PFN5900-722 W_Funding Program Recipient Story Form

OMB Control Number: 2060-0754
Expiration Date: MM/DD/YYYY

Funding Program Recipient Story Form
Burden Statement for EPA Form PFN 5900-722 This collection of information is approved by OMB under the Paperwork
Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0754). Responses to this collection of information are voluntary (2
CFR 200 at 2 CFR 1500). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden
for this collection of information is estimated to be 1.5 - 3 hours per response. Send comments on the Agency’s need for
this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent
burden to the Director, Information Engagement Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania
Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this
address.

Congratulations again on receiving EPA funding! Please fill out this form to share your story with
EPA. Sharing your story is a great way to educate others on the benefits of your participation in this
EPA funding program, connect with others who have worked through similar challenges, and guide
others interested in implementing similar projects.
Disclaimer: By completing this template, you are granting EPA permission to use this information in external
publications including, but not limited to, Reports to Congress, program websites, and/or social media. EPA
encourages those that fill out this form to also share this information with their communities via their own
communication channels.

Background Information
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•
•
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EPA Funding Program (including year):
Recipient Organization/Community:
Project Location (at least City, State):
Grant/Rebate Identification Number:

Narrative Questions
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Why did your organization/community apply for funding from this EPA program?

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What are some notable quantitative and qualitative benefits of the EPA-funded
equipment/activities?

•

Have you experienced any challenges at any point during project planning or
implementation process? If yes, how did you overcome them? If no, how did you prevent
them?

EPA Form Number: PFN 5900-7222

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OMB Control Number: 2060-0754
Expiration Date: MM/DD/YYYY

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What has been the response from the community (those involved, directly impacted, or
indirectly impacted)?

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Does your organization/community plan to expand on this project? Why or why not?

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Can EPA follow-up with you in the future to check-in on your EPA-funded project?

Collection of Testimonials
•

Please provide quotes from those involved in the project, those directly impacted by the
project, those indirectly impacted by the project, and/or other members of the community.
Please obtain all necessary permissions to use quote(s) from the interviewee and confirm
the final wording. For minors, please consult the parent/guardian about how they want the
minor portrayed (i.e. only provide the first name or use an alias) and obtain all necessary
permissions.

EPA Form Number: PFN 5900-7222

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OMB Control Number: 2060-0754
Expiration Date: MM/DD/YYYY

Guidance on Photos
•

Please share digital copies of your high-quality photos depicting the EPA-funded
equipment/activities in use/action. Please obtain all necessary permissions from any
individuals depicted in your photos. For minors, please follow your organization’s process
for obtaining permission from the minor’s parent/guardian. EPA will grant photo credit as
applicable if your photo is used in an EPA external publication.

Completion of Required Forms
__ EPA Video/Audio/Photo License Agreement
__

Official EPA Consent Form for use with Video/Photos/Voice Recordings

Authorized Representative Approval

Authorized Representative Name (Print)

Authorized Representative Signature

Authorized Representative Title

Email

EPA Form Number: PFN 5900-7222

Phone Number

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OMB Control Number: 2060-0754
Expiration Date: MM/DD/YYYY

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460

VIDEO/AUDIO/PHOTO LICENSE AGREEMENT
This license agreement dated__________________________, is between the U.S. Environmental Protection Agency, referred to as
(Date)

the “Licensee” and, ___________________________________________________________________ referred to as the “Licensor.”
(Name of Individual/Company/Organization)

Pursuant to this Agreement, Licensor grants Licensee a non-exclusive, no-cost, worldwide, transferable, perpetual, irrevocable license
to digitize, modify, alter, edit, excerpt, adapt, create derivative works, publish, display, distribute, publicly perform, exhibit, transmit,
broadcast, reproduce, and otherwise use _____________________________________________ (“the Work(s)”) in connection with
(Photos, Videos, Graphics, Audio Clips, etc.)

_____________________________________________________________, as produced by Licensee or by a contractor on Licensee’s
(Project Types: Video, Podcast, Photo, Infographics, etc.)

behalf, tentatively entitled _________________________________________________________________________ (“the Project”).
(Name of EPA Project)

