Indiana Revolving Fund Loan Program

Indiana Revolving Fund Loan Program

Due Diligence Form

Part I

SRF Names

1. Name of Qualified Entity (QE)______

2. Federal Tax Identification Number______

3. County or counties in which situated______

4. Mailing address ______

______

5. QE Contact

Name______Title______

Telephone______Email Address______

FAX Number ______

6. Type of QE:

City _____ ConservancyDistrict_____ County _____ Regional Sewer District _____

Sanitary District_____ Town _____ Private_____ Not-For-Profit_____

7. Legislative body (example: Town Council, Board of Directors or Trustees)

______

8. Estimated amount of proposed loan ______

a. Proposed loan authorized by ______

b. Date authorized ______

c. Dated date of bonds ______

d. Is SRF or Non-SRF loan subject to any constitutional or statutory debt limit?

YES [ ] NO [ ]

e. Debt limit (dollars) $______% of assessed valuation ______%

f. (i) Is SRF loan parity or junior? ______

(ii) Is Non-SRF loan parity or junior? ______

g. Desired closing date? ______

h.. Other fundinganticipated

Federal grant(s)* ______State grant(s)* ______

Issuer contribution ______SRF Loan ______

Non-SRF Loan ______

Other ______

*Identify entity/program(s) from which grant(s) is (are) anticipated

i. Grants or commitments received to date ______

______

j. Does QE plan to follow through with SRF if anticipated grants are not approved?

YES [ ] NO [ ]

9. Professional Advisors

a. Bond Counsel ______

Contact Name______Phone Number______

Email Address______Fax Number______

b. Political Subdivision's Counsel ______

Contact Name______Phone Number______

Email Address______Fax Number______

c. Project Engineer______

Contact Name______Phone Number______

Email Address______Fax Number______

d. Grant Administrator______

Contact Name______Phone Number ______

Email Address______Fax Number ______

e. Rate/Financial Consultant ______

Contact Name______Phone Number ______

Email Address ______Fax Number ______

f. Other______

Contact Name______Phone Number______

Email Addresss______Fax Number______

10. Are there any other factors, including threatened or pending litigation, not described above,

that might affect your revenues, expenditures or overall financial condition?

YES [ ] NO [ ] If yes, please submit an explanation in detail and attach to this form.

Part II

1. Fiscal Year (July 1 to June30) ______

2. List Political Subdivision's long-term debt (longer than one year) outstanding as of the date of this application with latest Standard & Poor's, Moody's, or Fitch ratings, if any:

* Example: "S&P/A-" or "M/Baa"

a. Tax supported: As of (date) ______Ratings*

General obligation:$ ______

Special taxing districts (if a city or county or a portion thereof):

______$ ______

Lease obligations:

______$ ______

Total tax supported $ ______

b. Revenue supported:

Water$ ______

Sewer$ ______

Electric$ ______

Gas$ ______

Other: $ ______

______$ ______

Total revenue supported $ ______

If no, please describe any retirement plan which the municipal employees are members of and include a brief description listing the estimate of unfunded pension liability, if any.

______

List temporary loans in anticipation of receipt of taxes, revenues, bond proceeds, federal

or state grants.

Item Amount Original Date Maturity Date

of Issuance

Taxes or revenues $______

Bonds$______

Grants $______

TOTAL$______

4. Debt outstanding by maturity of Political Subdivision (not including SRF or Non-SRF loan)

Year Principal Amount Aggregate Interest Total

Payable

2003 $ ______$ ______$ ______

2004 $ ______$ ______$ ______

2005 $ ______$ ______$ ______

2006 $ ______$ ______$ ______

2007 $ ______$ ______$ ______

2008 $ ______$ ______$ ______

2009 $ ______$ ______$ ______

2010 $ ______$ ______$ ______

2011 $ ______$ ______$ ______

2012 $ ______$ ______$ ______

2013 $ ______$ ______$ ______

2014 $ ______$ ______$ ______

2015 $ ______$ ______$ ______

2016 $ ______$ ______$ ______

2017 $ ______$ ______$ ______

2018 $ ______$ ______$ ______

2019 $ ______$ ______$ ______

2020 $ ______$ ______$ ______

2021 $ ______$ ______$ ______

2022 $ ______$ ______$ ______

2023 $ ______$ ______$ ______

2024 $ ______$ ______$ ______

2025 $ ______$ ______$ ______

2026 $ ______$ ______$ ______

2027 $ ______$ ______$ ______

2028 $ ______$ ______$ ______

2029 $ ______$ ______$ ______

2030 $ ______$ ______$ ______

TOTAL $ ______$ ______$ ______

5. In addition to the indebtedness described in part II number 2, list all debt that Political Subdivision is indirectly liable for and other expenses that are incurred by various overlapping government authorities and agencies, such as city, town, county, school, townships, special taxing

districts, etc.

