10-904 Lwcf Application And Revision (a&r)

NPS Form 10-904 (Rev. 8/2023) OMB Control No. 1024-0031

National Park Service Expiration Date XX/XX/20XX

LWCF

National Park Service U.S. Department of the Interior State and Local Assistance Programs

Application and Revision (A&R) Form

Project/Grant Name:
LWCF Grant Number (if known):	For amendments, include the amendment number (##-#####.#)
LWCF Grant Number(s) for prior LWCF Assistance (if applicable):
Federal Award ID # (P##AP#####):
Date this form was completed:

☐ 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 LWCF Manual Chapter 2)

☐ Amendment during active period of performance (fill out section 4.0 – check type(s), below)

☐ Scope change (fill out section 4.1; and if applicable, Section 3.C)

☐ 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 the project scope, focused on grant-funded elements (for amendments, describe only the changes proposed from the original scope):

Section 1.0 New project grant application

Project contact name:	(If different than what was submitted on the SF 424, otherwise delete)
Project contact number:
Project contact email:

1. Attachments checklist

The following should be transmitted to NPS in a draft or final application:

All Projects	As applicable
☐ SF 424	☐ Intergovernmental review comments
☐ SF 424C	☐ Relevant NEPA/SEPA documents
☐ SF 424D	☐ Applicable federal law compliance
☐ Project narrative	☐ Proof of flood insurance
☐ Project budget	☐ Proof of cold climate criteria qualification
☐ NHPA documentation	☐ Leases, MOA’s, MUA’s, etc.
☐ Location map	☐ Use schedule (school parks)
☐ LWCF boundary area map (proposed)	☐ Dingell-Johnson certification
☐ Pre-award site inspection report	☐ Waiver of retroactivity approval
☐ Evidence of ownership or other site control
☐ Description and Notification Form
☐ Project abstract
Acquisition & Combination Projects
☐ SF 429 Cover sheet and Attachment B	☐ conceptual design plan
☐ parcel map for acquisition parcel(s)	☐ donation acknowledgement (if applicable)
☐ UASFLA-compliant appraisal summary and review*	* If not available, include other basis for grant value
Development & Combination Projects	Grants with Indirect Costs
☐ site development plan	☐ Current or proposed Indirect Cost Rate Agreement
☐ building floor plan(s) if grant-funded	☐ SF 424A (optional - if costs not shown in 424C and budget narrative)

2. Project competition

1. How did this proposal rank according to the state’s Open Project Selection Process (OPSP) (e.g., 2^nd of 16)?

2. How does this project address your SCORP priorities (reference page number(s))?

3. 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)?

4. Financial

1. How was the estimate of the project’s costs derived? If the project involves land acquisition and there is not yet an appraisal, please describe the alternate approach used to assess the property value.

2. What assurances are there that the estimated costs 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?

1. ☐ No

2. ☐ Yes – Indicate the date from when those costs started being incurred (must be within 3 years of application submit date), the funding category/categories, the total amount of pre-award costs anticipated to be incurred before the period of performance start date, and whether the costs will serve as match or be requested for reimbursement. (Note: these should also be presented in the budget narrative.)

Section 2.0 Site Based Project Grants

1. Sub-recipient (grant sponsor) information (repeat if needed for co-sponsors)

Sub-Recipient Agency Name:
Sub-Recipient Contact Name:
Address:
Phone:		Email:

2. 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 in establishing the need.

Section 2.1 Acquisition and Combination Grants

1. Need

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

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

2. 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 Certification of valuation and review:
Signature Date
Name, Title, and Agency

3. Property information

1. From whom is this property being purchased?

2. Are any buildings or structures being purchased along with the property?

   1. ☐ No

   2. ☐ Yes – Describe what is planned for those structures (e.g., retain for future recreation-supporting use, demolish) and whether the project cost 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. When will access to the site for public outdoor recreation become available?

5. Describe development planned for the site(s) for the three (3) years following acquisition. As this will impact National Historic Preservation Act (NHPA) and National Environmental Policy Act (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 describe the opportunities 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?

