Activity Name and Grant Number:

Address:

Activity Description:

Estimated total Activity cost: $    

Funding Source: CDBG HOME ESG HOPWA EDI Other: ______________

√

The activity falls into the category below, which is listed at 24 CFR 58.34(a) as Exempt.

1.  Environmental and other studies, resource identification, and development of plans and strategies

2.  Information and financial services

3.  Administrative and manage4.  ment activities

Public services that will not have a physical impact or result in any physical changes including but not limited to services concerned with:

▪  Employment

▪  Crime prevention

▪  Child care

▪  Health

▪  Recreation needs

▪  Drug abuse

Education

▪  Counseling

▪  Energy conservation

▪  Welfare

▪  Other _______________

5. Inspections and testing of properties for hazards or defects

6. Purchase of insurance

7. Purchase of tools

Engineering or design costs

8.  Technical assistance and training

9.  Temporary or permanent improvements that do not alter environmental conditions and are limited to activities to protect, repair or arrest the effects of disasters or imminent threats to public safety, including those resulting from physical deterioration.

10.  Payment of principal and interest on loans made or obligations guaranteed by HUD

Are funds for acquisition (including equipment) or construction (including repair and rehabilitation) purposes?

Yes

Continue

No

Proceed to Section 2-Act does not apply

Is the Activity in an area identified as having special flood hazards (SFHA)?

Identify FEMA flood map used to make this determination:

________________________________

Community Name and Number

_________________________________

Map panel number and date

Yes

Document and Continue

No

Document and Proceed to Section 2-Act does not apply

Is the Community participating in the National Insurance Program (or has less than one year passed since FEMA notification of Special Flood Hazards)?

Yes-Document and follow instructions below.

No-Federal Assistance may not be used for this project.

Flood Insurance under the National Flood Insurance Program must be obtained and maintained for the economic life of the project, in the amount of the total project cost. A copy of the flood insurance policy declaration must be kept on file.

Does the project involve HUD assistance, subsidy or insurance for the purchase or sale of an existing property?

Yes

Continue

No—Proceed to Section 3--Regulation does not apply.

Is the project located within 2,500 feet of a civil airport or

15,000 feet of a military airfield?

Yes

Continue

No—Document and Proceed to Section 3--Regulation does not apply.

Is the project located within an FAA-designated civilian airport Runway Clear Zone (RCA) or Runway Protection Zone, or within the military Airfield Clear Zone (CZ) or Accident Potential Zone/Approach Protection Zone (APZ), based upon information from the airport or military airfield administrator identifying the boundaries of such zones?

Yes

Continue

No—Document and Proceed to Section 3—regulation does not apply.

Comply with 24 CFR Part 51, Subpart D. This may include providing a written notice to a prospective buyer or leaser of the potential hazards from airplane accidents and the potential that an airfield operator may wish to purchase the property. Maintain copies of the signed notice. For properties located in a military clear zone, make and document a determination of whether the use of the property is consistent with DOD guidelines. Notice Sample: http://www.hud.gov/offices/cpd/energyenviron/environment/compliance/qa/airporthazards.pdf)