DEPARTMENT OF STATE PARKS AND CULTURAL RESOURCES LAND AND WATER CONSERVATION FUND APPLICATION FOR FEDERAL ASSISTANCE Project Sponsor : Proposed Project Title: Cost of Proposed Project: All applications must include: 1. A completed application form with an original signature, dated and notarized, plus three (3) photocopies. 2. A completed Proposal Description and Environmental Screening Form (PD_ESF) form with an original signature, Form available on website. Begin as a New Project Application and do the best you can. Staff will revise and complete as necessary. And be accompanied by three (3) copies of each of the following: 2. Resolution authorizing project 3. Title or lease opinion 4. Area map 5. Boundary map 6. Site map 7. Environment impact information 8. Floor plan (if applicable) 9. Flood insurance documentation (if applicable) 10.Public health approval (if applicable) 11.Use time schedule (if school project) 12. Number of acres, Township, Range, Latitude and Longitude Return completed application to: Tracy Williams, Grants Specialist Department of State Parks & Cultural Resources Division of State Parks & Historic Sites 2301 Central Avenue Barrett Building, 4 th Floor Cheyenne, WY 82002 (307)777-8681 Page 1 of 12
Land and Water Conservation Fund Application Specific Instructions Item 1 Item 2 Item 3 Item 4 Item 5 Self-explanatory. Give the specific location and address, and if necessary, directions such as A corner of 12 th Street and Park Avenue. a) Legal Description b) Number of project acres and total number of park/area acres. Give the name of the sponsoring legal entity, the name of the individual in charge of the project along with the mailing address of the individual and a daytime phone number. Briefly describe the project and specifically explain the need. Make sure to include information about seasonal usage, the potential for multiple uses, and the level of local support/volunteerism for the project. Also, address the project sponsor s ability to properly maintain and operate the project for perpetuity. List a detailed break-down of the Elements of Cost. It is better to provide too much detail rather than too little. If you are submitting retroactive costs for reimbursement, please highlight those costs in your budget. Under Description of In-Kind Match, please be specific about the amount and overall percentage of local matching funds that consist of private cash donations and labor in-kind. If purchasing land, make sure to include it as one of the Elements of Cost. An example of a completed Elements of Cost is listed below. (A) (B) (D) (E) (F) (G) (H) (I) (J) Description Units Cost Per Unit Total Cost Federal Share Cash Match In-Kind Match Est Start Date Est Comp Date 1 Picnic Shelters 4 1,000.00 4,000.00 2,000.00 125.00 1,885.00 05-06-13 07-15-15 2 Picnic tables 27 125.00 3,375.00 1.687.50 1,687.50 06-15-13 06-30-15 3 Grills 14 50.00 700.00 350.00 350.00 06-15-13 06-30-14 4 Trash barrels 30 10.00 300.00 150.00 150.00 06-15-13 06-30-14 5 Site preparation 1 1,000,00 1,000.00 500.00 500.00 04-15-13 05-05-14 6 Engineering 1 3,000.00 3,000.00 1,500.00 1,500.00 01-01-12 03-15-13 TOTAL 12,375.00 6,187.50 4,312.50 1,875.00 Description of In-Kind Match: 3 shelters will be donated by local service clubs (labor $750.00; materials $1,875.50) approximately 42% of local cost share requirement. Description of Retroactive Request: Engineering costs were required to begin project in a timely manner. $2,000.00 are retroactive. Describe percentage of level of volunteerism, local cash donations, or cooperation by service organizations. Do donations & volunteer labor equal more than 50% of the local cost share requirement? YES X NO/ More than 25% but less than 50%? X YES NO/ Less than 25% of the 50% local cost share requirement? YES X NO. Page 2 of 12
Item 6 Item 7 Item 8 Local share of funding could include recreation budget, cash donations, labor inkind and so forth. Self-explanatory. Proof of land control must accompany the project application. If owned by the project sponsor, an updated Title Opinion signed by your attorney explaining the type of control you have is to accompany the project application. If there are any reserved rights, such as mineral rights, explain how this will or will not affect the project. (See Section A Title Opinions in the Handbook for Outdoor Recreation Projects, page 24). Projects for the acquisition of leasehold interest or the development of facilities on leased land which are not under lease from the federal government are ineligible for assistance. The expectation being if the lease is from one public agency to another that includes provisions which adequately safeguard the perpetual use requirement contained in the Land and Water Conservation Fund statute. Such safeguards may include joint sponsorship of the proposed project or other agreement whereby the lessor would assume compliance responsibility for the fund-assisted area in the event of default by the lessee or expiration of the lease. If property is leased and does not meet the criteria outlined above, stop the application process. Your project is ineligible for funding. Item 9 Item 10 Item 11 Item 12 Self-explanatory. Various forms of public participation could include, but are not limited to, any of the following: vote by city council vote by county commissioners public hearings public vote completed survey newspaper releases media programs citizens advisory committee public mass meeting open meetings public forum any other public participation Self-explanatory. Provide any documentation to substantiate economic development considerations pertaining to the project. Describe if the project will enhance tourism or local economic development. Page 3 of 12
