Congressman Michael C. Burgess, M.D.
FISCAL YEAR 2011
GENERAL APPROPRIATIONS REQUEST WORKSHEET AND QUESTIONNAIRE
Deadline for Submission: February 19, 2010
INSTRUCTIONS
Deadline: Please complete each applicable section below and submit this form to no later than February 19, 2010. If you do not have this form in an electronic version, please e-mail the above address to obtain the form.
Multiple Projects: To assist in processing requests, please e-mail only ONE request worksheet per e-mail. If your organization intends to seek funding for more than one project, please e-mail each request worksheet separately noting priority order of each project request.
Electronic Submission: When submitting your request via e-mail, please include the following information in the subject line of your electronic message: “FY11 Name of Appropriations Bill - Name of Organization -Location of Project - Priority Order of Project”. Example:
To:
From: your e-mail address
Subject: FY11 LHHS Appropriations Bill - Name of Organization - Anywhere, TX - #1
Confirmation: Upon proper submission, you will receive an e-mail confirmation. Due to the volume of requests, you may not receive a confirmation until February 26, 2010. If you do not receive an e-mail confirming that the form was received by this date, please contact the above e-mail address to determine if it is necessary to resubmit your request.
Completion of Questions: Please make every effort to fully complete every question. Please avoid submitting the same answer for each response. Please note that the form may be returned to your organization if any of the fields are left blank.
Font: Please submit your answers in 12-point, Times New Roman font. Please do not bold, underline, italicize or otherwise highlight your answers or responses.
Letters of Support and Attachments: Letters of support and any supplemental materials are encouraged to be submitted to the above e-mail address as they become available. Evidence of strong State and/or local support, including letters of support from State and/or local officials, will be weighed heavily.
Disclaimer: It is important to note that the amount of funding for directed projects is very limited and all proposals will be subject to considerable competition and scrutiny. Moreover, the budgetary constraints currently facing the federal government, coupled with new restrictions on the scope of individualized projects, will further limit the opportunities for directed project funding. Submission of this form should not be construed as a guarantee that funding will be awarded. Note: Funding requests will only be considered for public entities, non-profit organizations, and educational institutions. For-profit company requests will not be considered.
Disclosure: Please note that the information provided in the form may be disclosed to the public, including on Congressman Burgess’ official House website (http://burgess.house.gov).
Appropriations Request Worksheet
Appropriations Bills
Please check only ONE per request worksheet. If your organization intends to seek funding for more than one request, please submit a separate worksheet for each project request.
For Transportation and Bill or Report Language requests, you must complete a separate form. Please do NOT complete this form.
____Agriculture
____Defense
____Commerce, Justice and Science
____Energy and Water, includes Army Corps of Engineers
____Financial Services, includes the Small Business Administration
____Homeland Security
____Housing and Urban Development
____Interior and Environmental Protection Agency
____Labor, Health and Human Services and Education
____Military Construction
____State, Foreign Operations
Identify Federal Department or Agency which is best suited to provide funding for this project (only identify ONE)Identify Account or Program administered by the above Federal Department or Agency which is best suited to provide funding for this project (only identify ONE)
For Army Corp of Engineers Projects
Please specify if funding is requested for a (please check ONE):
____ New Study
____ Ongoing General Investigation (Reconnaissance study phase; feasibility study phase; preliminary engineering and design phase)
____ Construction
____ Operation and Maintenance
Background Information
Name of Organization (Legal grantee name)Name of Primary Point of Contact
Mailing Address
County
Business Phone Number
Cell Phone Number
Fax Number
Email Address
Municipality and County in Texas. Please describe the location where the requested funding is proposed to be spent.
Identify whether your organization is a public, private non-profit, or educational entity.
Lobbyist Contact Information. If applicable, please provide:
Name of Lobbying Firm
Name of Primary Point of Contact
Mailing Address
Business Phone Number
Cell Phone Number
Fax Number
Email Address
Member Visit. If applicable, please identify date and nature of any visit made by Congressman Burgess within the past two years.
Project Funding Information
Amount of Federal Funding Requested for Fiscal Year 2011Total Cost of the Project
President’s Fiscal Year 2011 Budget Request. If applicable, please include amount requested by the President.
Authorization: Please identify if this project is authorized under current law. If applicable, please provide the Authorization, including the Public Law # (P.L. #) and Section.
If your organization is requesting more than one project, please note the ranking for this request. (Example: 1st Priority would be highest).
If your organization is requesting more than one project and/or the same request in multiple appropriation bills, please list all other bills.
Federal Requests Submitted to other Members for this project. Please identify any other member of the House or Senate that you plan to submit a request for this project.
Federal Requests Submitted to other Members for another project. Please identify any other member of the House or Senate that you plan to submit a request for another project, including detail on the request and appropriations bill.
Appropriation Funding Questionnaire
1) Please list prior federal funding this project and/or your organization overall has received. Include all sources (Federal appropriations and authorization bill earmarks, Federal grant funds, etc.). Also, please include a brief description, specific amount, whether an earmark or grant, and awarding Department/Agency and Account/Program.
