Is the applicant a municipality, defined as a county, city, town, or village of the State of New York?

Is the proposed EVSE infrastructure a networked L2 charger with one or more SAE J1772 ports appearing on the NYSERDA, Utility Make Ready, or NYSOGS Contract lists and having a minimum charge capacity of 7.2kW OR a networked DCFC with any combination of CHAdeMO, SAE, or CCS ports with a minimum charge capacity of 50kW appearing on the Utility Make Ready or NYSOGS Contract lists, OR hydrogen fueling infrastructure utilizing hydrogen derived from electrolysis with a minimum pressure of 70 megapascals and the capacity to dispense at least 100 kg/day?

Will the applicant municipality be the owner of all infrastructure and project components funded by this grant application and ensure accessibility to, and functionality of, the infrastructure for a minimum of 10-years?

Is the applicant municipality registered in the Statewide Financial System Grants Management System (SFS GM)? Although application to the DEC Municipal Zero-emission Vehicle Infrastructure grant program takes place in the CFA, the contracting process occurs in the SFS GM. Therefore, all applicants must be registered in the SFS GM at the time of application. Applicants that are not registered will be deemed ineligible.

Is the site of EVSE installation publicly accessible?

Is the primary purpose of the facility public charging or fueling of zero-emissions vehicles?

Project Street Address: Please input the project street address (Street Number and Street Name only).

If the project has multiple locations, please input the primary street address of the project. If the project does not have a definite street address, please input the approximate street address of the project (Street Number and Street Name only).

Project City

Project State

Project county or counties.

Project ZIP Code. (please use ZIP+4 if known)

US Congressional District where the project is located. (This question's value will be filled automatically, based on the project address, when the application is finalized.)

Project Latitude (This question's value will be filled automatically, based on the project address, when the application is finalized.)

Project Longitude (This question's value will be filled automatically, based on the project address, when the application is finalized.)

NYS Assembly District where the project is located. (This question's value will be filled automatically, based on the project address, when the application is finalized.)

NY Senate District where the project is located. (This question's value will be filled automatically, based on the project address, when the application is finalized.)

Type of Applicant (select one)
Applicants will first select a single applicant type from the categories below and then a subtype based on their initial selection. Applicants should review the selections below which provides a list of subtypes by main applicant type.

1. For Profit entity options:
Limited Liability Corporation (LLC)
Limited Liability Partnership (LLP)
Sole Proprietorship
S Corporation
C Corporation
Limited Partnership (LP)
Other- applicant will be required to list their other for-profit designation.

2. Not-for profit entity options:
501(c)(1) Any corporation that is organized under an act of Congress that is exempt from federal income tax;
501(c)(2) Corporations that hold a title of property for exempt organizations;
501(c)(3) Corporations/funds/foundations that operate for religious/ charitable/ scientific/ literary/ educational purposes;
501(c)(4) Nonprofit organizations that promote social welfare;
501(c)(5) Labor, agricultural, or horticultural associations;
501(c)(6) Business leagues/chambers of commerce/etc. that are not organized for profit;
501(c)(7) Recreational organizations; and
Other- applicant will be required to list their other not-for-profit designation.

3. Government entity options:
Federal
State
County
City
Town
Village
Tribal
School District
County or Town Improvement District
District Corporation
Public Authority
Business Improvement District
Fire District
Board of Cooperative Education Services (BOCES)
Public Library
Association Library
Other- applicant will be required to list their other government designation.

Select the government entity of the applicant applying for funding:

Enter the applicant's 'Other' government entity designation.

Select an applicant ID type from the list below that you normally use to identify your organization on application forms.

Based on your selection from the previous question, enter the associated ID number.

Organization Legal Name

Applicant Street Address

Applicant City

Applicant State

Applicant ZIP Code. (please use ZIP+4 if known)

Applicant Telephone Number (please include area code)

Applicant Email Address

Contact Salutation

Contact First Name

Contact Last Name

Contact Title

Primary Organization

Contact Street Address

Contact City

Contact State

Contact ZIP Code (please use ZIP+4 if known)

Primary Contact Phone Number. (please include area code)

Contact Email

Additional Salutation

Additional Project Contact First Name

Additional Project Contact Last Name

Additional Contact Title

Additional Organization

Additional Contact Street Address

Additional Contact City

Additional Contact State

Additional Contact ZIP (please use ZIP+4 if known)

Additional Contact Telephone Number (please include area code)

Additional Contact Email Address

Project Description. Concisely describe the project, indicating the location, what will be planned, designed, acquired, and/or constructed, the issues/opportunities to be addressed, and expected outcomes and deliverables. Additional details will be collected later in the application process.

