Okaloosa County Project Data Collection Form
RESTORE ACT - Direct Component

BCC Proposal Number

(To Be Assigned by Grant Administration)

INTRODUCTION

The purpose of this data collection form is to assist Okaloosa County in prioritizing projects submitted for Direct Component (“Pot #1”) funds allocated from the Gulf Coast Restoration Trust Fund through the Resources and Ecosystems Sustainability, Tourist Opportunities and Revived Economies of the Gulf Coast States Act of 2012 (RESTORE Act).

The following terms are used in this data collection form:

• Applicant or Responsible Entity - the Okaloosa County Board of County Commissioners (BOCC)

• Project Proposer - the individual or organization completing this form

Prior to initiating this data collection form, it is recommended the Project Proposer download and review the entire form to understand the range of required information. Tools/data required to complete this form may include: permits, interlocal agreements, comprehensive plans, evidence of property ownership, and estimated project costs. Completing all required information in the collection form may require many hours; this will be a function of project complexity and proposer preparedness.

This data collection form differs from the U.S. Treasury Application Form (RESTORE Act Direct Component Guidance and Application to Receive Federal Financial Assistance; August 2014). This data collection form is designed to assist Okaloosa County in their task of developing a recommended list of potential projects for inclusion in an amendment to the BOCC’s Multiyear Plan.

Projects that are identified for funding in the Multiyear Plan amendment may require additional information from the Project Proposer. If a proposed project is ultimately included in the approved Multiyear Plan, failure of the Project Proposer to provide the required project information may preclude funding for that project.

Per RESTORE Act guidance, the responsible entity shall be solely responsible for the execution of each funded project, including procurement of professional services and/or construction services. The Okaloosa County BOCC reserves the right to delegate these services to sub-entities with the demonstrated capability to comply with all County and Federal procurement processes required by the RESTORE Act.

By proposing a project through this data collection form, the Project Proposer acknowledges there is no guarantee the proposed project will be funded. Further, the Project Proposer acknowledges no reimbursement or compensation shall be provided for completing the data collection form or any other activities associated with proposing a project.

PART A: GENERAL INFORMATION

Incomplete applications will not be considered. By submitting this project proposal, the proposer certifies that the statements herein are true, complete and accurate to the best of his/her knowledge. Any false, fictitious, or fraudulent statements or claims may cause the application to be rejected without the opportunity to re-submit.

A.1 Project Point of Contact: Provide the name and contact info including the mailing address, e-mail address and phone number of the Project Proposer.

Name:
Street 1:
Street 2:
City:
State:
Zip Code:
County:
E-Mail:
Phone Number:

A.2 Proposed Activity / Project Name: Provide the name of the Proposer Activity/Project

A.3. Requested Funding Amount: How much Direct Component (Pot #1) funding is being requested for this project?

A.4. Qualifying Eligible Activity: Please check the primary eligible activity in the first column and then all other eligible activities that apply in the second column by placing a check mark or selecting the radio button in the column in the row corresponding to the qualifying eligible activity.

Select Primary Activity (Select only one)	Select All Others That Apply	Qualifying Eligible Activity
1. Restoration and protection of the natural resources, ecosystems, fisheries, marine and wildlife habitats, beaches and coastal wetlands of the Gulf Coast Region
2. Mitigation of damage to fish, wildlife and natural resources
3. Implementation of a federally approved marine, coastal, or comprehensive conservation management plan, including fisheries monitoring
4. Workforce development and job creation
5. Improvements to or on State parks located in coastal areas affected by the Deepwater Horizon oil spill
6. Infrastructure projects benefitting the economy or ecological resources, including port infrastructure
7. Coastal flood protection and related Infrastructure
8. Planning assistance
9. Promotion of the consumption of seafood harvested from the Gulf Coast Region
10. Promotion of the consumption of seafood harvested from the Gulf Coast Region

A.5. Claimed in Oil Liability Trust Fund After July 6, 2012: Was this proposed activity included in any claim for compensation paid out by the Oil Spill Liability Trust Fund after July 6, 2012?

No.

Yes. (STOP) This activity is not eligible for RESTORE Direct Component.

A. 6. Location of Activity: Provide the project location. (If there is more than one location for the	activity, attach a list of the additional locations).

A.6.1. Address: Provide the actual address for the activity (street address, city/town, county/parish, state, zip code). (If there is no street number, provide the nearest intersection, or note boundaries on map submitted with Question A.6.2.

