Arkansasnatural Resources Commission

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(R-9/11)

ARKANSASNATURAL RESOURCES COMMISSION

FUNDING APPLICATION

I.GENERAL INFORMATION:

This application is designed for projects that will pledge water and/or sewer system revenues, Sales Tax revenues or Property Tax revenues. When asked to provide information on the system, provide information for the system or systems which will be pledging revenues to the loan.

FUNDING PROGRAM TO BE USED (Check applicable funding programs):

Federal Programs /  / State Programs / 
Clean Water RLF
(Sewer) / GO Bond
(Water and/or Sewer)
Drinking Water SRF
(Water) / Water Development Fund
(Water)
Water, Sewer, Solid Waste Fund
(Sewer)

TYPE OF ASSISTANCE REQUESTED (Check applicable type of assistance):

 /  / 
Loan / Deferred Loan / Grant
BORROWER / CONSULTING ENGINEER
Borrower’s Name: / Firm’s Name:
Contact Person: / Contact Person:
Contact Person’s Title: / Contact Person’s Title:
Mailing Address: / Mailing Address:
City, State & Zip Code: / City, State & Zip Code:
Telephone Number: / Telephone Number:
FAX Number: / FAX Number:
E-mail Address: / E-mail Address:
BOND COUNSEL / AUDITOR
Firm’s Name: / Firm’s Name:
Contact Person: / Contact Person:
Contact Person’s Title: / Contact Person’s Title:
Mailing Address: / Mailing Address:
City, State & Zip Code: / City, State & Zip Code:
Telephone Number: / Telephone Number:
FAX Number: / FAX Number:
E-mail Address: / E-mail Address:

Borrower's Employer Identification Number:

Arkansas Senate District: Arkansas House District:

U.S. Congressional District:

Provide a brief project description:

II.CURRENT FINANCIAL INFORMATION:

AUDITEDFINANCIAL STATEMENTS FOR THE SYSTEM:

Provide one copy of certified audits of the System’s Financial Statementfor the four most recent fiscal years. If audited Financial Statements are not available, provide unaudited Financial Statements of income and expense for these years.

In the table below, indicate the Fiscal Year of the Financial Statements provided, whether or not the Financial Statements were audited and whether or not they are attached to the application or have been sent to ANRC previously.

System Audits
Fiscal Year / Audited? / Attached?
Yes / No / Yes / No
Yes / No / Yes / No
Yes / No / Yes / No
Yes / No / Yes / No

CURRENT SYSTEM OPERATING BUDGET:

Provide one copy of the current fiscal year operating budget for the system. Also include a statement of year-to-date revenues and expenses. If available, include the draft or proposed budget for the next fiscal year.

Current budget year provided: ______

Proposed budget year provided: ______

BOND ORDINANCES FOR THE SYSTEM:

For each revenue bond pledging revenuesof the system and having outstanding balances, provide one copy of therevenue bond ordinances. Show in the table below for each bond ordinance: the name, number,dateand whether water, sewer or both revenues are pledged for each revenue bond issue.

Ordinance Name / Ordinance Number / Ordinance Date / Pledge
Water / Sewer / Both
Water / Sewer / Both
Water / Sewer / Both
Water / Sewer / Both
Water / Sewer / Both

BOND AMORTIZATION SCHEDULES:

Provide one copy of the amortization schedule for all bond issues shown above.

OTHER DEBT:

Provide one copy of any short term notes or loan agreements payable from system revenues.

List enclosures provided:

OTHER REVENUE SOURCES FOR THE SYSTEM:

Provide one copy of any Sales Tax ordinances or Property Tax ordinances that provide revenues to the system.

Describe how these revenues are used:

REVENUE SOURCE(S) DEDICATED TO THIS LOAN:

List the specific dedicated source(s) that will be pledged for the repayment of the loan (water and/or sewer revenues, sales tax or property tax):

Is this dedicated repayment source(s) currently servicing any other debt? ( ) Yes ( ) No

If yes, explain:

CURRENT SYSTEM CUSTOMER BASE:

If available, provide one copy of any financial design report or rate study that identifies the current and projected customer base. Fill in the table below for the system’s customer base. List each user class or meter size in your present rate structure (residential, commercial, industrial, low income, etcetera), the number of customers in each class, and the billable water for each class for the last 12-month period. “Billable water” is defined as adding together by class or meter size the water (or sewer) usage on each individual water (or sewer) bill for the most recent twelve (12) month period beginning with the latest month.