Statement of need: Provide a brief summary of the need for the project in the geographic area proposed and the project's financing needs, including funding gaps of the proposed project.

Current State of Project Development (i.e. planning, preliminary engineering, final design, etc. You may enter N/A for non-project related applications)

Estimated Project Timeline: include project start/completion dates, estimates for design, permitting and construction or other major steps.

Provide a list of all federal, state, and local reviews, approvals, or permits needed or completed, including the dates when they are expected to be completed or were completed. If Not Applicable, indicate "NA".

For each program to which you are applying under the CFA, explain your strategy for proceeding if the full amount of requested funding, required matching funds, and temporary financing are not secured as expected, or committed sources become unavailable.This explanation must address any proposed project phases, and both CFA and non-CFA sources of funds.

Applicants (municipalities) are required to download the Executive Order 16 Form provided in the link below, fill in the fields, sign the form, and upload the completed form. Form must be signed by the municipal applicant. Applications without a signed Executive Order 16 Form will be deemed ineligible.

Applicants are required to download the Sexual Harassment Prevention Certification Form provided in the link below, fill in the fields, sign the form, and upload the completed form. If the certification cannot be made, applicants are required to upload a signed statement detailing the reasons why the certification cannot be made. Applications without a signed Sexual Harassment Prevention Certification Form or a statement detailing the reasons why the certification cannot be made will be deemed ineligible.

Pursuant to NYS's Smart Growth Public Infrastructure Policy Act, a Smart Growth Assessment form must be completed as part of the application. Applicants are required to download the Smart Growth Assessment Form provided in the link below, fill in the fields, sign the form, and upload the completed form. Applications without a signed Smart Growth Assessment Form will be deemed ineligible.

Attach a proposed work plan for the project using the provided template. See the State Defined Work Plan (attached to the RFA) for guidance. Follow the SFS GM format of objectives (goals), tasks, and performance measures (deliverables). Applications that do not include a completed work plan, using the provided template, will be deemed ineligible. A Microsoft Word version of this template may be requested by e-mailing zevrebate@dec.ny.gov. Attachment cannot exceed 30MB.

Attach a budget for the project using the provided template. The budget information provided in the template should include ONLY grant and match for the Municipal ZEV Infrastructure Grant Program funded portion of the project. If the total project cost is above the grant plus match amount for this grant program, include the entire cost and all funding programs in the CFA budget. Applications that do not include a complete budget, using the provided template, will be deemed ineligible. A Microsoft Word version of this template may be requested by e-mailing zevrebate@dec.ny.gov.

Upload documents such as quotes and pricing sheets that substantiate the costs included in the budget for each budget category.

Upload specification sheets for all EVSE equipment to be installed as part of the proposed project.

Is the project a partnership between one or more municipalities or municipal and non-municipal entity(ies)?

Attach as a single file, letters of commitment, existing or draft Memoranda of Understanding/Agreement, lease arrangements, or other mechanisms authorizing the partnership and defining the roles, responsibilities, and financial contribution of each partner directly participating in the proposed project. The work plan must denote the tasks to be completed by each partner and the budget must denote the portion of match to be contributed by each partner.

Is the project site located in a disadvantaged community census tract?

Upload a map depicting the disadvantaged community(ies) within the municipal boundary AND a street-level map depicting the location of the project within the disadvantaged community census tract. Attachment C of the request for applications provides instructions on how to use the DECinfo Locator to map disadvantaged community census tracts within a municipality.

Upload a map of the project location overlaid with a FEMA effective flood insurance rate map (FIRM) or comparable flood-risk map if an effective FIRM is not available for the project site. Project sites located in a floodplain must floodproof the infrastructure.

Will all work take place on property owned by the municipal applicant?

Upload documentation of ownership, such as a deed, or documentation clearly depicting the municipal right-of-way (ROW) along the project area. Highlight the project area in ROW documentation.

Upload a notarized written statement from the property owner in support of the project, indicating an agreement to enter into a climate change mitigation easement (CCME), OR a draft CCME, OR agreement to enter into a DEC approved agreement from a government entity not authorized to enter into a CCME.

Will land value be used as match?

Upload 1. a map identifying the property including section-block-lot number and adjacent roadways; 2. appraisal report with the valuation date within one (1) year of application submission date; 3. copy of the recorded deed conveying title with legal and narrative descriptions and 4. method of calculation determining total land value (excluding buildings) of the parking spaces to be utilized for ZEVs. Note: Deed will need to be amended to contain Notice of Grant language.

