Local Program Review Or Obligation Request Form

LOCAL PROGRAM REVIEW OR OBLIGATION REQUEST FORM

To:Choose an item.

CC:Concurrence Only.

From:Click here to enter text.

Date:Click here to enter a date.

Subject:District , Sponsoring Agency and Federal Aid Number

Route, Type of Project, Bridge Number over ??

Choose an item.

The sponsor is requesting Choose an item. All applicable clearances, reviews and required modifications have been verified and approved. Please obligate federal funds for the subject project.

Project Information

Proposed Work: Click here to enter text. / Project Termini: Click here to enter text.
MPO Area: Choose an item. / TIP Number: Click here to enter text. (attach most current TIP sheet)

PE Authorization (ifPE allocation in TIP restricts federal participation, insert federal funds amount here.)

Design ESC Approval Date: Click here to enter a date. / Design PE By Local Forces Approval Date: Click here to enter a date.
ESC PE Contract Maximum: Click here to enter text. / Estimated Local Forces PE Cost: Click here to enter text.

Construction Authorization (Authority to Advertise for Bids)

NEPA Date: Click here to enter a date. / NEPA Classification:Choose an item.
Section 106 Date: Click here to enter a date. / Environmental Final Project Clearance Date: Click here to enter a date.
R/W: Choose an item.
Click here to enter a date. / CE Choose an item. federally funded
and will be conducted Choose an item.
DBE Goal: Click here to enter text. / Design PS&E Approval Date: Click here to enter a date.
Project Match: Choose an item. / Bridge PS&E Approval Date: Click here to enter a date.
EPG 136.3.3 Approved By:BRO County build Projects Only (FHWA) / EPG 136.3.3 FHWA Approval Date: BRO County Build Projects Only; Click for date.
Design Approval Date Work by Local Forces: Click here to enter a date.

Concurrence in Award

DBE Participation:Click here to enter text. / Low Bidder: Click here to enter text.
Design Concurrence Date: Click here to enter a date. / DBE Verification Date Provided by ECR: Click here to enter a date.

Project Total Cost per activity requesting obligationbased onChoose an item.:

PE: Click here to enter text. / CE Consultant: Click here to enter text.
Roadway: Click here to enter text. / CE In-House: Click here to enter text.
Signing/Striping/Signals/Lighting: Click here to enter text. / Bridge: Click here to enter text.
Work by Local Forces (please define): Click here to enter text. / Landscaping/Streetscaping: Click here to enter text.
Bike/Ped Facilities: Click here to enter text. / Utilities: Click here to enter text.
Other (please define): Click here to enter text. / Total Estimate or Bid Amount: Click here to enter text.

Comments: Click here to enter text.

Revised 11/9/11