Licensor understands that the Project may be publicly displayed and distributed in full or in part on EPA’s web site and/or on official
EPA social media pages, including those on Facebook (www.facebook.com/EPA), YouTube (www.youtube.com/user/USEPAgov),
Instagram (www.instagram.com/epagov), LinkedIn (www.linkedin.com/company/us-epa) and/or X, formerly known as Twitter
(www.twitter.com/EPA). In addition to the social platforms referenced above, Licensor agrees to license the Work(s) for use in all
media now known or hereafter devised in perpetuity throughout the universe. Licensor also understands and agrees that EPA may
be required to preserve, reproduce and/or distribute copies of the Work as required under the Freedom of Information Act, 5 U.S.C.
§ 552, the Federal Records Act, 44 U.S.C. chs. 21, 29, 31 & 33, EPA’s regulations at 40 C.F.R. Part 2, Subpart B or as otherwise required
by U.S. law. In granting this license for all of the above uses, Licensor hereby waives the right to inspect or approve the finished version of the Project.
Licensor hereby agrees to waive any and all compensation related to this Agreement for Licensor and, if applicable, the creator of
the Work(s) for whom Licensor is a legal guardian/custodian. EPA’s uses of the Work(s) will be limited to informational, educational
and/or public relations/outreach purposes that are noncommercial in nature. Licensee may or may not provide Licensor with an
on-screen/visual courtesy/credit/attribution for the Work(s) used in the Project. Any such courtesy/credit/attribution related to the
Licensor may be listed in the description, caption or share text of any EPA social media or web posts.
Licensor warrants and represents that it is the sole owner of the Work(s) and/or that Licensor has the legal right to enter into and
fully perform this Agreement and grant the rights addressed herein, including but not limited to, any such rights belonging to third
parties that are attached to any works, trademarks, images or voices appearing or otherwise featured in the Work. Licensor shall
indemnify, defend and hold harmless Licensee and any contractors acting on Licensee’s behalf from and against any and all lawsuits,
claims, liabilities, demands, costs, expenses, or damages arising out of Licensee’s Use of the Work(s) as provided herein, or arising
out of the breach of warranty or agreement made by Licensor herein.
This License contains the full understanding and agreement of the parties with respect to the subject matter addressed herein. Licensor affirms that he/she is at least 18 years of age, and, if applicable, a legal guardian/custodian of the creator of the Work(s) and is
competent to contract in Licensor’s own name or in the name of the creator of the Work(s) for whom Licensor is a legal guardian/
custodian. Licensor has read this Agreement before signing below, and Licensor fully understand the contents, meaning, and impact
of this Agreement.
AGREED AND ACCEPTED BY:
LICENSEE
Signature:

_____________________________

Printed name:
Title:

___________________________

________________________________

Office of:

______________________________
U.S. Environmental Protection Agency

EPA Form Number: PFN 5900-722

LICENSOR
Signature:

_____________________________

Printed name:
Title:

___________________________

________________________________

Organization:

____________________________
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OMB Control Number: 2060-0754
Expiration Date: MM/DD/YYYY

Official U.S. Environmental Protection Agency Consent Form
For use with Video, Photo(s), or Voice Recording(s)

I, ______________________________________________________________________ (“the Contributor”), hereby authorize the
(Name)

U.S. Environmental Protection Agency (“EPA”) to film, record and/or photograph me or my child (where I am the child’s parent or
legal guardian), as part of the EPA Project or Event titled, ___________________________________________________________
(Project Title)

(“Event or Project”) occurring on or about ________________________________ (“Recording(s) or Photo(s)”).
(Date)

I further grant a non-exclusive, no-cost, worldwide, transferable, perpetual, irrevocable license to digitize, modify, alter, edit,
excerpt, adapt, create derivative works, publish, display, distribute, publicly perform, exhibit, transmit, broadcast, reproduce, and
otherwise use the Recording(s) or Photo(s) for informational, educational and/or public relations/outreach purposes that are
noncommercial in nature, and in so doing, use the Contributor’s name, image, likeness, appearance, and/or voice as they appear in
the Recording(s) or Photo(s), in any and all media and formats and by any and all technologies and means of delivery whether now
or hereafter known or devised. Further, I irrevocably grant EPA or parties working on EPA’s behalf, the right to use Contributor’s
name, image, voice, likeness and professional biographical information, at no cost, in connection with any promotional activities or
online publications related to the Event or Project.
I understand that if the Recording(s) or Photo(s) includes an Event, they may be live-streamed online; the Recording(s) or
Photo(s) may also be publicly displayed and distributed in full or in part on EPA’s web site and/or on official EPA social
media pages, including those on Facebook (www.facebook.com/EPA), YouTube (www.youtube.com/user/USEPAgov),
Instagram (www.instagram.com/epagov), LinkedIn (www.linkedin.com/company/us-epa) and X, formerly known as Twitter
(www.twitter.com/EPA). I waive the right to inspect or approve the finished product, including written or electronic copies, wherein
the Contributor’s name, image, likeness, appearance, and/or voice appears. I understand that the videos, photos and/or voice
Recording(s) may remain online indefinitely and may subsequently appear in EPA paper/online publications/social media graphics or
other non-EPA publications that EPA deems appropriate to help promote or publicize the Event(s) or Project(s). I also understand
and agree that EPA may be required to preserve, reproduce and/or distribute copies of the Work as required under the Freedom of
Information Act, 5 U.S.C. § 552, the Federal Records Act, 44 U.S.C. chs. 21, 29, 31 & 33, EPA's regulations at 40 C.F.R. Part 2, Subpart
B or as otherwise required by U.S. law. I hereby agree to waive any and all compensation for myself and/or my custodian in regard
to the above-referenced uses of the Recording(s) or Photo(s).
I understand that disclosure of the Contributor’s name, likeness and professional biographical information for the foregoing
purposes is voluntary, and is collected and maintained under the authority of the Privacy Act of 1974, 5 U.S.C. 552a; failure to
disclose the personal information requested may result in the Contributor not being included in EPA multimedia products.
I hereby hold harmless and release and forever discharge the United States and EPA from all claims, demands, and causes of action
which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate or
that of my custodian have or may have by reason of this authorization.
I am at least 18 years of age, and/or the legal guardian/custodian of the Contributor, and I am competent to contract in my own
name or in the name of my child/ward for whom I am a legal guardian/custodian. I have read this release before signing below,
and I fully understand the contents, meaning, and impact of this release.
____________________________________________________________________
Signature of Individual or other legally authorized person
____________________________________________________________________
Print Name

____________________________
Date

____________________________

Email (Optional)

____________________________________________________________________
Organization and/or Title
Project/Production Notes:

EPA Form Number: PFN 5900-722

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OM 2024-2