All applicants must upload an Operations, Maintenance, and Mitigation Monitoring Plan. The plan must, at minimum, address the following: snow removal, floodproofing (if facility is located in a 100-year floodplain), cable and plug inspections, parking of non-EV vehicles in EV dedicated spaces, customer support, ensuring public access for 10-years, physical and software maintenance for a minimum of 10-years, ADA accessibility, modem/hardware upgrades and replacement, and long-term electrical costs (including possible demand charges) that may not be recouped from users. Applications without OMMM plans or OMMM plans that are found to be deficient will be deemed ineligible.

Will the proposed facility be used for municipal fleet charging?

Upload a shared use plan as defined in the RFA. The shared use plan must designate more than 50% of the available ports for public use.

Upload a satellite image showing the proposed site and location of the chargers on the site. Label adjacent roadways and points of interest.

Upload a site plan depicting the location of all EVSE, distance from existing or new electrical panel and/or meter, and power source location, if known (for charging stations). Distinguish between charging stations or hydrogen filling stations in existence prior to this grant application and charging stations or hydrogen filling stations to be added as part of this proposed project, as well as existing & planned infrastructure.

Will Utility Make Ready funds be used as match?

Upload a copy of the award letter or contract, or, if funds have not yet been award, a copy of the application.

Briefly describe the project, site work to be competed, and electrical needs at the location that corresponds with this application only.

Briefly describe the accessibility of the proposed facility location, and any limitations on public access, including gates, hours of closure, security, and/or physical site factors.

Provide the address where the EVSE will be installed. If there is not an exact address, approximate and address.

Provide the coordinates of the EVSE facility in WGS 84 Web Mercator.

List all project participants (staff, volunteers, contractors, departments, etc.) and describe their role(s) and their contribution to the tasks identified in the budget and work plan.

If the project site is located in a disadvantaged community census tract, what is the census tract identifier number? Attachment C of the RFA provides instructions on how to use the DECinfo Locator to map disadvantaged community census tracts within a municipality.

What is the municipal applicants MHI according to census table B19013? See Attachment B of the RFA for instructions.

What is the local match percentage based on the applicants MHI and the infrastructures' location inside or outside a disadvantaged community? See RFA for details.

Describe the local match in dollar amount, source, and percentage of total project cost. State and federal funding sources are not an eligible source of match.

Will Utility Make Ready Funds be used as match?

Detail what costs will be coved by Utility Make Ready Program and what costs will be covered by the DEC Municipal ZEV Infrastructure Grant. Note that Utility Make Ready Programs typically do not cover the cost of charging stations.

Will the project be undertaken in partnership with any other municipal or non-municipal entities?

Identify all project partners and briefly describe partner roles, responsibilities, and match contribution. (Does not apply to contractors.)

Is the proposed facility Level 2 EVSE, DCFC EVSE, a combination of Level 2 and DCFC, or a hydrogen fuel facility?

What is the manufacturer, make, and model of the Level 2 station(s) to be installed? Eligible models can be found on the NYSERDA Charge Ready, Utility Make Ready, and OGS State Contract documents linked in the request for applications

What is the total number of Level 2 charging STATIONS to be installed?

What is the total number of Level 2 PORTS to be installed?

What type of ports will be included on the Level 2 charger?

What is the minimum charging capacity of the proposed Level 2 charging station(s)?

Will the Level 2 charging station(s) be networked?

Has THIS Level 2 infrastructure (to be installed), at THIS facility, received funding from NYSERDAs Charge Ready NY program?

Will the Level 2 charging stations use Open Charge Alliance's Open Charge Point Protocol (OCPP) v2.0.1 or later?

Is the facility directly connected to a source of, or exclusively purchases, renewable energy (wind, solar)? Describe.

Is the facility directly connected to energy storage (e.g., battery)? Describe.

What is the cost for cable, conduit, trenching, and restoration costs, including supplies, materials, and labor. Will this work be contracted or performed by municipal staff? If any work is to be performed by municipal staff, separate the cost of contractual work from personnel costs.

What are the costs for electrical infrastructure such as panels and breakers, including supplies, materials, and labor. Will this be supplied by the contractor or purchased directly by the municipality?

What is the cost for all non-electrical infrastructure costs such as bollards, signage, striping and mounting bases and/or hardware. Will these be supplied by the contractor or purchased by the municipality?

What is the manufacturer, make, and model of the DCFC station(s) to be installed? Eligible models can be found on the Utility Make Ready and OGS State Contract documents linked in the request for applications.

What is the total number of DCFC PEDESTALS to be installed?

What is the total number of DCFC PORTS to be installed?

