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SUPPLEMENTAL SHEET FOR

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					                                       SUPPLEMENTAL SHEET FOR
                                         BRIDGE PROJECTS

1.   Functional Classification (Definitions can be found on page 16 of Application Guidelines Booklet)
     (please check only one which best describes your project ) F1A

       Arterial         Collector        Subcollector         Local          Minor           Cul-de-sac


2.   Remaining Useful Life (please check only one) F3B

         Closed (Please fill out questions on next page)      1 – 2 years remaining
         Restricted to 50% or less of legal load               3 – 5 years remaining
                                                               6 – 10 years remaining

3.   Current Sufficiency or General Appraisal Rating                  F4A


4.   Indicate the total Per Capita Current Indebtedness (Bonds, Notes, etc.) for Capital Improvements
     other than water and sewer projects. Include letter from chief fiscal officer as Attachment G.
     F6A3
     $


5.   Indicate with a  which Tax or Fee the local subdivision will be utilizing for a match for SCIP
     funding and include the dollar amount of that Fee. (Applicant must receive all or part of Taxes or Fees).
     Include letter from chief fiscal officer as Attachment L. F6A4

                  County $5.00 Vehicle License Fee $
                  Municipal $5.00 Vehicle License Fee $
                  Township $5.00 Vehicle License Fee $
                  Second $5.00 Vehicle License Fee $
                  Third $5.00 Vehicle License Fee $
                  **Levy or Sales Tax      Names of Levy/Sales Tax        $
                             ** Must be Road and Bridge Levy or Road and Bridge Sales Tax

6.   Are you applying for an OPWC Loan? (please circle Yes or No) Include letter from chief fiscal officer
     as Attachment H stating the subdivision will accept the loan, the specific dollar amount and term. F7B

                  YES                     NO

     If Yes, what is the dollar amount of the loan you are applying for?          $
     What is the term of the loan you are applying for?                                   years
     (term cannot exceed useful life of project)

7.   Are you applying for Loan Assistance? (please circle Yes or No) F7B
     If Yes, what is the dollar amount of loan assistance you are applying for?    $
     (You must include as Attachment O a loan amortization schedule to justify the
       amount of loan assistance you are applying for)
                      Closed or Out of Service Supplemental Sheet

1.      Explain conditions causing closure of infrastructure.




2.      Explain measures taken to provide service (i.e., water and sewer service or diversion of
     local traffic) while infrastructure is closed or out of service.




3. Identify the population that is affected by the closure.

				
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