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APPLICATION FOR APPROVAL OF PROJECT (PURSUANT TO G.S. 159 C-7) The _ County Industrial Facilities and Pollution Control Financing Authority (the "Authority"), a political subdivision and body corporate and politic of the state of North Carolina created by resolution adopted by the Board of Commissioners for the County of __ on [Date] _ , in accordance with the provisions of Chapter 159C of the General Statutes of North Carolina (the "Act") hereby files with the Secretary of the Department of Commerce of the State of North Carolina pursuant to the provisions of Section 159C-7 of the Act, this application for approval of its proposed industrial project described herein (the "Project") for [Name of Owner/Operator] __ (the "Operator"), the Project to be financed by an issue of bonds of the Authority pursuant to the Act. The Authority has transmitted a notice of this filing to the Secretary of the Local Government Commission of North Carolina pursuant to Section 159C-7 of the Act. Dated: __



_________________________ CHAIRMAN




Information regarding Operator A. Owner: Name of Company: _ __ Contact Person/Title: _ __ Address: __ __ Telephone Number: __ __ Fax Number: __ __ Email Address: __ __ NAICS Code: __ __ State of Incorporation: __ __ Corporation□ LLC Partnership Federal Employer ID #: __ __ B. Operator (if different from Owner) Name of Company: Contact Person/Title: Address: Telephone Number: Fax Number: Email Address: NAICS Code: State of Incorporation: Corporation□ LLC Federal Employer ID#: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Partnership __ __

Sole Proprietorship

Sole Proprietorship



Description and Local Approval of the Project Site Location: __ __ Address: __ __ County/Municipality: __ __ Current # of Full-time Employees at Site (if applicable): __ # of Full-time jobs to be created at Site: __ __ # of Full-time jobs to be saved at Site: __ __ Local Economic Developer: __ __ Commerce Department Economic Developer: __ __ State/Local Incentives being sought? Yes No If yes, described: __ __


Estimated real and personal property tax revenues projected to be generated by the Project (at current rates) after completion. Include both County and municipal taxes if applicable. Real property taxes: Personal property taxes: III. Project Description (Exhibit A) A. Describe the project in detail. The “project” will encompass the total capital expenditures which may be completely or partially financed by a bond issue. It will be important to relate this project to the corporate product line and general line or lines of business. Use a separate sheet of paper (marked “Exhibit A, Attachment 1”) if required. __ __ __ __

B. Please attach the following marked as Exhibit A, Attachments 2 - 4: 1. 2. 3. Map of the county or city, denoting the exact location of the site Plat map of the site, with line drawings for construction or location of existing building Time schedule for construction



Complete the following Project Budget Bond Funds Other Assistance (grants, incentives) Company Funds Total


ACQUISITION: Land Buildings Machinery and Equipment (including installation) Subtotal GENERAL CONSTRUCTION New Construction Renovation Subtotal INFRASTRUCTURE/ SITE PREPARATION Roads & Streets Parking Other (Describe)


Inducement Resolution

The Authority adopted an inducement resolution with respect to the issuance of Bonds to finance the Project on __ __. A copy of the inducement resolution and related inducement agreement between the Owner/Operator and the Authority should be marked Exhibit B and attached to this Application.


Employment Profile (Exhibit C)

Please provide information about the number and types of jobs expected to be created and/or saved as a result of the financing. Please complete and sign the form attached hereto as Exhibit C. (The employment profile form is attached at the end of this application. This form is also available to be completed electronically. Just click on the link “Employment Profile – Exhibit C” in our Industrial Revenue Bond website.)



Environmental Considerations (Exhibit D)

Describe the impact of the project on the environment. In particular, if the Division of Environmental Management has issued Air Quality or Water Quality (discharge or pretreatment) permits for the project, they should be included. If applications are being filed for such permits, submit a cover letter stating this. The Division should be consulted, and, if applicable, a letter containing their determination that either Air Quality or Water Quality permits will not be required must be included and marked Exhibit D.


Approval in Principle of Project by County Governing Body (Exhibit E)

Approval in principle of the project will be expressed by a resolution by the Board of Commissioners of the County in which the project is to be located after a public hearing held after notice thereof is published in the local newspaper at least 14 days prior to the hearing. An affidavit of publication of the public hearing notice, and a certified copy of such resolution must be filed before the application receives final approval. However, such resolution may be filed after the rest of this application. Please indicate the date on which such action is expected by the County. Bond counsel should be consulted as to the content of the notice of the public hearing and the form of the resolution. The affidavit and executed resolution should be marked as Exhibit E.

