting Period Start Date: Reporting Period End Date:

Instructions:

Fill out the header information above with your Recipient Name & Agreement # (CID) and the current Reporting Period's Start and End Dates.

The Location(s) of Work report is required to be validated on a quarterly basis. This document will be used to identify each known location being served directly as a project work site location or a location impacted by the project. This includes the location(s) of construction or alteration activity and/or communities that may be a part of the proposed project's supply or waste life cycle (e.g., where raw materials come from, where waste is being sent).

If the recipient is an EECBG Grantee, Please select "yes" from the dropdown:

1. Column B: Identify the Location Type ( a project work or operations site or a community that is part of the project's supply or waste life cycle).

2. Column E: Input Subrecipient (if the location site was identified as a subrecipient location, indicate the subrecipient's name) or Community Name (If the location is an impacted location, identify the name of the impacted community).

3. For all other Columns: Select from the dropdown or input the requested information for each location identified.

Note: If you need additional rows, be sure to 'Copy' existing rows and 'Insert Copied Cells' for the drop-downs and conditional formatting to function properly.

Template Version: 3

Location(s) of Work

ZIP Code™ Lookup Latitude & Longitude Finder Climate and Economic Justice Screening Tool

Location Type Is this a Principal Place of Performance? Prime or Subrecipient Location? Subrecipient/Community Name Facility Name (if applicable) Briefly describe the primary activity at this location or with this population. For example, management headquarters; construction, operations, production; raw materials extraction, waste disposal, etc. Is location in a foreign country? Street Address City State 5-Digit Zip Code + 4

DS22: For assistance determining Zip Code use the USPS e-link in the header.

Latitude

Jacobi, Jennifer: For assistance in determining latitude and longitude, go to Google maps, right click on your location and lat and long will display. Or use the Latitude/Longitude Finder e-link in the header.

Please truncate latitude and longitude in excess of 6 digits after the decimal point. Longitude Does the location or community qualify as a disadvantaged community (DAC) according to the Climate and Economic Justice Screening Tool (CEJST)?

DS22: For help determining DAC qualification use the CEJST e-link in the header. If DAC, add the census tract number or describe the distributed disadvantaged community served (e.g. migrant workers):

DS22: Census Tract data will show in the column to the right of the map using the CEJST e-link in the header.

DS22: For assistance determining Zip Code use the USPS e-link in the header.

Jacobi, Jennifer: For assistance in determining latitude and longitude, go to Google maps, right click on your location and lat and long will display. Or use the Latitude/Longitude Finder e-link in the header.

Please truncate latitude and longitude in excess of 6 digits after the decimal point.

DS22: For help determining DAC qualification use the CEJST e-link in the header. Is construction signage installed at this location? Enter the % of work performed at this location

End of Table

Do not submit Protected Personally Identifiable Information (Protected PII) to DOE. For more information on Protected PII, see Appendix A of the BIL Federal Assistance Reporting Checklist.

https://tools.usps.com/zip-code-lookup.htm?byaddresshttps://screeningtool.geoplatform.gov/https://www.latlong.net/

Source

Location Type Category State

Project Work Site AL

Impacted Community: Project Supply AK

Impacted Community: Waste Cycle AZ

AR

AS

CA

Principal Place of Performance CO

Yes CT

No DE

FL

Prime or Subrecipient Location FM

Prime Recipient GA

Subrecipient GU

HI

Is location in a foreign country ID

Yes IL

No IN

IA

KS

Grantee KY

0 LA

ME

MD

MA

MH

MI

MN

MS

MO

MP

MT

NE

NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

PR

PW

RI

SC

SD

TN

TX

UM

UT

VT

VA

VI

WA

WV

WI

WY

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Disclosure of Lobbying Activities (SF-LLL)

D:20061124112418- 05'00'

D:20061124112418- 05'00'

10. a. Name and Address of Lobbying Registrant:

9. Award Amount, if known:$

* Street 1

* City

State

Zip

Street 2

* Last Name

Prefix

* First Name

Middle Name

Suffix

DISCLOSURE OF LOBBYING ACTIVITIES

Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352

OMB Number: 4040-0013

Expiration Date: 02/28/2025

1. * Type of Federal Action:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Type of Federal Action is required: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. * Status of Federal Action:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Status of Federal Action is required: Identify the status of the covered Federal action.

3. * Report Type:

Report Type: Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the previously submitted report by this reporting entity for this covered Federal action. This field is required.

For Material Change Only:

year quarter date of last report

4. Name and Address of Reporting Entity:

Reporting Entity: Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. This field is required.

Reporting Entity is required: Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

Tier if known:

* Name

* Street 1

Street 2

* City

State

Zip

Congressional District, if known:

Congressional District, if known:

* Name

* City

State

* Street 1

Street 2

Zip

6. * Federal Department/Agency:

7. * Federal Program Name/Description:

CFDA Number, if applicable:

8. Federal Action Number, if known:

b. Individual Performing Services (including address if different from No. 10a)

Prefix

* First Name

Middle Name

* Street 1

* City

State

Zip

Street 2

11.

