Attachments- HALEU Innovative Technology NOFO.pdf

Notice of Funding Opportunity: DE-FOA-0003487

High-Assay Low-Enriched Uranium (HALEU) Innovative Technology

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. Application for Federal Assistance

2. Statement of Project Objectives

3. Project Management Plan

4. Research and Related Budget – Section A-B Form

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

6. Community Benefits Plan for Topic Area 1-Demonstration & Deployment

7. Community Benefits Plan for Topic Area 2-Research & Development

8. Current and Pending Support

9. Location(s) of Work

10. Offeror Environmental Report

11. Environmental Impact Checklist

12. Disclosure of Lobbing Activities

13. Certification Regarding Lobbing

14. FFRDC-Field Work Proposal Budget

15. Summary for Public Release

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

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:

ID F 450.01

(10/2024) Replaces (04/2020)

U.S. DEPARTMENT OF ENERGY

IDAHO OPERATIONS OFFICE

Offeror Environmental Report

Directions: The following information must be provided to and approved by the Department of Energy (DOE) before a proposal/project can be awarded. Please address each section of this outline in narrative report form and submit with the project proposal. The information provided in this report is important for establishing the basis, expediting the DOE environmental review process, and enabling DOE to make a National Environmental Policy Act (NEPA) determination. If any query below does not apply to the project, cite as “N/A”, and include a short explanation.

1.0 Project title

1.1 Applicant/offeror organization

1.2 Applicant/offeror organization contact

1.3 Telephone number and email address

2.0 Description of the proposed project: Please prepare a self-contained description that summarizes the proposed action in detail. Discuss the objectives of the proposed project and describe the proposed site. Describe the work to be performed, the schedule, associated requirements (e.g., land, natural resources), and changes that will be necessary to the existing site, systems, or processes. Provide a complete description of potential alternatives to the project including a “no action” alternative, and alternatives to technology specific, process design, site-specific location project aspects. If the project changes for any reason during the application period, you must notify DOE and describe the changes. Please include a project site plan and topographic map of the area. Off-site facility requirements shall also be identified in this description.

3.0 Existing environment and potential/anticipated environmental impacts: Discuss the existing environment at the project location(s) and the potential environmental impacts from the project including consequences from any construction, operation/testing, and disposition activities. Ensure postulated direct, indirect, short-term, and long-term impacts resulting from project activities are identified clearly. Identify mitigative measures formulated that will address these impacts. This information must convey subject matter expert level knowledge of the environmental conditions.

4.0 Land use: Provide a description of the affected land area and its dimensions; a discussion of current land usage (e.g., farming, industrial, etc.); and descriptions of nearby pipelines and transmission lines, as well as transportation access (rail, road, barge, etc.). Describe land use impacts from any construction and operation activities; waste disposal problems (for non-toxic, toxic, and/or hazardous substances); and effluent discharges requiring the development of settling ponds.

5.0 Air quality: Identify the air quality control regions in the project area, the local climate and existing air quality conditions in the immediate proposed project/site area.

6.0 Hydrologic conditions/water quality: Identify watersheds and downstream drainage, surface and groundwater quality (nearby aquifers and the depth of groundwater) in the project area, existing floodplains, unique aquatic habitats, recreational areas, public water supplies; describe constraints on water availability imposed by treaties, court decree, state and Federal water laws; and identify existing wastewater treatment and/or disposal facilities. Describe changes in groundwater/surface water quality and quantity, stream diversion resulting from construction, runoff from storage piles (source, discharge rate, discharge frequency and duration), leachates from waste disposal sites; and wastewater treatment and discharges.

7.0 Geologic/soil conditions: Describe the topographic stability (e.g., formations and/or faulting, karst), the productivity of soil, unique soil species, and the soil’s susceptibility to erosion. Describe notable seismic conditions, subsidence that might be caused by construction; possible erosion, stream diversion, floodplain and wetland intrusion, and increases or decreases in soil permeability and infiltration.

