456

							LOCAL GOVERNMENTS AND RURAL WATER SYSTEMS IMPROVEMENTS BOARD
    DRINKING WATER SYSTEMS IMPROVEMENTS REVOLVING LOAN FUND
                          APPLICATION

  1. LOAN NUMBER

           DWI-H280_____________


  2. LOAN APPLICANT'S FISCAL YEAR (Month to Month)



  3. LOAN APPLICANT (Name, Address, Telephone Number)




  4. PROJECT DESCRIPTION




  5. AGREEMENT

           The                                                     (Loan Applicant) hereby
           applies for a Drinking Water Systems Improvements Revolving Loan Fund
           (DWSIRLF) loan in the amount of $                         and agrees to comply
           with the DWSIRLF Program Regulations and all applicable State and Federal
           laws. I certify that all costs requested for loan award and payment under this
           DWSIRLF loan have not been, and will not be, also requested or received from
           other State or Federal agency sources.



           Authorized Project Representative (Signature)         Date


           Printed Name




HDWILF11 (11/25/08)                                                                 Page 1 of 4
 6. PROJECT COST BREAKDOWN
                                      TOTAL                  LOAN               LOAN
 ITEM                             PROJECT COST              ELIGIBLE           AMOUNT
                                                           REQUESTED*           COST
 Construction                      $                   $                   $
 Equipment                         $                   $                   $
 Supplies                          $                   $                   $
 Testing                           $                   $                   $
 Contingency                       $                   $                   $
 Land, Easements, Rights-of-       $                   $                   $
 Way
 Allowance for Facilities          $                   $                   $
 Planning & Design
 Allowance for Construction        $                   $                   $
 Phase Professional Services
 Subtotal                          $                   $                   $
 DWSIRLF Administrative Fee        $                   $                   $
 Total                             $                   $                   $
*Do not include costs that have been, or will be, also requested or received from other State or
Federal agency funding sources.


 7. PROJECT FUNDING SOURCES

 FUNDING SOURCE                                             AMOUNT
 DWSIRLF Loan                                    $
 CDBG Grant                                      $
 RUS Loan                                        $
 RUS Grant                                       $
 ARC Grant                                       $
 Bond Issue                                      $
 Local Funds (Specify)                           $
 Other (Specify)                                 $
                                                 $
 Total                                           $




 HDWILF11 (11/25/08)                                                                      Page 2 of 4
 8. ESTIMATED PROJECT SCHEDULE

      ACTION                                                                                             DAYS

 Time after loan award needed to submit plans, specifications, and contract
 documents (all contracts) and related submittals per DWSIRLF Reg. III.D(3)

 Contract time (longest contract)


                      INSTRUCTIONS FOR THE PROJECT COST BREAKDOWN (BLOCK 6):

1.       The "Total Project Cost" column should contain the totals of all costs for each line item of the project.
         Total project cost includes all costs relating to the project, whether they are eligible or ineligible or
         whether they will be paid for with DWSIRLF funds or other funds. Calculate a subtotal for the line items.

2.       The "Loan Eligible Cost" column should contain the totals of all costs for each line item of the project
         which have been determined to be eligible by the Mississippi State Department of Health. Do not include
         any costs that have been, or will be, also requested from other State or Federal agency funding sources
         or that are not eligible in accordance with the DWSIRLF Program Regulations. Calculate a subtotal for
         these line items.

3.       The "Loan Amount Requested" column should contain the totals of all DWSIRLF eligible costs for each
         line item for which DWSIRLF funds are being requested. (The Loan Applicant may choose to request
         less than the entire eligible amount.) Calculate a subtotal for the line items. Add the 5% DWSIRLF
         Administrative Fee (based on 5% of the subtotal of this column) to reach a total for this column.


                      INSTRUCTIONS FOR THE PROJECT FUNDING SOURCES (BLOCK 7):

This block should contain a list of all funding sources (including local funds) which will be used to fund the project.
The total amount calculated in this block should equal the subtotal amount calculated in Block 7, Column 1, "Total
Project Cost."


                  INSTRUCTIONS FOR THE ESTIMATED PROJECT SCHEDULE (BLOCK 8):

If awarded, the DWSIRLF loan agreement will include a project schedule with which the loan recipient must
comply. The schedule will be based on the timeframes supplied in Block 8, an estimated 90 days after submittal
of plans, specifications, and contract documents to secure Department approval, and the standard timeframes
found in DWSIRLF Reg. III.F.(7), unless justified otherwise.




HDWILF11 (11/25/08)                                                                                       Page 3 of 4
9. RELATED DOCUMENTS: The following items must be completed and submitted with the loan
application form in accordance with DWSIRLF Reg. III.B.2:

A.   Items that must be submitted on forms provided by the Department:

     1. Procurement Certification on HDWILF74.

     2. Loan Applicant's Certification regarding Debarment, Suspension and Other Responsibility Matters on
        HDWILF88.

     3. Construction phase professional service providers’ Certification(s) Regarding Debarment, Suspension
        and Other Responsibility Matters on HDWILF88 (for all professional contracts $25,000 or greater).

     4. Financial capability summary (only if requested loan amount is significantly greater than that shown in
        facilities plan) on HDWILF14, Attachment 1.

     5. Legal Certification on HDWILF69.

     6. Executed Preaward Compliance Review Report (EPA Form 4700-4).

     7. Request for Taxpayer Identification Number and Certification (IRS Form W-9).

     8. All applicable waste disposal permit applications (if not previously submitted).

B.   Other submittals:

     1. Draft user charge system and ordinance/corporate resolution.

     2. Detailed cost proposal for planning and design phase professional services (only if the requested
        Allowance for Facilities Planning and Design exceeds the recommended maximum from DWSIRLF
        Regulations, Appendix B, Table 1).

     3. All proposed or executed contracts for bidding and construction phase professional services (for required
        contents, see HDWILF44).

     4. Detailed cost proposal for bidding and construction phase professional services (only if the requested
        Allowance for Construction Phase Professional Services exceeds the recommended maximum from
        DWSIRLF Regulations, Appendix B, Table 2).

     5. Copies of all required intergovernmental review (IGR) agency clearances/permits or copies of letters from
        the appropriate IGR agencies which state that no clearances/permits are required (if not previously
        submitted).

     6. Clearance from the Mississippi Department of Finance and Administration/Office of Policy Development
        and New Initiatives.

     7. Certified copy of a resolution by the loan applicant's governing body which authorizes submission of the
        application and designates an individual or office as authorized representative.

     8. All existing or proposed interlocal agreements. Such agreements must be executed prior to loan offer.

     9. Documentation of loan applicant’s tax exempt status under federal or state law (only if other than a
        county, municipality or district).




HDWILF11 (11/25/08)                                                                                  Page 4 of 4