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LAND & WATER CONSERVATION FUND
GRANT APPLICATION MANUAL
2014
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TABLE OF CONTENTS
1. Land and Water Conservation Fund
Page 3
2. Application Submission Information
Page 4
3. Project Eligibility
Page 5
4. Perpetuity Requirements
Page 5
5. Requirements For Acquisition Projects
Pages 6-10
6. Section 6 (f) (3) Metes and Bounds Map
Pages 8-9
7. Requirements For Development Projects
Page 10-11
8. How To Compete for a LWCF Award
Page 12
9.
Page 12
LWCF Review Process
10. LWCF Timeline
Page 13
11. Appendices
Pages 14-42
a.
b.
c.
d.
e.
f.
Sample Governing Resolution
Section 6 (f) and Deed Wording
Environmental Review and Public Comment Requirements
Frequently Asked Questions
2014 Scoring Criteria
Federal Forms and Taxpayer Identification Form
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Pages 15-16
Pages 17-19
Pages 20-25
Pages 26-29
Pages 30-33
Pages 34-42
2
LAND AND WATER CONSERVATION FUND
(LWCF)
The Department of Conservation and Recreation (DCR) administers a grant-in-aid program for the
acquisition and/or development of public outdoor recreation areas and facilities. Grants are for public
bodies only. Towns, cities, counties, regional park authorities, and state agencies may apply for 50%
matching fund assistance from the Land & Water Conservation Fund. These funds are provided from a
federal apportionment from the National Park Service (NPS), a subunit of the United States Department
of the Interior (USDOI).
A key feature of the program is that sites assisted with funding from the program must be open, operated
and maintained in perpetuity as public outdoor recreation areas and may not be converted to other uses
without prior approval by the DCR and NPS acting on behalf of the USDOI.
The program is a matching, reimbursement program, meaning that the sponsoring agency must provide a
match and be capable of financing the project in its entirety while requesting periodic reimbursement.
Information herein describes highlights of the program and is designed to assist in application submission.
Prospective applicants should note that additional information may be required in order to render a proper
decision about individual proposals.
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APPLICATION SUBMISSION INFORMATION
2014 LWCF Grant Focus
The 2014 LWCF grant cycle will focus on awarding funds to projects that qualify for one of more of the
following: 1) ready to be submitted to the National Park Service (NPS) for approval, 2) acquisition for
new park development, 3) represent the next logical development phase of an open LWCF grant 4)
enhance existing LWCF protected parks, 5) provide access to state waters for recreational purposes,
and/or construct recreational trails.
Projects that are ready to be submitted to the NPS for approval will be given funding preference. Projects
considered ready for submission to the NPS are those that have completed the necessary environmental
coordination requirements, have completed a public commenting period, have completed construction
plans, have a recent appraisal to federal standards (if acquisition is involved) and have necessary permits
issued.
Application Deadline
4:00 pm on Thursday 5 June 2014. Four complete copies of the application plus one complete
electronic version on CD or flash drive must be delivered to the Virginia Department of Conservation &
Recreation (DCR) by 4:00 pm on 5 June 2014 at 600 East Main Street, Richmond, Virginia 23219. Faxed
applications and email submissions will not be accepted. Applications mailed with postmarks dated 5
June 2014 will not be accepted. Applicants are responsible for effecting delivery by the deadline and late
submissions will be rejected without consideration.
Grant Amounts.
The maximum grant request amount is $500,000 ($1,000,000 minimum total project cost). The minimum
grant request amount is $300,000 ($600,000 minimum total project cost).
Approximately $1,000,000 is available for funding. Half of the available amount will be used on the
highest ranking, eligible, local projects. Half of the available amount will be used on the highest ranking,
eligible state agency projects. If insufficient requests are submitted from eligible state entities, the
remaining funding will be provided to the local share. It is anticipated 3-5 projects will be selected for
funding depending upon the number of funding requests received.
Application Submission Requirements

Submit four (4) original applications.
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Provide a copy of the complete application including attachments on CD or flash drive.
Documents should be saved in an electronic file format which will enable them to be searched,
copied and pasted for the purpose of moving the proposal through the review process. All photos
and maps become the property of the Department of Conservation and Recreation.

Applications must be delivered to DCR no later than 4:00 pm on Thursday 5 June 2014. Send
application packages to 600 East Main Street Richmond, Virginia 23219. Faxed applications and
email submissions will not be accepted. Applications mailed with postmarks dated 5 June 2014
will not be accepted. Applicants are responsible for effecting delivery by the deadline and late
submissions will be rejected without consideration.
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PROJECT ELIGIBILITY
Eligible Applicants
All cities, towns, counties, eligible state agencies, and park authorities responsible for providing public
recreation services under the Code of Virginia are eligible for funding. Private and non-profit
organizations are not eligible although they may be participating partners in the project.
Eligible Projects
LWCF assistance is available to political jurisdictions for:
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Public outdoor recreation land acquisitions.
Public outdoor recreation development projects.
Combination projects-those that involve both acquisition and development.
Applicants are encouraged to review the grant focus for the 2014LWCF grant cycle provided on page 4.
Eligible Cost Examples
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Swimming/ fishing facilities
Boating Facilities
Picnic Areas
Trails
Soccer fields
Land purchase for public outdoor recreation park
Ineligible Cost Examples
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Restoration of Historic Structures
Amusement facilities, convention facilities and commemorative exhibits
Support facilities for public indoor activities
Recreation centers/gymnasiums
Incidental costs relating to acquisition
Condemnation of any kind of interest in property
Indirect Costs/administrative fees
Perpetuity Requirements
All sites receiving LWCF assistance are required to be opened, operated and maintained in perpetuity for
public outdoor recreation, and may not be converted, either partially or in full, for uses other than public,
outdoor, recreation as outlined Section 6(f0 of the Land & Water Conservation Fund Act of 1965.
All recipients of grant funds will be required to submit two, signed and dated copies of a Section 6 (f)
map.
All recipients of grant funds will be required to record in the deed of the property that the area is
protected through Section 6 (f) of the Land and Water Conservation Fund Act. Please see appendices for
deed wording. All applicants should read the Land and Water Conservation Fund program compliance
requirements posted on line at http://www.dcr.virginia.gov/recreational_planning/lwcfprogreq.shtml
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REQUIREMENTS FOR ACQUISITION PROJECTS
No transfer of property should occur until the applicant has a signed LWCF grant agreement with the
Department of Conservation & Recreation.
Eligible Projects
Acquisition of lands for public, outdoor, recreation including new areas or additions to existing parks,
forests, wildlife areas, beaches, and other similar areas dedicated to outdoor recreation are eligible for
assistance. Areas acquired may serve a wide variety of outdoor recreation activities including but not
limited to walking for pleasure, sightseeing, hiking, fishing, swimming, picnicking, nature study, boating,
hunting, camping, bicycling, and other outdoor sports and activities.
Natural areas and preserves may be acquired but must be open to the general public for outdoor recreation
to the extent that the natural attributes will not be seriously impaired or lost. The percentage of land
available for public use within the natural area will be taken into consideration.
Means of Acquisition
Acquisition of lands may be accomplished through purchase, transfer or by gift. Lands may not be
obtained through condemnation.
Reservation and Rights
Reservations and rights held by others on the subject property may be permissible only if it is determined
by DCR/NPS that the outdoor recreation purposes and environment could not be significantly affected.
The project sponsor shall provide a description of all outstanding rights and interests, if any, held by
others and identify them on the project boundary map.
Acquisition for Delayed Development
LWCF assistance may be available to acquire property for which the development of public outdoor
recreation facilities is planned at a future date. In the interim, between the acquisition and development,
the property must be able to be made immediately open for use by the public for those recreation purposes
which the land is capable of supporting or which can be achieved with minimum financial public
investment. Non recreation uses occurring on the property may continue for a specified period of time if
approved by DCR/NPS during the application process.
If development will be delayed for more than one year from the date of the acquisition, the sponsor shall
include the following information about the project in the application:
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Why immediate acquisition of the property is necessary.
What facilities will be developed and when such development will occur.
What type of interim recreational use will be allowed before development occurs?
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Uniform Relocation and Acquisition
All projects utilizing LWCF assistance must be made in accordance with the applicable provisions of
Public Law 91-646, the Uniform Relocation Assistance and Real Property Acquisition Polices Act of
1970, as amended (Uniform Relocation Act). The acquisition itself does not need to be federally-funded
for the rules to apply. If Federal funds are used in any phase of the project, the rules of the Uniform
Relocation Act apply. The rules encourage negotiation with property owners in a prompt and amicable
manner so that litigation can be avoided.
Ineligible Acquisitions

Acquisitions of historic sites and structures will not receive LWCF assistance. Exceptions may be
made only when it is clearly demonstrated that the acquisition is primarily for outdoor recreation
purposes and that the historic aspects are secondary to the primary recreation purposes. This
exclusion need not prevent the consideration of projects involving the acquisition of property
contiguous to or near historic sites and structures which meet priority outdoor recreation needs.
Compliance with the National Historic Preservation Act of 1966 is required for all acquisitions.

