Economic Recovery Funds (ERF) - Project Consideration Form

This form MUST be completed and returned electronically to the Division of Water (DOW) no later than February 27, 2009 for any applicant to receive Economic Recovery Funds consideration. If the project is not currently ranked on the 2010 priority list, a Project Questionnaire and the additional required materials must be submitted to the DOW by February 27, 2009 to be ranked for ERF consideration. The Division of Water contacts for submittal of the above forms are listed below:

For Drinking Water Projects: Amanda Yeary

For Wastewater Projects: Anshu Singh

Applicant (Must be governmental entity): ______

County: ______

Project Name: ______

WX / SX Number (required): ______

Priority Ranking Information

Rank from 2010 Intended Use Plan (if applicable) ______Score ______

Funding Information

Total Project Cost: ______

Requested SRF Amount: ______

If the SRF loan will not fully fund the project, is the remaining funding package complete? Yes ______No ______

If yes, what are the other funding sources and the status of their commitments?

Funding Source / Amount / Status

Green Infrastructure Aspect of Project

If your project includes green infrastructure components (this includes water or energy efficiency improvements or other environmentally innovative activities), please provide the details of the “green” components and what dollar amount of the SRF loan requested, would be to fund these components.

SRF $ Amount related to “green” component $______

Provide details of “green components”: ______

______

______

Ready-to-Proceed Verification

(Please see the below questions and check Yes or No)

Yes / No
Have Plans and Specifications been approved by DOW?
Has the project received an E-Clearinghouse endorsement?
Was the E-Clearinghouse Endorsement Conditional?
Has the Environmental Review been completed?
Does the project qualify for a Categorical Exclusion (CE)?
Have the necessary permits been obtained for construction?
Have all land acquisitions and easements needed for the project been obtained?
Does the Project Profile description in WRIS accurately reflect the project?
Is the system under sanction from any enforcement agency?
Does the system anticipate a rate increase related to the project’s implementation?

Project Schedule and Milestone Dates

Milestones / For consideration, must be prior to date listed below / Date
Plans & Specifications Submission / 4/17/09
Plans & Specifications Approval / 8/1/09
E-Clearinghouse Submission
E-Clearinghouse Endorsement
Environmental Review Completion / 8/1/09
Proposed Bid Advertisement / 10/1/09
Proposed Construction Start / 2/16/10
Proposed Construction End Date / 2/16/2012

Jobs Information

Please provide the anticipated number of jobs retained or created for this project? ______

Please provide contact information for questions relating to this form only:

Contact: ______

Email: ______

Telephone: ______

Please execute below acknowledging that the information provided is the most recent available at the time of submission:

Signed: ______

Name: ______

Title: ______