Form 10-904 LWCF Proposal Description and Environmental Screening Fo

NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

APPLICATION AND REVISION (A&R)
Land and Water Conservation Fund

F State & Local Assistance Program
Grant Name:
LWCF Grant Number (if known):

For amendments, include the amendment number
(e.g. ##-#####.#)

PRISM Number (if known):

☐New project grant application (fill out section 1.0, 2.0 with relevant sub-section(s), and 3.0):
☐ Acquisition (fill out section 2.1)
☐ Development/Renovation (fill out section 2.2)
☐ Combination Acquisition & Development/Renovation (fill out both sections 2.1 and 2.2)
☐New Planning Grant Application (attach narrative – see manual)
☐Amendment during active period of performance (fill out section 4.0) – check all that apply, below
☐Scope change (fill out section 4.1)
☐Cost increase (fill out section 4.2)
☐Time extension (fill out section 4.3)
☐Other administrative change (fill out this page and include explanation in transmittal)
Brief Description of Proposal (for amendments, describe only the changes proposed):

RECORDS RETENTION – PERMANENT ACTIVE. (NPS Records Schedule, National Assistance Programs (Item 8.A.2) (N1-79-08-7))

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 1.0 NEW PROJECT GRANT APPLICATION
Project contact name:
Project contact number:
Project contact email:
A.

if different than what was submitted on the SF 424, otherwise delete

Attachments checklist

The following should be transmitted to NPS, either directly or via Grants.gov.
All projects

As applicable

☐ Location map

☐ intergovernmental review comments

☐ LWCF boundary map (proposed)

☐ relevant NEPA/SEPA documents

☐ NHPA documentation

☐ applicable federal law compliance

☐ SF 424

☐ proof of flood insurance

☐ SF 424C

☐ proof of cold climate criteria qualification

☐ SF 424D

☐ leases, MOA’s, MUA’s, etc.

☐ project budget

☐ use schedule (school parks)

☐ proof of ownership

☐ Dingell-Johnson certification

☐ pre-award site inspection report

☐ waiver of retroactivity

Acquisition & Combination Projects

☐ acquisition donation acknowledgement

☐ parcel map for acquisition parcel(s)
☐ conceptual design plan
Development & Combination Projects

Grants with Indirect Costs

☐ site development plan

☐ SF 424 A

☐ building floor plan(s) if grant-funded

☐ Indirect cost rate agreement

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NPS Form 10-904 (Rev. 12/2019)
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B.

Project competition
1. Explain how this proposal was ranked using the state’s Open Project Selection Process (OPSP).
2.

C.

D.

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

Explain how this project meets SCORP priorities.

Risk assessment
1. How did you assess the sub-recipient’s financial risk and capacity to deliver this project?
2.

How did you assess the applicant’s ability to complete the project as scoped and within the proposed time frame?

3.

What is the applicant’s recent experience completing similar projects with federal grant funding (LWCF or other)?

Financial
1. How was the cost estimate derived?
2.

What assurances are there that the costs listed are reasonable?

3.

Describe any project elements or costs that will improve site resiliency and facility longevity, if any.

4.

Are any eligible pre-award costs being included as part of the grant request?
a. ☐ No
b. ☐ Yes – Indicate the date from when those costs started being incurred, the funding category/categories, the
total amount of pre-award costs anticipated to be incurred before the grant start date, and whether they are
included for match purposes or for reimbursement. (Note: these should also be presented in the budget
narrative.)

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 2.0 SITE BASED PROJECT GRANTS
A.

Sub-recipient (grant sponsor) information (repeat if needed for co-sponsors)
Sub-Recipient Agency Name:
Sub-Recipient Contact Name:
Address:
Phone:

B.

Email:

Public benefit
1.

Describe both short- and long-term outdoor recreation benefits that will be achieved as a result of this project.

2.

Explain how this project fits as part of any other projects planned for this same site in the next three years.

