SANTA MONICA MOUNTAINS CONSERVANCY GRANT APPLICATION Project Name: Amount of Request: $100,000 San Gabriel Mountains Transit & Infrastructure Program, Planning: Phase IIa for the Mt. Wilson Express/Highway 2 Transit Route Total Project Cost: $150,000 Applicant Name: Matching Funds: $50,000 Nature for All Lat/Long:34.268956 -118.146357 ​ (Switzer Picnic Area) There are 5 sites total Applicant Address: Project Address: 4 sites in Angeles National Forest & San Gabriel Mountains National Monument, + 1 in Pasadena 201 W. Garvey Avenue, Suite 102-503, Senate Assembly County Monterey Park, CA 91754 District District Los Angeles County 25 41, 43 Phone: (626) 614-4990 Tax 83-1265253 Email: [email protected] ID: Grantee’s Authorized Representative: Belinda Faustinos, Executive Director (626) 614-4990 Name and Title Phone Overhead Allocation Notice: ✓ Any overhead costs will be identified as a separate line item in the budget and invoices. ✓ The Conservancy encourages grantees to reduce overhead costs including vehicle and phone expenses. ✓ The overhead allocation policy has been submitted prior to, or with, the grant application. Outreach and Advertising Requirement: ✓ Applicant has read the staff report and board resolution regarding contract policies. ✓ Applicant has adopted contract policies for the purpose of increasing outreach and advertising to disadvantaged businesses and individuals. All check boxes must be checked Brief Project Description: The San Gabriel Mountains Transit & Infrastructure Program (SGM-TIP)’s purpose is to provide transit access to the San Gabriel Mountains National Monument/Angeles National Forest for diverse, underserved communities - a gamechanger for environmental justice and equity across the Los Angeles basin. In this access grant proposal, SGM-TIP Planning Phase IIa will focus on conceptual design plans for five shuttle stops on the Mt. Wilson Express/Highway 2 transit route in the Santa Monica Mountains Conservancy (Conservancy) territory of the San Gabriel Mountains. Phase IIa will also include stakeholder engagement, preliminary community engagement, conceptual level: transit program development, shuttle stop design standards, and educational/interpretive content planning. These Phase IIa planning deliverables will set the stage for Phase IIb funding to reach 100% construction design plans, then implementation funding. Tasks / Milestones: Budget: Completion Date See attached Tasklist/Timeline and Budget For Acquisition APN(s): N/A Projects: Acreag N/A e: I certify that the information contained in this Grant Application form, including required attachments, is accurate. 2/12/21 Signature of Authorized Representative Date STATE OF CALIFORNIA ◆ THE NATURAL RESOURCES AGENCY ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ DocuSign Envelope ID: 8587A59C-83F2-4DB2-A607-B1E1229BC537 Grantee Data Sheet Print Form State of California The Natural Resources Agency 5750 Ramirez Canyon Road Malibu, California 90265 Phone: 310-589-3200 Santa Monica Mountains Conservancy Fax: 310-589-3207 www.smmc.ca.gov Date: Feb. 12, 2021 New Revised Grantee Name: Nature for All Project Name: San Gabriel Mountains TIP Planning Address: 201 West Garvey Ave, Ste 102-503, Monterey Park State/Province: CA Zip/Postal Code: 91754 Tax ID Number: 85-1265253 Primary Contact Information Phone: 626 614-4990 Name (1): Belinda V. Faustinos Fax: N/A Address: 201 W. Garvey Ave, Suite 102-502, Monterey Park Information State/Province: CA Zip/Postal Code: 91754 Will administrative/overhead costs be included? Yes Phone (1): 626 614-4990 If yes, is the overhead policy attached to this sheet? Yes Phone (2): Fax: N/A Will vehicle costs be included? No Email: [email protected] If yes, is the vehicle policy attached to this sheet? Name (2): Bryan Matsumoto Will cell phone costs be included? No Address: 201 W. Garvey Ave, Suite 102-503, Monterey Park State/Province: CA If yes, is the phone policy attached to this sheet? Zip/Postal Code: 91754 Phone (1): 626 246-8634 I have completed and submitted the STD 204 Payee Data Record form. Phone (2): Fax: N/A I have read and accepted the policies and procedures Email: [email protected] within the Santa Monica Mountains Conservancy Grant Administration Manual. Notes: I am aware that the Santa Monica Mountains Conservancy has urged a reduction of costs associated with overhead, cell phone, and vehicle charges. Signature Field *If a reduction in the above costs has been made, please document the reductions and attach