Acquisition of museums and sites to be used for museums or primarily for archeological
excavations will not receive LWCF assistance.
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Acquisitions of land to help meet a public school minimum size requirement will not receive
LWCF assistance.
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Acquisitions of areas and facilities designed for semi-professional and professional arts and
athletics will not receive LWCF assistance.
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Acquisition of areas to be used solely for game refuges or fish production purposes will not
receive LWCF assistance. However, such areas and facilities may be eligible if they will be open
to the public, like any public park, for compatible recreation.
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Acquisition of areas to be used mainly for the construction of indoor facilities will not receive
LWCF assistance.
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Areas where existing indoor recreation facilities, if left in place, will not leave sufficient land at
the site for the development of outdoor recreation facilities to justify the cost of the acquisition are
ineligible.
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Acquisition of sites containing lodges, hotels, motels, restaurants and similar elaborate facilities
that are to be operated by the project sponsor or a concessionaire to provide food and sleeping
quarters will not receive LWCF assistance. The location of these type features if planned for the
site or already existing at the site must be excluded from the 6(f)(3) areas.

Acquisition of agricultural land primarily for preservation in agricultural purposes will not receive
LWCF assistance.
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Acquisition of federal surplus property will not receive LWCF assistance unless legislatively
authorized by Congress in a specific situation.
Required Acquisition Documentation
After an application has been selected by DCR for recommendation for funding but prior to submission to
the National Park Service (NPS) for final approval, the following documentation is required on all
acquisition projects:
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Appraisal to Uniform Appraisal Standards for Federal Land Acquisition (UASFLA.) An
original and one copy must be submitted to DCR. UASFLS standards are commonly referred
to as “yellow book” standards.
A copy of the written offer to purchase the property including a statement of just compensation
Relocation Plan, advisory services program and appeals procedure where displacement occurs.
Documentation showing that the owner or his designated representative has been given the
opportunity to accompany the appraiser during the inspection of the property.
Two maps showing the Section 6 (f) boundary. The boundary should be clearly indicated. See
details regarding the 6(f) map in this manual.
Certification to UASFLA standards and concurrence with the valuation of property from an
independent appraisal reviewer. DCR coordinates the certification review with the NPS
approved independent appraiser.
All cost associated with the appraisal are the responsibility of the applicant and are not eligible for
reimbursement.
 If a current appraisal to UASFLA standards already exists for the property, please submit it with
the LWCF grant application. A current UASFLA appraisal is one conducted between 1 January
2104 and 4 June 2014.
Section 6 (f) Map
The purpose of a section 6 (f) boundary map is to define the area being developed and/or acquired with
federal LWCF grant assistance. This area will be given the protection of Section 6 (f) of the LWCF Act,
which states that the property acquired or developed with LWCF assistance shall not be converted to uses
other than public outdoor recreation and must be maintained in perpetuity as such. In rare circumstances,
a conversion of the property may be authorized through a conversion of use request. Applicants should
read the Land and Water Conservation Fund program requirements posted on line at
http://www.dcr.virginia.gov/recreational_planning/lwcfprogreq.shtml
The Section 6 (f) map also ensures that the area defined by the boundary line is a viable recreation unit.
Normally, this will be the total area of the facility receiving assistance. In no case will it be less than the
area to be developed or acquired under a given LWCF application. All projects must have a Section 6 (f)
boundary map.
According to LWCF rules and regulations, the project area within the Section 6 (f) boundary will become
encumbered as an outdoor recreation site in perpetuity. This means that it must be managed for outdoor
recreation forever.
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At a minimum, the 6 (f)(3) map should include:
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Title of Map.
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Date Map was prepared.
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Scale in feet.
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A north compass point.
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The Section 6 (f)(3) metes and bounds line should be distinct from all other lines on the map.
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The words “Section 6 (f) boundary” should be written on the map with an arrow pointing to
the line.
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Boundary lines should be shown by dotted or bold lines and distinct from all other lines on the
map.
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Latitudes and longitudes for the boundary lines must be provided.
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Match lines should be distinguishable and easily matched among parcels.
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Whenever possible, maps should include some permanent locator, natural landmarks, public
roadways etc. to aid in determining boundaries in the field.
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The number of acres being placed under Section 6 (f) protection must be noted.
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Applicants should consider any existing or potential non-recreational uses of the park property
that should be excluded (“carved out” and/or “setback”) from the 6(f) protection. These areas
should be clearly marked on the map and identified as been excluded from the 6(f) area. It is
highly recommended that applicants consult with the Virginia Department of Transportation to
determine if any planned road construction or improvement projects might impact the
proposed 6(f) boundary and make adjustments now to avoid creating future conversion of use
issues.
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Any easements (utility, conservation, wetland, etc.) must be clearly shown on the map.
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Maps should be as high a quality as possible.
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Whenever possible, the finished map should be submitted on ledger size paper (11 x 17). If
using this size paper compromises legibility please use a larger size.
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Two, signed and dated copies of the map are required. Signature should be of local
representative authorized to submit the application request.
Additional information regarding Section 6(f)(3) is available in the appendices.
Appraisals
The LWCF program requires that appraisals shall be in accordance with the Uniform Appraisal Standards
for Federal Land Acquisition (UASFLA). The UASFLA standards are online at
www.usdoj.gov/enrd/land-ack . The cost of the appraisal is the sole responsibility of the applicant and is
ineligible for reimbursement.
Since professional appraisers license are based on the Uniform Standards of Professional Appraisal
Practice (USPAP), which differ from requirements for federal and federally assisted land acquisition,
applicants must ensure that the appraisers appropriately follow both UASFLA and USPAP. All appraisals
are to include the required certification statements by appraisers as provided for in the UASFLA and
USPAP. Copies of the USPAP are unavailable online; however, they may be purchased from the
Appraisal Foundation, 1029 Vermont Avenue, NW, Suite 900, Washington, and D. C. Appraisals not
meeting these standards could result in withdrawal of the project, delay in approval, and/or the need for a
new appraisal and subsequent certification review.
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The LWCF program requires DCR to submit all appraisals to an independent appraisal reviewer for
certification. The review of the appraisal and certification review are conducted at the expense of the
grant recipient. The cost of the appraisal review may qualify as an eligible reimbursement expense if the
grant is awarded formal approval, the item is included in the project budget submitted with the grant
application and the project is completed according to the approved project agreement for the project.
Appraisals are not required until an applicant receives tentative grant approval from DCR. However, if a
current appraisal to UASFLA standards has been completed it should be included with the LWCF grant
application submission. A current UASFLA appraisal is one conducted between 1 January 2014 and 5
June 2014.
Acquisition at less than Just Compensation
Nothing in the LWCF regulations is to be construed to prevent or deter a property owner from making a
full or partial donation of property.
In those circumstances involving a partial donation, documentation must be provided that gives evidence
that the owner has been provided with a statement of just compensation. Additionally, a written statement
by the owner that he is making a partial donation is also required. An offer of just compensation is not
necessary when acquisition is by full donation—the legal act of donation itself precludes the necessity for
this. Relocation benefits must still be complied with under all circumstances.
To determine the amount eligible for matching, an appraisal and independent review certification as
described above are necessary. The cost of the appraisal and independent certification review for donated
properties are the sole responsibility of the applicant.
Donations required by law or regulations are ineligible as the project sponsors matching share.
REQUIREMENTS FOR DEVELOPMENT PROJECTS
Development projects selected for funding must be in the public interest and in accord with the Statewide
Comprehensive Outdoor Recreation Plan, which is known in Virginia as the Virginia Outdoors Plan.
Development projects are subject to all conditions, policies, and regulations of the LWCF program,
guidelines that may be developed by the Secretary of Interior/National Park Service and all applicable
state and local laws.
A development project may consist of one improvement or a group of related improvements designed to
provide facilities for outdoor recreation, including facilities for access, safety, maintenance and protection
of the area.
Project proposals must be a logical unit of work to be accomplished within a two year time frame.
Funding of development project proposals may cover construction, renovation, site preparation, and
similar activities essential for the proper undertaking of the project.
Plans for the development of land and/or facilities should be based on the needs of the public, the
expected use, and the type and character of the project area. Facilities should be attractive for public use
and consistent with the environment. Plans and specifications for the improvements/facilities should
utilize sustainable and low impact designs and established engineering and architectural practices.
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Emphasis should be given to the protection of the natural resources of the area, the health and safety of
the users and accessibility to the general public.
All facilities developed with assistance from the program must be designed in conformance with 1) the
Architectural Barriers and the “Uniform Federal Accessibility Standards” or 2) the Department of the
Interior regulations on Section 504 of the Rehabilitation Act of 1973 and the “Minimum Guidelines and
Requirements for Accessible Design” as issued by the Architectural and Transportation Barriers
Compliance Board, 36 CFR Part 1190.
Development projects must be for recreational facilities on land and/or water owned in fee simple by the
applicant agency.
Parks receiving LWCF assistance must be open and maintained in perpetuity as public outdoor recreation
facilities in accordance with Section 6 (f) of the LWCF Act.
Development projects must have a Section 6 (f) Map. Please see details on the Section 6(f)(3) map above
and in the appendix.
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HOW TO COMPETE FOR A LWCF AWARD
1. Read the 2014 Land & Water Conservation Fund Manual which has a detailed program
description covering the focus of the grant cycle eligibility, match requirements, program rules
and regulations.
2. Carefully review the grant manual, program requirements, application and scoring criteria posted
on the DCR website at www.dcr.virginia.gov/recreational_planning/vof.shtml before you begin
completing the application.
3. Read the Frequently Asked Questions.
4. Complete the application. The application is a fillable Microsoft Word document. Answer all
questions in the spaces provided. Do not exceed the required space allotment or attach pages
unless specifically directed to do so.
5. Deliver 4 complete copies of the application plus one complete version on CD or flash drive to
DCR at 600 East Main Street, Richmond, Virginia 23219. Faxed applications and email
submissions will not be accepted. Applications mailed with postmarks of 5 June 2014 will not be
accepted. Applicants are responsible for effecting delivery by the deadline and late submissions
will be rejected without consideration.
LWCF REVIEW PROCESS

