Applicant:
Project Title:
Project Priority: / # / of / Application Submissions

BUTLERCOUNTY COMMUNITY DEVELOPMENT

Public Facilities & Improvements

Please check which code defines your project:

03 / General
03A / Senior Centers
03B / Handicapped Centers
03C / Homeless Facilities
03D / Youth Centers
03E / Neighborhood Facilities
03F / Parks, Recreational Facilities
03G / Parking Facilities
03H / Solid Waste Improvements
03I / Floor Drainage Improvements
03J / Water / Sewer Improvements
03K / Street Improvements
03L / Sidewalks
03M / Child Care Centers
03N / Tree Planting
03O / Fire Station / Equipment
03P / Health Facilities
03Q / Abused and Neglected Children’s Facilities
03R / Asbestos Removal
*Other

* If other, please describe:

SECTION I:APPLICANT INFORMATION

Contact Person:
Title:
Address:
Phone 1: / Phone 2:
Fax: / E-Mail:

A.MUNICIPAL APPLICANTS

Yes / No
1. / Is this project consistent with the needs determined by your
Community Survey, submitted with the 2005-2009 Butler County
Consolidated Plan?

2.Explain how the proposed project is or is not consistent with the needs determined by the Community Survey:

B.NOT-FOR-PROFIT APPLICANTS

Yes / No
1. / Is this project consistent with the Mission Statement of your agency?

2.Explain how the proposed project is or is not consistent with the Mission Statement of your agency:

SECTION II:NATIONAL OBJECTIVE

A.NATIONAL OBJECTIVE:Low / Moderate Benefit

Complete this question if your project meets the National Objective of providing a benefit to low and moderate income people, either through “Area Benefit” or “Limited Clientele”.

1. Area Benefit Project:

1a.This project qualifies as an LMI area determined by:

Census data / Census information to be provided in Section III
Survey / Surveys and Survey Summary to be included as an Attachment
and labeled as Attachment

1b.Demographics:

Number of households in area:
Number of residents in area:
Percentage of LMI residents:

2. Limited Clientele Project:

2a.How many people will use and benefit from this project: ______

2b.Does this project primarily benefit a specialized population such as:

Disabled
Elderly
Homeless
Other:

B.NATIONAL OBJECTIVE:Elimination of Slum or Blighted Condition

1.What is the condition addressed by your project?

(ie. Deteriorated building, lack of adequate infrastructure)

2.Describe the comprehensive strategy that will be implemented to address the conditions described above:

Attach a copy of the municipal board resolution designating the area as slum and blight.
This Attachment is labeled as Attachment

C.NATIONAL OBJECTIVE:Urgent Need

1. / What is the condition that is causing a threat to the health and welfare of the community?
2. / When did this condition occur?
3. / From what sources did the community seek to address this problem?
Source / Date of Request

SECTION III:PROJECT INFORMATION

A.Project Narratives

Provide a narrative description of the project, answering questions 1-5 below.

The Narrative is labeled as Attachment
1. / How will this project impact the community?
2. / How does this project address the National Objective?
3. / What is the goal of the project?
4. / How do you expect to measure the success of the project?
5. / What are the quantifiable results of the project?
i.e. feet of sidewalk, number of buildings renovated, number of people assisted, additional jobs created, etc…
6. / How many people will directly benefit from this project?

B.Project Location

Attach a base map, clearly delineating the geographic location of the project.

This Attachment is labeled as Attachment

Indicate the Service Area of the project.

Label the Census Tract and Block Group(s) where the project is located.

Census Tract:
Block Group(s):

C.Project Detail

Yes / No
1. / Does this project involve real property acquisition?
2. / Will this project cause the relocation of residents?
3. / Do you have completed engineered drawings?
4. / Have you obtained a survey?
5. / Have the services of a consultant be retained?
Engineer
Architect
Planner
Other
6. / Who will be responsible for the maintenance of this project upon completion?
7. / Are there any current or proposed projects that may affect the timing of this project?
8. / What is the current status of this project?
ie. What has been accomplished, what collaborations have been developed…
9. / Other information you wish to provide regarding this project:

SECTION IV:BUDGET

A.GENERAL

Estimate must be itemized and prepared by a third party, and signed by a qualified source.

Road surface improvements must be certified for a minimum of 8 years.

Any project above $2,000 must adhere to Federal Prevailing Wages.

The original cost estimate for this project must be provided as an Attachment.
This Attachment is labeled as Attachment
Yes / No
1. / Prevailing wages have been included in the estimate
2. / Architectural / Engineering fees are included in the estimate:
3. / Estimate provided is valid for what time period?

B.HUD FUNDS

Indicate how the HUD funds will be expended:
Acquisition of real property: / $
Construction and/or Materials: / $
Architectural / Engineering / Consulting Services: / $
Personnel / Staffing: / $
Other: / $
Explain “other”
TOTAL HUDFUNDS: / $

C.TOTAL PROJECT BUDGET

Provide a total Project Budget, showing how all funding sources contribute towards the project:
This Attachment is labeled as Attachment
Amount requested from HUD funds: / $
Amount requested from other resources: / $
Amount of applicant contribution: / $
TOTAL PROJECT COST: / $
1. / Explain any additional resources which have been applied for and the status of the request(s):
2. / As the applicant, what is your contribution towards this project?

SECTION V:ENDORSEMENT

I, the undersigned, as official representative of the applicant, hereby acknowledge that if a grant is awarded, the terms, conditions, and budget pursuant to the Action Plan submitted to the U.S. Department of Housing and Urban Development, and the sequential Project Agreement between Butler County Board of Commissioners and the applicant will be the limit of participation from the Board of Commissioners of Butler County.

I also hereby certify that the information contained in this application is true and accurate to the best of my knowledge.

Name / Title
Signature / Date

Municipalities:

Each application from a municipality must contain a copy of a resolution from the Board of Trustees or City Council endorsing the submission of the project application, stating the amount of the grant request in the application, and the amount to be contributed by the municipality for the project.

Not-For-Profit Organizations:

Each application from a not-for-profit organization must contain a resolution from the organization’s Board of Directors endorsing the submission of the application, stating the amount of the grant request in the application, and stating the amount to be contributed by the organization.

A SEPARATE RESOLUTION IS REQUIRED FOR EACH APPLICATION

1