   1. ☐ No

   2. ☐ Yes – How will it support and enhance the existing park?

4. Acquisition approach

1. Is this property being acquired under threat of condemnation?

   1. ☐ No

   2. ☐ Yes – Explain:

2. Was the property listed for public sale?

   1. ☐ No

   2. ☐ Yes – Explain how the property owner was made aware of the grant sponsor interest in the property.

3. Does this project involve donated property?

   1. ☐ No

   2. ☐ 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.)

Section 2.2 Development and Combination Grants

1. Grant elements

1. What new facilities will be constructed as part of this project (grant-funded and/or used as match)?

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, 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 are also eligible for Dingell-Johnson or Wallop-Breaux Act funding (i.e., boat/fish access)?

   1. ☐ No

   2. ☐ Yes – Please explain and 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?

   1. ☐ No

   2. ☐ Yes

      1. Explain how it was determined that the site meets the cold climatic criteria described in the Manual. Provide a copy of the cold climatic data used to make the eligibility determination with the application.

2. 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?

3. 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)?

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

2. Design elements

1. How will access required by the Americans with Disabilities Act (ADA) and Architectural Barriers Act (ABA) be addressed for each element of the 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?

Section 3.0 Site Information

1. Basic information

1. Will this proposal create a new public park/recreation area where none previously existed?

   1. ☐ No

   2. ☐ Yes – Explain:

2. Is this an existing LWCF-protected park/recreation area?

   1. ☐ No (go to question 4)

   2. ☐ Yes (go to question 3)

3. If this is an existing LWCF park/recreation area, has the name changed since the last grant?

   1. ☐ No (go to question 4)

   2. ☐ Yes – Provide the previous and new names of the park/recreation area

4. Is this project located in a floodplain?

   1. ☐ No

   2. ☐ Yes – Explain and confirm that you have met applicable federal insurance requirements.

5. Is your site contiguous with or connected to any federally owned recreation area?

   1. ☐ No

   2. ☐ Yes – Explain:

6. Is your site part of a larger management area, such as a greenway or regional recreation area?

   1. ☐ No

   2. ☐ Yes – Explain:

7. Describe the existing site conditions.

8. Explain how the site is suitable for the type(s) of outdoor recreation being proposed.

9. Does the site include any features that visually detract from the outdoor recreation experience or that will represent a potential public safety hazard?

1. ☐ No

2. ☐ Yes – Explain and describe whether this project will help to address those concerns.

10. What is/will be the applicant’s type of ownership and control of the property?

    1. ☐ Fee simple ownership.

    2. ☐ Less than fee simple. Explain what rights the applicant has or will have, and what entity holds the underlying fee title.

    3. ☐ Lease. Include a copy of the lease with the application.

2. Stewardship considerations

1. Is this a multi-use site (i.e., school, reservoir, state forest, etc.)?

   1. ☐ No

   2. ☐ Yes – Explain:

      1. How often will the public have recreation access to the site?

      2. What kinds of restrictions to public outdoor recreation will occur?

2. Explain who will manage and operate the site(s).

3. Describe any rights-of-way, easements, reversionary interests, etc. within the proposed LWCF boundary area here and as appropriate, show them on the LWCF Boundary Area Map:

4. Are there any pre-existing or planned indoor facilities that would not themselves be eligible for LWCF grant funding and need a public facility request or should be excluded from the LWCF boundary?

   1. ☐ No

   2. ☐ Yes – Describe and explain if/how the structure(s) support public outdoor recreation or not.

5. Is the proposed LWCF boundary the same as the boundary of the park/recreation area as it exists in its totality?

   1. ☐ Yes

   2. ☐ No – Explain any area proposed for exclusion and why (rationale must be in accord with the LWCF Manual), 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.)?

   1. ☐ No

   2. ☐ 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?

   1. ☐ No

   2. ☐ 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.

3. 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 serve as a record of the environmental resources present at the site, whether the proposed action is likely to have impacts on those resources. 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 or negative impacts are anticipated to result from the action. Or indicate if the particular resource will not be impacted or is not present.