8.0. Vegetation resources: Identify the vegetative biome and predominant/representative plant species in the project area. Describe impacts to indigenous flora, state and Federally listed endangered species and their habitats, and sensitive plant habitats such as wetlands, floodplains, or other ecologically sensitive terrain.

9.0 Wildlife resources: Identify the predominant/representative wildlife species in the project area, local indigenous flora and fauna, state and Federally listed endangered or threatened wildlife species and their habitats, and sensitive habitats such as wetlands, floodplains, or other ecologically sensitive terrain.

10.0 Visual resources: Describe any scenic values/vistas or existing aesthetic environmental conditions in the project area.

11.0 Climate change: Considerations related to climate change include: 1) the potential effects of a proposed action on climate change (through greenhouse gas emissions or carbon sequestration and reductions from the proposed action). Climate change analysis also enables agencies to evaluate reasonable alternatives and mitigation measures that could avoid or reduce potential climate change-related effects and help address mounting climate resilience and adaptation challenges. 2) the effects of climate change on a proposed project and how climate change may influence the purpose and need for projects in the short-term (within the next 10 to 15 years) and long-term (over the next several decades); and, 3) the implications of climate change on the environmental effects of a proposed action.

12.0 Historic/cultural resources: Describe historic and/or cultural places in the project area, as well as archeological sites, disturbance to historical or archaeological sites caused by construction, interference with Native American tribal or other religious practices or sites; and impacts on local community character. This includes the potential impact to an historic property or building that may be governed by provisions of the National Historic Preservation Act. Describe consultation predicted or undertaken with potentially affected American Indian Tribes.

13.0 Waste generation: This section shall describe waste material (solid, hazardous or radioactive) that will be generated from project activities. Include the source/type of any and all wastes produced, and the approximate weight, density, and volume of the waste, its method of disposal, location, and any permitting requirements necessary.

14.0 Socioeconomic conditions and environmental justice implications: Discuss the population in the project area and describe the employment, labor mix and potentially disadvantaged communities that may be marginalized, underserved, or overburdened by pollution.

Describe if and how the project may be able to benefit these communities across one or more of the following seven areas: climate change, clean energy and energy efficiency, clean transit, affordable and sustainable housing, training and workforce development, remediation and reduction of legacy pollution, and the development of critical clean water and wastewater infrastructure.

15.0 Health and safety aspects: Discuss the current/background conditions at proposed project areas including emissions, effluents and noise and the potential cumulative effects of the project proposal.

16.0 Environmental regulation: Briefly describe current and anticipated state and Federal environmental regulations, permits and agreements that will govern the project.

ID F 450.02

(03/2024) Replaces 04/2020

ENVIRONMENTAL CHECKLIST

DIRECTIONS: This Form shall be used when a proposal or project is expected to have minimal to no potential for impact to the environment. DOE does not expect a detailed environmental evaluation. However, the information provided should allow DOE to make a determination without additional research, documentation or inquiry. If the proposal/project exceeds this criterion a more detailed effort may be required. Please submit the completed form with the project proposal.

SECTION A. Descriptive Information: Provide project title, applicant/offeror, and contact information Project Title:

Organization:

Contact Name:

Telephone Number & Email:

SECTION B. Environmental Aspects / Potential Sources of Impact: Check the applicable box for the following environmental aspects by reviewing the applicability statements. Ask yourself, “How can this activity affect the environment?”

ENVIRONMENTAL

ASPECT

APPLICABILITY STATEMENT YES NO

1. Air Emissions Air emissions apply to operations or activities that have the potential to generate air pollutants including but not limited to radionuclides, chemical and combustion emissions, fugitive dust, and ozone-depleting substances. Includes activities that may break up, dislodge, disturb or block access to regulated asbestos-containing material, handle asbestos-containing material, manage asbestos waste, or conduct decommissioning or demolition.

