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Public Works Commission (Miami County Commissioners)

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BROWSE MIAMI COUNTY COMMISSIONERS (OH) FORMS

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Application for Financial Assistance
State of Ohio
IMPORTANT: Please consult “Instructions for Financial Assistance for Capital Infrastructure Projects” for guidance in completion of this form.
Applicant:
District Number:
Subdivision Code:
County: Date:
Contact: Phone:
Applicant
Email: FAX:
(The individual who will be available during business hours and who can best answer or coordinate the response to questions)
Project
District Recommendation
For OPWC Use Only
Project Name:
Zip Code:
Subdivision Type
Funding Request Summary
Project Type
Total Project Cost:
Funding Requested:
Grant:
Loan:
Loan Assistance/
Credit Enhancement:
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
6. Stormwater
Solid W
aste
Water Supply
Wastewater
Bridge/Culvert
Road
Water (6119 Water District)
Township
Village
City
County
1.
2.
3.
(Select one)
(Select single largest component by $)
(Automatically populates from page 2)
Funding Type Requested
(Select one)
Small Government Program
Local Transportation Improvement Program
State Capital Improvement Program
SCIP Loan - Rate:
Term: Amount:Yrs%
RLP Loan - Rate:
Term: Amount:Yrs%
LTIP:
Amount:Grant:
Amount:
Local Participation:
OPWC Participation:
Loan Amount:
T
otal Funding:
Loan Type:
Date Maturity:
Rate:
Term:
Project Number:
Release Date:
OPWC Approval:
Grant Amount:
%
%
SCIP
STATUS
%
Yrs
Form OPWC0001 Rev. 12.15
Page 1 of 6
.00
.00
.00
.00
.00
.00
.00
(T
o be completed by the District Committee)
Date Construction End:
RLP
District SG Priority:
Public Works Commission
.00
.00
.00
.00
.00
Amount: .00Loan Assistance / Credit Enhancement:
Revolving Loan Program
0
0
0
0
0
1.0ProjectFinancialInformation
FormOPWC0001Rev.
12.15
Page2of6
1.1ProjectEstimatedCosts
EngineeringServices
PreliminaryDesign:
FinalDesign:
TotalEngineeringServices:
RightofWay:
Construction:
MaterialsPurchasedDirectly:
Permits, Advertising,Legal:
ConstructionContingencies:
TotalEstimatedCosts:
1.2ProjectFinancialResources
LocalResources
LocalIn-KindorForce Account:
LocalRevenues:
OtherPublicRevenues:
ODOT /FHWA PID:
USDA RuralDevelopment:
OEPA /OWDA:
CDBG:
CountyEntitlementorCommunityDev.“Formula”
DepartmentofDevelopment
OPWCFunds
Grant:
Loan:
Loan Assistance/CreditEnhancement:
SubtotalOPWCFunds:
TotalFinancialResources:
Other:
Subtot
alLocalResources:
%
%
%
a.)
b.)
c.)
d.)
e.)
f.)
g.)
a.)
b.)
c.)
n.)
(AllCost
sRoundedtoNearestDollar)
%
%
(Checkallrequestedandenter
Amount)
Construction Administration:
d.)
e.)
f.)
g.)
j.)
k.)
m.)
l.)
h.)
i.)
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
%
%
ofOPWCFunds
ofOPWCFunds
0
0
0
0
0
0
0
0
0
0
100
FormOPWC0001Rev.
12.15
Page3of6
1.3 AvailabilityofLocalFunds
4.1UsefulLife/CostEstimate / AgeofInfrastructure
AttachRegisteredProfessionalEngineer'sstatement,withsealorstampandsignatureconfirmingthe
project'susefullifeindicatedaboveanddetailedcostestimate.
Attachastatementsignedbythe listedinsection5.2certifying
requiredfortheprojectwillbeavailableonorbeforetheearliestdatelistedintheProject
Schedulesection. TheOPWC Agreementwillnotbereleaseduntilthelocalresourcesarecertified.
Failuretomeetlocalsharemayresultinterminationoftheproject. Applicantneedstoprovidewritten
confirmationforfundscomingfromotherfundingsources.
ChiefFinancialOfficer alllocal
resources
ProjectUsefulLife:
Years Age:
2.0Rep
air/ReplacementorNew/Expansion
3.0ProjectSchedule
2.1 TotalPortionofProjectRepair/Replacement:
2.2 TotalPortionofProjectNew/Expansion:
3.1Engineering/Design/RightofWay
3.2Bid Advertisementand Award
3.3Construction
BeginDate:
EndDate:
ConstructioncannotbeginpriortoreleaseofexecutedProject AgreementandissuanceofNoticetoProceed.
Failuretomeetprojectschedulemayresultinterminationofagreementforapprovedprojects.
Modificationofdatesmustberequestedinwritingbyprojectofficialofrecordandapprovedbythe
CommissiononcetheProjectAgreementhasbeenexecuted.
%
%
BeginDate:
BeginDate:
EndDate:
EndDate:
2.3 TotalProject:
%
4.0ProjectInformation
Iftheprojectismulti-jurisdictional,informationmustbeconsolidatedinthissection.
.00
.00
.00
RoadorBridge:
W
ater/W
astewater:
ResidentialWaterRate
Current ADT
Stormwater:
Current$ Proposed$
Year Projected ADT