FY10 Senate –
FY10 House –
FY09 -
FY09 -
FY08 -
FY07 -
FY06 -
FY05 -
FY04 -
FY03 -
2) If Congress has previously provided directed funding for this project, please provide specific details on the use of these funds. If applicable, please describe whether the project has met previously stated goals and has produced tangible benefits.
3) Has all prior funding been obligated? If not, please provide an explanation.
4) Please provide a detailed budget breakdown for requested Fiscal Year 2011 funds.
5) Please identify funds from public, non-federal sources, including local, regional or State funding (dollar amount, source and percentage of total cost).
6) Please identify funds from private sources (dollar amount, source and percentage of total cost).
7) Federal grant programs often require a non-federal match and the amount can be as much as 50% of the total grant award. Is your organization able to match up to 50% of the total amount of federal funding requested (Yes/No)? In addition, please specify whether any conditions exist on the availability of these funds and whether any alternative funds are available if the committed funds cease to be available.
8) Often funding cannot be provided at the level requested. Is there a minimum amount that could be obligated upon enactment to advance the project? If so, please identify that amount and state how it would be used.
9) Please identify any reason why the funding requested could not be obligated upon enactment.
10) Do you anticipate a need for federal funding in subsequent fiscal years? If so, how much funding? Please include a Project plan/cost schedule to completion.
11) If applicable, upon completion of this project, does your agency have the funding in your budget to maintain and operate the completed project? (Please explain).
Appropriation Project Questionnaire
1) Please provide a Project Name (as you would like it to be listed in the bill or report).
2) Please provide a brief summary of this project and identify the specific purpose of this initiative (programming, equipment, acquisition, construction, planning, design, etc.). Example: Funding will be used for ______in Texas. (Please limit to no more than 2 sentences).
3) In 100 words or less, please provide a concise rationale for why Congress should consider funding this project, including why it is a valuable use of taxpayer funds.
4) Please provide a narrative describing the project, including background, need and use of funding. (Please limit to no more than 2 paragraphs).
5) Please describe the national significance of this project. (Please limit to no more than 2 paragraphs).
6) Please describe the importance of this project to the 26th Congressional District in Texas. (Please limit to no more than 2 paragraphs).
7) Please describe the anticipated benefit of this project to the local community. (Please limit to no
more than 2 paragraphs).
8) Does this project enjoy support from State and/or local officials? If so, please provide letter (s) indicating this support.
9) Please state any benefits this project will have with respect to economic development, job growth/training, energy efficiency, environmental restoration/protection, safety, health care, education and agriculture (this list is not exclusive). Please list any other benefits that you wish to be considered.
10) What are the specific goals of this project? How will you measure success?
11) Has your organization in general or this project in particular been the subject of any negative scrutiny?
12) Is your organization currently under local, State or Federal criminal investigation of any type, or has it been in the past? If yes, please provide explanation and current state of investigation.
12) Does any individual at your organization earn compensation in excess of $500,000? If so, please explain.
Request Certification Form
Congressman Michael C. Burgess, MD
I, ______ATTEST THAT THIS PROJECT REQUEST MADE ON
BEHALF OF______MEETS THE FOLLOWING CRITERIA:
§ All appropriations requests must be a priority for the 26th District and/or the country at large as defined as enhancing life, liberty, or the general welfare. All requests must be a proper and wise use of federal taxpayer dollars and must be justified as such.
§ None of the funding requested will be used for a new building, program, or project that has been named for a sitting Member of Congress. Exceptions for previously named buildings, programs, or projects must be fully justified. No request will be made in which Congressman Burgess or his wife has any financial interest.
§ None of the funding requested will be passed through to another entity for non-support or non-procurement activities and the primary purpose of this request is NOT to secure funds for other entities. For entities that are NOT a unit of federal, state, or local government, the requesting entity agrees that the entity itself will spend at least 50% of the requested funds.
§ For earmarks distributed in the form of a grant, where the receiving entity is NOT a unit of federal, state or local government, OR where the entity receiving the funding will NOT be providing support to a federal, state or local government, or will NOT be providing research, the requesting entity is to provide matching funds including in-kind contributions of 5% or more above statutory requirement.
§ All requests shall be made in accordance with House of Representatives rules and within Appropriations Committee deadlines. No funding request will be submitted after the deadline established by the Committee.
§ Attachment of detailed finance plan MUST include:
o anticipated sources of the funding for the duration of the project;
o percent and source of required matching fund; and
o justification for use of federal taxpayer dollars.
Name of person certifying: ______
Title of person certifying: ______
Project Name as it will appear in the bill: ______
Legal name of entity making request: ______
Address: ______
______
______
Signature of person certifying Date
(Please scan a signed copy of this form and include the PDF with your email submission. Further, mail the original to: Congressman Michael Burgess, 229 Cannon House Office Building, Washington, DC 20515)
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