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S OUTHEAST R URAL C OMMUNITY A SSISTANCE (County of Campbell)

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BROWSE COUNTY OF CAMPBELL (VA) FORMS

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S OUTHEAST R URAL C OMMUNITY A SSISTANCE
P ROJECT, INC.
W ATER/WASTEWATER L OAN A PPLICATION
LOAN APPLICATION CHECKLIST
Please check the boxes of those requirements which have been fulfilled and enclosed with the application;
if a requirement has not been completed, please explain why in the space below or if the information does
not apply to the project, then please state the reason for its non-application.
o Typed and completed application;
o Check or money order for 1% origination/application fee;
o Resolution to apply which authorizes this application for a Southeast Rural Community
Assistance Project loan;
o Referendum to authorize application (if required); please give date_____________;
o Attorney's opinion of the applicant's legal capacity to borrow;
o Engineering studies/reports;
o Map of project area and topography, flood plain or FEMA map of project site;
o Request for Environmental Information [FmHA Form 1940-20 (if required)];
o Water and/or sewer rate schedule;
o Specifications as advertised for bids;
o Copies of bids received for the project;
o Current organization's budget;
o Recent audit or financial statements (balance sheets, income statements);
o Copy of funding sources approval or commitment letters.
Comments: __________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Southeast Rural Community Assistance Project , Inc. 1
1. Date: _________________________________
2. Borrower______________________________ Contact person: ___________________________
Address: ______________________________ Title:____________________________________
City: _________________________________ Phone #: _________________________________
State: ___________ Zip: _________________ Fax #: ___________________________________
Community name:_______________________ County:__________________________________
3. Type of organization: o Government (city, town, county) o Non-Profit
o Public Service Authority o User Association
4. Date of incorporation:__________ Tax exemption:____________ State: ____________________
Federal identification number: _____________ Statute incorporated under: __________________
5. Outstanding indebtedness: ________________ Debt limit: _______________________________
6. Rural Development District:_______________ Planning District: __________________________
Community Action Agency:__________________________________________________________
GENERAL INFORMATION
1. Loan amount: __________________________ Funds needed by: ___________________________
(Date)
2. Term requested: ________________________ Repayment requested: _______________________
(# of Months/Years) ($ amount per month, quarter, etc.)
3. What type of security will Southeast RCAP have for the loan? If the loan will be secured by
property, what lien position will Southeast RCAP have?
_______________________________________________________________________________
_______________________________________________________________________________
4. How will Southeast RCAP’s loan be repaid (from what source)?
_______________________________________________________________________________
_______________________________________________________________________________
5. What will Southeast RCAP’s loan be used for?
_______________________________________________________________________________
_______________________________________________________________________________
Southeast Rural Community Assistance Project, Inc. 2
APPLICANT INFORMATION
6. Type of project: o Water o Wastewater o Other___________________
7. Purpose of project: o Pre-Development o Upgrade/Extension
o New Construction o Other___________________
8. Total population for the project area (persons): __________________________________________
Number of low/moderate income persons in the project area:_______________________________
PROJECT INFORMATION
1. Please give a description of the project: (If a separate sheet is needed, please attach)
___________________________________________________________________________________
___________________________________________________________________________________
2. Date of construction start:_________________ Completion date: __________________________
3. Total project cost: _______________________ Total # of water connections _________________
Total # of sewer connections _________________
4. Number of residential water connections: ________ existing ________ proposed
Number of commercial water connections: ________ existing ________ proposed
Number of residential sewer connections: ________ existing ________ proposed
Number of commercial sewer connections: ________ existing ________ proposed
5. Water connection fees: ___________________ Wastewater connection fees: _________________
6. Availability fees:________________________ Reserve fees: _____________________________
7. Describe the procedures for setting rates for the system and provide a short description of
the last rate increase, including the date and amounts:
___________________________________________________________________________________
___________________________________________________________________________________
8. Please briefly describe the applicant's experience in providing its services:
(If a separate sheet is needed, please attach)
___________________________________________________________________________________
___________________________________________________________________________________
9. Has the proposed service area been cited for violations: o Yes o No
If yes, please give the date the violation must be corrected: ________________________________
10. Please describe the existing facilities, deficiencies and/or conditions:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Southeast Rural Community Assistance Project, Inc. 3
GENERAL INFORMATION (Continued)
PROJECT INFORMATION (Continued)
11. Please note the key people involved with this project:
Staff/Consultants: Name/Title Address Phone/Fax
_________________________________________________________
_________________________________________________________
Legal Counsel: Name/Title Address Phone/Fax
_________________________________________________________
_________________________________________________________
Engineer: Name/Title Address Phone/Fax
_________________________________________________________
_________________________________________________________
12. Please describe the current status of the project:
___________________________________________________________________________________
___________________________________________________________________________________
13. What are the next steps in developing this project:
___________________________________________________________________________________
___________________________________________________________________________________
14. Please describe the financing package being sought for this project:
___________________________________________________________________________________
___________________________________________________________________________________
15. What are the primary industries in the area:_____________________________________________
16. What is the unemployment rate in the area: _____________________________________________
17. What is the projected annual growth for the area: ________________________________________
18. # of minority persons in the area: _____________________________________________________
# of elderly persons in the area: ______________________________________________________
# of female head of household in the area:______________________________________________
19. US Representative (in project area): __________________________________________________
US Senators (in project area)::_______________________________________________________
Southeast Rural Community Assistance Project, Inc. 4
Outstanding Indebtedness
Lender’s Name &
Phone #
Original
Amount
Original
Date
Present
Balance
Rate of
Interest
Maturity
Date
Monthly
Payments
Purpose
Security
Current-
Y/N?