Latitude/Longitude (if available):
Street Address:
City/Town:
County/Parish:
State:
Zip Code:

A. 6.2. Map: Provide a map of the project location and describe how the proposed activity will be carried out in the Gulf Coast Region as defined in 31 CFR 34.2.

(END OF PART A)

PART B: PROJECT DETAILS

B.1 Proposed Scope of Work: Provide a detailed scope of work that fully describes the project or program for which funding is requested. Including:

Need, purpose and objectives;

How the project/program meets the identified primary activity designated in A4;

Specific tasks, milestones and related timeframes (also captured in Milestones Report); and

Description of all funding sources.

NOTE: The RESTORE Act requires projects designed to protect or restore natural resources to be based on Best Available Science (BAS). (Complete Question B.4 also.)

If additional space is needed attach document. (2,000 characters max)

B.1.1 Part of a Larger Project: If the proposed project is part of a larger project outside the scope of this proposal, describe the larger project and the proposed project’s relationship to it.

B.2 Monitoring: During the project & following its completion, will the project be subject to a monitoring program to evaluate project success?

No

Yes (provide information on monitoring and evaluation)

B.3 Management/Maintenance Program: Will the project be subject to a management/maintenance program to ensure project success?

No

Yes (Provide information on how the project will be monitored and maintained as well as the	party (or parties) responsible for performing these tasks.)

B.4. Best Available Science (BAS), if applicable

Is the proposed activity designed to protect or restore natural resources?

No Yes ( If “yes” complete this section).

B.4.1 Protection or Restoration Objective(s) of the Project– State clearly the objective(s) below:

B.4.2 Methods Used to Achieve Objective(s) – Describe below:

B.4.3 Methods Based on BAS – Explain in detail how the methods are based on BAS:

B.4.4 Peer Reviewed Information – Summarize the peer-reviewed information that justifies the proposed objective(s) including methods used for the proposed activity below:

B.4.5 Alternative Scientific Information Sources – if Peer Reviewed information is unavailable; explicitly stated this and provide a brief explanation of what sources were used. If sources are publicly available, please also provide a link below:

B.4.6 Literature Sources Used for BAS – if applicable, list the sufficient citations including: Title, Journal in which the literature source appeared, if applicable; Publication date; Author(s); and Web address if downloaded or available online that would apply to the proposed project B4.4.1

B.4.7 Conclusion of Literature Sources in B4.6– Summarize the literature sources’ conclusions and any uncertainties or risks in the scientific basis that would apply to the proposed project including any uncertainties or risks that were identified by the public or by a Gulf Coast Ecosystem Restoration Council member below:

B.4.8 Gulf Coast Region adaptability, if applicable – Summarize how the method’s used reasonably support and are adaptable to the Gulf Coast Region if the information supporting the proposed project does not directly pertain to the Gulf Coast Region below:

B.4.9 Evaluation of Uncertainties and Risks – Summarize an evaluation of uncertainties and risks in achieving the project’s BAS objective(s) over the longer term. For example, is there an uncertainty or risk that in 5-10 years the project/program will be obsolete or not function as planned given projections of sea level rise or other environmental changes such as in freshwater inflows to estuaries?

B.5 Project Narrative

Provide a narrative of your project and why this project should be funded. Discuss the following items as a minimum:

Explain how the proposed budget supports the proposed scope of work

Project Expenditures (long term and short term)

Project Revenues

Program Income, including nature and source, if any

Key personnel involved with the project

Will a subrecipient be required to complete the project

Specific objectives

Permits or land acquisition required

Design status

Similar project success or if new technology explain

Environmental impact (species affected, existing plans supported, etc.)

Risks to implement and maintain the activity

Jobs Created (short term, long term, and wage scales)

(1,000 characters max)

B.6 Project Budget

In the “Project Budget” table, provide best estimates of the costs and revenues associated with the proposed project during the period of performance.

There are two Project Budget tables below, one is for “Non-Construction” and the other is for “Construction”. Both mirror the budget format required for the forthcoming grant application. Complete the one that best pertains to your project.

Expenditures – Line 6.(a-g) – Section B

For each expenditure entered, it must be associated with a task as listed in the scope of work. You will be required to describe and justify the expenditure in the section that follows.

Indirect Charges – Line 6.(i). (if applicable)

Indirect cost rate (if applicable) as determined by 2 CFR Appendix to Part 200.