+	indicates positive impacts are anticipated to result from the action
-	indicates negative impacts are anticipated to result from the action

Site Name:

	How will the project affect the following resources?	+	-	N/A or Not Present
1	Air quality	☐	☐	☐
2	Circulation and transportation	☐	☐	☐
3	Climate	☐	☐	☐
4	Contamination or hazardous materials even if remediated	☐	☐	☐
5	Endangered species: (listed or proposed threatened or endangered) including associated habitat	☐	☐	☐
6	Environmental justice: minority and low-income populations	☐	☐	☐
7	Geological resources: soils, bedrock, slopes, streambeds, landforms, etc.	☐	☐	☐
8	Historic or cultural resources	☐	☐	☐
9	Invasive species	☐	☐	☐
10	Land use plans or policies from other agencies including tribes	☐	☐	☐
11	Lightscapes, especially night sky	☐	☐	☐
12	Migratory birds	☐	☐	☐
13	Recreation resources	☐	☐	☐
14	Socioeconomics: changes to tax base or competition with private sector	☐	☐	☐
15	Sound (noise impacts)	☐	☐	☐
16	Unique ecosystems, such as biosphere reserves, World Heritage sites, old growth forests, etc.	☐	☐	☐
17	Water quality and/or quantity	☐	☐	☐
18	Water: coastal barrier resources or coastal zones	☐	☐	☐
19	Water: marine and/or estuarine	☐	☐	☐
20	Water: stream flow characteristics	☐	☐	☐
21	Water: wetlands and floodplains	☐	☐	☐
22	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” for any of the mandatory criteria, you must develop an EA or EIS regardless of your answers in table 1.

Site Name:

	Will your proposal:	Y	N
1	Have significant negative impacts on public health or safety?	☐	☐
2	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?	☐	☐
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?	☐	☐
7	Have significant adverse effects on properties listed or eligible for listing in the National Register of Historic Places as determined by NPS?	☐	☐
8	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?	☐	☐
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 reviews that are relevant to the grant project or this site?

   1. ☐ No

   2. ☐ Yes – Summarize the findings and determinations:

2. Explain any negative 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 source(s) 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 permit(s)/approval(s) needed for the grant project and the date(s) acquired.

6. List all state and local permits/approvals needed for the grant project, including their current status and timeline to approval if not yet acquired.

NEPA Pathway Recommendation

Attach documentation of NPS concurrence with the recommended NEPA Pathway (choose only one NEPA pathway, and if the proposal qualifies for a Categorical Exclusion (CE), choose only one)

☐ 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).

4. Cultural and historic resources review

Have there been any previous cultural and/or historic resource surveys completed (prior to this application) that included this site within the area of potential effect that was assessed?

☐ No – Describe any construction planned as part of this project that will extend beyond the pre-existing disturbance area (including surface area and depth).

☐ Yes – Attach survey and summarize findings, including page number references, below.

Provide a brief summary of consultation initiated with the State Historic Preservation Office (SHPO) for this application, including date(s) and recommendations:

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 re-compete to be eligible? If it had to re-compete, include how it ranked.

1. 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? If yes, please fill out Section 3.C.

4. Is your disturbance prism increasing as compared to what was previously reviewed by NPS?

1. ☐ No

2. ☐ Yes –

1. By how much and in what direction?

2. Are you moving into any soil that is previously undisturbed?

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

2. 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 estimates for the cost increase derived?

3. Time extensions

☐ SF 424

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

2. How much additional time is needed/what is the new proposed period of performance end date?

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

4. Provide a timeline for how the remaining elements will be accomplished within the new time frame.

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

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 the Information Collection Officer, National Park Service, 13461 Sunrise Valley Drive, MS-242 Rm. 2C114, Reston, VA 20192. Please do not send your completed form to this address.

RECORDS RETENTION – PERMANENT ACTIVE. (NPS Records Schedule, National Assistance Programs (Item 8.A.2) (N1-79-08-7)) 2 of 15