Year
Numberofhouseholdsserved:
Numberofhouseholdsserved:
Current$ Proposed$
Basedonmonthlyusageof4,500gallonsperhousehold;attachcurrentordinances.
ResidentialWastewaterRate
Numberofhouseholdsserved:
4.2UserInformation
(Yearbuiltoryearoflastmajorimprovement)
0
0
0
100
FormOPWC0001Rev.
12.15
Page4of6
4.3ProjectDescription
B:
C:
PHYSICAL DIMENSIONS(Describethephysicaldimensionsoftheexistingfacilityandthe
proposedfacility.Includelength,width,quantityandsizes,mgdcapacity,etcindetail.)500
characterlimit.
PROJECT COMPONENTS(Describethespecificworktobecompleted;theengineer’sestimate
doesnotreplacethisrequirement)1,000characterlimit.
A:
SPECIFICLOCATION(Supplyawrittenlocationdescriptionthatincludestheprojecttermini;a
mapdoesnotreplacethisrequirement.)500characterlimit.
FormOPWC0001Rev.
12.15
Page5of6
5.0ProjectOfficials
5.1ChiefExecutiveOfficer
5.2ChiefFinancialOfficer
5.3ProjectManager
ChangesinProjectOfficialsmustbesubmittedinwritingfromanofficerofrecord.
Name:
Title:
City:
Phone:
E-Mail:
FAX:
Address:
State:
Zip:
Name:
T
itle:
City:
Phone:
E-Mail:
FAX:
Address:
State:
Zip:
Name:
T
itle:
City:
Phone:
E-Mail:
FAX:
Address:
State:
Zip:
(Personauthorizedinlegislationtosignprojectagreements)
(CannotalsoserveasCEO)
FormOPWC0001Rev.
12.15
Page6of6
6.0 Attachments/Completenessreview
7.0 ApplicantCertification
Theundersignedcertifies:(1)he/sheislegallyauthorizedtorequestandacceptfinancialassistancefromthe
OhioPublicWorksCommissionasidentifiedintheattachedlegislation;(2)tothebestofhis/herknowledgeand
belief,allrepresentationsthatarepartofthisapplicationaretrueandcorrect;(3)allofficialdocumentsand
commitmentsoftheapplicantthatarepartofthisapplicationhavebeendulyauthorizedbythegoverningbody
oftheapplicant;and,(4)shouldtherequestedfinancialassistancebeprovided,thatintheexecutionofthis
project,theapplicantwillcomplywithallassurancesrequiredbyOhioLaw,includingthoseinvolvingBuyOhio
andprevailingwages.
Acertifiedcopyofthelegislationbythegoverningbodyoftheapplicantauthorizingadesignated
officialtosignandsubmitthisapplicationandexecutecontracts.Thisindividualshouldsignunder
7.0,ApplicantCertification,below.
Acertificationsignedbytheapplicant'schieffinancialofficerstatingtheamountof
fundsrequiredfortheprojectwillbeavailableonorbeforethedateslistedintheProjectSchedule
section.Iftheapplicationinvolvesarequestforloan(RLPorSCIP),acertificationsignedbytheCFO
whichidentifiesaspecificrevenuesourceforrepayingtheloanalsomustbeattached.Both
certificationscanbeaccomplishedinthesameletter.
alllocalshare
Aregisteredprofessionalengineer'sdetailedcostestimateandusefullifestatement,asrequiredin
164-1-13,164-1-14,and164-1-16oftheOhioAdministrativeCode
.Estimatesshallcontainan
engineer's sealorstampandsignature.
Acooperativeagreement(iftheprojectinvolvesmorethanonesubdivisionordistrict)whichidentifies
thefiscalandadministrativeresponsibilitiesofeachparticipant
.
FarmlandPreservationReview-TheGovernor'sExecutiveOrder98-llV,“OhioFarmlandProtection
Policy”requirestheCommissiontoestablishguidelinesonhowitwilltakeprotectionofproductive
agriculturalandgrazinglandintoaccountinitsfundingdecisionmakingprocess.Pleaseincludea
FarmLandPreservationstatementforprojectsthathaveanimpactonfarmland.
CapitalImprovementsReport.CIRRequiredbyO.R.C.Chapter164.06onstandardform.
SupportingDocumentation:Materialssuchasadditionalprojectdescription,photographs,economic
impact(temporaryand/orfulltimejobslikelytobecreatedasaresultoftheproject),accident
reports,impactonschoolzones,andotherinformationtoassistyourdistrictcommitteeinranking
yourproject.BesuretoincludesupplementswhichmayberequiredbyyourlocalDistrictPublicWorks
IntegratingCommittee.
ApplicantcertifiesthatphysicalconstructionontheprojectasdefinedintheapplicationhasNOTbegun,
andwillnotbeginuntilaProject AgreementforthisprojecthasbeenexecutedwiththeOhioPublicWorks
Commission. ActiontothecontrarywillresultinterminationoftheagreementandwithdrawalofOhio
PublicWorksCommissionfundingfromtheproject.
Confirmintheboxesbelowthateachitemlistedisattached(Checkeachbox)
OriginalSignature/DateSigned
CertifyingRepresent
ative(Printedform,TypeorPrintNameandTitle)
Print Application
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Public Works Commission (Miami County Commissioners)

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Completed 24 November 2020

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