3.

Describe the process that led to the development of this proposal and how the public was involved.

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 2.1 ACQUISITION AND COMBINATION GRANTS
A.

B.

Need
1. Why is this acquisition (whether attained via purchase or donation) needed?
2.

Describe the existing resources and features of the site that make it desirable for public outdoor recreation.

3.

Explain how you envision this acquisition contributing to outdoor recreation in the long term.

Acquisition schedule & appraisal/waiver valuation certification

Reproduce table as needed for multiple parcels
Parcel Name
Parcel Size
Parcel Value
Anticipated Acquisition Date
☐ A State-certified Review Appraiser has reviewed the appraisal and has determined that it was prepared in conformity with
the Uniform Appraisal Standards for Federal Land Acquisitions
OR
☐ The State has prepared a waiver valuation for this property in conformity with 49 CFR 24.102(c)(2)(ii)

SLO/ASLO Signature

Date

Name, Title, and Agency

C.

D.

Property information
1. From whom is this property being purchased?
2.

Are any buildings or structures being purchased along with the property?
a. ☐ No
b. ☐ Yes – Describe what is planned for those structures and whether the grant funded project includes the value
of those structures.

3.

How will the site be made open and accessible for public outdoor recreation use (signage, entries, parking, site
improvements, allowable activities, etc.)?

4.
5.

When will access to the site for public outdoor recreation become available?
Describe development planned for the site(s) for the three (3) years following acquisition. As this will impact NHPA and
NEPA compliance, focus on what you reasonably expect to accomplish.

6.

If development will be delayed by more than three years from grant close, explain why this acquisition is still a priority
for grant funding at this time and what ability the public will have to use the site in the interim.

7.

Is this acquisition an addition to an existing park or other recreation area?
a. ☐ No
b. ☐ Yes – How will it support and enhance that existing park?

Acquisition approach
1. Is this property being acquired under threat of condemnation?
a. ☐ No
b. ☐ Yes – Explain:
2.

Was the property listed for public sale?
a. ☐ No
b. ☐ Yes – Explain how the property owner was made aware of the grant sponsor interest in the property.

3.

Does this project involved donated property?
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a.
b.

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☐ No
☐ Yes – Include evidence that the seller was offered the fair market value of the property as just
compensation and willingly chose to donate the property instead. (If the donation is subject to a waiver of
retroactivity the evidence must pre-date the donation.)

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 2.2 DEVELOPMENT AND COMBINATION GRANTS
A.

Grant elements
1. What new facilities will be constructed as part of this project?
2.

What existing facilities will be renovated or replaced (specify which) as part of this project?

3.

What general site improvements (e.g. demolition, site preparation, landscaping, habitat improvements, etc.) will be
completed as part of this project?

4.

What is the anticipated life span of the facilities that will be funded as part of this project?

5.

Does the project scope include facilities that also eligible for Dingell-Johnson or Wallop-Breaux Act funding (i.e.,
boat/fish access)?
a. ☐ No
b. ☐ Yes – Ensure necessary SLO certification is included (see manual)

6.

Does this project involve the new development of a sheltered/enclosed swimming pool or ice skating rink or the
sheltering/enclosure of an existing outdoor pool or rink?
a. ☐ No
b. ☐ Yes
i. Explain how it was determined that the site meets the cold climatic criteria described in the LWCF
manual. Provide a copy of the cold climatic data used to make the eligibility determination with the
application (see manual).
ii. Explain the nature of the project – is this a new sheltered facility, or construction of the shelter only?
If the pool or ice rink already exists, was it LWCF-funded? If yes, what year was it built and how
much LWCF assistance was provided?
iii. What is the total cost of the sheltered facility and what amount of grant funding will be spent on the
actual shelter/enclosure structure itself (if any)?
iv.

B.

Explain the significantly increased public use that will be made possible by the shelter/enclosure to
justify the construction of such a facility.

