Kane County Revolving Loan Fund for Energy Efficiency LOAN APPLICATION Please review the attached Application Checklist before submitting this application.
Date Application Submitted
___________________
Loan Amount Requested
___________________
Applicant Information Business / Organization Name ___________________________________________________ Address _______________________________________________________________________ _______________________________________________________________________ Contact ______________________________
Title ___________________________________
Phone ________________________
Email ________________________________________
Fax __________________________
Website _______________________________________
FEIN# ________________________
Date of Incorporation __________________
Applicant Tax / Legal Status – Check all that apply Not for profit
Tax Exempt 501(c) 3
Government / Public Entity
Tax Exempt Other_______________
Other _________________________
General Information on Project/Loan Request Description of project __________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Full address of project ______________________________________________________________________________ ______________________________________________________________________________
PIN
__________________________
Total square feet of floor space
___________________
Total square feet of residential space
___________________
What is the current environmental condition of the site? ______________________________________________________________________________ ______________________________________________________________________________ Status of Real Estate Taxes Current
Tax Exempt
Delinquent
Amount Delinquent $______________
Summary Project Budget Sources
Amount
Applicant equity / cash
$
Revolving Loan Fund
$
Other _______________
$
Total Sources $ Uses
Total Project
Loan Proceeds
HVAC
$
$
Insulation
$
$
Appliances
$
$
Windows
$
$
Energy Production
$
$
Consultants
$
$
Other
$
$
Other
$
$
Other
$
$
Total Uses $
$
Project Team 1. Project Manager (if different from applicant contact)______________________________ Address _____________________________________________________________________ City ___________________
State _____ Zip __________ Phone __________________
2. Legal Counsel ______________________________________________________________ Address _____________________________________________________________________ City ___________________
State _____ Zip __________ Phone __________________
3. Architect __________________________________________________________________ Address _____________________________________________________________________ City ______________________ State _____ Zip __________ Phone _________________
4. General Contractor/Builder ___________________________________________________ Address _____________________________________________________________________ City ______________________ State _____ Zip __________ Phone _________________
5. Other Contractor
_________________________________________________________
Address _____________________________________________________________________ City ______________________ State _____ Zip __________ Phone _________________
6. Other Contractor
_________________________________________________________
Address _____________________________________________________________________ City ______________________ State _____ Zip __________ Phone _________________
7. Energy Related Consultants __________________________________________________ Address _____________________________________________________________________ City ______________________ State _____ Zip __________ Phone _________________
Energy Information Has an energy audit been completed?
Yes
No
Does the applicant/building have a building energy manager or operations staff? Yes
No
What energy source is used to heat the building? Electricity
Natural Gas
Steam
Do you have access to monthly utility billing statements?
Yes
No
If not, please make arrangements to do so for necessary tracking of consumption, post-retrofit work.
Utilities Information – Please provide data for building presented for retrofit activity
Provider Electric Natural Gas Other
Account Number
Total Usage over last 12 month period Total Cost kWh $ therms $
Disclosures & Certifications Check if the Applicant is involved or threatened with a bankruptcy, lawsuit or other litigation? Has Applicant ever defaulted on a loan? _______________ If yes, please explain _______________ _____________________________________________________________________________________ _____________________________________________________________________________________
Applicant certifies that all financial records, statements, and plans requested in the above application are accurate and enclosed herein. _________________________________ Signature
________________________________ Name (Type or Print)
_________________________________ Title
________________________________ Date
Applicant authorizes Kane County to inquire/verify information pertaining to bank accounts, loans and/or credit cards with relevant financial institutions. _________________________________ Signature
________________________________ Name (Type or Print)
_________________________________ Title
________________________________ Date
Applicant hereby acknowledges that the Kane County Revolving Loan Fund for Energy Efficiency is funded by an Energy Efficiency and Conservation Block Grant (EECBG) through the United States Department of Energy (DOE) as part of the American Recovery and Reinvestment Act (ARRA). More information available at www1.eere.energy.gov/wip/guidance.html#eecbg Applicant understands project must follow the most recent ARRA provisions and EECBG guidance regarding the Buy American Provision, the Davis-Bacon Act, Historic Preservation requirements, the National Environmental Policy Act (NEPA), Waste Stream Guidance and any additional requirements as determined by DOE. _________________________________ Signature
________________________________ Name (Type or Print)
_________________________________ Title
________________________________ Date