blm ca l15as00117 ccsp commitment document must.doc

DEPARTMENT OF INTERIOR

Bureau of Land Management

L15AS00117 CALIFORNIA ONLY

Challenge Cost Share Program (CCSP)

COMMITMENT DOCUMENT

Please complete the following application for the current fiscal year Challenge Cost Share Program project funding. This document is used to outline the relationship and understanding of specific project responsibilities between the BLM and the cooperator.

1.

PROJECT INFORMATION

Project Title:

Estimated Start Date:

Estimated Completion Date:

Current Fiscal Year:

WBS Number:

BPS Number:

2.

BLM INFORMATION

State Office:

Field Unit:

Affected Trail, Site, Resource:

Contact:

Title:

Telephone:

Fax:

Email:

3.

PROJECT COOPERATOR INFORMATION

Organization Name:

Address:

Telephone:

Fax:

Email:

Authorized Official:

Title:

Organization Name:

Address:

Telephone:

Fax:

Email:

Authorized Official:

Title:

Role of Cooperator(s):

NO:

NO:

If the answer to both questions is "NO" explain how the CCSP funds will be used in conjunction with the Cooperator's match:

4.

COOPERATOR PARTICIPATION

In the space provided below, describe how the cooperator(s) will participate in the success of this project.

5.

MATCHING REQUIREMENTS

In the space provided below, list the amounts, types (funds, in-kind labor, travel, materials, volunteer time, etc.), and sources of non-Federal matching share. Is the matching share secured and available? If no, please explain.

6.

PROJECT BUDGET SUMMARY

Enter the total amounts budgeted for the project from the Detailed Budget Breakdown on the following pages. Total budgeted costs must be clearly documented on the Detailed Budget Breakdown form.

PROJECT BUDGET SUMMARY

(Enter totals from Detailed Budget Breakdown form)

A) Personnel Costs

B) Fringe Benefit Costs

C) Travel Costs

D) Equipment Costs

E) Supply Costs

F) Contracted Costs

G) Construction Costs

H) Other Costs

I) Total Direct Costs

J) Indirect Costs

K) Total Project Costs

7.

AUTHORIZED SIGNATURES

The Cooperator and the BLM Program Officer must both sign this Commitment Document

COOPERATOR SIGNATURE

The Cooperator’s representative must sign and date this form certifying commitment of this proposal.

Name:

Title:

Signature:

Date:

BLM SIGNATURE

The appropriate BLM representative must sign and date this form signifying support of this proposal.

Name:

Title:

Signature:

Date:

Challenge Cost Share Program

COMMITMENT DOCUMENT

Detailed Budget Breakdown Enter the budgeted project costs below (expand the fields as necessary). Enter each category total in its corresponding field in Item 6. Project Budget Summary above. Use each category's Narrative box to clearly show how the total charge for that item was determined.

PLEASE NOTE: This budget narrative must include any non-federal match. If a 1:1 match is not being made with this project, please identify or link to another project that will make up the matching requirement. Federally appropriated funds may not be used as a match. All non-Federal matching must be contributed during the project period, which begins when the agreement is awarded by the BLM Grants Management Officer.

A)

PERSONNEL SALARIES & WAGES

A1) For Salaried Employees (for Hourly Wage Employees, see below) Budgeted cost of salaries paid to recipient employees working directly on this agreement. Indicate Key Personnel with an asterisk (*) and list all Names and Titles, if known.

(if applicable)

BLM

Funds Total

Funding

Narrative:

A2) For Hourly Wage Employees

Budgeted cost of hourly wages paid to recipient employees working directly on this agreement. Indicate Key Personnel with an asterisk (*) and list all Names and Titles, if known.

(if applicable)

BLM

Funds Total

Narrative:

B)

EMPLOYEE FRINGE BENEFITS

Budgeted cost of fringe benefits paid to recipient employees working on the agreement. Fringe Benefits may include such items as, FICA, Health Insurance, Workers’ Compensation, Vacation, etc. List each employee or position and their respective rate.

(Budgeted from Section A above)

(if applicable)

BLM

Funds Total

Narrative:

C)

TRAVEL COSTS

C1) Lodging & Per Diem Reimbursement Budgeted cost of lodging and per diem necessary to carry out agreement activities. Explain the details and purpose of the travel in the Narrative box below.

Note: If your organization has no written travel policies, reimbursement for travel costs may not exceed Federal Government per diem rates. Current Federal rates may be found online at: http://www.gsa.gov/portal/category/21287.

