OMB Control No. 2060-0578 

Approval Expires 04/30/2009 

Partner’s Letter of Intent 

for State, Local, Tribal Agencies 

With this letter ________________________________________________________ (State/Local/Tribal Agency) 

joins EPA's Combined Heat and Power (CHP) Partnership and commits to work with EPA to promote the 

benefits of CHP and support development of new CHP projects within our state/locale. 

Sincerely, __________________________________________________________________________________ 

Authorized State/Local/Tribal Agency Representative Signature 

Name: _____________________________________________________________________________________ 

Title: ___________________________________________________________ Date: ______________________ 

The State/Local Partner Agrees to: 

1. Designate a liaison for EPA's CHP Partnership. 

2. Host a workshop to promote the benefits of CHP and support development of new CHP projects within the 

state/locale. 

3. Provide input to EPA-developed CHP Partnership tools and services, including state/locale-specific data and 

analysis. 

4. Employ CHP Partnership tools and services, as appropriate, to recognize and promote CHP development within 

the state/locale. 

EPA Will: 

1. Support the State/Local Partner with tools and services including state/locale-specific data and analysis. 

2. Support the State/Local workshop through logistics and planning. 

Please fax the completed Letter of Intent (2 pages) to 617/482-1320 (contractor in support of EPA) 

3.	 Designate a Program Manager as Partner liaison. 

General Terms: 

1.	 This agreement can be terminated by either party, at any time, without prior notification, penalties or further 

obligation. 

2.	 The State/Local Partner agrees that the activities it undertakes associated with this voluntary agreement are not 

intended to provide services to the federal government and that the Partner will not seek compensation from a 

federal agency. 

3.	 The State/Local Partner agrees that it will not claim or imply that its participation in the Partnership constitute EPA 

approval or endorsement of anything other than its commitment to the Partnership. 

Please complete the information on page 2. 
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State Partner's Liaison: 

Name: __________________________________________________________________________________________ 

Title: ____________________________________________________________________________________________ 

State/Local Agency: ________________________________________________________________________________ 

Address: _________________________________________________________________________________________ 

City: _________________________________________________________ State:_______ Zip: __________________ 

Telephone: __________________________________________ Fax: ________________________________________ 

E-mail: __________________________________________________________________________________________ 

Additional Partner Information: 

Your agency’s Web site address: _____________________________________________________________________ 

Does your agency have a CHP-related Web page? If so, please list here: 

May we provide a link to your CHP-related Web page?  Yes  No 

Please provide a brief profile of your agency’s involvement in CHP. (If the space below is not adequate, please mail or 

fax this information to us on separate pages, along with your signed Letter of Intent.): 

The government estimates the average time needed to fill out this form is 4.9 hours and welcomes suggestions for reducing this level of effort. Send comments 

(referencing OMB control number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. 

PLEASE FAX THE COMPLETED LETTER OF INTENT TO 617/482-1320 (contractor in support of EPA) 

Office of Air and Radiation EPA-430-F-05-035 

(6202J) www.epa.gov/chp

October 2005 

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