Political Subdivision’s

Category Outstanding Share of Outstanding

Debt Debt

City or Town ______$ ______%

County ______$ ______%

School ______$ ______%

Township ______$ ______%

Special Taxing District: (for example, sanitary districts)

______$ ______%

Other: ______$ ______%

______$ ______%

TOTAL $ ______

6. Authorized but unissued debt (not including SRF or Non-SRF loan):

Remaining

To be Included Authorized

Purpose Amount in this Issue (But Unissued)

______$ ______$ ______$ ______

TOTALS $ ______$ ______$ ______

7. Other than your SRF project(s), are any other capital projects currently planned?

If yes, please describe the plans and funding sources for implementing the projects.

______

Part III

1. Assessed Valuation (last five years)

Total Net

Year Real Personal Assessed True Tax

Property Property Valuation Value

2003 $ ______$ ______$ ______$ ______

20__ $ ______$ ______$ ______$ ______

2. Tax anticipation note borrowing (last five years)

Date of Amount of Issue Due Date

Issue

2003 $ ______

20__ $ ______

3. Tax collections (last five years)

Year Total Property Collected by % Collection

Tax Levy Year End

2003 $ ______$ ______%

20__ $ ______$ ______%

4. Gross tax rate, including city, town, school, county, district, townships,

etc., for the last five years (or include copy of tax rate tables):

______

Category 2003 20__ 20__ 20__ 20___

______

TOTALS ______

5. Ten largest taxpayers (list in descending order)

NameType of Most Recent Property Tax

Business Assessed For FY 19__

Valuation

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

7. ______

8. ______

9. ______

10.______

a. Note any of the ten largest taxpayers listed above that have been delinquent in paying property taxes (more than 90 days after due date) during any one or more of the last three fiscal years.

______

6. Describe geographical location, number of square miles and the major transportation facilities available in the QE and the surrounding area.______

______

Part IV

1. Population (as reported in U.S. Census)

QE Total

1990 Census Data ______

2000 Census Data ______

Percentage Change ______

PrincipalCounty in which QE is Situated

1990 Census Data ______

2000 Census Data ______

Percentage Change ______

2. Personal income (as reported in most recent U.S. Census)

QE County

20___ Median Household Income ______

20___ Per Capita Income ______

3. Largest employers (more than ten employees) in descending order for 2003.

Circle whether Political Subdivision, SMSA or County information.

Name Business Number (Approximately)

of Employees

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

7. ______

8. ______

9. ______

10. ______

4. Employment

By industry (circle whether QE, SMSA or County information.)

(Source: Indiana Employment Security Division)

Average Number % Total

of Employees Employment

Agriculture, forestry, mining ______

Construction ______

Manufacturing ______

Transportation ______

Communications ______

Utilities ______

Wholesale, retail trade ______

Finance, insurance, real estate ______

Services & Other ______

Total Employment ______

Employment Trends QE

Annual Average 20______

5. Unemployment Rates QE

Annual Average 20______

6. Building permits (last five years):

Year Residential Non-Residential Other Total Value

20___ $ ______$ ______$ ______$ ______

7. Distribution of assessment of taxable property:

Year Residential Commercial Industrial

20______% ______% ______%

8. General economic characteristics:

______

Part V

1. Rate covenants

a.) Rates must be set to generate net revenues at 125% of debt at service.

b.)Have you been in violation of this covenant during the past five years?

If so, explain.______

______

c. Provisions for additional parity bonds ______

______

d. Debt service reserve

1) Required debt service reserve (Maximum Annual Debt Service, Other)

______

2) After this issue, debt service reserve will be $ ______

3) Have you ever had to use debt service reserve? [ ] YES [ ] NO

If yes, please give details (when, amount withdrawn, when was fund replenished?

______

4) Source of funds (for example: a five year build up from pledged

revenues, one time deposit, bond issue)?

______

2. Rates

a. Who sets rates? ______

b. Regulatory approval required? YES [ ] NO [ ]

By Whom? ______

Date of Approval: ______Remonstrance period: ______

c. Has the QE opted out of Indiana Utility Regulatory Commission (IURC)? YES [ ] NO [ ]

d Rate History:

Year Rate Requested Rate Approved

19___ $ ______$ ______

20___ $ ______$ ______

3. Customers

a. Ten largest customers (in descending order)

Usage

NameRevenues (circle whether Gals, or CCF)

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

7. ______

8. ______

9. ______

10. ______

b. Use by type of customer:

For FY 20__ % of Total Consumption % of Total Revenues

Commercial ______

Industrial ______

Residential ______

c. Customer Base

Year Number of Users Total Consumption

20______

4. Preliminary Engineering Report approved? YES [ ] NO [ ]

I hereby certify that the foregoing information is true and correct to the best of my

knowledge and belief.

Qualified Entity: ______

Title: ______Date: ______

Upon completion, please return the original and ONE COPY of this form AND any additional documentation to: 100 North Senate Avenue, Room 1275, Indianapolis, Indiana 46204

Emma Kottlowski (317) 234-1463