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Rev. 1/11, 9/12, 7/15/15, 7/16/15, 3/14/16
Applicant Information
Applicant: _____________________________________________________________________
Address: ______________________________________________________________________
Phone: _____________ Fax: _______________ Email: ___________________
Contact Name/Title: _____________________________________________________________
Project Information
Site Address for Brownfields Assessment/Cleanup Loan:
Purpose of Loan/Grant: Phase I ___ Phase II ___ Phase III ___ RAP ___ Remediation ___
Please describe the activities to be conducted with the proceeds from the loan. Must include
status of conversations between the property owner, the municipality, and interested parties.
Please indicate the assessment information already developed on the site:
Phase I ___ Phase II ___ Phase III ___ RAP ___
LEP contact: ____________________ Phone: __________________ Email: _____________
Proposed reuse: Housing___ Commercial___ Retail___ Industrial___ Mixed___
Please provide estimates of the outcomes of your project:
New taxes $ ___________ New or retained jobs _____________
New investment $ ___________
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Rev. 1/11, 9/12, 7/15/15, 7/16/15, 3/14/16
Please describe any other benefits to be derived from the project such as reduction of blight,
clean up of a contaminated condition, new construction, etc. (use an additional page if required):
Amount requested $______________ Date required _____________________
The following credit information/history shall be provided by non-municipal applicants only:
Three (3) years of tax returns/bank statements/W-2's/property income
statements/financial statements.
The Naugatuck Valley Council of Governments is a public agency. Any information provided may
be subject to disclosure. The credit information will be provided directly by the Applicant to the
underwriter and is not considered part of this document but may be subject to disclosure pursuant
to Connecticut General Statutes Section 1-200 et. seq. The Applicant hereby grants permission
for NVCOG staff to contact the LEP to discuss the environmental information provided to the
NVCOG and to obtain a credit review. The receipt of the pre-application and review of the
information provided does not ensure that a loan will be made. All loans are subject to the review
and approval of the NVCOG Board of Directors and/or the US Environmental Protection Agency
and the Connecticut Department of Economic and Community Development.
The Applicant understands and acknowledges that this pre-application is for informational
purposes only in order for the Naugatuck Valley Council of Governments to have an opportunity
to review the information to determine eligibility, qualifications, etc.
The Applicant acknowledges that the above is understood and accepted and hereby requests a
review of this pre-application.
__________________________ _____________________
Applicant Date