Program Income – Line 7 (if any)

Program Income means gross income earned by the Non-Federal entity that is directly generated by a supported activity or earned as a result of the Federal award during the period of performance except as provided in §200.307 paragraph. Enter the estimated amount of income, if any, expected to be generated from this project. Do not add or subtract this amount from the total project amount. In the project narrative define the nature and source of income. The estimated amount of program income may be considered by the Federal grantor agency in determining the total amount of the grant. See 2 CFR §200.80 for more details.

Non-Federal Resources – Lines 8-11 – Section C

Restore Direct Component funds DO NOT require matching funds. Enter the total amount of RESTORE Direct Component funds that will be need to execute your project in column 1 Federal. However, if you are receiving matching funds from other sources to complete your project, the source of those funds will be listed separately in column a. on lines 8-11 and the respective amounts in columns b.- e.

For example, if you are proposing a $2 million construction project and are asking for $1 million from RESTORE Direct Component to match a $1 million, you would enter $1 million from RESTORE and $1 million in non-Federal for the Proposer. However, once proposed, accepted and awarded by Treasury, the $1 million in non-Federal proposed funds would then become a required cash match from the Proposer.

Use current year dollars rounded to the nearest dollar.

(“Project Budget Information table” is on the next page)

B.6.1 Non-Construction Project Budget table

PROJECT BUDGET INFORMATION – Non-Construction Programs
SECTION B – BUDGET CATEGORIES
6. Cost Classification	(1) Federal	(2)	(3)	(4)	(5) TOTAL
a. Personnel	100	100	100	100	$ 400
b. Fringe Benefits	100	100	100	100	$ 400
c. Travel	100	100	100	100	$ 400
d. Equipment	100	100	100	100	$ 400
e. Supplies	100	100	100	100	$ 400
f. Contractual	100	100	100	100	$ 400
g. Other (specify)	100	100	100	100	$ 400
100	100	100	100	$ 400
100	100	100	100	$ 400
h. Total Direct Charges (sum a-g)	$ 900	$ 900	$ 900	$ 900	$3,600
i. Indirect Charges	100	100	100	100	$ 400
j. TOTAL (sum a-i)	$1,000	$1,000.	$1,000	$1,000	$4,000
7. Program Income (see 2 CFR §200.80)	100	100	100	100	$ 400
SECTION C – NON-FEDERAL RESOURCES
(a) Identify Funding Source: (Note: No Matching Funds are Required)	(b) Proposer	(c) State	(d) County	(e) Other	(f) TOTAL
8.	100	100	100	100	$ 400
9.	100	100	100	100	$ 400
10.	100	100	100	100	$ 400
11.	100	100	100	100	$ 400
TOTAL (sum of lines 8-11)	$ 400	$ 400	$ 400	$ 400	$1,600
Reference: OMB Standard Form 424-A

B.6.2 Construction Project Budget table

PROJECT BUDGET INFORMATION – Construction Programs
SECTION B – BUDGET CATEGORIES
Cost Classification	(1) Federal	(2)	(3)	(4)	(5) TOTAL
1. Administrative and Legal expenses	100	100	100	100	$ 400
2. Land, structures, right-of-way, appraisals, etc.	100	100	100	100	$ 400
3. Relocation expenses and payments	100	100	100	100	$ 400
4. Architectural and engineering fees	100	100	100	100	$ 400
5. Project inspection fees	100	100	100	100	$ 400
6. Site Work	100	100	100	100	$ 400
7. Demolition and Removal	100	100	100	100	$ 400
8. Construction	100	100	100	100	$ 400
9. Equipment	100	100	100	100	$ 400
10. Miscellaneous	100	100	100	100	$ 400
11. SUBTOTAL (sum of lines 1-10)	$1,000	$1,000	$1,000	$1,000	$4,000
12. Contingencies	100	100	100	100	$ 400
13. SUBTOTAL	$1,100	$1,100	$1,100	$1,100	$4,400
14. Program income - (see 2 CFR §200.80)	100	100	100	100	$ 400
15. TOTAL PROJECT COSTS (subtract 14-13)	$1,000	$1,000	$1,000	$1,000	$4,000
SECTION C – NON-FEDERAL RESOURCES
Identify Funding Source: (Note: No Matching Funds are Required)	(b) Proposer	(c) State	(d) County	(e) Other	(f) TOTAL
a.	100	100	100	100	$ 400
b.	100	100	100	100	$ 400
c.	100	100	100	100	$ 400
d.	100	100	100	100	$ 400
TOTAL (sum of lines a-d)	$ 400	$ 400	$ 400	$ 400	$1,600
Reference: OMB Standard Form 424-A

