Southwest District Rural Intersection Cost Share Application

MoDOT Partnership Development Application Form

Southwest District Intersection Cost Share Program

Application Checklist

An application must include the following items.

Section A: / Applicant Information
Section B: / Project Information
1. Project Name
2. Location
3. Description
4. Significance and Need
5. Applicant’s Level of Financial Participation and Source of
Funding
6. Timeline
Section C: / Project Funding
1. Estimated Project Costs
2. Services Performed By
3. Funding Sources
4. Current Status
Section D: / Applicant Certification
Section E: / Submission Acknowledgement
Exhibit I: / Project Location Map
Exhibit II: / Conceptual Plan and EA/EIS
Exhibit III: / Supporting Documentation: Project Significance and Need
Exhibit IV: / Supporting Documentation:Timeline

*Please contact the MoDOT Southwest District Transportation Planning Department at 417-895-7727 for assistance in completing this application.

SECTION A - Applicant Information

Name of Applicant:

Applicant shall be a city, county, special road district, transportation development district or school district.

Business Address:

Mailing Address (if different from above):

Contact Person Name:

Contact Person Title:

Mailing Address for Contact Person (if different from above):

Telephone:

Fax:

E-Mail Address:

Applicant Information:

Describe Applicant's organizational structure, history, ownership and legal structure (e.g., individual, state governmental agency, local governmental agency, corporation or partnership).

SECTION B- Project Information

1. Project Name

Assign a short name to the project, for purposes of identification. Also include the MoDOT Job Number, if applicable.

2. Location

Describe the location of the project, including major intersecting highways and rail routes, cities, towns, metropolitan planning organizationsor regional planning commissions. Attach a map as Exhibit I.

3. Description

Describe the purpose and need for the project (e.g., safety, preservation, expansion), its basic design features and what it will accomplish.

Describe any environmental reviews completed to date. Note any known environmental impacts.

Attach as Exhibit II anyConceptual Plan and environmental review documents, as applicable.

4. Significance and Need

Describe the significance of the project and the impact it could have on Missouri’s transportation system. Provide known traffic volumes, turning movements and crash data. Describe how the project meets signal and/or turn lane warrants. Supporting documentation may be attached as Exhibit III.

5. Applicant’s Level of Financial Participation and Source of Funding

Describe the level of your financial participationof the total project costs (50 percent or greater) and the source of the funds (e.g., federal, state [non-MoDOT], local, private, other). MoDOT’s maximum contribution is 50% of the total project cost. The applicant is responsible for any cost overruns in excess of the eligible costs submitted with this application.

6. Timeline

Provide the estimated/desired project schedule from beginning to completion. Show all major aspects of the project including preliminary engineering, right of way acquisition, utilities and construction. The anticipated schedule for these projects assumes funding for right-of-way purchases in State Fiscal Year 2017 and construction contract bid letting in State Fiscal Year 2018. Any supporting documentation may be attached as Exhibit IV.

Additional Project Information:

Who is designing the project?
Design plans are what percent complete?
Is the project ready to advertise for construction bids?
Who is letting the project?
What is the estimated letting date?
Current Average Daily Traffic (ADT) or similar information for multimodal projects
Future ADT and Year or similar information for multimodal projects
Length of project (miles)
Is ROW acquisition required? If yes, who will be acquiring the ROW?
Extent of preliminary work completed

SECTION C - Project Funding

Estimated Project Costs

Total project costs include preliminary engineering, environmental assessment, right of way (ROW) acquisition, ROW acquisition incidentals, utilities, construction contract and/or construction engineering.

Provide a breakdown of these costs on the Project Estimate and Funding chart below. Include other cost categories as necessary.All project cost estimates should be expressed on a cash (fiscal year-of-expenditure July to June) basis and should include narrative describing assumptions used to arrive at such estimates.All future costs should be adjusted for inflation to year-of-expenditure.

Funding Sources

Describe the funding source for each item on the Project Estimate and Funding Chart.Funding sources may include federal, state (non-MoDOT), local, private or any other contributions.

Current Status

Provide the current status of the project. What work has been done so far?

Project Estimate
Current Estimate
Preliminary Engineering / $
Right-of-way / $
Right-of-way Incidentals / $
Utilities / $
Construction w/ Contingency / $
Non-contractuals / $
Inspection and Letting / $
Total / $
Funding Chart / Cost Split
Local Fund Source 1 / $ / Total Local Share
Local Fund Source 2 / $ / $
Local Fund Source 3 / $ / %
MoDOT SW in-kind (engineering) / $ / Total MoDOT Share
MoDOT Construction Funding / $ / $
MoDOT Fund Source 3 / $ / %
Total / $

Section D - Applicant Certification

Federal Requirements. This project complies with, and/or will comply with, the requirements of (check all that apply):

_____ Title 23 of the U.S. Code

_____ Title 49 of the U.S. Code

National Environmental Policy Act. The project complies with, and/or will comply with, all provisions of the National Environmental Policy Act of 1969 (42 W.S.C. 4321 et seq.).

Yes _____No _____ If no, explain on an attached sheet.

The project (check all that apply):

Yes _____No _____Received a Categorical Exclusion.

Yes _____No _____Received a Finding of No Significant Impact (FONSI).

Yes _____No _____Circulated a Draft Environmental Impact Statement.

Yes _____No _____Circulated a Final Environmental Impact Statement.

Yes _____No _____Received its Record of Decision. (If no, provide on an attached sheet the estimated date for receipt of the Record of Decision.)

Uniform Relocation. This project complies with, and/or will comply with, all provisions of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1070 (42 U.S.C. 4601 et seq.).