to this data sheet. DocuSign Envelope ID: 42FBBC63-0BB4-49FD-A77E-C58224D5E47BPrint Form Reset Form STATE OF CALIFORNIA-DEPARTMENT OF FINANCE PAYEE DATA RECORD (Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 10/2019) INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date, and return to the state agency (department/office) address shown in Box 6. Prompt return of this fully completed form will prevent delays when 1 processing payments. Information provided in this form will be used by California state agencies to prepare Information Returns (Form1099). See next page for more information and Privacy Statement. NOTE: Governmental entities, i.e. federal, state, and local (including school districts), are not required to submit this form. BUSINESS NAME (As shown on your income tax return) 2 Nature for All SOLE PROPRIETOR, SINGLE MEMBER LLC, INDIVIDUAL (Name as shown on SSN or ITIN) Last, First, MI E-MAIL ADDRESS [email protected] MAILING ADDRESS BUSINESS ADDRESS 201 W. Garvey Ave, Suite 102-503 201 W. Garvey Ave, Suite 102-503 CITY STATE ZIP CODE CITY STATE ZIP CODE Monterey Park CA 91770 Monterey Park CA 91770 ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): 8 5 – 1 2 6 5 2 5 3 NOTE: 3 Payment will not PARTNERSHIP CORPORATION: be processed PAYEE MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) without an ENTITY ESTATE OR TRUST accompanying TYPE LEGAL (e.g., attorney services) taxpayer EXEMPT (nonprofit) identification number. CHECK ALL OTHERS ONE BOX ONLY ENTER SSN OR ITIN: – – SOLE PROPRIETOR, INDIVIDUAL, OR Social Security Number (SSN) or Individual Taxpayer Identification SINGLE MEMBER LLC (Disregarded Entity) Number (ITIN) are required by authority of California Revenue and Tax Code sections 18646 and 18661) CALIFORNIA RESIDENT - Qualified to do business in California or maintains a permanent place of business in California. 4 CALIFORNIA NON RESIDENT (see next page for more information) - Payments to nonresidents for services may be subject to state income tax withholding. PAYEE RESIDENCY No services performed in California. STATUS Copy of Franchise Tax Board waiver of state withholding attached. I hereby certify under penalty of perjury that the information provided on this document is true and correct. 5 Should my residency status change, I will promptly notify the state agency below. AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Type or Print) TITLE TELEPHONE (include area code) Belinda V. Faustinos Executive Director 626 614-4990 SIGNATURE DATE E-MAIL ADDRESS 2/12/21 [email protected] Please return completed form to: 6 DEPARTMENT/OFFICE UNIT/SECTION MAILING ADDRESS TELEPHONE (include area code) FAX CITY STATE ZIP CODE E-MAIL ADDRESS DocuSign Envelope ID: 42FBBC63-0BB4-49FD-A77E-C58224D5E47B STATE OF CALIFORNIA-DEPARTMENT OF FINANCE PAYEE DATA RECORD (Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 10/2019) Requirement to Complete the Payee Data Record, STD 204 1 A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business. Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC). Enter the payee's legal business name. The name must match the name on the payee's tax return as filed with the federal Internal Revenue Service. Sole proprietorships and single member limited liability companies (LLCs) must also include the 2 owner's full name. An individual must list his/her full name as shown on the SSN or as entered on the W-7 form for ITIN. The mailing address should be the address at which the payee chooses to receive correspondence. The business address is the address of the business' physical location. Check only one box that corresponds to the payee business type. Corporations must check the box that identifies the type of 3 corporation. The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by the R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations. Payees must provide one of the following TINs on this form: social security number (SSN), individual taxpayer identification number (ITIN), or federal employer identification number (FEIN). The TIN for sole proprietorships, single member LLC (disregarded entities), and individuals is the SSN or ITIN. Only partnerships, estates, trusts, corporations, and LLCs (taxed as partnerships or corportations) will enter their FEIN. Are you a California resident or nonresident? 4 A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California. A partnership is considered a resident partnership if it has a permanent place of business in California.