B.6.3 Budget Justification

Explain in detail how the above proposed budget supports the proposed scope of work. Provide specific justification for ALL project budget categories that apply, including a justification of how the proposed costs within each of the budget categories on the above SF-424A are necessary, reasonable, allowable, and allocable. (2,500 characters max)

B.7 Real Property or Land

B.7.1 Property Ownership/Use: If project requires the use of land, provide details of property to include land acquisition, ownership, agreements to use property, permits, easements, etc.

B.7.2 Attach documentation (i.e. letter of commitment, Memorandum of Understanding, deed, etc.)

B.7.3 Land Acquisition: Will land or interest in land be acquired?

Yes, answer questions B.7.5 – B.7.12.13

No

B.7.4 Land Improvements: Will land be improved?

Yes, answer questions B.7.5 – B.7.10, B.7.12.4

No

B.7.5 Legal Rights: What are the legal rights that will be acquired?

Fee Title Easement Other (explain):

B.7.6 Easement: If an easement, what is the life or term of the easement?

B.7.7 Title: Will the Project Proposer hold title to the land? Yes No

B.7.8 Land Size: What is the total acreage of the proposed property interest to be acquired (easement or fee title)?

B.7.9 Appraisal: Has a recent certified appraisal of the property been obtained?

No

Yes (attach a copy of the appraisal)

B.7.10 Title Opinion or Certificate: Has a recent title opinion or certificate been obtained?

No

Yes (attach a copy of the title opinion or certificate)

B.7.11 Statement: Attach a signed statement from the seller(s) that he/she is a willing seller and has not been coerced into selling or conveying the property interest.

B.7.12 Legal Description & Parcel ID: Attached is the legal description of the property and the parcel identification number.

B.7.12.1 Land Description: Provide a description of the land to be purchased.

B.7.12.2 Federal Interest in Real Property: Are you aware that “Federal Interest” refers to real property that is acquired or improved, in whole or in part, with RESTORE Act Direct Component Funds, which must be held in trust by the recipient for the benefit of the project for the Estimated Useful Life of the Project, during which period Treasury retains an undivided equitable reversionary interest in the real property (i.e. the “federal interest”) To document the federal interest, a “Covenant of Purpose, Use and Ownership” (Covenant) will be prepared and recorded against the real property for which the funding was awarded.

No Yes

B.7.12.3 Use of Real Property with Federal Interest: Are you aware that the property on which there is a federal interest may not be used for purposes other than the authorized purpose for which funding was awarded without prior written approval from Treasury. The property must not be sold, conveyed, transferred, assigned, mortgaged, or in any manner encumbered except as expressly authorized in writing by Treasury.

No Yes

B.7.12.4 Insurance: Are you aware that the recipient of Restore funds, must at a minimum, provide the equivalent insurance coverage for real property improved with federal funds as required by 2 CFR 200.310.

B.8 Construction Activities

B.8.1 Permits: Does the proposed activity require any federal, tribal, state, or local permits?

No

Yes (If yes, list the specific federal, tribal, state or local permits required for this project and the	status of the permits below)

B.9 Relocation Assistance: Will the proposed project cause the displacement of any persons, businesses, or farm operations?

No

Yes (If yes, as required by Titles II and III of the Uniform Relocation Assistance and Real Property	Acquisition Policies Act of 1970, explain:

the number of displaced persons, including businesses and farm operations;

what fair and reasonable relocation payments and advisory services will be provided to any displaced persons;

and what provisions will be made to ensure that safe, decent, and sanitary replacement dwellings will be available to such persons within a reasonable period of time prior to displacement.

(End of Part B)

(End of Data Collect Form)

PROJECT RISK ASSESSMENT

Please complete the Direct Component Proposer/Subrecipient Questionnaire which may be found at www.co.okaloosa.fl.us/grants.

The Project Data Collection Form and the Proposer/Subrecipient Questionnaire plus any required supporting documentation must be submitted in order for the project submission to be considered complete.

Project submissions shall be submitted to jevans@co.okaloosa.fl.us.