Applications are reviewed for consistency with the Statewide Comprehensive Outdoor Recreation
Plan (SCORP) known in Virginia as the Virginia Outdoors Plan.
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The Department of Conservation and Recreation staff reviews all applications and eliminates those
applications that are clearly ineligible.
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Projects are then reviewed in accordance with the intent of the Land & Water Conservation Fund
program, the 2014 grant cycle focus, state and federal grant requirements, need, and the scoring
criteria.
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Projects that are ready to be submitted to the National Park Service for approval will be given
funding preference. Projects considered ready for submission to the NPS are those that have
completed the necessary environmental coordination requirements, have completed construction
plans, have completed a public commenting period, have a recent appraisal to federal standards (if
acquisition is involved) and have necessary permits issued.
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A site and field inspection of the highest ranking projects will be made to ascertain conditions and
suitability for funding recommendation.
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When the National Park Service approval is obtained a project agreement must be issued by DCR
and authorized before any activity can occur. No costs can be incurred until a project agreement
has been authorized by both DCR and the grantee.
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LWCF TIMELINE
5 June 2014
LWCF application due no later than 4:00 pm.
Four complete copies of the application plus one complete version on CD or
flash drive must be received by DCR no later than 4:00pm at 600 East Main
Street, Richmond, Virginia 23219. Faxed applications and email
submissions will not be accepted. Applications mailed with postmarks of 5
June 2014 will not be accepted. Applicants are responsible for effecting
delivery by the deadline and late submissions will be rejected without
consideration
June 2014
Application review, scoring, and site inspection.
June 2014
All applicants notified of status.
July- September 2014
Review and approval by NPS
October-December 2014
DCR-grantee agreements issued and authorized.
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Appendices
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Sample Governing Resolution
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The General Provisions of the Land and Water Conservation Fund require evidence that the grantee
possesses legal authority to apply for the grant, and to finance and construct the proposed facilities. As
such, the applicant as part of the grant application to DCR must provide evidence that a resolution, motion
or similar action has been duly adopted or passed in the locality authorizing the filing of the LWCF
application.
Below is a sample resolution for use in preparing your LWCF grant application package. If the resolution
cannot be signed before the LWCF deadline an indication of when the signed resolution can be submitted
must be included in the application. A draft of the resolution to be approved must also be included.
Land & Water Conservation Fund Authorizing Resolution
A resolution authorizing application(s) for federal funding assistance from the Land and Water Conservation Fund (LWCF) to
the Virginia Department of Conservation & Recreation (DCR) as provided in the LWCF Act of 1965, as amended.
WHEREAS, under the provisions of LWCF, federal funding assistance is requested to aid in financing the cost of land
acquisition and/or facility development; and
WHEREAS, ______________________considers it in the best public interest to complete the land acquisition and/or
development project described in the application;
NOW, THEREFORE, BE IT RESOLVED that:
1. The ___________________________ [Mayor, Manager, County Administrator, etc.] be authorized to make formal
application to DCR for funding assistance;
2. Any fund assistance received be used for implementation and completion of (Elements to be funded)
________________________________________within the specified time frame;
3. _______________________hereby certifies that project funding is currently available and is committed for this project
4. We are aware that the grant, if approved by the National Park Service, will be paid on a reimbursement basis. This means
we may only request payment after eligible and allowable costs have already been paid to our vendors and evidence of such
has been provided to DCR in the format required.
5. We acknowledge that any property acquired and/or developed with financial aid from the Land & Water Conservation Fund
must be placed in use and be retained in perpetuity as a public outdoor recreation area in accordance with the provisions and
requirements of the Land & Water Conservation Fund Act of 1965, as amended;
6. We acknowledge that any non-recreational uses may not be made of the property without undergoing a conversion of use
process and obtaining approval from the Department of Conservation and Recreation and the U.S. Department of
Interior/National Park Service;
8. We acknowledge that we are responsible for compliance with the National Environmental Policy Act, Endangered Species
Act, Historic Preservation Act, Executive Orders 11988 and 11990 ( Floodplain Management and Wetlands Protection) and
all other applicable state and federal laws;
7. We acknowledge that appropriate opportunity for public comment _____________ [has been or will be] provided on this
application and evidence of such is a required component for approval.
8. This resolution becomes part of a formal application to the Virginia Department of Conservation & Recreation.
This resolution was adopted by ____________________________ during the meeting held:
Location Date
Signed and approved by the following authorized representative:
Signed: _____________________________________
Date: _____________________________________
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Title: ______________________________________
Attest: _____________________________________
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Section 6(f)(3) Map and Deed Wording
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Section 6(f)(3) map and Restrictive Deed Wording
Section 6 (f)(3)
Section 6 (f) (3) of the Land & Water Conservation states that: “No property acquired or developed with
assistance under this section shall without approval of the Secretary [of the Interior] be converted to other
than public outdoor recreation uses”. The LWCF program realizes that in certain instances there is no
alternative to converting a portion of a LWCF property. In those extreme cases where there is no feasible
alternative, the grantee must begin a conversion of use process with DCR. In short, the conversion of use
process requires that a suitable piece of replacement property be found before a conversion occurs at a
LWCF site. “Suitable” means equivalent in fair market value and can serve as a viable public outdoor
recreation area without reliance upon adjoining or additional areas.
Restrictive Deed Wording
In order for the section 6 (f) (3) regulations to be enforced, the following language is to be incorporated
into the deed and recorded in the city, town or county court house of the project area:
The property identified below has been acquired or developed with federal assistance provided by
the National Park Service of the Department of the Interior in accordance with the Land and Water
Conservation Fund Act of 1965, as amended, 16 U.S.C. 4601-5 et seq. (170 ed.). Pursuant to a
requirement of that law, this property may not be converted to other than public outdoor recreation
uses (whether by transfer, sale, or in any other manner) without the express written approval of the
Virginia Department of Conservation & Recreation and the Secretary of the Department of the
Interior. By law, the Secretary shall approve such conversion only if it is in accord with the then
existing Statewide Comprehensive Outdoor Recreation Plan (SCORP) and only upon such
condition as the substitution of other recreation properties are of at least equal fair market value
and of reasonably equivalent usefulness and location.
Section 6 (f)(3) Map
The purpose of a Section 6(f)(3) map is to legally define the area being developed or acquired with federal
LWCF grant money. This area will be given the protection of Section 6(f)(3)(3) of the LWCF Act, which
states that property acquired or developed with LWCF money shall not be converted to uses other than
public outdoor recreation.
A Section 6(f)(3) map also ensures that the area defined by the boundary line is a viable recreation unit.
Normally, this will be the total area of the facility receiving assistance. In no case will it be less than the
area to be developed or acquired under a given LWCF application. All projects must have a Section
6(f)(3) map.
According to LWCF rules and regulations, the project area within the Section 6(f)(3) boundary will
become encumbered as an outdoor recreational site in perpetuity. This means that it must be open and
managed for public outdoor recreation forever.
Each project application must include a 6(f)(3) metes and bounds map unless the project is for an
acquisition project.
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At a minimum, the 6 (f)(3) map should include:

Title of Map.

