Applications for Subawards – August Launch

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 - n t al 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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Initial Form Designer

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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Employer Identification Number

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XX-XXXXXXX

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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

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

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Initial Form Designer

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

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

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Initial Form Designer

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?

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

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Initial Form Designer

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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I . 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)?

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

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Initial Form Designer

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Other (please describe)

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V. Project Plan, Goals, Outputs, and Outcomes

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Project Plan, Goals, Outputs, and Outcomes

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