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APPLICATION FOR SECTION 205 NONPOINT SOURCE MANAGEMENT PROGRAM GRANT
State Form 53970 (6-09)

IDEM USE ONLY FFY: APP #:

Indiana Department of Environmental Management INSTRUCTIONS:

Date REC'D: 1. Read the application instructions carefully before completing this form. 2. Mail a completed, signed and dated original application by the deadline to: IDEM-OWQ-Nonpoint Source Program MC 65-44 IGCN 1255, Indianapolis, Indiana 46204-2251 and; 3. Email an electronic copy of the completed application by the deadline to [email protected] 1. APPLICANT INFORMATION

Name of project Name of sponsoring organization

Sponsor address

Sponsor organization type: (check one) Municipality County government State government Other public organization Federal government Regional planning commissions 2. PROJECT CONTACT INFORMATION Project coordinator (if different than primary contact) Address and affiliation

Sponsor taxpayer ID number

Primary contact Address and affiliation

Telephone number Email address

FAX #

Telephone number Email address

FAX #

3. PROJECT OVERVIEW Is any part of the proposed project in a Municipal Separate Storm Sewer System (MS4) area (as defined in 327 IAC 15-13)? No Yes - see application instructions Section 205 funds requested $ Proposed project start date (month, day, year) Proposed project end date (month, day, year) Nonpoint source priorities addressed by project (Check all that apply and provide additional information as required) Planning in a watershed with an approved TMDL Planning in a watershed that includes waterbodies in Category 5A on the 303(d) List of Impaired Waterbodies Statewide planning to address water quality issues Title of approved TMDL in project watershed (if applicable) Title of watershed management plan in project watershed that meets or will meet IDEM's checklist (if applicable) Approval date of watershed management plan in project watershed that meets IDEM's checklist (if applicable) Watershed name(s) Watershed hydrologic unit code(s) Names of major water bodies within the project watershed

Counties and states within the project watershed Segment ID number(s) and cause(s) of impairments for waterbodies within the project watershed as listed on the 303(d) List of Impaired Waterbodies, Category 5A

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4. WATER QUALITY PROBLEM TO BE ADDRESSED BY PROJECT Describe the water quality problem(s) that you will address with this project. Include a description of the land use, human activities, ecosystem characteristics, or other appropriate information that will help explain the problem(s). Also include references to any reports, water quality studies or data that support your assessment of the water quality problem, including the 303(d) List of Impaired Waterbodies. Be concise and limit your response to one page. Do not exceed the space allocated.

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5. PROJECT APPROACH TO SOLVING THE PROBLEM A. Overview Provide a GENERAL overview of the proposed project. You will be asked to provide more detail in other sections of the application. Your overview should include a description of the goals of the project (what you hope to achieve), and how the project will result in improved water quality. Do not exceed the space allocated.

B. Goals and measures of success Document the outcome(s) of your project and how you will measure success, including administrative achievements, environmental/water quality benefits, and social or behavioral changes. This may include identifying changes in land use, measuring success of outreach efforts, monitoring water quality improvements, assessing habitat improvement, or other measures of success (see instructions). I. Project goal Measure of success

II. Project goal Measure of success

III. Project goal Measure of success

IV. Project goal Measure of success

V. Project goal Measure of success

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C. Tasks List and describe in detail the tasks that will be completed by this project. List tasks by letter (see BUDGET). Include products/deliverables produced by each task. Tasks must correspond to the budget. See application instructions for more information.

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D.

Partners List your partners on this project and how or what they will contribute. Attach letters of commitment from partners that detail their commitments of specific amounts of time, money, activities, or other specified resources for the project. General letters of support (those not showing time, money or specific resource commitment) may be submitted, but will not receive the same consideration as letters of commitment when ranking proposals. Type(s) of commitment to project success

Name of partner

E. Public involvement How will the public be involved in your project? How will you make your community aware of the project? Who will be included in planning and decision making?

F. Future activities List any future activities planned or anticipated after the completion of this project and actions steps needed to reach post-project (long term) goals.

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6. SCHEDULE Time period First quarter Anticipated activities/milestones

Second quarter

Third quarter

Fourth quarter

Fifth quarter

Sixth quarter

Seventh quarter

Eighth quarter

Ninth quarter

Tenth quarter

Eleventh quarter

Twelfth quarter

Thirteenth quarter

Fourteenth quarter

Fifteenth quarter

Sixteenth quarter

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7. BUDGET

Section 205 Grant-Funded Expenses TASKS Task A Task B Task C Task D Task E Task F Task G TOTAL ITEMIZED EXPENSES (Describe in detail the items, services, or contract expenses associated with this project) Administrative Personnel/ Fringe Admin.* Travel Equipment Supplies Contractual Other Total 205 **

Equipment

Supplies

Contractual

Other

* Administrative expenses are limited to 5% of the total 205 funds ** Total 205 Expenses must match "Section 205 Funds Requested" on Page 1

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8. PROJECT AUTHORIZATION I authorize that to the best of my knowledge the contents of this application are true and accurate. I understand that if funded, the contents of this application will be used to draft a contractual agreement as a mechanism for executing the grant project. _____________________________________________________ Signature of Sponsoring Organization's Authorized Representative ______________ Date

Typed Name of the Representative:

Title of the Representative:

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