Date Map was prepared.

Scale in feet.

A north compass point.

The Section 6 (f)(3) metes and bounds line should be distinct from all other lines on the map.

The words “Section 6 (f) boundary” should be written on the map with an arrow pointing to
the line.

Boundary lines should be shown by dotted or bold lines and distinct from all other lines on the
map.

Latitudes and longitudes for the boundary lines must be provided.

Match lines should be distinguishable and easily matched among parcels.

Whenever possible, maps should include some permanent locator, natural landmarks, public
roadways etc. to aid in determining boundaries in the field.

The number of acres being placed under Section 6 (f) protection must be noted.

Applicants should consider any existing or potential non-recreational uses of the park property
that should be excluded (“carved out” and/or “setback”) from the 6(f) protection. These areas
should be clearly marked on the map and identified as been excluded from the 6(f) area. It is
highly recommended that applicants consult with the Virginia Department of Transportation to
determine if any planned road construction or improvement projects might impact the
proposed 6(f) boundary and make adjustments now to avoid creating future conversion of use
issues.

Any easements (utility, conservation, wetland, etc.) must be clearly shown on the map.

Maps should be as high a quality as possible.

Whenever possible, the finished map should be submitted on ledger size paper (11 x 17). If
using this size paper compromises legibility please use a larger size.

