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Final Intended Use Plan for the NYS Drinking Water State Revolving Fund

New York State Department of Health
Drinking Water State Revolving Fund (DWSRF)
Pre-Application Form

ATTACHMENT IV

DOH Use Only

Drinking Water State Revolving Fund (DWSRF) Pre-Application Form
Preliminary Project Schedule and Cost Estimate
For Intended Use Plan (IUP) Listing Purposes
Instructions for form PWS I.D.
No.___________________
Project Tracking No. __________
Date Received:____/____/____

Date Prepared: ___/___/___

PROJECT INFORMATION

Name of Water System:     ____________________________________________
Municipality:     ______________________________________________________

County:     __________________________________________________________

Legislative Districts - Congressional:  ______NYS Senate: _______NYS Assembly: _______

Project Description/Location:     _________________________________________

__________________________________________________________________

__________________________________________________________________

Population Served by Water System:     __________________________________

Population Served by Project:     _______________________________________

Has this project been listed in a DWSRF Intended Use Plan (IUP)? Yes or No.
If yes, please indicate the DWSRF project tracking number:     ________________________

Are there other funding sources anticipated for the project: Yes or No.
If yes, please attach a separate sheet of paper and include source of funding, amount of funding, type of funding, and letter of confirmation.
Project Cost Estimate
Construction Costs:      $_________

Engineering Fees:       $________

Other Expenses:       $________

Equipment Costs:      $________

Land Acquisition:      $________

Contingencies (___% used):   &________

Subtotal Project Costs:   $________

Deduct other funding
sources (HUD, RD, etc.)   $________

Add Est. Issurance Costs
(Estimated issuance costs are
approximatey 3% of
project costs:      $________

Total Amount to Finance:   $________

CONTACT INFORMATION

Name of Borrower:  ___________________________________ Consulting Engineer:  ___________________________________

Contact Person, Title:  _________________________________ Contact Person, Title:  __________________________________

Address:  ____________________________________________ Address:  ____________________________________________

Phone #:  ____________________________________________ Phone #:  _____________________________________________

Fax #:  _______________________________________________ Fax #:  ______________________________________________

E-Mail Address:   ______________________________________ E-Mail Address: ______________________________________

If applicable, on a separate sheet of paper provide contact information for additional parties who should be included on project mailing list, including system owner (if different than borrower) and person responsible for completing subsequent application package.

PROJECT SCHEDULE DATES
(T) Target or (A) Actual
Please return completed form to:

Submit Engineering Report
(     ) __________
       (Date) New York State Department of Health
Bureau of Public Water Supply Protection
547 River Street, Flanigan Square, Room 400
Troy, New York 12180
Phone:    (518) 402-7650
Fax:      (518) 402-7659

When will all Technical Submittals be completed?
(     ) __________
       (Date)

Start of construction date (date Notice to Proceed was issued)?
(     ) __________
       (Date)

Is this project being submitted for Refinancing? Yes or No (circle correct response)
If yes, Construction Completion Date (actual date)?
(     ) __________
       (Date)

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Final Intended Use Plan for the NYS Drinking Water State Revolving Fund

Name of Borrower: ___________________________________	Consulting Engineer: ___________________________________
Contact Person, Title: _________________________________	Contact Person, Title: __________________________________
Address: ____________________________________________	Address: ____________________________________________
Phone #: ____________________________________________	Phone #: _____________________________________________
Fax #: _______________________________________________	Fax #: ______________________________________________
E-Mail Address: ______________________________________	E-Mail Address: ______________________________________

PROJECT SCHEDULE	DATES (T) Target or (A) Actual	Please return completed form to:
Submit Engineering Report	( ) __________ (Date)	New York State Department of Health Bureau of Public Water Supply Protection 547 River Street, Flanigan Square, Room 400 Troy, New York 12180 Phone: (518) 402-7650 Fax: (518) 402-7659
When will all Technical Submittals be completed?	( ) __________ (Date)
Start of construction date (date Notice to Proceed was issued)?	( ) __________ (Date)
Is this project being submitted for Refinancing? Yes or No (circle correct response) If yes, Construction Completion Date (actual date)?	( ) __________ (Date)