5800-093 EJ TCTAC Intake Form Center C

OMB Control Number: 2030-0051

Expiration Date: 05/31/2024

EJ TCTAC Intake Form Center C

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 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 15 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.

Required: The collection of information required for the rendering of appropriate services deployed by Center C

Contact Information

Name

Phone Number

Email

Do you represent a Tribe, Tribal organization, or Inter Tribal consortium? Please identify.

• Tribe

• Tribal Organization

• Inter-Tribal Consortium

• Other

In what state is your community located? If your Tribal boundaries are in more than one state, select the state your headquarters are in.

Please describe the environmental, climate justice or clean energy concern you would like to address.

What type of technical assistance are you seeking?

• Search for appropriate/relevant federal funding

• Federal funding application assistance

• GIS Mapping Services

• Resources and Information

If you have documents you would like to attach to your request, please email them toenvironmentalhealth@nihb.org.

Example documents: sample budget, grant narrative, etc.

Acknowledgement

• By checking this box, I acknowledge that all requests for assistance are subject to the availability and existing obligations of NIHB environmental health staff and that NIHB retains the right to deny requests for any reason.

EPA Form: 5800-093