Two, signed and dated copies of the map are required. Signature should be of local
representative authorized to submit the application request.
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Environmental Review
And Public Comment
Requirements
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ENVIRONMENTAL REVIEW AND PUBLIC COMMENT REQUIREMENTS
One of the main areas of focus for the 2014 LWCF is on projects that are ready to be submitted to the
National Park Service for approval. Projects considered ready for submission to the NPS are those that
have completed the necessary environmental coordination requirements, have completed construction
plans, have completed a public commenting period, have a recent appraisal to federal standards (if
acquisition is involved) and have necessary permits issued.
 Applicants are not required to have completed the environmental review and public comments
described below in order to submit a grant application during the 2014 LWCF grant cycle.
However, those projects that have completed the requirements or are closer to completing the
requirements will be given funding preference. No projects can be approved by the National Park
Service until evidence of compliance with the federal laws and regulations governing federal
actions is given.
As a federally funded program all Land and Water Conservation Fund grants are considered federal
actions. Therefore, applicants must be able to demonstrate compliance with the National Environmental
Policy Act; Section 106 of the Historic Preservation Act; Section 7 of the Endangered Species Act; and
Executive Orders 11988 and 11990 (Floodplain Management and Wetland Protection,) and where
applicable, consistency with the Coastal Zone Management Act.
The purpose of the environmental review is to provide information about the Land and Water
Conservation Fund (LWCF) state assistance proposal and the anticipated impacts. The environmental
documentation becomes part of the federal record for the project. Indentifying potential impacts helps
guide the NPS on which National Environmental Policy Act pathway should be pursued: 1) a
recommendation for a Categorical Exclusion (CE), 2) production of an Environmental Assessment (EA),
or 3) production of an Environmental Impact Statement (EIS).
The federal legislation that coordinates the consideration of the potential for impacts to the human
environment as a result of a federal action is the National Environmental Policy Act (NEPA). The
National Environmental Policy Act (NEPA) of 1969, as amended, is landmark environmental protection
legislation which established creating a balance between the use and preservation of natural and cultural
resources as a goal. LWCF proposals are considered federal actions because the funding for the program
is federal. The NEPA process coordinates compliance with applicable related federal, state, and local
environmental requirements such as the Endangered Species Act, Historic Preservation Act and Coastal
Zone Management Act.
NEPA requires: 1) analysis of the impacts of and alternatives to proposed federal actions,
2) the analysis to be used in deciding whether to proceed with the actions; and, 3) public comment.
To demonstrate compliance with public comment requirement of NEPA, public input to the proposed
project must be solicited through a legal advertisement in a daily newspaper with the widest circulation in
the immediate project area. This advertisement should run for a minimum of one day with at least 30 days
allowed for the public to comment. The notice must include a brief description of the proposed project
with the name, address, and contact information of the project sponsor. Comments should be provided in
writing. Evidence of the public comment if conducted should be included in the LWCF grant application.
Evidence of the public comment must be submitted to DCR before any grant could be awarded.
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To satisfy evidence of a public comment period the following information should be submitted:
a) A photocopy of the legal advertisement showing the date on which it ran in the newspaper.
b) Describe the total public involvement for this project beyond the legal advertisement.
c) Describe the nature of the public comments received during the official public comment period. Tally
numbers of comments in support of the project and the numbers against.
d) Summarize the most important comments received and your responses to these comments. For
example, if a reviewer made suggestions on how the project could be made better, how did you respond to
that suggestion? Submit this summary with the LWCF application.
e) Describe any changes to the project design or scope of work based on public input.
f) Comments received and made must be available to DCR for review upon request
For LWCF proposals, the NEPA process coordinates compliance with separate but related federal, state,
and local environmental requirements as applicable.
At a minimum, compliance by the applicant with the following federal laws and executive orders shall be
coordinated during the NEPA process and should be integrated into the impact analysis required.
National Historic Preservation Act, (NHPA) Section 106, as amended.
Section 106 of NHPA requires analysis of the effects of federal actions on historic properties. The State
Historic Preservation Office (SHPO), Tribal Historic Preservation Officers (THPO), and as necessary, the
Advisory Council on Historic Preservation must be given a reasonable opportunity to review and
comment on these actions. Section 106 review and NEPA are two separate, distinct processes. They can
and should occur simultaneously, but one is not a substitute for the other. The information and mitigation
gathered as part of the Section 106 review must be included in the NEPA document, and the Section 106
process must be completed by the project sponsor before NPS can sign a categorical exclusion, or issue a
finding of no significant impact (FONSI) or a record of decision (ROD) so that the proposal may be
approved for a grant.
In Virginia, the Department of Historic Resources (DHR) is the resource agency responsible for issuing
determinations regarding compliance with NHPA, Section 106. Project sponsors must READ and
FOLLOW the instructions posted on the DHR website for obtaining a NHPA Section 106 project review.
The DHR website with instructions is located at: http://www.dhr.virginia.gov/review/orcFedPrjRev.html.
The ePix online project review portal of DHR is located at https://solutions.virginia.gov/ePIX/.
Registration with ePix is required to use the system. Registration with the system is free. Please follow
the instructions and answer all required fields. For the purposes of this review, the federal entity is the
National Park Service, the program is the Land and Water Conservation Fund and the Code of
Federal Domestic Assistance number is 15.916. The review process is a two part process. An archival
review followed by a federal project review. The archival review is a required component of the project
review process for Section 106 reviews. A letter from DHR that provides a NHPA Section 106
determination is required for obtaining project approval from the NPS. If a determination letter has been
issued by DHR for your project, please include it with the 2014 LWCF application submission.
Endangered Species Act, (ESA) Section 7
Section 7 of the Endangered Species Act (ESA) requires consultation with the U.S. Fish and Wildlife
Service and/or the National Marine Fisheries Service on any action that may affect endangered or
threatened species or candidate species, or that may result in adverse modification of critical habitat. For
LWCF purposes the applicant must carry out this consultation and provide evidence that it has occurred.
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The U.S. Fish and Wildlife Service – Virginia Field Office has created an online review. The website is
http://www.fws.gov/northeast/virginiafield/endspecies/Project_Reviews_Introduction.html. Applicants
should READ and FOLLOW the instructions for obtaining a review. Note that Step 2 requires an
“official species list” to be generated by the USFWS and Step 3 requires coordination with the Virginia
Division of Natural Heritage and the Virginia Department of Game and Inland Fisheries (see below).
Applicants must submit to DCR a copy of the USFWS online review process: IPAC area, Official
Species List, Species Conclusion Table and the supporting documentation along with an ESA, Section 7,
determination letter from the USFWS letter in order to be approved for funding. If applicants have
completed this process within the past 6 months, please include the USFWS, ESA, Section 7, review
package and determination letter with the 2014 LWCF application.
Virginia Division of Natural Heritage
Instructions for obtaining project review comments from the Virginia Division of Natural Heritage are
online at http://www.dcr.virginia.gov/natural_heritage/infoservices.shtml#techserv under “Environmental
Review Services” located toward the bottom of the webpage. Project sponsors may request the review
either online or through a mail in form. Please READ and FOLLOW the instructions for obtaining a
review. Applicants must provide a copy of the comment letter received from the Virginia Division of
Natural Heritage to DCR before any grant could be approved for the project. The USFWS requires that
any information regarding federally listed species received from the Division of Natural Heritage must be
documented on the Species Conclusion Table for the USFWS project review.
Virginia Department of Game and Inland Fisheries
Instructions for obtaining project review comments from the Virginia Department of Game and Inland
Fisheries are online at http://www.dgif.virginia.gov/environmental-programs/environmental-servicessection.asp under “Project and Permit Review Process”. Please note that there are several additional types
of information DGIF may require in addition to the project description, location coordinates and
topographical map showing the project location. Therefore it is imperative that applicants follow the on
line instructions precisely and submit the projects to the Department of Game and Inland fisheries
electronically via ProjectReview@dgif.virginia.gov Applicants must provide copy of the comment letter
received from the Virginia Department of Game and Inland Fisheries before any grant could be approved
for the project. The USFWS requires that any information regarding federally listed species received
from the Department of Game and Inland Fisheries must be documented on the Species Conclusion Table
for the USFWS project review.
Floodplain Management and Wetland Protection, Executive Orders 11988 and 11990
Executive Orders 11988 and 11990 direct the avoidance to the extent possible of long and short term
adverse impacts associated with modifying or occupying floodplains and wetlands. These orders also
require the avoidance of direct or indirect support of floodplain or wetland development whenever there is
a practical alternative. For LWCF purposes, applicants must comply with this executive order. Evidence
documenting the applicant’s coordination efforts with responsible state and federal authorities for
determining floodplain management and wetland impacts must be submitted to DCR. For proposals
involving floodplain areas coordination with the local entity responsible for floodplain management is
advised to determine potential impacts. For proposals involving wetlands or potential wetlands,
coordination with the Virginia Department of Environmental Quality, U.S. Army Corps of Engineers and
Virginia Marine Resources should be initiated. The Virginia Department of Environmental Quality has
general guidance information on wetlands posted at http://www.deq.state.va.us/wetlands/permitfees.html.
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Coastal Zone Management Act Federal Consistency Determination
Pursuant to the Coastal Zone Management Act (CZMA), federal actions with potential effects on any land
or water use or natural resources within Virginia's coastal zone must be consistent with the enforceable
policies of the Virginia Coastal Resources Management Program. The federal consistency regulations
implement the CZMA requirement that federal actions be consistent with the enforceable policies of a
coastal state’s federally approved coastal management program, before they can occur. Effects include
both direct and indirect which result from the activity. The Virginia Department of Environmental Quality
(DEQ) is responsible for compliance with CZMA and issuing consistency determinations. DEQ has
created an online Federal Consistency Information Package. The link to the package is
http://www.deq.state.va.us/Programs/EnvironmentalImpactReview/FederalConsistencyReviews.aspx
Item 3, under “Review Procedure” addresses federally assisted projects. Applicants with proposals
occurring within the Coastal Zone Management Area must request a consistency determination from the
DEQ. Please READ the Federal Consistency Information Package and follow the instructions. Please
provide a project description which indicates the request for the federal consistency determination is
due to federal funding assistance from the Land and Water Conservation Fund of the National
Park Service and administered in Virginia by the Department of Conservation and Recreation. The
DEQ fact sheet available at
http://www.deq.state.va.us/export/sites/default/eir/pdf/FederalConsistencyFactSheet.pdf provides the