What type of ports (CCS, CHAdeMO, CCS /SAE, CHAdeMO/SAE) will be included on each charger? Some units contain 1 DCFC port and one SAE J1772, others contain two DCFC ports.

What is the minimum charging capacity of the DCFC?

Will the DCFC EVSE be networked?

Will the units use Open Charge Alliance's Open Charge Point Protocol (OCPP) v2.0.1 or later?

Is the facility directly connected to a source of, or exclusively purchases, renewable energy such as wind or solar? Describe.

Is the facility directly connected to energy storage (e.g., battery)? Describe.

What is the cost for cable, conduit, trenching, and restoration costs, including supplies, materials, and labor? Will this work be contracted or performed by municipal staff? If any work is to be performed by municipal staff, separate the cost of contractual work from personnel costs.

What are the costs for electrical infrastructure such as panels and breakers, including supplies, materials, and labor? Will this be supplied by the contractor or purchased directly by the municipality?

What is the cost for all non-electrical infrastructure costs such as bollards, signage, striping and mounting bases and/or hardware? Will these be supplied by the contractor or purchased by the municipality?

What is the manufacturer, make, and model of the Level 2 station(s) to be installed? Eligible models can be found on the NYSERDA Charge Ready, Utility Make Ready, and OGS State Contract documents linked in the request for applications. (Spec sheet to be uploaded to the corresponding attachment question).

What is the total number of Level 2 charging STATIONS to be installed?

What is the total number of Level 2 PORTS to be installed?

What type of ports will be included on the Level 2 charger?

What is the minimum charging capacity of the Level 2 charger?

Will the Level 2 EVSE be networked?

Has THIS Level 2 infrastructure (to be installed), at THIS facility, received funding from NYSERDAs Charge Ready NY program?

What is the manufacturer, make, and model of the DCFC station(s) to be installed? Eligible models can be found on the Utility Make Ready and OGS State Contract documents linked in the request for applications.

What is the total number of DCFC PEDESTALS to be installed?

What is the total number of DCFC PORTS to be installed?

What type of ports (CCS, CHAdeMO, CCS /SAE, CHAdeMO/SAE) will be included on each charger? Some units contain 1 DCFC port and one SAE J1772, others contain two DCFC ports.

What is the make and model of each DCFC charging station to be installed? (

What is the minimum charging capacity of the DCFC EVSE?

Will the DCFC EVSE be networked?

Will the DCFC units use Open Charge Alliance's Open Charge Point Protocol (OCPP) v2.0.1 or later?

Is the DCFC facility directly connected to a source of, or exclusively purchases, renewable energy such as wind or solar? Describe.

Is the DCFC facility directly connected to energy storage (e.g., battery)? Describe.

What is the cost for cable, conduit, trenching, and restoration costs, including supplies, materials, and labor. Will this work be contracted or performed by municipal staff? If any work is to be performed by municipal staff, separate the cost of contractual work from personnel costs.

What are the costs for electrical infrastructure such as panels and breakers, including supplies, materials, and labor. Will this be supplied by the contractor or purchased directly by the municipality?

What is the cost for all non-electrical infrastructure costs such as bollards, signage, striping and mounting bases and/or hardware. Will these be supplied by the contractor or purchased by the municipality.

What components of a hydrogen fuel filling station are proposed to be purchased and installed as part of this proposed project?

What is the manufacturer, make, and model of all hydrogen fuel filling station equipment to be installed?

What is the total number of hydrogen fuel cell nozzles to be installed with these funds?

What Is the source of the hydrogen fuel (how is it created)?

What is the minimum pressure and daily dispensing capacity of the hydrogen fuel filling station?

What hydrogen fuel filling station components will be charged to this grant for both grant dollars and match dollars?

What funding will cover the balance of the project costs?

What is the cost for all hydrogen fuel filling station components including supplies, materials, and labor. Will this work be contracted or performed by municipal staff? If any work is to be performed by municipal staff, separate the cost of contractual work from personnel costs.

By entering your name in the box below, you certify that you are authorized on behalf of the applicant to submit this application. You further certify that all of the information contained in this Application and in all statements, data and supporting documents which have been made or furnished for the purpose of receiving Assistance for the program described in this application, are true, correct and complete to the best of your knowledge and belief. You acknowledge that offering a written instrument knowing that the written instrument contains a false statement or false information, with the intent to defraud the State or any political subdivision, public authority or public benefit corporation of the State, with the knowledge or belief that it will be filed with or recorded by the State or any political subdivision, public authority or public benefit corporation of the State, constitutes a crime under New York State Law.