Schedule of Collateral
-Real Estate-
Address
Year
Acquired
Original
Cost
Market Value
Amount of
Lien
Lien Holder Name & Phone #
-Other Property & Assets-
Address
Year
Acquired
Original
Cost
Market Value
Amount of
Lien
Lien holder Name & Phone #
Southeast Rural Community Assistance Project , Inc. 5
FINANCIAL INFORMATION
PROJECT FINANCIAL INFORMATION (CONTINUED)
Current Yearly Operating Budget
Date Beginning:________________ Date Ending:_______________
OPERATING REVENUES WATER WASTEWATER
Customer service charges $___________ $_____________
Connection Fees ___________ _____________
Availability fees/charge ___________ _____________
Miscellaneous ___________ _____________
Total Operating Revenues $___________ $_____________
OPERATING EXPENSES
Auto expenses $___________ $_____________
Bad debt expense ___________ _____________
Insurance ___________ _____________
Office supplies and expenses ___________ _____________
Professional services (engineering, surveying) ___________ _____________
System supplies and repairs ___________ _____________
Salaries and wages ___________ _____________
Taxes, insurance and bonds ___________ _____________
Utilities (electric, water, sewer, gas) ___________ _____________
Interest on debt service ___________ _____________
Fees (accounting, audit, legal) ___________ _____________
Depreciation ___________ _____________
Miscellaneous ___________ _____________
Total Operating Expenses $___________ _____________
Net Operating Income or Loss $___________ $ ____________
Add Depreciation $___________ $_____________
Net operating income or loss after depreciation $___________ _____________
Reserve for future capital improvements $___________ $_____________
Balance available for principal payments
on debt services $___________ $_____________
Southeast Rural Community Assistance Project, Inc. 6
PROJECT FINANCIAL INFORMATION (CONTINUED)
Proposed Yearly Operating Budget
Date Beginning:________________ Date Ending:_______________
OPERATING REVENUES WATER WASTEWATER
Customer service charges $___________ $_____________
Connection Fees ___________ _____________
Availability fees/charge ___________ _____________
Miscellaneous ___________ _____________
Total Operating Revenues $___________ $_____________
OPERATING EXPENSES
Auto expenses $___________ $_____________
Bad debt expense ___________ _____________
Insurance ___________ _____________
Office supplies and expenses ___________ _____________
Professional services (engineering, surveying) ___________ _____________
System supplies and repairs ___________ _____________
Salaries and wages ___________ _____________
Taxes, insurance and bonds ___________ _____________
Utilities (electric, water, sewer, gas) ___________ _____________
Interest on debt service ___________ _____________
Fees (accounting, audit, legal) ___________ _____________
Depreciation ___________ _____________
Miscellaneous ___________ _____________
Total Operating Expenses $___________ _____________
Net Operating Income or Loss $___________ $_____________
Add Depreciation $___________ $_____________
Net operating income or loss after depreciation $___________ _____________
Reserve for future capital improvements $___________ $_____________
Balance available for principal payments
on debt services $___________ $_____________
Southeast Rural Community Assistance Project, Inc. 7
PROJECT CONSTRUCTION COST INFORMATION
Complete the following information below which applies to the project
Source of Source of Source of
Funds Funds Funds
__________ __________ ___________
(Name) (Name) (Name)
PREDEVELOPMENT COST
Preliminary engineering report/study
(consultants, architects, engineers) $______________ $_____________ $_______________
Land, easements, right-of-ways,
Water rights, site options _____________ _____________ _______________
Soil and water tests ___________ ___________ _____________
Legal, bonding & other misc. fees _____________ _____________ _______________
TOTAL PREDEVELOPMENT COST =
(Attach copy of studies & test reports)
New Construction Cost
Labor $___________ $___________ $_____________
Materials ___________ ___________ _____________
Equipment ___________ ___________ _____________
TOTAL NEW CONSTRUCTION COST =
(Attach copy of plans and specifications)
System Up-Grade Cost
(Rehabilitations, extensions)
Labor $___________ $____________ $____________
Materials ____________ ____________ ____________
Equipment ____________ ____________ ____________
TOTAL NEW CONSTRUCTION COST =
(Attach copy of plans and specifications)
Contingencies _____________ ______________ _______________
TOTAL PROJECT COST =
(Attach copy of successful bid)
Southeast Rural Community Assistance Project, Inc. 8
Southeast Rural Community Assistance Project, Inc.
