Grantmaker A_Online Application Option_Competitive Awards_June2024

OMB Control Number=2035.NEW, Expiration Date =mm/dd/yyyy

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The use of this provided template is optional. EPA will not penalize or withhold a benefit from the respondent for providing the requested information in another format.

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Thriving Communities
Environmental
Protection Agency Grant - Initial Form

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Organization Name *

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I. Organization Information

If Fiscally Sponsored please list your Fiscal Sponsor and the name of your project

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Brief Description of Applicant Organization

Provide a brief description (100 words or less) of the applicant organization, including
its mission and key ongoing projects and activities in which it is involved

Mailing Address
Country
Select...
Address

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Address Line 2 (optional)

City

State, Province, or Region

Zip or Postal Code

Site Address (if different from above)

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Country

Address

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Select...

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Address Line 2 (optional)

City

State, Province, or Region

Zip or Postal Code

Organization Phone Number

Organization Website
example.com

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Congressional District

Census Tract

Employer Identification Number

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XX-XXXXXXX

XXXXXXXXXXXX

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Unique Entity Identifier

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Organization Annual Budget

Choose File

Upload a file. No files have been attached yet.
Acceptable file types: .csv, .doc, .docx, .odt, .pdf, .rtf, .txt, .wpd, .wpf, .gif, .jpg, .jpeg,
.png, .svg, .tif, .tiff, .epub, .key, .mobi, .mus, .musx, .ppt, .pptx, .sib, .xls, .xlsx, .zip

Provide Income Statement for most recently completed fiscal year

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.png, .svg, .tif, .tiff, .epub, .key, .mobi, .mus, .musx, .ppt, .pptx, .sib, .xls, .xlsx, .zip
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632

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Year Organization Founded

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II. Contact Information

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How many full-time equivalent employees (FTE) does your
organization employ?

Primary Contact Name

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First Name

Last Name

Individual will be responsible for ongoing reporting and administration of this grant

Primary Contact Title

Primary Contact Phone Number

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Primary Contact Email
[email protected]

Authorized Person Contact Name
First Name

Individual with signatory authority

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Last Name

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Authorized Contact Phone Number

Authorized Contact Email

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[email protected]

Other Contact Information

III. Project Phase

Which Project Phase are you applying for?

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Phase I - Assessment for up to $150,000 for a one-year project period
PHASE II - Planning for up to $250,000 for a one to two-year project period
PHASE III - Development for up to $350,000 for a two-year project period
PHASE I - Noncompetitive Fixed Amount Subaward

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IV. Environmental Justice Issue(s) to Be Addressed

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Other

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What are the local environmental/public health issue(s) that your
project seeks to assess (Phase I) or address (Phase II and III)?

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Other (please describe)

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V. Impacted Communities

What is the target area and general characterization of the
community your project will impact?

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Describe communities within the target area: What are the area’s
primary environmental justice challenges?

Using the EPA Inflation Reduction Act Disadvantaged
Communities tool, or other Environmental Justice Mapping
resources, what kinds of environmental and health burdens does
the community face?

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a) Disadvantaged Area: Identified as Disadvantaged and above the 90th
percentile in the following categories: Climate Change, Energy, Health,
Housing, Legacy Pollution, Transportation, Water and Wastewater,
Workforce Development

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b) Environmentally Burdened: At or above the 80 percentile in one or more
Environmental Justice Index indicators: Particulate Matter 2.5, Ozone, Diesel
particulate, Air Toxics Cancer Risk, Air Toxics Respiratory HI, Traffic
Proximity, Lead Paint, Superfund Proximity, RMP Facility Proximity,
Hazardous Waste Proximity, Underground Storage Tanks, Wastewater
Discharge
c) Rural Community

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d) Indigenous/Tribal Land
e) Other

f) None of the Above

EPA geoplatform screening tool:
https://screeningtool.geoplatform.gov/en/#3/33.47/-97.5
Disadvantaged Communities webinar here: https://communitychangeta.org/webinarrecordings . They demonstrate how to make a map step-by-step.

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Disadvantaged Community fact sheet here: https://communitychangeta.org/fact-sheets
Environmentally Burdened mapping link: https://ejscreen.epa.gov/mapper/
Rural Community health information link: https://www.ruralhealthinfo.org/am-i-rural
Indigenous/Tribal Land Tribal Directory Assessment Tool: https://egis.hud.gov/TDAT/

Other (please describe)

Are Indigenous/Tribal Communities impacted by your project?

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Yes

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No

How will the project recognize and support Tribal-led Indigenous
Knowledge?

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Given the sensitivity of Indigenous Knowledge, how will this
knowledge be appropriately handled?

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How does this project plan to involve local Indigenous/Tribal
communities, address their priorities, and/or contribute to their
economies?

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Describe what barriers will be removed to allow Indigenous/Tribal
communities to engage with this project.

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If your project impacts disadvantaged or environmentally burdened
areas, briefly describe (250 words or less) the track record of your
organization in working in disadvantaged and/or environmentally
burdened areas.