Design elements
1. How are access requirements under the Americans with Disabilities Act (ADA) and Architectural Barriers Act (ABA)
being addressed in this project?
2.

What design elements are included that contribute to preserving environmental resources as part of ensuring a quality
outdoor recreation experience for present and future generations?

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 3.0 SITE INFORMATION
A.

Basic information
1. Will this proposal create a new public park/recreation area where none previously existed?
a. ☐ No
b. ☐ Yes – Explain:
2.

If this is an existing LWCF site, has the park name changed since the last grant?
a. ☐ No
b. ☐ Yes – Explain:

3.

Is this project located in a floodplain?
a. ☐ No
b. ☐ Yes – Explain and confirm that you have met applicable federal insurance requirements.

4.

Is your site contiguous with or connected to any federally owned recreation area?
a. ☐ No
b. ☐ Yes – Explain:

5.

Is your site part of a larger management area, such as a greenway or regional recreation area?
a. ☐ No
b. ☐ Yes – Explain:

6.

Describe the existing site conditions.

7.

Explain why the site is suitable for the type of outdoor recreation proposal being submitted.

8.

Does the site include any elements that visually detract from the outdoor recreation experience or that represent a
potential public safety hazard?
a. ☐ No
b. ☐ Yes – Explain and describe whether this project will help to address those concerns.

9.

What is/will be the applicant’s type of ownership and control of the property?
a. ☐Fee simple ownership.
b. ☐Less than fee simple. Explain what rights the applicant has and what agency holds the underlying fee
simple ownership.
c. ☐Lease. Include a copy of the lease with the application.

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NPS Form 10-904 (Rev. 12/2019)
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B.

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

Stewardship considerations
1. Is this a multi-use site (i.e. school, reservoir, state forest, etc.)?
a. ☐ No
b. ☐ Yes – Explain:
i. How often will the public have recreation access to the site?
ii. What kinds of restrictions to public outdoor recreation will occur?
2.

Who will manage and operate the site(s)?

3.

Describe the nature of any rights-of-way, easements, reversionary interests, etc. within the proposed LWCF boundary
area:

4.

Are there any pre-existing or planned indoor facilities on site that would not themselves be eligible for LWCF grant
funding?
a. ☐ No
b. ☐ Yes – Describe and explain how/if the structure(s) support public outdoor recreation.

5.

Is the proposed LWCF boundary the same as the boundary of the park/recreation area as it exists in its totality?
a. ☐ Yes
b. ☐ No – Explain any area proposed for exclusion and why, and ensure it is clearly depicted on the proposed
LWCF boundary map

6.

Are there any pre-existing or planned resource management practices (i.e. timber management, grazing, etc.)?
a. ☐ No
b. ☐ Yes – Describe the nature of the practice, the anticipated duration, and how the practice supports outdoor
recreation.

7.

Are there any pre-existing or planned uses on site that are incompatible with LWCF requirements that should be
excluded from the LWCF boundary?
a. ☐ No
b. ☐ Yes – Describe the nature of the use and ensure it is clearly depicted on the proposed LWCF boundary
map. Clarify whether the future intent is for the area to become subject to LWCF once the use is terminated,
or if the intent is for the use to continue within the park in perpetuity.

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

C. Environmental Resources Survey
Consultation with NPS regarding the NEPA pathway for a proposal should occur prior to the completion of this section. If you
have already determined that the proposal will require an EA or EIS, you may go directly to the questions following Tables 1 and
2.
The tables below serves as a record of the environmental resources present at the site, whether the proposed action is likely to
have a significantly negative impact those resources, and whether further information is needed to determine the potential
impact. Review the listed resources and identify any resources that may be significantly impacted by the action. The
Environmental Resources Survey should be completed with professional input from resource experts and in consultation with
relevant local, state, tribal, and federal governments, as appropriate.
Table 1 – For each resource indicate if positive impacts or negative impacts are anticipated to result from the action or if further
information is needed to determine the potential impact.
+
?