names of program contacts. Applicants with projects occurring in the Coastal Zone Management Area
must submit the response letter from the DEQ in order to be approved for funding.
Environmental Justice in Minority and Low-Income Populations, Executive Order
12898. Executive Order 12898 directs federal agencies to assess whether their actions have is
proportionately high and adverse human health or environmental effects on minority and low-income
populations. For LWCF purposes, applicants must specifically analyze and evaluate the impact of the
LWCF proposal on minority and low-income populations and communities, as well as the equity of the
distribution of the benefits and risks of the decision in the NEPA document. If it does not apply, this
should be noted and how it does not apply needs to be described.
Environmental Resources and Mandatory Criteria Tables
There are two tables in the environmental section of the 2014 LWCF grant application that must be
submitted. The Environmental Resources table provided as Item 8, under the “Environmental Review and
Project Readiness” section of the LWCF application list several environmental resource topics.
Applicants are requested to choose an impact estimate level (none, negligible, minor, exceeds minor,
more data needed) that describes the degree of potential negative impact for each listed resource that
may occur directly, indirectly and/or cumulatively as a result of the proposal. For each impacted
resource, provide a brief explanation of how the resource might be affected, how the impact level was
determined, and why the chosen impact level is appropriate. Be sure to reference any experts that assisted
in determining the anticipated impact levels. If the resource does not apply or no negative impact is
anticipated, be sure to explain.
The Mandatory Criteria table provided as Item 9, under “Environmental Review and Project Readiness”
section of the LWCF application contains a list of mandatory criteria that preclude the use of categorical
exclusions for the purpose of the National Environmental Policy Act. Please provide an answer and
explanation for each answer. If you answer “yes” or “maybe” for any of the mandatory criteria, more
detailed information on your project would be needed in order for it to continue to be considered for
funding. In this situation, if the application scores high enough for funding, DCR will contact the
applicant to discuss details.
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The information provided in the two tables is required to be submitted to the NPS to guide their selection
of one of the following NEPA “pathways”: 1) a Categorical Exclusion recommendation 2) the necessity
of further environmental analysis through an Environmental Assessment (EA) or 3) Environmental
Impact Statement (EIS).
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Frequently Asked Questions
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What are examples of eligible LWCF projects?
LWCF assistance is available to political jurisdictions for: public outdoor recreation land acquisitions,
public outdoor recreation development projects and/or combination projects involving acquisition and
development.
Be sure to review the 2014 Grant focus for project funding above.
Who may apply?
Eligible grant recipients include cities, towns, counties, Native American Tribes, regional park authorities
and state agencies. Private individuals and organizations, including non-profit and charitable
organizations are not eligible for funding assistance. All eligible applicants compete for LWCF funds.
What is the total funding available for 2014?
The available funding for the 2014 grant cycle is $1,000,000.00
What are the maximum and minimum grant award funding levels?
The maximum grant award request amount is $500,000 (minimum total project cost $1,000,000). The
minimum grant award request amount is $300,000 (minimum total project cost $600,000).
How many grants will be awarded?
It is anticipated that 3-6 awards will be made depending of course on the number of requests received and
amounts requested per applicant.
Are matching funds required?
Yes, the LWCF program is a 50-50 matching reimbursement program. Project sponsors do not receive
grant funds at the time of approval. The sponsor must, in essence, incur 100 percent of the total project
cost; submit evidence of eligible expenditures and payment thereof and request reimbursement from
DCR. In signing the application signature page the applicant is certifying that funding is currently
available and committed to the project for its completion.
What is a Letter of Commitment?
The Letter of Commitment is a letter from a willing donor of property/materials that shows the intent to
make the donation is real.
What is the application deadline?
The application deadline is 4:00pm, 5 June 2014. Deliver 4 complete copies of the application plus one
complete version on CD to DCR at by 4:00 pm on 5 June 2014 at 600 East Main Street, Richmond,
Virginia 23219. Faxed applications and email submissions will not be accepted. Applications mailed with
postmarks dated 5 June 2014 will not be accepted. Applicants are responsible for effecting delivery by the
deadline and late submissions will be rejected without consideration.
Are there any long-term commitments associated with this program?
Yes. Properties acquired, improved or developed with LWCF assistance must be open, maintained and
operated in perpetuity for public outdoor recreation. Other commitments include proper maintenance and
operation, nondiscrimination, facilitating audits, posting of a Land & Water Conservation Fund
Acknowledgement, and maintaining the integrity of the 6(f)(3) protected area boundary. More
information associated with grantee compliance and commitments is available online under “Program
Requirements”.
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What does "in perpetuity" mean?
The phrase "in perpetuity" means forever. Parkland acquired and/or developed with LWCF assistance
must be open and remain as public outdoor recreation facilities forever. Grant recipients must place
restrictive wording in the deed of the park that the property is protected in perpetuity in accordance with
the Land & Water Conservation Act. Evidence that this restriction on the property has been recorded in
the local court records is required prior to processing final reimbursement on the project.
What is the 6(f)(3) metes and bounds map?
The 6(f) boundary is the legal description, metes and bounds of the area that is being protected in
perpetuity by Section 6 (f) (3) of the Land and Water Conservation Fund Act of 1965. Section 6(f)(3)
states that the property acquired, developed or improved with LWCF assistance shall not be converted to
uses other than public outdoor recreation. The 6(f) (3) boundary ensures that the area defined by the
boundary is a viable recreation unit. The 6(f) boundary map goes on record with the locality, National
Park Service and the Department of Conservation and Recreation showing the area being placed under
protection of the Land & Water Conservation Act.
What is Section 6(f)(3) of the LWCF Act?
Section 6 (f) (3) of the Land & Water Conservation Act states that: “No property acquired or developed
with assistance under this section shall without approval of the Secretary [of the Interior] be converted to
other than public outdoor recreation uses”. The LWCF program realizes that in certain instances there is
no alternative to converting a portion of a LWCF property. In those extreme cases where there is no
alternative, the Project Sponsor must begin a conversion of use process with DCR. In short, the
conversion of use process requires that a suitable piece of replacement property be found before a
conversion occurs at a LWCF site. “Suitable” means equivalent in fair market value and can serve as a
viable public outdoor recreation area without reliance upon adjoining or additional areas. In order for the
section 6 (f) (3) regulation to be enforced, the following language is to be incorporated into the deed and
recorded in the city, town or county courthouse of the project area: The property identified has been
acquired or developed with federal assistance provided by the National Park Service of the Department of
the Interior in accordance with the Land and Water Conservation Fund Act of 1965, as amended, 16
U.S.C. 4601-5 et seq. (170 ed.). Pursuant to a requirement of that law, this property may not be converted
to other than public outdoor recreation uses (whether by transfer, sale, or in any other manner) without the
express written approval of the Virginia Department of Conservation & Recreation and the Secretary of
the Department of the Interior/National Park Service. By law, the Secretary shall approve such conversion
only if it is in accord with the then existing Statewide Comprehensive Outdoor Recreation Plan (SCORP)
and only upon such condition as the substitution of other recreation properties are of at least equal fair
market value and of reasonably equivalent usefulness and location. All grantees must include this
language in the deed for their LWCF assisted site.
I want to use donated land as match - Can it be property already owned by the city, town or
county?
No.
Must the environmental review and public commenting requirements be completed to submit an
application during the 2014 grant cycle?
No. However, evidence of the completed environmental review and public commenting requirements as
outlined in the 2014 LWCF grant manual must be completed in order for the project to be submitted to the
National Park Service to obtain approval. Therefore, funding preference will be given to projects that are
ready to be submitted to the NPS.
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What is the focus of the 2014 LWCF grant cycle?
The 2014 LWCF grant cycle will focus on awarding funds to projects that qualify for one of more of the
following: 1) ready to be submitted to the National Park Service (NPS) for approval, 2) acquisition for
new park development, 3) represent the next logical development phase of an open LWCF grant 4)
enhance existing LWCF protected parks, 5) provide access to state waters for recreational purposes,
and/or construct recreational trails.
I am developing a park facility that may only be used during certain seasons and/or months of the
year for organized activity. If funded through LWCF, is it permissible to close and lock the facility
during the non-use days or months and/or lock it up after the activity is over?
No. LWCF guidelines state that the park facility must be open during reasonable hours for public use
every day of the year. Some exceptions include holidays, portions of Sundays, wet field conditions, etc.
Even if it is the "off-season" for programming, the facility must remain open and accessible to the general
public.
For additional questions, contact :
Synthia Waymack,
Land & Water Conservation Fund Program
Department of Conservation and Recreation
600 East Main Street
Richmond, Virginia 23219-2010
(804) 786-4379
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2014 Scoring Criteria
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2014 Land & Water Conservation Fund Scoring Criteria
Name of Project:____________________________________
1. Purpose and need of the proposal. (0-10 points)
Creates a new park or area for recreation, score 8-10 points
Represents the next logical phase of an existing LWCF grant, score 5-7 points.
Extends or expands/ enhances the use of existing facilities parks, score 1-4 points
Not adequately addressed score 0 points.
2. To what extent does the proposal meet recreational needs identified in the Virginia Outdoors Plan (VOP)? (0 - 5 points)
provides for access to state waters for recreational use (swimming, fishing, boating, etc.), score 5 points
Creates recreational trails, score 2-4 points
If this project is a general need (anything other than water access or trails) of the VOP, score 1 point
3. Does this proposal represent the creation of the first public park in the locality? Score, 0-10 points
4 . Score the management, operation and maintenance of the park and its facilities. (Committed P&R Department staff,
Public Works, Volunteers, etc, regular, sporadic, etc) (0-5 points)
Committed management, operation and maintenance provided on a regular basis (P&R Department staff and/or
other local government entity), score 3-5 points
Maintained by volunteers, score 1-2 points
Answer not adequately addressed or maintenance schedule seems inadequate for facilities provided or the
compliance requirements of the LWCF program, score 0 points.
5. Rate the extent to which the project is accessible to (and usable by) disabled citizens. (0-10 points)
Proposal provides 100% accessibility, score 10 points
Majority of the proposal provides for accessibility and sponsor clearly details why the entire project cannot be
accessible, score 4-9 points
Only one element is proposed and only a portion of it is accessible. Sponsor clearly demonstrates why the entire
element cannot be accessible, score 1-3 points.
Not addressed or application does not clearly indicate the accessibility to be available, score 0 points
6. Rate the extent of public comment involved in the proposal. (Score 0-10 points)
The public was involved in the early stages of the planning for the proposal: public meetings were held specifically
to engage the public and interested stakeholders on this proposal, a formal commenting period was held, responses
were provided by sponsor to comments received. Evidence of public comment is included with application, score 510 points
