LORAIN COUNTY STORM WATER DISTRICT APPLICATION FOR FINANCIAL ASSISTANCE October 7, 2013 TOWNSHIP: _________________________________________________ CONTACT: ________________________________ PHONE #(_____)___________________ (Contact person should be the individual who will be available during business hours and who can best answer or coordinate the response to questions) FAX: (______) _______________________________ E-MAIL: _______________________________
PROJECT NAME: ____________________________________________________________ TOTAL PROJECT COST: $ ________________ FUNDING REQUESTED: $ ________________
1.0 PROJECT INFORMATION If the project is multi-jurisdictional, information must be consolidated in this section. 1.1 PROJECT NAME: _______________________________________________________________ 1.2 BRIEF PROJECT DESCRIPTION – (Sections A through D): A. SPECIFIC LOCATION AND WATERSHED:
B. PROJECT COMPONENTS:
C: PHYSICAL DIMENSIONS:
D: Number of households served by Project and/or acreages of land improved by the Project, and/or potential assessments/levies:
2.0 PROJECT FINANCIAL INFORMATION
2.1 PROJECT ESTIMATED COSTS: (Round to Nearest Dollar)
Force Account Dollars TOTAL DOLLARS
a.) Basic Engineering Services:
$ _____________.00
$ ___________
$ ______________.00
$ ___________
b.) Acquisition Expenses: Land, Right-of-Way, Or Easements
$ ______________.00
$ ___________
c.) Construction Costs:
$ ______________.00
$ ___________
d.) Equipment Purchased Directly or Leased:
$ ______________.00
$ ___________
e.) Permits, Advertising, Legal: (Or Interest Costs for Loan Assistance Applications Only)
$ ______________.00
$ ___________
f.) Construction Contingencies:
$ ______________.00
$ ___________
g.) TOTAL ESTIMATED COSTS:
$ ______________.00
$ ___________
Preliminary Design $ __________________ Final Design $ __________________ Bidding $ __________________ Construction Phase $ ___________________ Additional Engineering Services *Identify services and costs below.
*List Additional Engineering Services here: Service:
Cost:
3.0 PROJECT SCHEDULE:* 4.1 4.2 4.3 4.4
Engineering/Design: Bid Advertisement and Award: Construction: Right-of-Way / Land Acquisition:
BEGIN DATE ______/_____/______ _____ /_____/______ _____/_____/______ ____ /_____ /______
END DATE ____ / ____ /______ ____ /_____/_______ ____ /_____ /_______ ____ /_____/_______
4.0 APPLICANT CERTIFICATION: The undersigned certifies: (1) he/she is legally authorized to request and accept financial assistance from the Lorain County Storm Water District; (2) to the best of his/her knowledge and belief, all representations that are part of this application are true and correct; (3) all official documents and commitments of the applicant that are part of this application have been duly authorized by the governing body of the applicant; and, (4) should the requested financial assistance be provided, that in the execution of this project, the applicant will comply with all assurances required by Ohio Law, including those involving Buy Ohio and prevailing wages.
__________________________________________________________ Certifying Representatives (Types or Print Name and Title)
___________________________________________/ _______________ Original Signatures / Date Signed