Item 13 Item 14 Item 15 Item 16 Describe how the proposed project will improve the existing recreation facility. Will the project increase usage or hours of use, cater to special populations or the elderly, or renovate facilities that are in danger of being lost for public use? Also, please indicate if the project is a continuation of a previous L&WCF project. Please refer to the Rehabilitation Act of 1973, Section 504 regarding the use of federal funds and handicapped accessibility. Applications must be accompanied by the required attachments. Number of Project Acres & Legal Description Applications must bear the original signature of the person authorized by the project sponsor. ANSWER >YES= TO THE FOLLOWING QUESTIONS BEFORE YOU CONTINUE: 1. Are local funds available for the project? 2. Is property owned or leased within the parameters of grant requirements? 3. Are reserved rights (i.e. mineral rights) compatible with the project? 4. Does the legal description of the land for the project agree with the site map? 5. Have provisions been made for operation and maintenance of project in perpetuity? 6. Is the construction time schedule realistic? 7. Is sufficient detail for Elements of Cost available? 8. Has an environmental assessment been conducted? 9. Has there been public input into the planning of the project? 10. Is the project compatible with Section 504 of the Rehabilitation Act of 1973 (Handicapped Accessibility)? Page 4 of 12
APPLICATION FOR LAND AND WATER CONSERVATION FUNDS General Instructions Please type or print application. Complete application in its entirety. Use additional paper as required. 1. Project Title: 2. Project Location: 3. Project Sponsor: _ 4. Contact Person: Address: Telephone Number: E-mail Address: Project Narrative: Page 5 of 12
5. Summary of the elements of Cost (See Sample on Page 2) (A) (B) Description Units (D) Cost Per Unit (E) Total Cost (F) Federal Share (G) Cash Match (H) In-Kind Match (I) Estimated Start Date (J) Estimated Completion Date 1 2 3 4 5 6 7 8 9 10 11 12 TOTAL Description of in-kind match: Description of retroactive costs: Describe percentage of level of volunteerism, local cash donations, or cooperation by service organizations. Do donations & volunteer labor equal more than 50% of the local cost share requirement? YES NO/ More than 25% but less than 50%? YES NO/ Less than 25% of the 50% local cost share requirement? YES NO. Page 6 of 12
6. Is the local share of funding committed and available for this project now? Yes. Please explain the source (Give Name(s)) of sponsor funding. (Note: If Labor in-kind or cash donations are to be used, please indicate and describe). Upon project approval cash donations must be on deposit. Stop the application process. If local funding is not available, the project cannot be submitted to the Wyoming State Parks and Cultural Resources Commission for consideration. 7. Will any other federal funds be used in this project? Yes. Provide the name(s) of the federal funding agency, grant name, state agency administering the program (if applicable), amount of funding and intended use. 8. Land Control. A. Is the proposed project to be located on property clearly owned by the project sponsor? Yes. Date of purchase: B. Sponsor is purchasing or intends to purchase the property? Yes. Anticipated date of closing: Page 7 of 12
C. 1. Are the reserved rights (mineral rights, etc.) Compatible with the proposed project? 2. Who owns the surface and sub-surface mineral rights? Yes. Explain how this will be resolved: D. Sponsor is leasing the property. (Note: Review instructions for lease requirements. Leased projects are generally ineligible for funding). 9. Site Information. Yes. Name of property owner: Date Property was leased: Date lease expires: A. Are there existing overhead utility lines? Yes. Explain plans to relocate, bury or screen the lines: B. Is public access readily available? List specific months of use and accessibility this project will offer. Also explain if project will allow for extended hours of operation or extend the length of stay. Yes. Please describe access, month of use and possible extention of hours: Explain how access issues will be resolved: Page 8 of 12