Project Area Demographics
(Answer to the best of your knowledge. Information from census may be substituted for these pages)
Gender Number of
Persons
Family Size Number of Families
a. Male a. One
b. Female b. Two
Age
c. Three
a. 0-5 d. Four
b. 6-11 e. Five
c. 12-17 f. Six
d. 18-13 g. Seven
e. 24-44 h. Eight or more
f. 45-54
Family Income Sources
g. 55-69 a. No Income
h. 70+ b. TANF
Ethnicity/Race
c. SSI
a. Black/Not Hispanic d. Social Security
b. White/Not Hispanic e. Pension
c. Native
American/Alaskan
f. General Assistance
d. Asian/Pacific Islander g. Unemployment Insurance
e. Other h. Employment + other
sources
Education
i. Employment only
a. 0-8 j. Other
b. 9-12/non graduate
c. High school grad/GED
k. Unduplicated number of
Families reporting income
d.12+some post secondary
e. 2-4 yr college graduate
Southeast Rural Community Assistance Project, Inc. 9
Southeast Rural Community Assistance Project, Inc.
Project Area Demographics
(Answer to the best of your knowledge. Information from census may be substituted for these pages)
Other Characteristics Number of
Persons
Level of Family Income
(% Poverty)
Number of Families
a. Have Health Insurance a. Up to 75%
b. Are Disabled b. 76% to 100%
c. Are Veterans c. 101% to 125%
d. Have no Health Insurance d. 126% to 150%
e. Are Not Disabled e. 151% and over
f. Are Not Veterans
Family Type Number of
Families
Housing
a. Single parent/female a. Own
b. Single parent/male b. Rent
c. Two parent household c. Homeless
d. Single person d. Other
e. Two adults/no children
Other Family
Characteristics
f. Other
a. Receive Food Stamps
b. Farmer
c. Seasonal Farmworker
d. Do not receive foodstamps
e. Is not a Farmer
f. Is not a Seasonal
Farmworker
Southeast Rural Community Assistance Project, Inc. 10
S
ECURITY OFFERED
Please indicate the security offered for the proposed Southeast Rural Community Assistance Project Loan
o Full Faith and Credit o Water and Sewer Revenues
o Water Revenues Only o Sewer Revenues Only
o Property ______________ o Other _________________
CERTIFICATION
I (We), the undersigned representative(s) of the above named applicant hereby certify that the
applicant has sought financing from other sources, but the request was refused or the terms offered were
not affordable.
I (We), the undersigned representative(s) of the above named applicant hereby certify that this
application is a duly authorized action of the applicant and that the information contained herein and
attached herewith is true and correct to the best of my (our) knowledge and belief. It is hereby further
agreed and certified that any additional or supplemental information requested in connection with this
application will be submitted as true and correct to the best of my (our) knowledge and belief.
Given under my (our) hand(s) this _________ day of __________________, 20____________
_____________________________________
Signature
_____________________________________
Signature
Below please type or print the name and title of the above parties:
_____________________________________________________________________________________
_____________________________________________________________________________________
Southeast Rural Community Assistance Project, Inc. 11
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S OUTHEAST R URAL C OMMUNITY A SSISTANCE (County of Campbell)

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Completed 5 August 2020

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