HOST: Environmental Review Questionnaire

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Please complete the following Environmental Review Questionnaire as completely and accurately as possible. The HOST Environmental Review Officer will review it and get back to you with any needed follow up questions or documentation and to let you know the status of the review.

Your email:

I. Project Location

A. Project Name

B. Parcel Number

C. Project Location

D. Map of Project Area. Upload a map (.pdf, .jpg) showing the project location, including the limits of ground distributing activities and parcel boundaries involved.

II. Project Contact Information

E. Who is the HUD Grant Recipient (i.e. the Pass Through Funding Entity)? Please select one:

F. Applicant Organization (i.e. Company Name)

G. Primary contact for this application. Please provide name, email and phone number.

H. Additional contact #2 for this application (if needed.) Please provide name, email and phone number.

I. Additional contact #3 for this application (if needed.) Please provide name, email and phone number.

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III. HUD Funding Information (Project Initiation)

J. HUD Funding Source #1

1. Provide the name of the HUD grant program (e.g. CDBG, HOME, etc.)

2. Grant Number (e.g. B-21-MC-08-0005)

3. Dollar Amount (if applicable) or

4. Number of Vouchers

K. HUD Funding Source #2 (if applicable)

1. Provide the name of the second HUD grant program (e.g. CDBG, HOME, etc.)

2. HUD Grant #2 Number (e.g. B-21-MC-08-0005)

3. Dollar Amount of HUD Grant #2 (if applicable) or

4. Number of Vouchers for HUD Grant #2

L. HUD Funding Source #3 (if applicable)

1. Provide the name of the third HUD grant program (e.g. CDBG, HOME, etc.)

2. HUD Grant #3 Number (e.g. B-21-MC-08-0005)

3. Dollar Amount of HUD Grant #3 (if applicable) or

4. Number of Vouchers

M. Estimated Total HUD Funding Amount (total of the HUD grant amounts provided above.)

N. Estimated Total Project Funded Costs (Sum of HUD and non-HUD funds)

O. Does this project anticipate the use of funds or assistance from another Federal agency in addition to HUD (e.g. FEMA)?

If you selected “Yes” please describe the additional non-HUD funds and their amounts

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Individual Actions: Individual actions apply only to projects affecting four or fewer residential units and do not apply to rehabilitation of a building for residential use.

26. An individual action on up to four dwelling units, where there is a maximum of four units on any one site. The units can be four one-unit buildings or one four-unit building or any combination in between.

27. An individual action on a project of five or more housing units when the housing units are developed on scattered sites, the site are more than 2,000 feet apart, and there are not more than four housing units on any one site.

28. Disposition: Disposition of an existing structure provided that the disposed of structure will be retained for the same use.

29. Equity Loans: Equity loans on an existing structure provided that the financed structure will be retained for the same use.

30. New Construction.

31. Demolition.

32. Change in land use.

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