# **RESTORE Act Environmental Compliance Form - Department of the Treasury**

OMB Approval Number 1505‐0250

*The following questions will aid the applicant in identifying the environmental laws that may apply to the eligible activity and the environmental documents that should be submitted with the application. If a response of ‘Yes’ is recorded to any of the following questions, the applicant should summarize the status of any actions taken to implement the requirements of the law. If a response of ‘No’ is recorded to any of the following questions, the applicant has the option to summarize their analysis and conclusion regarding the non-applicability of the environmental law.**Treasury will use submitted documents to record the applicant’s assertion that it has complied with applicable environmental laws. For projects that will be implemented by a subrecipient, applicants may submit an RESTORE Act Environmental Compliance Form completed by the subrecipient’s authorized representative. A signed statement from the applicant attesting to its review of the subrecipient’s RESTORE Act Environmental Compliance Form must be included with the application.*

***Please note: More information, references, and links to all the laws and executive orders can be found in the Environmental Checklist Reference Guide on Treasury’s RESTORE Act website.***

A. **FORM INTAKE**

1) **[footnoteRef:2]**Please offer the following details about who provided the information to complete this form. (completed by the subrecipient) [2: Throughout the form the asterisk (*) indicates that the question is required to be completed in all cases.] 

Name: Click or tap here to enter text.

Title: Click or tap here to enter text.

Organization: Click or tap here to enter text.

Date: Click or tap here to enter text.

2) *****For projects that do not involve construction activities, has the applicant identified any environmental laws that may apply to the eligible activity?

☐ Yes. If yes, the applicant will proceed to question 3.

☐ No. 

☐ Not applicable. The project includes construction activities.

3) *****Will the project be implemented by a subrecipient?

☐ Yes. If yes, provide the subrecipient organization: 

☐ No. If no, proceed to Section B.

4) Has the subrecipient’s authorized representative completed and certified the Environmental Compliance Form?

☐ Yes. If the subrecipient has completed and certified the Environmental Compliance Form at time of application, the applicant should upload the certified form and any supporting documentation. 

☐ No. If the subrecipient has not completed and certified the Environmental Compliance Form review at time of application, please provide a brief explanation (for example, the subrecipient agreement has not been executed and the applicant will require the subrecipient to submit a completed and certified Environmental Compliance Form prior to commencing construction activities within the scope of work.)

Click or tap here to enter text.

5) Certification of Review

If the Environmental Compliance Form is completed and certified by the subrecipient, the applicant must complete the following statement attesting to review of the subrecipient’s Environmental Compliance Form.

*The Applicant certifies that it has reviewed the subrecipient’s RESTORE Act Environmental Compliance Form and attest to its accuracy.*

Signature of Applicant’s or Authorized Senior Official: 

Name: Click or tap here to enter text.

Date: Click or tap here to enter text.

Title: Click or tap here to enter text.

Organization: Click or tap here to enter text.

B. **ASSESSMENT OF APPLICABILITY OF ENVIRONMENTAL LAWS**

If the project will be implemented by the recipient, the following questions must be completed by the applicant.

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C. **Other Permits and Certifications**

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D. **Certification**

*****Please select the statement that most accurately reflects the status of the information provided on the Environmental Compliance Form submitted with this application.

 ☐    The information provided on this form is preliminary. The Applicant will complete and submit an updated Environmental Compliance form, certified by the Applicant’s Authorized Official (and subrecipient, if applicable), prior to or with its written request to Treasury for permission to commence construction or to initiate other project implementation activities that require prior approval. (This option may be appropriate when the proposed scope of work includes an initial planning and design phase during which any applicable environmental laws will be identified, and all required permits, certifications or authorizations will be identified and acquired.)

☐     The information provided on this form is final, to the best of the Applicant’s knowledge, and the Applicant’s Authorized Official certifies to its accuracy and completeness.

**Once completed, please upload a PDF of this form, and any supporting documentation, via the RESTORE Grants Management System (RGMS).**

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