Name months of accessibility and use for project: 10. Have you actively solicited public participation and input concerning this project beyond minimum requirement? Yes. Please list and document the different methods used and dates: 11. Project Coordination. A. Is this project being coordinated with other public or private agencies providing for joint use of facilities? Yes. List all agencies and joint use: B. Do you have a written agreement for joint use between the coordinating agencies? 12. Economic development. Yes. Attach copies of the agreement or agreements. Not applicable. A. Will the project enhance tourism or local economic development? Yes. Please explain: Page 9 of 12
13. Existing facilities. A. Project is a modification/enhancement of an existing park or recreation area. Yes. Please explain and name separate outdoor recreational activities available within project area: B. Project is part of and/or a continuation of a previously completed and maintained L&WCF project. Yes. Please explain and name separate outdoor recreational activities available within project area: 14. Have provisions been made with respect to the requirements invoked by Section 504 of the Rehabilitation Act of 1973 regarding handicapped accessibility? Yes. Please explain: Section 504 of the Rehabilitation Act of 1973 requires that recipients of federal monies implement compliance procedures to ensure that their programs, facilities, and employment practices are not discriminatory in regard to the handicapped. If response is NO, federal monies cannot be used for the project. 15. Attachments. Projects will not be processed if attachments are not complete. A. Copy of resolution or minutes of meeting whereby sponsor authorized the project. B. Copy of Title Opinion with proper signature. C. Three (3) copies of the following: (Maps must be to scale). 1. An area map showing geographic location of the project and use of the surrounding area; 2. A subdivision plat or boundary map showing the exterior boundary of the project. This map must agree with the legal description of the lease or title opinion. On an acquisition project, this map would agree with the legal description of the land to be acquired; Page 10 of 12
3. Site map showing all existing facilities and all proposed facilities. Color coding should be used; 4. Floor plans of all proposed buildings must be submitted with the project application. If available, submit a preliminary design or architectural concept of the proposed buildings; otherwise describe the type of construction in narrative; 5. Flood insurance if building a structure in the 100 year flood plain. D. A copy of the Wyoming Department of Public Health s approval for all projects requiring same. For example, facilities involving water supply, sewage disposal, swimming pools, etc., require public health approval. If approval is not yet obtained, please indicate and be mindful that submission of the public health approval is required prior to the first request for reimbursement. E. Environmental Assessment Narrative. In order to determine if an Environmental Impact Statement is necessary, address the following items in an environmental assessment narrative: 1. Proposed Action. A complete description (what, where, when and how) of the project; 2. Immediate and Surrounding Environment. A description of the soil, terrain, water, grasses, other vegetation, geologic outcroppings, fauna, buildings, etc.; 3. Environmental Impact of the proposed project - both negative and positive impacts; 4. Alternatives to the proposed action - address alternatives to the proposed action such as other locations, less or greater development and no action; 5. Public Controversy concerning the project - address whether or not it exists or if it is expected to manifest itself at a later date. 16. Total number of project acres. If this is a new project, meaning there are no previously encumbered acres, then indicate the number of acres acquired or developed within the 6(f) boundary. If this project is within previously encumbered acres, then indicate the number of enhanced acres and the total number of encumbered acres. These would be two different amounts, i.e., XYZ Park totals 10 previously encumbered acres and the new playground within XYZ park is ½ acre. The Section 6(f) boundary map must clearly show key features/uses such as: Number of acres acquired OR developed Township, Range, Latitude/Longitude Roads with names indicated Bodies of water Structures/improvements Utilities Restrictions/easements/rights-of-ways Wetlands Trails Page 11 of 12
Any other characteristics to aid in understanding the protected outdoor Recreation resources Clearly identify/describe all public access points to the parcel. The area to be covered by the 6(f) must be clearly outlined. I hereby certify that the application form and all attachments are correct to the best of my knowledge. Authorized Contact Person Name (Typed or Printed) Title Date Notary Date of Notary Notary - Date Commission Expires Notary Seal TO BE COMPLETED BY DIVISION Request is: Approved Denied Priority Rank: Cost of Project: Federal Share: Project Number: Percent of Match: Completion Date: Date forwarded to National Park Service: Date approved by National Park Service: Page 12 of 12