Expected date of Public Hearing and Resolution: __




Water, Sewer, Electric and Gas Services (Exhibit F)

Describe how water, sewer, electric and gas services will be provided to the site. If an extension of services or improvement in services is required for the operation of the Project, include written commitments for those extensions, including a description of how those services will be financed. A letter should be obtained from each utility provider indicating its ability to provide the services to the Project. Those letters must be included in the application, and marked Exhibit F.

IX. Abandonment Statement - The Operator of the Project must sign the following statement, or provide the information indicated below. The development of the Project will not cause or result in the abandonment of another facility in North Carolina, owned or operated by the Operator or any affiliate of the Operator. __ Name of Company

Signature of Officer __ Printed Name and title of Officer NOTE: If the closing of any such facility is planned or anticipated, but that abandonment has no cause and effect relationship with the proposed financing, include on a separate sheet, marked Exhibit G a statement reporting the planned closing and explaining why that facility is being closed. If, in fact, a North Carolina facility is to be closed or abandoned as a result or cause of the proposed financing, the statement will provide facts which demonstrate that the concerned facility is being abandoned because of obsolescence, lack of available labor or site limitations. Other North Carolina facilities and interests must be identified. The discussion of those facilities will identify any relationships with the proposed project, and in particular whether employees at the facility being closed will be offered employment opportunities at the new facility.



Operator’s Capability and Financial Resources

Please provide information prepared or furnished by the Owner which demonstrates that the Owner has the ability to financially sustain and operate the Project. If the Operator is different from the Owner, provide information that demonstrates this capacity for the Operator as well. Please provide a corporate structure chart for both the Owner and the Operator (if different from the Owner) showing corporate and management relationship among the entities. In particular, identify parent corporation, holding company, individual or other legal entity which beneficially owns controlling interest of the Owner and of the Operator (if different),and identify all affiliates and subsidiaries, including the amount of ownership held and the nature of any relationship to the Project. Entities which must be included as affiliates or subsidiaries are those in which the Owner or Operator (if different) or any of their principals (officers, directors, stockholders) holds an interest greater than 5%. Annual reports and financial statements for the latest three years and the most recent 10-K of the Owner and Operator (if different) and their respective corporate parents (or other beneficial owners). If the Owner or Operator seeks to maintain confidentiality of any nonpublic financial materials, please so indicate on the cover letter accompanying the financials. Pro-forma financial statements should accompany proposals for new ventures. Projects should be accompanied by assumptions, including method of depreciation, interest rates, timetable, capital expenditure schedule and sources of financing. Feasibility studies should be submitted if the venture involves new technology, products or markets. Please indicate if the company or any management of the company, or its affiliates, or any other concern with which management has been connected, has ever been involved in bankruptcy, creditor rights or receivership proceedings, or involved in criminal proceedings bearing on the handling of financial matters. Please indicate if the company is involved in litigation which could have a material effect on solvency. Please describe any credit agreement, debt indenture or any other instrument, which in any way limits the company’s indebtedness or affects the use of property or operations in the proposed project. Please provide a copy of the commitment letter or other indication from the bank(s) or similar financial institutions that are expected to purchase the bonds, underwrite the bonds, and/or provide credit enhancement (in the form of a letter of credit, bond insurance or liquidity facility) for the bonds, as applicable. All of the foregoing should be marked Exhibit H.


MAIL APPLICATION* TO: North Carolina Department of Commerce Commerce Finance Center 301 North Wilmington Street (27601) 4318 Mail Service Center (27699-4318) Raleigh, North Carolina If you have questions on the Application, contact Mary Mae Johnson at (919)733-0886 or email: mmjohnson@nccommerce.com

Date: ___

* Note: Once Parts I, II and III and the cover sheet have been completed and submitted and a pre-application conference has been held, the Owner/Operator is encouraged to submit additional parts and exhibits as they become available. It is not necessary to submit the entire application at one time. The application will not be deemed officially received for purposes of Section 04 NCAC 01E .0204 of the North Carolina Administrative Code until all items have been received by Commerce.



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