IDEM CFI Project Intake Form IDEM - Charging and Fueling Infrastructure - Project Interest Form IDEM CFI Project Intake FormPlease complete the form below with information about your project related to the Round 2 Charging and Fueling Infrastructure (CFI) Grant Opportunity (Round 2). IDEM will utilize this information to develop a statewide application to enhance Indiana's EV Charging and alternative fueling options.Organization Name(Required) Organization Name Contact Name(Required) First Last Title Contact Email Address(Required) Contact Phone Number(Required)Site Host Owner?(Required)YesNoThird Party Ownership(Required)YesNoDoes the project location serve a disadvantaged community?(Required)YesNoIs your company or the site host a DBE, Minority-owned Business, Women-owned Business, or 8(a) Firm?(Required)YesNoTotal Project Budget(Required) What's the total cost of your project including hardware, software, and associated installation costs?Local Match Source?(Required) Where is the 20% match being sourced from?Brief Project Description(Required) What is the need for infrastructure? Where is it being installed? Type of fueling infrastructure? Electric, CNG, Hydrogen, LPG?Organization Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Proposed Project Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Project Location Latitude Project Location Longitude Project Merit Criteria Considerations Related to Scoring Criterion(Required)Provide a brief description how this project relates to: 1. Safety 2. Climate Change, Resilience and Sustainability 3. Equity, Community Engagement, and Justice40 4. Workforce Development, Job Quality and Wealth Creation 5. CFI Program Vision Project Readiness Criteria:(Required)Provide a brief description of your project related to: 1. SOW; 2. Energy Sources and relevant role of utility providers; 3. Infrastructure upgrades to site; 4. Assessment of ROW and acquisition necessary; 5. Inclusion of project relevant to State, MPO or Local planning documents; 6. Any project approvals or permits already obtained; 7. Known project risks; 8. Public Engagement; 9. DBE participation engagement; 10. Equity and Accessibility requirements met; 11. Anticipated timeline; 12. Project scope related to 23 CFR Part 680 requirements. Would you like someone from the GOEVIN team to reach out to you? Yes, by Email. Yes, by Phone. Your Comments/Questions(Required)