User Class
or Meter Size / Number of Customers / Billable Water for the
Last 12 Months, in Gallons

Complete the table below regarding Wholesale customers of the system for the most recent twelve (12) month period beginning with the latest month. Submit one copy of the wholesale contract for each customer.

Wholesale Customer Name / Number of Customers / Billable Water for the
Last 12 Months, in Gallons

CURRENT USER CHARGES AND CUSTOMER INCOME:

Provide the current user charge ordinance showing the rate structure for the system.

Ordinance Number: Date of Ordinance:

List the:

Median Household Income for the community:

Year of this income data:

Current average annual cost per household for water service:

Current average annual cost per household for sewer service:

SYSTEM DELINQUENT ACCOUNTS ANALYSIS:

Complete the following table for the most recent twelve (12) month period beginning with latest month. Show the total amount billed each month and the amount more than 30 days past due (delinquent).

Month / Year / Total Amount Billed / Total Amount Delinquent
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
12-Month Totals / $ 0 / $ 0

GENERAL REVENUE TURNBACK FUNDS:

In the table below, enter the actual amount of general revenue turnback funds received in the last 3fiscal years and the estimated amount expected for the current fiscal year.

Year / General Revenue
Turnback Amount
$
$
$
$

III.PROJECTED FINANCIAL INFORMATION:

LINE ITEM BUDGET ESTIMATES FOR THE PROJECT, NOT JUST FOR THE LOAN AMOUNT:

Engineering-Planning & Design / $
Engineering-Construction / $
Engineering-Post Construction / $
Construction Cost, Plant / $
Construction Cost, Lines / $
Land and Easements* / $
Legal / $
Administrative / $
Capitalized Interest during Construction (if applicable)** / $
Issuance Fee
(3% of Principal Amount) / $
Other / $
Contingencies / $
Total Capital Cost / $ 0

* Land and Easements may not qualify for Loan Participation.

**Interest accrued during construction may be paid directly by the Borrower or paid from the loan.

PROPOSED PROJECT FUNDING BREAKDOWN:

Show the proposed RLF loan amount, the Borrower contribution and any other source of funding for the proposed project. If another funding agency is involved, list the agency and describe the status of that funding application (not applied, applied, approved or awarded). The Total Project Funding must equal the Total Capital Cost shown above.

Funding Source / Funding Amount / Status
Proposed ANRC Funds: / $
Borrower Contribution: / $
USDA – Rural Development Grant: / $
USDA – Rural Development Loan: / $
ADED Grant: / $
Other: / $
Total Project Funding / $ 0

PROJECTED SYSTEM CUSTOMER BASE:

Provide the projected number of system customers that will be available when construction is complete. List each user class or meter size in your present rate structure (residential, commercial, industrial, low income, etcetera), the number of customers in each class, and the billable water for each class.

User Class
or Meter Size / Number of Customers / Billable Water for the
Last 12 Months, in Gallons

CURRENT & PROJECTED EXPENSES:

Complete the table below showing the current and projected annual system expenses. The projected annual expensebegins following project completion and includes loan repayment expense. Sufficient revenues must be generated to cover the projected costs for debt service and other non-operating costs as well as the costs for operation, maintenance and replacement (OM&R). A Replacement Reserve or Depreciation Fund must be maintained to cover equipment replacement and major maintenance activities.