* Last Name

Suffix

Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

* Signature:

*Name:

Prefix

* First Name

Middle Name

* Last Name

Suffix

Title:

Telephone No.:

Date:

Federal Use Only:

Authorized for Local Reproduction

Standard Form - LLL (Rev. 7-97)

XDPFirstField:

Mandatory:

Disclosure Statement: Click the button to read the "Review Public Burden Disclosure Statement".:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Contract: Click if the Type of Federal Action is a contract.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Grant: Click if the Type of Federal Action is a grant.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Cooperative Agreement: Click if the Type of Federal Action is a cooperative agreement.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Loan: Click if the Type of Federal Action is a loan.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Loan Guarantee: Click if the Type of Federal Action is a loan guarantee.:

Type of Federal Action: Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. This field is required.

Loan Insurance: Click if the Type of Federal Action is a loan insurance.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Bid, Offer, Application: Click if the Status of Federal Action is a bid, an offer or an application.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Initial Award: Click if the Status of Federal Action is an initial award.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Post Award: Click if the Status of Federal Action is a post-award.:

Report Type: Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the previously submitted report by this reporting entity for this covered Federal action. This field is required.

Initial Filing: Click if the Report Type is a initial filing.:

Report Type: Identify the appropriate classification of this report. If this is a follow up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the previously submitted report by this reporting entity for this covered Federal action. This field is required.

Material Change: Click if the Report Type is a material change.:

Year: If this is a follow up report caused by a material change to the information previously reported, enter the year in which the change occurred.:

Quarter: If this is a follow up report caused by a material change to the information previously reported, enter the quarter in which the change occurred.:

Date of last report: Enter the date of the previously submitted report by this reporting entity for this covered Federal action.:

ReportTypeAttr:

ReportingEntityEntityType:

Reporting Entity: Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. This field is required.

Prime: Click to designate the organization filing the report as the Prime Federal recipient.:

SubAwardee: Click to designate the organization filing the report as the SubAwardee Federal recipient. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.:

ReportEntityType:

Tier: Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. :

Reporting Entity Organization Name: Enter the name of reporting entity. This field is required.:

Street 1: Enter the first line of the street address for the Reporting Entity. This field is required.:

Street 2: Enter the second line of the street address for the Reporting Entity.:

City: Enter the city of the Reporting Entity. This field is required.:

State: Select the state for the Reporting Entity's address from this pull down menu.:

Zip / Postal Code: Zip Code (or ZIP+4) of the Reporting Entity.:

Congressional District: If known, the Congressional District of the reporting entity. Should be numeric characters.:

Section5Text:

Prime Organization Name: If the organization filing the report in item 4, checks "Subawardee", enter the full name of the prime Federal recipient.:

Street 1: If the organization filing the report in item 4, checks "Subawardee", enter the address of the prime Federal recipient.:

Street 2: If the organization filing the report in item 4, checks "Subawardee", enter the address of the prime Federal recipient.:

City: If the organization filing the report in item 4, checks "Subawardee", enter the city of the prime Federal recipient.:

State: If the organization filing the report in item 4, checks "Subawardee", select the appropriate state from this pull down menu.:

Zip / Postal Code: If the organization filing the report in item 4, checks "Subawardee", enter the zip code.:

Congressional District: If the organization filing the report in item 4, checks "Subawardee", enter the Congressional District of the prime Federal recipient, if known. Should be numeric characters.:

EntityType: Prime

Federal Department/Agency: Enter the name of the Federal Department or Agency making the award or loan commitment. This field is required.:

Federal Department/Agency: Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments. :

CFDA Number: Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments.:

Federal Action Number: Enter the most appropriate Federal identifying number available for the Federal action, identified in item 1 (e.g., Request for Proposal (RFP) number, invitation for Bid (IFB) number, grant announcement number, the contract, grant, or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001".:

Award Amount: For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment of the prime entity identified in item 4 or 5.:

Prefix: Enter the prefix (e.g., Mr., Mrs., Miss), if appropriate, for the Lobbying Registrant.:

First Name: Enter the first name of Lobbying Registrant. This field is required.:

Middle Name: Enter the middle name of Lobbying Registrant.:

Last Name: Enter the last name of Lobbying Registrant. This field is required.:

Suffix: Enter the suffix (e.g., Jr. Sr., PhD), if appropriate, for the Lobbying Registrant.:

Street 1: Enter the first line of street address for the Lobbying Registrant.:

Street 2: Enter the second line of street address for the Lobbying Registrant.:

City: Enter the city of the Lobbying Registrant.:

State: Select the appropriate state of the Lobbying Registrant.:

Zip / Postal Code: Enter the Zip Code (or ZIP+4) of the Lobbying Registrant.:

DataEntered1:

Prefix: Enter the prefix (e.g., Mr., Mrs.,…