A public commenting period is underway and evidence of the public comment announcement is included with the
application, score 2-4 points
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The proposal was presented/discussed as part of the regularly scheduled board of supervisors/ town council/ city
council/ meeting, as required where the public is invited to attend. Score 1 point
7. Rate the environmental review and project readiness of the project. (0-17 points)
If constructions plan are complete for the project, score 10 points.
If all permits for the project have been identified and have been obtained or their issuance is underway and
applicant has clearly documented this, score 6-7 points.
If permitting process is not underway and applicant has described a site analysis or environmental scoping process
that was conducted for the specific land disturbing activities associated with the LWCF proposal which indicates the
NEPA, Endangered Species Act and Historic Preservation Act determinations, etc. should proceed quickly resulting
in a recommendation for a categorical exclusion and determinations of not likely to adversely effect, score 1-5
points.
If no site analysis or environmental scoping has been conducted for the project or it is unclear what steps have been
taken to determine that property is suitable for the proposed land disturbing activities being proposed, score 0
points.
8. Rate the readiness of projects involving acquisition only.(0-5 points)
If there is a current UASFLA appraisal exists on the project which was submitted with the application, score 5
points.
It an appraisal to UASFLA standards is underway, score 3- 4 points.
If an appraisal to only USPAPS standards has been conducted , score 1-2 points
If it is unclear on the status of the appraisal and there is no documentation supporting the reported value of the
property, score 0 points.
9. Is the provided timeline realistic? Consider site specific conditions as described in application, extent of project readiness
demonstrated, number of elements to be assisted, etc. (Score 0-5 points)
10. Did applicant respond to the unmet needs section of the application and provide a methodology on how the dollar
estimate was calculated? (1-8 Points)
If applicant provided a dollar estimate and methodology on calculating the unmet needs, score 1-5 points.
If applicant failed to completely answer the question (estimate, methodology and breakdown were not all provided),
score negative 5 points
11. Rate the budget are all of the items included in the budget eligible for assistance? Is a detailed budget submitted? Is the
budget realistic? Has sponsor clearly shown funding is in place to finance the project in its entirety while seeking periodic
reimbursement? Is the match a hard or soft match? (0-5 points)
12. Rate the application preparation. Have all questions been answered? All attachments provided? Has applicant provided
a clear indication of what the project is and what the LWCF funding will assist with? Have all directions been followed, etc.
( 0-5 points)
13. Rate the Five Minute Sales Pitch.
Applicant indicates in a clear, convincing and/or creative manner the uniqueness and significance of the proposal and why
it should be funded. (Score: 0- 5 points)
Score:________
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14. Rate applicant’s performance on existing or previous (within past 5 years) recreational grants at DCR. Have extensions,
changes in scope of work, etc. been needed? Has sponsor kept project on schedule, submitted status reports in a timely
fashion, followed project agreement requirements, submitted requested information in a timely fashion, etc?.
Points awarded for this criterion may be either negative for poor performance or positive for good performance,
(score 0-5 points for applicants with good performance and compliance. Deduct 0-5 points for poor performance
or compliance issues).
When scoring this criterion for applicants that would be first time grantees score 0-5 points. Base awarded points
on the quality of the project (ownership of property/funds available/maintenance of facilities/facilities to be
developed, public comment, etc.).
______________________________________________________________________________________________________
________________________________________
Total Project Points =
(105 Maximum points )
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Federal Forms and Taxpayer Identification Form
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Version 7/03
APPLICATION FOR
FEDERAL ASSISTANCE
1. TYPE OF SUBMISSION:
Application
2. DATE SUBMITTED
Applicant Identifier
3. DATE RECEIVED BY STATE
State Application Identifier
4. DATE RECEIVED BY FEDERAL AGENCY
Federal Identifier
Pre-application
Construction
Construction
Non-Construction
5. APPLICANT INFORMATION
Legal Name:
Non-Construction
Organizational Unit:
Department:
Organizational DUNS:
Division:
Address:
Street:
Name and telephone number of person to be contacted on matters
involving this application (give area code)
Prefix:
First Name:
City:
Middle Name
County:
Last Name
State:
Zip Code
Suffix:
Country:
Email:
6. EMPLOYER IDENTIFICATION NUMBER (EIN):
Phone Number (give area code)
Fax Number (give area code)
7. TYPE OF APPLICANT: (See back of form for Application Types)
8. TYPE OF APPLICATION:
New
Continuation
If Revision, enter appropriate letter(s) in box(es)
(See back of form for description of letters.)
Revision
Other (specify)
Other (specify)
9. NAME OF FEDERAL AGENCY:
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:
U.S. Department of Interior, National Park Service
15
TITLE (Name of Program):
- 916
Land & Water Conservation Fund
12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):
13. PROPOSED PROJECT
Start Date:
Ending Date:
15. ESTIMATED FUNDING:
a. Federal
$
b. Applicant
$
c. State
$
d. Local
$
e. Other
$
f. Program Income
$
g. TOTAL
$
14. CONGRESSIONAL DISTRICTS OF:
a. Applicant
b. Project
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
THIS PREAPPLICATION/APPLICATION WAS MADE
a. Yes.
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON
DATE:
b. No.
PROGRAM IS NOT COVERED BY E. O. 12372
OR PROGRAM HAS NOT BEEN SELECTED BY STATE
FOR REVIEW
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
Yes If “Yes” attach an explanation.
No
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT. THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE
ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. Authorized Representative
Prefix
First Name
Middle Name
Last Name
Suffix
b. Title
c. Telephone Number (give area code)
d. Signature of Authorized Representative
e. Date Signed
Previous Edition Usable
Authorized for Local Reproduction
Standard Form 424 (Rev.9-2003)
Prescribed by OMB Circular A-102
Reset Fields
Print
INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE
ADDRESS PROVIDED BY THE SPONSORING AGENCY.
This is a standard form used by applicants as a required face sheet for pre-applications and applications submitted for Federal
assistance. It will be used by Federal agencies to obtain applicant certification that States which have established a review and comment
procedure in response to Executive Order 12372 and have selected the program to be included in their process, have been given an
opportunity to review the applicant’s submission.
Item:
1.
Entry:
Select Type of Submission.
Item:
11.
2.
Date application submitted to Federal agency (or State if applicable)
and applicant’s control number (if applicable).
12.
3.
State use only (if applicable).
13
Enter the proposed start date and end date of the project.
4.
Enter Date Received by Federal Agency
Federal identifier number: If this application is a continuation or
revision to an existing award, enter the present Federal Identifier
number. If for a new project, leave blank.
Enter legal name of applicant, name of primary organizational unit
(including division, if applicable), which will undertake the
assistance activity, enter the organization’s DUNS number
(received from Dun and Bradstreet), enter the complete address of
the applicant (including country), and name, telephone number, email and fax of the person to contact on matters related to this
application.
14.
List the applicant’s Congressional District and any District(s)
affected by the program or project
15
Amount requested or to be contributed during the first
funding/budget period by each contributor. Value of in kind
contributions should be included on appropriate lines as
applicable. If the action will result in a dollar change to an
existing award, indicate only the amount of the change. For
decreases, enclose the amounts in parentheses. If both basic
and supplemental amounts are included, show breakdown on
an attached sheet. For multiple program funding, use totals
and show breakdown using same categories as item 15.
Applicants should contact the State Single Point of Contact
(SPOC) for Federal Executive Order 12372 to determine
whether the application is subject to the State
intergovernmental review process.
This question applies to the applicant organization, not the
person who signs as the authorized representative. Categories
of debt include delinquent audit disallowances, loans and
taxes.
5.
6.
Enter Employer Identification Number (EIN) as assigned by the
Internal Revenue Service.
16.
7.
Select the appropriate letter in
the space provided.
I.
State Controlled
A. State
Institution of Higher
B. County
Learning
C. Municipal
J. Private University
D. Township
K. Indian Tribe
E. Interstate
L. Individual
F. Intermunicipal
M. Profit Organization
G. Special District
N. Other (Specify)
H. Independent School
O. Not for Profit
District
Organization
Select the type from the following list:
•
"New" means a new assistance award.
•
“Continuation” means an extension for an additional
funding/budget period for a project with a projected completion
date.
•
“Revision” means any change in the Federal Government’s
financial obligation or contingent liability from an existing
obligation. If a revision enter the appropriate letter:
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
Name of Federal agency from which assistance is being requested
with this application.
17.
8.
9.
10.
18
Entry:
Enter a brief descriptive title of the project. If more than one
program is involved, you should append an explanation on a
separate sheet. If appropriate (e.g., construction or real
property projects), attach a map showing project location. For
preapplications, use a separate sheet to provide a summary
description of this project.
List only the largest political entities affected (e.g., State,
counties, cities).
To be signed by the authorized representative of the applicant.
A copy of the governing body’s authorization for you to sign
this application as official representative must be on file in the
applicant’s office. (Certain Federal agencies may require that
this authorization be submitted as part of the application.)
Use the Catalog of Federal Domestic Assistance number and title of
the program under which assistance is requested.
SF-424 (Rev. 7-97) Back
Print
OMB Approval No. 0348-0042
ASSURANCES - CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0042), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
Awarding Agency. Further, certain Federal assistance awarding agencies may require applicants to certify to additional
assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the applicant:
1.
Has the legal authority to apply for Federal assistance,
and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project costs) to ensure proper planning,
management and completion of the project described in
this application.
8. Will comply with the Intergovernmental Personnel Act
of 1970 (42 U.S.C. §§4728-4763) relating to prescribed
standards for merit systems for programs funded
under one of the 19 statutes or regulations specified in
Appendix A of OPM’s Standards for a Merit System of
Personnel Administration (5 C.F.R. 900, Subpart F).
2.
Will give the awarding agency, the Comptroller General
of the United States and, if appropriate, the State,
through any authorized representative, access to and
the right to examine all records, books, papers, or
documents related to the assistance; and will establish
a proper accounting system in accordance with
generally accepted accounting standards or agency
directives.
9. Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. §§4801 et seq.) which
prohibits the use of lead-based paint in construction or
rehabilitation of residence structures.
3.
Will not dispose of, modify the use of, or change the
terms of the real property title, or other interest in the
site and facilities without permission and instructions
from the awarding agency. Will record the Federal
interest in the title of real property in accordance with
awarding agency directives and will include a covenant
in the title of real property aquired in whole or in part
with Federal assistance funds to assure non­
discrimination during the useful life of the project.
4.
Will comply with the requirements of the assistance
awarding agency with regard to the drafting, review and
approval of construction plans and specifications.
5.
Will provide and maintain competent and adequate
engineering supervision at the construction site to
ensure that the complete work conforms with the
approved plans and specifications and will furnish
progress reports and such other information as may be
required by the assistance awarding agency or State.
6.
Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding
agency.
7.
Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.
10. Will comply with all Federal statutes relating to non­
