5900-685 TCD Utility Partnership Agreement

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

EPA Office of Transportation and Air Quality
Transportation and Climate Division

Burden Statement for EPA Form 5900-685: This collection of information is approved by OMB under
the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-NEW). 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 2 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 Regulatory Support Division Director, 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.

TCD Utility Partnership Template
Instructions: Planning early for long-term electric charging infrastructure needs is important for project
success. This form was created for the convenience of applicants and utility providers to assist in
discussing the potential new zero-emission vehicle/equipment project and infrastructure projects,
including key components such as anticipated costs and timelines.
The intent of this form is to ensure awareness of all parties involved in the potential new zeroemission vehicle project. This document is not binding, meaning that applicants and utility providers do
not need to complete a full utility analysis or otherwise fully commit to proceeding with the
potential new zero emissions vehicle/equipment project as outlined on this form.
The information identified in this worksheet may be used to support the Project Narrative component of
the grant application package, but it is not required. Applicants may include a copy of this worksheet for
each project location included in the application.
Regardless of whether applicants use this worksheet, the EPA strongly encourages applicants to
coordinate with their and electric utility providers to determine anticipated costs and timelines.
Additionally, applicants should keep fleet electrification expansion plans in mind, as futureproofing
for upcoming needs can ultimately decrease overall utility upgrade costs.

EPA Form Number: 5900-685

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

EPA Office of Transportation and Air Quality
Transportation and Climate Division

1. Fleet Information
Requested in Application
[Please provide the number of
mobile source equipment (by
type) and chargers requested in
your application.]

Current Electric Fleet at
time of Application
Submission
[Please provide the number of
vehicles and chargers already
in your electric fleet.]

Type and Number of Electric
Vehicles/Equipment:
Number of DC Fast Charger
Units:
Number of Level 2 AC
Charger Unites:
Number of Other EV
Charger Units:
(please specify the type of chargers)

Number of Shore Power
Pedestals:
Number of Units of Other
Eligible Charging and/or
Fueling Infrastructure:
(please specify the type of
infrastructure)

Expected location(s) (street,
city, state) of Charger and/or
Electrical Infrastructure
Installations:

EPA Form Number: 5900-685

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

EPA Office of Transportation and Air Quality
Transportation and Climate Division

2. Utility Information
The EPA recommends that applicants fill out information for each individual utility provider they are
communicating with about their potential electric infrastructure project. The EPA recommends that
applicants communicating with more than one utility identify whether the project scope occurring with a
specific utility provider would constitute all or only part of the potential electric infrastructure project.

a. Utility Provider #1
Name of the Utility Provider:
Utility Contact Name:
Utility Contact Phone:
Utility Contact Email:
b. Utility Provider #2
Name of the Utility Provider:
Utility Contact Name:
Utility Contact Phone:
Utility Contact Email:
c. Utility Provider #3
Name of the Utility Provider:
Utility Contact Name:
Utility Contact Phone:
Utility Contact Email:
d. Utility Provider #4
Name of the Utility Provider:
Utility Contact Name:
Utility Contact Phone:
Utility Contact Email:

EPA Form Number: 5900-685

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

EPA Office of Transportation and Air Quality
Transportation and Climate Division

3. Applicant and Utility Coordination Affirmation
By signing this Affirmation, I certify that I am an Authorized Representative for the Applicant or
Utility Provider identified below.
If an applicant has not received a response from their local utility provider(s) after repeated attempts to
discuss this form, then they may submit the document with signatures from all parties involved in the
application except for the utility, with the understanding that there will be continued outreach with the
utility after the application deadline. During application review, the EPA may reach out to request an
updated copy of this form that includes all required signatures. The EPA expects all the appropriate
signatures to be present at the time of award, and omission of these signatures may compromise an
applicant’s selection status.
•

For applicants to the Clean Heavy-Duty Program: In the event the applicant attempted to contact the utility
provider about this form, but received no response, the applicant should also email cleanhdvehicles@epa.gov
with the following information: name of the utility, name of utility point of contact they’ve been working with,
(or attempting to work with), and information on when the applicant attempted to contact the utility provider.

Applicant Affirmation
I have discussed the project plan for the fleet and charging infrastructure outlined above with the
Utility Company, and if applicable with the School District and/or Port Authority, and others as
appropriate.
__________________________

_________________________________

___________

Applicant Organization Name

Authorized Representative (Signature)

Date

Utility Provider Affirmation
I have discussed the project plan for the fleet and charging infrastructure outlined above with the
Applicant listed above, and if applicable, the third parties below, including the relevant School
District and/or Port Authority, and others as appropriate.
__________________________
Utility Provider #1 Name

_________________________________
Authorized Representative (Signature)

___________
Date

__________________________
Utility Provider #2 Name

_________________________________
Authorized Representative (Signature)

___________
Date

__________________________
Utility Provider #3 Name

_________________________________
Authorized Representative (Signature)

___________
Date

__________________________
Utility Provider #4 Name

_________________________________
Authorized Representative (Signature)

___________
Date

EPA Form Number: 5900-685

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

EPA Office of Transportation and Air Quality
Transportation and Climate Division

Other Entity Affirmation
(applicable only if part of project; e.g., school district, other state or local agencies, including
Port Authorities)
I have discussed the project plan for the fleet and charging infrastructure outlined above with the
Utility Company and Applicant Organization, listed above, and others as appropriate.
__________________________

_________________________________

___________

Entity Organization Name

Authorized Representative (Signature)

Date

EPA Form Number: 5900-685

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

EPA Office of Transportation and Air Quality
Transportation and Climate Division

4. OPTIONAL: Planning for Utility Upgrades
This section is NOT required to be completed and/or submitted to the EPA, however, the EPA strongly
encourages applicants and utility providers to discuss the items listed in Section 4. Additionally,
applicants should keep fleet electrification expansion plans in mind, as futureproofing for upcoming
needs can ultimately decrease overall utility upgrade costs.

Please work with your utility to provide a rough estimate of the total
engineering and construction cost for utility owned infrastructure
(in front of the meter) for the project based on the number of
vehicles and eligible charging and/or fueling infrastructure listed in
the applicant’s application:
In the box below, please briefly describe the scope of any needed utility upgrades for the
project. Please consider whether engineering, construction, and/or permitting is needed,
whether an interconnection study is necessary, and the extent of services needed for
completion. This should include whether upgrades are necessary for the following pieces of
equipment:
•
•
•
•
•
•

Power transformer
Terminator Pole
Service lateral/conductor
Metering
Primary line extension
Any additional equipment

Based on the information provided above, please provide an estimate of time required to
complete the necessary utility-owned infrastructure (in front of the meter) upgrades:

EPA Form Number: 5900-685