indicates positive impacts are anticipated to result from the action
indicates negative impacts are anticipated to result from the action
indicates further information is needed to determine the potential impact

Site Name:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

How will the project affect the following resources?
Air quality
Circulation and transportation
Climate
Contamination or hazardous materials even if remediated
Endangered species: (listed or proposed threatened or endangered) including
associated habitat
Environmental justice: minority and low-income populations
Geological resources: soils, bedrock, slopes, streambeds, landforms, etc.
Historic or cultural resources
Invasive species
Land use plans or policies from other agencies including tribes
Lightscapes, especially night sky
Migratory birds
Recreation resources
Socioeconomics: changes to tax base or competition with private sector
Sound (noise impacts)
Unique ecosystems, such as biosphere reserves, World Heritage sites, old growth
forests, etc.
Water quality and/or quantity
Water: coastal barrier resources or coastal zones
Water: marine and/or estuarine
Water: stream flow characteristics
Water: wetlands and floodplains
Other important resources
Explain:

+
☐
☐
☐
☐

☐
☐
☐
☐

?
☐
☐
☐
☐

☐

☐

☐

☐

☐

☐

☐

☐

☐
☐
☐

☐

☐
☐
☐

☐
☐
☐
☐
☐

☐
☐
☐

☐
☐
☐
☐
☐

☐

☐
☐
☐
☐
☐

☐

☐
☐
☐
☐
☐
☐

☐

☐
☐
☐
☐
☐
☐

☐
☐
☐
☐
☐
☐

Table 2 – This is a list of mandatory impact criteria that preclude the use of a categorical exclusion. If you answer “yes” or “?” for
any of the mandatory criteria, you must develop an EA or EIS regardless of your answers in table 1.
Site Name:
1

Will your proposal:
Have significant negative impacts on public health or safety?

Y
☐

N
☐

?
☐

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Have significant negative impacts on unique natural resource or geographic
characteristics such as historic or cultural resources; park, recreation, or refuge lands;
wilderness areas; wild or scenic rivers; national natural landmarks; sole or principal
drinking water aquifers; prime farmlands; wetlands; floodplains; national monuments;
migratory birds; and other ecologically significant or critical areas?

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Have significant negative impacts to species listed, or proposed to be listed, on the List of
Endangered or Threatened Species or have significant impacts on designated critical
habitat for these species?

☐

☐

☐

9

Violate a federal law, or a state, local, or tribal law or requirement imposed for the
protection of the environment?

☐

☐

☐

10

Have a disproportionately high and adverse effect on low income or minority populations
(EO 12898)?

☐

☐

☐

11

Limit access to and ceremonial use of Indian sacred sites on federal lands by Indian
religious practitioners or significantly adversely affect the physical integrity of such sacred
sites?

☐

☐

☐

☐

☐

☐

3

Have highly controversial environmental effects or involve unresolved conflicts concerning
alternative uses of available resources?

4

Have highly uncertain and potentially significant environmental effects or involve unique or
unknown environmental risks?

5

Establish a precedent for future action or represent a decision in principle about future
actions with potentially significant environmental effects?

6

Have a direct relationship to other actions with individually insignificant but cumulatively
significant environmental effects?
Have significant adverse effects on properties listed or eligible for listing in the National
Register of Historic Places as determined by NPS?

7
8

12

Contribute to the introduction, continued existence, or spread of noxious weeds or
nonnative invasive species known to occur in the area or actions that may promote the
introduction, growth, or expansion of the range of such species?

1.

Have there been any previous NEPA/SEPA documents that are relevant to this project or this specific site?
a. ☐ No
b. ☐ Yes – Attach and summarize findings and include page number references below

2.

Explain any negative or unknown impacts identified in Table 1 of the Environmental Resources Survey, or any boxes
marked “yes” in Table 2 (mandatory criteria).

3.

