5800-089 Environmental and Climate Justice Community Change Techn

OMB Control Number: 2030-0051

Expiration Date: 05/31/2024

Environmental and Climate Justice Community Change

Technical Assistance Request Form

The EPA Environmental and Climate Justice Program’s Community Change Grants (Community Change Grants) aims to support environmental and climate justice activities that benefit disadvantaged communities through projects that reduce pollution, increase community climate resilience, and build community capacity to respond to environmental and climate justice challenges.  Under the Inflation Reduction Act (IRA), EPA received $200 million for technical assistance (TA), which includes TA to provide support for preparing an application for the Community Change Grants.

To request TA for preparing a Community Change Grant application, please fill out this form [insert link when web-based form is developed] or call (xxx) xxx-xxxx [to be filled in once the EPA contractor sets up a call-in number]. See Spanish version of the TA request form here [insert link when the form is translated into Spanish]. If you need other language assistance, please send an email to [email protected].

If you include your email address in your form, you will receive a confirmation email from [email protected]. Your intake form will be reviewed to determine if you are eligible to receive TA based on the IRA requirements. You will be notified of the eligibility determination, and whether TA will be provided, in an email that outlines next steps. Response times may vary depending on the volume and types of requests received. You may be contacted with any questions, or clarifications needed, regarding the TA you are requesting.

Receiving TA does not guarantee that you will receive funding under any EPA or other program.

If you have any questions or concerns about this form, please contact: [email protected] To receive updates on EPA programs, helpful resources, and notifications of upcoming webinars and training events, please sign up for the EPA-EJ Listserv or visit the Community Change Grants website here.

Burden Statement Template

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0051. Responses to this collection of information are voluntary. 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 approximately four (4) minutes 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 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.

[Above draft language will appear on the EPA website where the on-line Request Form can be accessed. The language still needs to be reviewed/approved by our webmaster, but is provided to the EPA ICR office for context.]

1. Requester Information

1. Name:

2. Email:

3. Phone number:

4. Affiliation (name of the organization you represent):

5. Preferred form of contact - email, phone number

2. Intent and Eligibility to Apply for Community Change Grants

Community Change TA is available to eligible entities seeking support to prepare an application for the Community Change Grants. Please refer here [link to the CCG NOFO will be inserted here when available] for information on eligible entities under the Community Change Grants and for definitions of the types of organizations described in b) below.

1. Please confirm that you intend to apply for a Community Change Grant.

Yes/no – check one

2. What type of organization do you represent? (select one) –

• Community-Based Non-Profit Organization (CBO)

• Local Government

• Federally-Recognized Tribe

• Institution of Higher Education

3. Do you have, or intend to enter into, a partnership with other eligible entities to apply for a Community Change Grant?
   
   Yes/No

3. Disadvantaged Community Benefit

Community Change Grants must benefit a disadvantaged community as defined here [link to the CCG NOFO will be inserted here when available]. Please review the definition of disadvantaged communities and identify the disadvantaged community that the grant application you plan to submit is intended to benefit in 3.a below.

1. Name and location of the community (please identify City/Town, County, State, Territory, Tribe, zip code, latitude and longitude, and include a map screen shot, if available.)

2. Please explain how the proposed project will directly benefit disadvantaged communities, as described above.

[Narrative Response, maximum 500 Characters]

4. Project Description

1. What type of project do you need technical assistance with? (please check all that apply)

• Climate resilience and adaptation (including but not limited to community greening, stormwater management, mobility, energy efficiency, waste reduction, brownfields redevelopment projects).

• Pollution reduction (including but not limited to indoor/outdoor air quality, toxic remediation, clean water infrastructure, waste, and pollution monitoring projects).

• Alaska Native Claims Settlement Act (ANCSA) pollution remediation projects.

• Workforce development that supports the reduction of greenhouse gas emissions and other air pollutants, and other environmental economic projects.

• Facilitating the engagement of disadvantaged communities in State and Federal advisory groups, workshops, rulemakings, and other public processes.

2. Briefly describe other types of projects not listed in 4.a) above for which you intend to apply for a Community Change Grant.

[Narrative Response, max 500 characters]

5. Type of Technical Assistance Requested (please check all that apply):

• Support with developing, preparing, and submitting a grant application and addressing eligibility issues.

• Project Planning and Development: This includes TA with preparing project maps/designs, permitting and site control, determining project feasibility and readiness, developing project budgets, schedules, and implementation plans as well as obtaining specific subject matter expertise and relevant data (e.g., hydrology, landscape architecture, flood mitigation, sustainable buildings).

• Outreach and Engagement: This includes TA support in conducting community outreach and developing community engagement plans.

• General Capacity Building: This includes TA support in developing partnerships and governance structures.

6. Is there any additional information you would like to provide about your potential types of projects and TA needs not identified in 5) above?

[Narrative response, max 250 Characters]

EPA Form: 5800-089 4