discrimination. These include but are not limited to: (a)
Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race,
color or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C. §§1681­
1683, and 1685-1686), which prohibits discrimination
on the basis of sex; (c) Section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C.
§794), which prohibits discrimination on the basis of
handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C. §§6101-6107), which prohibits
discrimination on the basis of age; (e) the Drug Abuse
Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to nondiscrimination on the basis of
drug abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) §§523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee3), as amended, relating to confidentiality of alcohol
and drug abuse patient records; (h) Title VIII of the
Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale,
rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and, (j) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
Standard Form 424D (Rev. 7-97)
Previous Edition Usable
Authorized for Local Reproduction
Print Form
Prescribed by OMB Circular A-102
11.
Will comply, or has already complied, with the
requirements of Titles II and III of the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of
1970 (P.L. 91-646) which provide for fair and equitable
treatment of persons displaced or whose property is
acquired as a result of Federal and federally-assisted
programs. These requirements apply to all interests in real
property acquired for project purposes regardless of
Federal participation in purchases.
12.
Will comply with the provisions of the Hatch Act (5 U.S.C.
§§1501-1508 and 7324-7328) which limit the political
activities of employees whose principal employment
activities are funded in whole or in part with Federal funds.
13.
Will comply, as applicable, with the provisions of the DavisBacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract
Work Hours and Safety Standards Act (40 U.S.C. §§327­
333) regarding labor standards for federally-assisted
construction subagreements.
14.
15.
Will comply with flood insurance purchase requirements of
Section 102(a) of the Flood Disaster Protection Act of 1973
(P.L. 93-234) which requires recipients in a special flood
hazard area to participate in the program and to purchase
flood insurance if the total cost of insurable construction
and acquisition is $10,000 or more.
Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the
National Environmental Policy Act of 1969 (P.L. 91­
190) and Executive Order (EO) 11514; (b) notification
of violating facilities pursuant to EO 11738; (c)
protection of wetlands pursuant to EO 11990; (d)
evaluation of flood hazards in floodplains in accordance
with EO 11988; (e) assurance of project consistency
with the approved State management program
developed under the Coastal Zone Management Act of
1972 (16 U.S.C. §§1451 et seq.); (f) conformity of
Federal actions to State (Clean Air) Implementation
Plans under Section 176(c) of the Clean Air Act of
1955, as amended (42 U.S.C. §§7401 et seq.); (g)
protection of underground sources of drinking water
under the Safe Drinking Water Act of 1974, as
amended (P.L. 93-523); and, (h) protection of
endangered species under the Endangered Species Act
of 1973, as amended (P.L. 93-205).
16. Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. §§1271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.
17. Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 U.S.C. §470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of
1974 (16 U.S.C. §§469a-1 et seq.).
18. Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act Amendments of 1996 and OMB Circular No. A-133,
"Audits of States, Local Governments, and Non-Profit
Organizations."
19. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
governing this program.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
TITLE
APPLICANT ORGANIZATION
DATE SUBMITTED
SF-424D (Rev. 7-97) Back
Print Form
U.S. Department of the Interior
Certifications Regarding Debarment, Suspension and
Other Responsibility Matters, Drug-Free Workplace
Requirements and Lobbying
Persons signing this form should refer to the regulations
referenced below for complete instructions:
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters - Primary Covered Transactions - The
prospective primary participant further agrees by
submitting this proposal that it will include the clause
titled, "Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion - Lower Tier Covered
Transaction," provided by the department or agency
entering into this covered transaction, without
modification, in all lower tier covered transactions and in
all solicitations for lower tier covered transactions. See
below for language to be used or use this form certification
and sign. (See Appendix A of Subpart D of 43 CFR Part 12.)
PART A:
Certification Regarding Debarment, Suspension, Ineligibility
and Voluntary Exclusion - Lower Tier Covered Transactions (See Appendix B of Subpart D of 43 CFR Part 12.)
Certification Regarding Drug-Free Workplace Requirements
- Alternate I. (Grantees Other Than Individuals) and
Alternate II. (Grantees Who are Individuals) - (See Appendix
C of Subpart D of 43 CFR Part 12)
Signature on this form provides for compliance with
certification requirements under 43 CFR Parts 12 and 18.
The certifications shall be treated as a material
representation of fact upon which reliance will be placed
when the Department of the Interior determines to award the
covered transaction, grant, cooperative agreement or loan.
Certification Regarding Debarment, Suspension, and Other Responsibility MattersPrimary Covered Transactions
CHECK____IF THIS CERTIFICATION IS FOR A PRIMARY COVERED TRANSACTION AND IS APPLICABLE.
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a)
Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any
Federal department or agency;
(b)
Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against
them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a
public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust
statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
(c)
Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local)
with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and
(d)
Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal,
State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective
participant shall attach an explanation to this proposal.
PART B:
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions
CHECK____IF THIS CERTIFICATION IS FOR A LOWER TIER COVERED TRANSACTION AND IS APPLICABLE.
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently
debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this
transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective
participant shall attach an explanation to this proposal.
This form was electronically produced by Elite Federal Forms, Inc.
DI-2010
June 1995
(This form replaces DI-1953, DI-1954,
DI-1955, DI-1956 and DI-1963)
PART C:
Certification Regarding Drug-Free Workplace Requirements
CHECK___IF THIS CERTIFICATION IS FOR AN APPLICANT WHO IS NOT AN INDIVIDUAL.
Alternate I. (Grantees Other Than Individuals)
A. The grantee certifies that it will or continue to provide a drug-free workplace by:
(a)
Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or
use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be taken
against employees for violation of such prohibition;
(b)
Establishing an ongoing drug-free awareness program to inform employees about-(1) The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
(c)
Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the
statement required by paragraph (a);
(d)
Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant,
the employee will -(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the
workplace no later than five calendar days after such conviction;
(e)
Notifying the agency in writing, within ten calendar days after receiving notice under subparagraph (d)(2) from an
employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide
notice, including position title, to every grant officer on whose grant activity the convicted employee was working,
unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the
identification number(s) of each affected grant;
(f)
Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph (d)(2), with
respect to any employee who is so convicted -(1)
(2)
(g)
Taking appropriate personnel action against such an employee, up to and including termination, consistent
with the requirements of the Rehabilitation Act of 1973, as amended; or
Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;
Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a) (b),
(c), (d), (e) and (f).
B. The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the
specific grant:
Place of Performance (Street address, city, county, state, zip code)
Check___if there are workplaces on files that are not identified here.
PART D: Certification Regarding Drug-Free Workplace Requirements
CHECK___IF THIS CERTIFICATION IS FOR AN APPLICANT WHO IS AN INDIVIDUAL.
Alternate II. (Grantees Who Are Individuals)
(a)
The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant;
(b)
If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he
or she will report the conviction, in writing, within 10 calendar days of the conviction, to the grant officer or other
designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made
to such a central point, it shall include the identification number(s) of each affected grant.
DI-2010
June 1995
(This form replaces DI-1953, DI-1954,
DI-1955, DI-1956 and DI-1963)
PART E:
Certification Regarding Lobbying
Certification for Contracts, Grants, Loans, and Cooperative Agreements
CHECK____IF CERTIFICATION IS FOR THE AWARD OF ANY OF THE FOLLOWING AND
THE AMOUNT EXCEEDS $100,000: A FEDERAL GRANT OR COOPERATIVE AGREEMENT;
SUBCONTRACT, OR SUBGRANT UNDER THE GRANT OR COOPERATIVE AGREEMENT.
CHECK___IF CERTIFICATION FOR THE AWARD OF A FEDERAL
LOAN EXCEEDING THE AMOUNT OF $150,000, OR A SUBGRANT OR
SUBCONTRACT EXCEEDING $100,000, UNDER THE LOAN.
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of an agency, a Member of Congress, and officer or employee
of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making
of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting
to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its
instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at
all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all
subrecipients shall certify accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered
into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, title
31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000
and not more than $100,000 for each such failure.
As the authorized certifying official, I hereby certify that the above specified certifications are true.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
TYPED NAME AND TITLE
DATE
DI-2010
June 1995
(This form replaces DI-1953, DI-1954,
DI-1955, DI-1956 and DI-1963)
REQUEST FOR TAXPAYER IDENTIFICATION NUMBER(S) AND CERTIFICATION
Substitute Form W-9
Each person/organization doing business with the Commonwealth must provide the following information or be subject to backup withholding.
1
2
Social Security Number
AND/OR
Federal Identification Number
Dun & Bradstreet Number
3 Is this form being completed for disbursement of grant funds?
Y/N
If yes, skip item 4
4 Provide a general description of goods/services to be sold to the Commonwealth:
0*
Other
6
Corporation
A*
Partnership
2
Federal Agency
7*
Sole Proprietor/Reportable Individual
B*
Estate
3
State Agency
8*
Medical Corporation
C*
Trust
4
Local Government
9
Non-Reportable Individual
D*
Limited Liability Company
5
Political Subdivision
* Indicates vendor may be eligible to receive a form 1099
LEGAL NAME
TRADE NAME
Order Address
Contact Person
Telephone No.
E-mail Address
FAX No.
Remittance Address
Contact Person
IS THIS BUSINESS:
Telephone No.
Minority Owned1
Y/N
Woman Owned2
Y/N
Small3
Y/N
1) Business concern at least 51% owned by one or more minorities or in the case of a corporation, partnership or LLC or other entity, at least 51% of the equity
ownership interest in which is owned by one or more minorities and whose management and daily business operations are controlled by one or more of such
individuals. Such persons include, but are not limited to; African Americans, Hispanic Americans, Asian Americans, Native Americans, Eskimos, and Aleuts.
2) Business concern at least 51% owned by one or more women who are U.S. citizens or legal resident aliens, or in the case of a corporation, partnership or LLC or
other entity, at least 51% of the equity ownership interest in which is owned by one or more women, and whose management and daily business operations are
controlled by one or more such individuals.
3) An independently owned and operated business which, together with affiliates, has 250 or fewer employees, or average annual gross receipts of $10 million or less
averaged over the previous 3 years.
CERTIFICATION
Under penalties of perjury, I certify that:
1. The number(s) shown on this form is/are my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: [a] I am exempt from backup withholding, or [b] I have not been notified by the Internal
Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or [c] the IRS has notified me
that I am no longer subject to backup withholding.
Certification Instructions - You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because of under reporting interest or dividends on your tax return.
Signature
8/25/04
Date