PFN5900-722 W_Funding Program Recipient Story Form

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

Environm ental Protection
Agency

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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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?

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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

Environm ental Protection
Agency

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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
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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

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Environmental Protection
Agency

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Guidance on Photos
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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
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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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