(if applicable)

BLM

Funds Total

Funding

To:

From:

To:

To:

To:

To:

To:

To:

Example:

Portland, OR

Eugene, OR

Narrative:

C2) Mileage Reimbursement Budgeted cost of reimbursement for mileage travelled in carrying out agreement activities. Explain the details and the purpose of the travel in the Narrative box below.

NOTE: If your organization has no written travel policies, mileage reimbursement rates may not exceed Federal Government rates. Current Federal rates may be found online at: www.GSA.gov.

(if applicable)

BLM

Funds Total

Funding

To:

To:

To:

To:

To:

To:

To:

Example:

Portland, OR

Eugene, OR

Narrative:

D)

EQUIPMENT COSTS

Budgeted cost of equipment (property with a useful life of more than one (1) year and costing $5,000 or more per unit). Explain the details and the purpose of the equipment in the Narrative box below.

(if applicable)

BLM

Funds Total

Narrative:

E)

SUPPLY COSTS

Budgeted cost of materials and supplies used directly on this project, such as ear plugs, safety glasses, work gloves, etc. Explain the details and purpose in the Narrative box below.

(if applicable)

BLM

Funds Total

Narrative:

F)

CONTRACTED COSTS

Budgeted cost of contracted services and/or sub-recipient agreements. Provide names and explain the details and purpose of the costs in the Narrative box below.

(if applicable)

BLM

Funds Total

Narrative:

G)

CONSTRUCTION COSTS

The estimated cost of construction.

(if applicable)

BLM

Funds Total

(NOT APPLICABLE)

Narrative:

H)

OTHER COSTS

Budgeted costs that don't fit any other Object Class Category, such as duplicating and printing, postage and freight, leased equipment, etc. Explain the details and purpose in the Narrative box below.

(if applicable)

BLM

Funds Total

Narrative:

I)

TOTAL DIRECT COSTS

The total of all direct budgeted costs applicable to this project.

(if applicable)

BLM

Funds Total

Funding

J)

INDIRECT COSTS

Budgeted costs of an organization which can't be readily identified and charged to a particular project, such as building rent, utilities, miscellaneous office supplies, etc. Such costs are usually charged to the project as a percentage of some or all of the budgeted direct costs (items 6a.-6h. above). This percentage is called the Indirect Cost Rate.

Choose Option A or B below if Indirect Costs will be charged to this project

OPTION A - For Recipients with a Negotiated Indirect Cost Rate Agreement (NICRA)

If your organization has a NICRA, submit a copy of it with your SF-424 Application for Federal Assistance packet.

Federal Agency that issued NICRA:

Approved Indirect Cost Rate (%):

Base against which this rate will be applied:

(Total Direct Costs, Total Labor Costs, etc.)

Base amount for this Grant($):

Rate to be used on this Grant (%):

(if applicable)

BLM

Funds Total

Funding

OPTION B - For Recipients with no NICRA

Indirect Costs may not be charged to this project, unless:

1) An Indirect Cost Rate proposal is submitted to the Department of the Interior, Interior Business Center (DOI-IBC) Indirect Cost Services Directorate (ICSD) within 90 days after the effective date of the award. The Grants Management Officer may approve a provisional rate of up to 10% of total direct costs until the approved NICRA is established.

OR

2) Your organization is a small non-profit entity and the Grants Management Officer allows a non-negotiated rate of up to 10% of the total direct costs to be charged. In which case, your organization must provide documentation clearly showing what costs are included as indirect, what the rate will be applied to, and that it is reasonable.

Rate to be used on this Grant (%):

Base against which this rate will be applied ($):

(Total Direct Costs, Total Labor Costs, etc.)

Base amount for this Grant ($):

(if applicable)

BLM

Funds Total

Funding

K)

TOTAL BUDGETED PROJECT COSTS

The total of Direct and Indirect Costs (Sum of 6i. & 6j.) budgeted for this project.

(if applicable)

BLM

Funds Total

Funding

SUPPLEMENTAL INFORMATION

Please complete this supplemental information. Keep responses to the length of this form. Do not attach continuation sheets.

Project Description In the space provided below, summarize the proposed project. Discuss the problem or issue addressed, proposed solution, and duration and timing of the project. Provide quantitative references, if possible.

Project Justification In the space provided below, describe the critical need(s) addressed by this project. Discuss project history, the existing situation, and improvements that can be made if funding is secured for the project. Include information about the target audience for the project.

Measurable Results In the space provided below, describe the tangible results or product(s) that will be in place at the end of the project. As appropriate, provide critical numbers, as in people trained, copies of publications distributed, resources preserved, etc.

CCS Commitment Document Dec 2013