2. Discharging to Surface, Storm, or Ground Water

This applies to activities that have the potential to contaminate Waters of the U.S., wetlands, ground water, or storm water that could reach Waters of the U.S.

3. Disturbing Cultural Resources

Cultural resource disturbance applies to activities that have the potential to impact cultural resources, such as disturbing soils by grading, excavating, sampling, off-road vehicle use, or removing vegetation, as well as to personnel working in areas where cultural resources are located. It also applies to modifications or demolition of historical buildings or structures, or activities that could result in loss or damage to these resources. Examples of culture resources include buildings, structures or objects or 50 years old or those identified as historic due to special significance, archaeological resources, historic home sites, trails, and canals, and places or items of significance to Native Americans and/or others.

4. Disturbing Natural Resources

This includes activities that have potential to interact with, disturb or affect wildlife (all biological organisms) or their habitats (e.g. soil disturbance, land clearing, mowing) or activities involving revegetation, weed control, vegetation management, or invasive species. Also please discuss any resource use/extraction required such as water, energy, fuels, minerals, borrow material, wood or paper products, and other materials derived from natural resources.

5. Generating and Managing Waste

Regulated, hazardous, or radioactive material and waste packaging and transportation applies to activities that generate, store, treat, or dispose of solid, sanitary, hazardous, radioactive, mixed, industrial, or nanoparticle waste.

6. Releasing Contaminants

Releasing contaminants applies to activities that may release potentially hazardous or regulated contaminants into air, water, soil, or other non-contaminated or previously contaminated locations. These activities may include, but are not limited to, the use of industrial and laboratory chemicals; the use of radionuclides; hazardous, radioactive, and mixed waste treatment and decontamination operations; and contaminated soils disturbance. This aspect also applies to asbestos containing material remediation; repair, replacement, and/or disposal of contaminated tanks and associated piping; and the handling and disposal of PCB-contaminated equipment and waste.

7. Environmental Justice and Climate Change

Environmental Justice refers to the “just treatment and meaningful involvement of all people, regardless of income, race, color, national origin, Tribal affiliation, or disability, in agency decision-making and other Federal activities that affect human health…” Will the proposal have a human health or environmental impact, positive or negative, on disadvantaged communities or Federally Recognized Tribes that are marginalized, underserved, and overburdened by pollution including those related to climate change.

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SECTION C. Description of Environmental Aspects: For each environmental aspect checked “YES,” provide specific information such as types and amounts of chemical, waste, effluent, or emissions; size of modification, soil disturbance; or type of tank, equipment, or process and pollution prevention measures for each item checked.

Briefly discuss the potential environmental impacts that could occur from project activities. If the proposal is expected to have positive or mitigative effects on the environment please describe them here. If more space is needed, please attach relevant information.

DESCRIPTION OF ENVIRONMENTAL ASPECTS:

SECTION D. CERTIFICATION – To the best of the offeror’s knowledge at the time of this signing, the responses given above are complete and accurate. Should new issues or concerns arise, or changes occur any time after award and/or during the course of performance, the applicant/offeror will alert DOE immediately.

APPLICANT/OFFEROR NAME AND TITLE

Signature:

FOR DOE USE ONLY

NEPA Document #: NEPA CX Applied: Solicitation #:

Contract Specialist: Approved

Project Manager: Signature:

Project Title:

Check Box30: Off

Organization:

Contact Name:

Telephone Number Email:

Check Box17: Off

Check Box18: Off

Check Box19: Off

Check Box20: Off

Check Box21: Off

Check Box22: Off

Check Box23: Off

Check Box24: Off

Check Box25: Off

Check Box26: Off

Check Box27: Off

Check Box28: Off

Check Box29: Off

DESCRIPTION OF ENVIRONMENTAL ASPECTS:

Date_2:

Date:

NEPA Document:

NEPA CX Applied:

Solicitation:

Contract Specialist:

Project Manager:

Applicant/Offeror Name and Title:

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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…