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Safe Streets and Roads for All
Action Plan Application Template
This document is not meant to replace the NOFO. Applicants should follow the instructions in the NOFO to correctly apply for a grant. While using this template
is not required, DOT encourages its use to provide elements of the required application information. Additional information is required, to be submitted
separately. See page 2 of this template and the SS4A website for more information about required materials: https://www.transportation.gov/SS4A
Lead Applicant: UEI:
Funding request:
(choose one)
NOFO Criterion #1 NOFO Criterion #2
Applicant(s) Jurisdiction Population (#)
Total Count Motor Vehicle-Involved Roadway Fatalities 2016 – 2020 (#)
Alternative Fatality Data
Optional (indicate source below)
Average Annual Fatality Rate (per 100,000 population)
Percent of Population in
Underserved Communities Census Tracts (%)
U.S. Census Data FARS Data U.S. Census Data
Total Value for Application: %
Supplemental Planning Activities Additional planning activities must have a conforming Action Plan
documented by a Self-Certifcation Eligibility Worksheet
Complete Action Plan Complete or update components of an existing
plan(s) to create a conforming Action Plan
New Action Plan Create a new conforming
Action Plan
If submitting a joint application, provide the aggregated values for the full plan area in this row.
If submitting a joint application, provide the individual values for the lead applicant and each joint applicant’s individual portion of the plan area in the rows below.
Lead Applicant:
%
Joint Applicant(s):
1 %
2 %
3 %
4 %
If more than 4 joint applicants, attach a separate table with additional rows for each additional joint applicant
Still have questions? Visit the SS4A website
SS4A Action Plan Application Template | Page 1 of 2
Safe Streets and Roads for All
Action Plan Application Template
Lead Applicant’s State: Additional State #1 that thisMark “NA” if a Federally Action Plan grant will serve:recognized Tribal government
Funding Request for Lead Applicant’s State ($): Funding request for$ $Additional State #1 ($):Provide total cost if a Federally recognized Tribal government
Narrative:
Additional State #2 that this Action Plan grant will serve:
Funding request for $Additional State #2 ($):
NOFO Criterion #3
(300-word limit)
Remember Map Required Forms to provide separately:
Self-Certifcation Eligibility Worksheet Only Required for Supplemental Other Documentation Planning Activities Optional
SF-424 Application for Federal Assistance
SF-424A Budget Information for Non-Construction Programs
SF-424B Assurances for Non-Construction Programs
SF-LLL Disclosure of Lobbying Activities
Apply to Grants.gov package: PKG00274330
Still have questions? Visit the SS4A website
SS4A Action Plan Application Template | Page 2 of 2