How was the information identified in the tables derived and what sources of data were used to justify the impact
selection?

4.

Who contributed to filling out the Environmental Resources Survey (include name, title, agency) and what qualifications
do they have that provide the necessary resource expertise to determine impact significance?

5.

List all required federal, state, and local permits/approvals needed for the proposal and explain their purpose and
status.

NEPA Pathway Recommendation
Attach documentation of NPS concurrence with the recommended NEPA Pathway
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NPS Form 10-904 (Rev. 12/2019)
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OMB Control No. 1024-0031
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☐ This proposal qualifies for a Categorical Exclusion (CE). List: __________
☐ This proposal requires an Environmental Assessment (EA), which is attached and has been produced in
accordance with the LWCF Manual.
☐ This proposal may require an Environmental Impact Statement (EIS).
D. Cultural and historic resources review
Have there been any previous cultural and/or historic resource surveys completed that included this site within the area of
potential effect that was assessed?
☐ No – Describe any construction planned as a result of this project that will extend beyond the pre-existing
disturbance area (including surface area and depth).
☐ Yes – Attach survey and summarize findings and include page number references below.

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
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SECTION 4.0 AMENDMENTS
1.

Describe the nature of the proposed amendment and why it is needed.

2.

If the changes proposed by this amendment had been part of the project from the beginning, how would the OPSP
scoring have been affected?

3.

Is the scope of the amendment within the authority for modifications granted through your OPSP or did it have to recompete to be eligible? If it had to re-compete, also share how it ranked.

A. Scope changes
Attachments checklist:
☐ NEPA revision
☐ NHPA revision
☐ updated site development plan
☐ revised parcel map for acquisition parcel(s)
Amendment elements:
1. Describe any specific elements are being revised or removed from your original project.
2.

Describe any elements being added to your original project.

3.

Will the disturbance prism for your project change from what was originally assessed? That is, will construction extend
in any direction (including depth) beyond what was reviewed by NPS, the SHPO, and any other consulting parties?

4.

Is your disturbance prism is increasing as compared by what was previously reviewed by NPS?
a. ☐ No
b. ☐ Yes –
i. By how much in what direction?
ii. Are you moving into any soil that is previously undisturbed?

5.

Is any additional vegetation clearing needed to accommodate this scope change?

B. Cost increases
Attachments checklist:
☐ SF 424
☐ SF 424A (planning & indirect costs) and/or C (project)
☐ Revised project budget
Amendment elements:
1. Are the additional funds being requested for increased costs associated with original scope elements, new
scope elements, or both?
2.

Does this amendment change the original approved cost share ratio and if so, how?

3.

How were the costs for the increase derived?

C. Time extensions
1. What is/are the cause of the delay(s) in executing the project?
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2.

How much additional time is needed/what is the new proposed end date?

3.

Describe the elements of the grant that still need to be completed.

4.

How will these remaining scope elements be accomplished within the requested time frame?

5.

What assurances can you provide that this additional time will be ensure successful completion of the project?

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NPS Form 10-904 (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
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NOTICES
Paperwork Reduction Act Statement
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is
authorized by the Land and Water Conservation Fund Act of 1965 (54 U.S.C. 200301 et. seq.). Your response is required to
obtain or retain a benefit. We use this information to obtain descriptive and environmental information about a proposed grant
project or revision. We may not conduct or sponsor and you are not required to respond to a collection of information unless it
displays a currently valid Office of Management and Budget control number. OMB has assigned control number 1024-0031 to
this collection.
Estimated Burden Statement
Completion times vary depending on the use of the form. We estimate that the average completion time for this form is 16 hours
for an application and 3 hours for an amendment, including the time necessary to read, gather data, review instructions, and
complete the form. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to Phadrea Ponds, Acting NPS Information Collection Clearance Officer, 1201
Oakridge Drive, Fort Collins, CO 80525. Please do not send your completed form to this address.

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