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<br /> 3 <br />Environmental Review Form <br />Pursuant to 24 CFR Part 58.34(a) and 58.35(b) <br />COMPLETE ONLY THE HIGHLIGHTED <br /> <br />Project Information <br /> <br />Grant Recipient: Orange County <br /> <br />Funded Activity X RRH ☐SO ☐ES ☐PRV ☐HMIS <br /> <br /> <br />Responsible Entity: NC DHHS – DAAS ESG Office <br /> <br />State/Local Identifier (LPA) <br /> <br />Preparer Name & Title: Rachel Waltz, Homeless Programs Manager <br /> <br />Certifying Officer Name and Title: Lisa Worth, ESG Homeless Programs Coordinator <br /> <br />Consultant (if applicable): N/A <br /> <br />Physical Address of Funded Activity: Community based service is to be provided in Participants’ <br />homes or other community locations to meet the needs of the Participants. <br />*If multiple locations, please list all below. <br />Office locations include: 2501 Homestead Rd, Chapel Hill, NC 27516 and 300 W. Tryon Rd, <br />Hillsborough, NC 27278 <br /> <br /> <br />Description of the Proposed Project: The proposed project will provide evidence based Rapid Re- <br />housing components to households currently experiencing homelessness and in accordance with 24 <br />CFR 576: rapid re-housing assistance, housing relocation and stabilization services, and rental <br />assistance. Referrals will be received from the CoC By Name List meetings referred to as the HOME <br />Committee. <br /> <br /> <br />If this project anticipates the use of funds or assistance from another Federal agency in addition to <br />HUD (if applicable list sources): N/A <br /> <br /> <br /> <br />Estimated Total Project Cost (HUD and non-HUD funds): $565,452 <br /> <br /> <br />Preparer Signature: __________________________________________Date: ________ <br /> <br />Name/Title/Organization: Rachel Waltz / Homeless Programs Manager / Orange County <br /> <br />DocuSign Envelope ID: A80A68F0-12D3-42DA-80C7-45C66A2BB398 <br />11/18/2021