VI. Project Plan, Goals, Outputs, and Outcomes

Project Plan, Goals, Outputs, and Outcomes

Choose File

Upload a file. No files have been attached yet.

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Initial Form Designer

Acceptable file types: .csv, .doc, .docx, .odt, .pdf, .rtf, .txt, .wpd, .wpf, .gif, .jpg, .jpeg,
.png, .svg, .tif, .tiff, .3gp, .avi, .flv, .m4v, .mkv, .mov, .mp4, .mpg, .webm, .wmv, .epub,
.key, .mobi, .mus, .musx, .ppt, .pptx, .sib, .xls, .xlsx, .zip, .adoc, .ai, .bbl, .dae, .dwg, .eps,
.fbx, .fdx, .heif, .hevc, .iba, .ibooks, .ltx, .mpp, .mpx, .psd, .step, .stl, .stp, .tex, .vdx, .vsd,
.vss, .vst, .vsx, .vtx
(Project Plan submission not to exceed 5 pages, single-spaced, 12-point font size, and
1-inch margins.)
1. Project description, goals, and community need for project
2. Organizational history in the project community and capacity for completing the
project

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3. How will the impacted community and/or community partners be involved in the
assessment (Phase I), planning (Phase II), or implementation (Phase III), and evaluation
of the project?

5. Project Schedule

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4. Project Activities

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6. Outputs: Output means an environmental activity, effort, and/or associated work
product related to an environmental goal or objective that will be produced or
provided over a period of time or by a specified date. Outputs may be quantitative or
qualitative but must be measurable during the funding period. Please list at least three
outputs.
7. Outcomes: Outcome means the result, effect or consequence that will occur from
carrying out an environmental program or activity that relates to an environmental or
programmatic goal or objective. Outcomes may be environmental, behavioral, healthrelated, or programmatic in nature; must be quantitative; and may not necessarily be
achievable within an assistance agreement funding period. Please list at least one
each: short-term, intermediate, and long-term outcome.
a) Short-term (change in knowledge) – Example: Increase in number of residents
that know about indoor asthma triggers (during project)
b) Intermediate (change in behavior) - Example: Increase in number of residents
that install and routinely check their home indoor air monitor (6 - 12 months after
project)
c) Long-term (change in conditions) – Example: Reduction in asthma rates among
community residents (2+ years after project)

https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632

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VII. Performance Measurement Plan

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How will you determine whether your project has achieved its
intended outputs and outcomes? Consider what your data source
will be (e.g., people, existing records, observation, etc.) and how
you will collect the data (e.g., observing behavior changes,
administering pre- and post-tests). Describe up to three indicators.

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What support do you need from Thriving Communities Technical
Assistance Centers (TCTACs) or technical assistance would be
helpful to facilitate your ability to report on these outputs and
outcomes?

VIII. Budget and Expense Tracking
Basic budget form will be provided for the applicant to ensure it aligns with the overall

expense tracking plan.

Is this your first Federal grant?
Yes
No

How will you manage tracking expenses and invoices?

https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632

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Thriving Communities Grant Draft Budget
**Imbedded Budget Template provided at end of document**

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Other Total

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Total Budget
Summary

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Personnel Total

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Contractual

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Please use template to complete Draft Budget or upload external file in next
submission field

Thriving Communities Grant Draft Budget Upload

Choose File

Upload a file. No files have been attached yet.
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632

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Acceptable file types: .csv, .doc, .docx, .odt, .pdf, .rtf, .txt, .wpd, .wpf, .gif, .jpg, .jpeg,
.png, .svg, .tif, .tiff, .epub, .key, .mobi, .mus, .musx, .ppt, .pptx, .sib, .xls, .xlsx, .zip
If not using template above please upload your Draft Budget file here

IX. Approval to Submit Application

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Please enter the name and title of the individual submitting this
application.

Does your organizational leadership approve the submission of this
application?
Yes

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No

X. Other Information

Does the organization need additional support or technical
assistance for technical and financial matters (invoicing, reporting,
etc.) to manage the award effectively?
Yes
No
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632

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If yes, please describe needs

Please describe the group that governs your organization.

Indigenous/Tribal Council

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Other Governing Group

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Board of Directors

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Please list the members of your Board of Directors

Please describe the geographic region(s) where your organization
does its work.

Briefly describe (100 words or less) how this grant impacts your
organization’s ability to accomplish its mission.

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EPA EJ Thriving Communities Subgrant Program Budget
Budget Template/Format
Instructions; You do not have to fill out every category. This template is simply to help with applying for
the Thriving Communities Region 9 Grant.
CATEGORY
YEAR 1
YEAR 2
TOTAL

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Contractual Total
TRAVEL

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-

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Travel Total
SUPPLIES

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Grand Total

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Other Total

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Personnel Total
CONTRACTUAL

Supplies Total
OTHER

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PERSONNEL (Salaries and Wages)