CEO of the Recipient (If a LUG, this is the Responsible Entity) Date IHCDA Staff Approving Signature Date (Responsible Entity for NFP & FP entities, and Certifying Official for all projects.) Exhibit F CONTACT SHEET Application/Award# ______________________________________________________________ Recipient Name: Development Location: NOTE: Not all agencies may be applicable to your particular project. Please complete Exhibit G, the Environmental Review Workbook, to determine which agencies you need to contact. Then complete this form to assist you in your tracking. Applicable Agency Date Date Attach Section of ? Sent Received Exhibit G, (Y/N) (Y/N) Review Worksheet 2-1-1 Unit of Government - Zoning IN-DNR Lake Michigan Coastal – 2-1-2 Program Indiana Department of 2-1-3 Environmental Management (IDEM) U.S. Environmental Protection 2-2 Agency USDA - Natural Resources 2-3 Conservation Service 2-5 IN-DNR Water – 3-4-1 IDEM Office of Air Quality – 3-5-2 IN-DNR Fish and Wildlife – 3-6-4 Indian Tribes 4-4 Indiana Geological Survey Local Soil and Water Conservation 4-4 District Other: Other: Other:
CEO of the Recipient (If a LUG, this is the Responsible Entity) Date IHCDA Staff Approving Signature Date (Responsible Entity for NFP & FP entities, and Certifying Official for all projects.) Exhibit F CONTACT SHEET Application/Award# Recipient Name: ______________________________________________________________ Development Location: NOTE: Not all agencies may be applicable to your particular project. Please complete Exhibit G, the Environmental Review Workbook, to determine which agencies you need to contact. Then complete this form to assist you in your tracking. Applicable Section of Exhibit G, Review Worksheet Agency (Y/N) Date Sent Date Received (Y/N) 2-1-1 Unit of Government - Zoning 2-1-2 IN-DNR – Lake Michigan Coastal Program 2-1-3 Indiana Department of Environmental Management (IDEM) 2-2 U.S. Environmental Protection Agency 2-3 USDA - Natural Resources Conservation Service 2-5 IN-DNR – Water 3-4-1 IDEM – Office of Air Quality 3-5-2 IN-DNR – Fish and Wildlife 3-6-4 Indian Tribes 4-4 Indiana Geological Survey 4-4 Local Soil and Water Conservation District Other: Other: Other: Attach ?