Budget Item / Current
Expenses / Projected
Expenses
Labor / $ / $
Utilities / $ / $
Materials and Supplies / $ / $
Contract Services / $ / $
Miscellaneous / $ / $
Replacement Reserve or
(Depreciation Fund) / $ / $
Total Annual OM&R Costs / $ 0 / $ 0
Debt Service / $ / $
Total Annual Expenses / $ 0 / $ 0

IV.PROJECT SCHEDULE:

Task / Date
Application Certification
Loan Closing
Advertisement for Bids
Award Construction Contract(s)
Start Construction
O&M Manual Approval (Federal Programs Only)
Complete Construction
Certification of Project Performance (Federal Programs Only)

V.OTHER FORMS AND DOCUMENTS THAT MUST ACCOMPANY THIS APPLICATION

These forms are only applicable to ANRC’s federal funding programs: the Clean Water RLF and the Drinking Water SRF. These forms are not needed for the Water Development Fund, the Water, Sewer, Solid Waste Fund or the General Obligation Bond Fund.

A.CIVIL RIGHTS: The EPA Preaward Compliance Review Report concerning civil rights, EPA FORM 4700-4, must be completed, signed and dated by the designated signatory authority of the Borrower.

B.MBE/WBE: The Contract Reporting Form concerning the procurement of minority and women's business utilization must be completed, signed and dated by the designated signatory authority of the Borrower. (Note: Normally, the only procurement to report at this stage in the project is the procurement of professional services.)

C.DEBARMENT AND SUSPENSION, BORROWER: The EPA Certification Regarding Debarment, Suspension, and Other Responsibility Matters, EPA Form 5700-49 must be completed, signed and dated by the designated signatory authority of the Borrower.

D.DEBARMENT AND SUSPENSION, ENGINEER: The EPA Certification Regarding Debarment, Suspension, and Other Responsibility Matters, EPA Form 5700-49 must be completed, signed and dated by the authorized representative of the Consulting Engineer.

E.CLEARINGHOUSE: Each project is required to be reviewed by the Water/Wastewater Advisory Committee (WWAC). As part of their review, a copy of the Preliminary Engineering Report and a SF-424 is sent to the IGS State Clearinghouse. The Clearinghouse will send the Contact Person listed on the SF-424 a letter after 30 days stating that the Clearinghouse has or has not received any comments on the project. A copy of that letter must be included with the ANRC application.

F.LOBBYING CERTIFICATION: The EPA Certification Regarding Lobbying, EPA Form 6600-06 must be completed, signed and dated by the designated signatory authority of the Borrower.

For Sewer Projects Only:

F.DESIGNATED MANAGEMENT AGENCY RESOLUTION: If the Borrower has not previously been designated as the management agency responsible for providing wastewater collection/treatment services in the proposed service area, a resolution in conformance with form RLF-3 must be provided by the Borrower. This resolution is required for unsewered communities where the project will result in a new discharge and for sewer improvement districts.

VI.DOCUMENT APPROVALS REQUIRED PRIOR TO LOAN CERTIFICATION

The documents listed below must be submitted to the ANRC’s Water Resources Development Division (WRDD) in accordance with the signed Memorandum of Agreement (MOA) between the Borrower and the ANRC.

For Both Water and Sewer Projects:

A.PROPOSED/ENACTED USER CHARGE ORDINANCE: A proposed User Charge Ordinance must be submitted in accordance with the MOA. The Water Resources Development Division (WRDD) will review and indicate approval of the proposed ordinance. The Ordinance must be enacted and submitted as specified in the MOA.

B.ENGINEERING REPORT: The WRDD must review and approve the final engineering report.

C.PLANS AND SPECIFICATIONS: The WRDD must review and approve the plans and specifications (P&S) for the proposed project prior to loan application certification. The Borrower must obtain the Arkansas Department of Health’s approval of the project plans and specifications. The Borrower must obtain the Arkansas Department of Environmental Quality’s approval of sewer project plans and specifications.

For Sewer Projects Only:

A.PROPOSED/ENACTED SEWER USE ORDINANCE: A proposed Sewer Use Ordinance must be submitted in accordance with the MOA for review and approval. The approved, proposed ordinance must be enacted and submitted as specified in the MOA.

For the Federal Funding Programs Only (Clean Water RLF and Drinking Water SRF):

A.ENVIRONMENTAL INFORMATION DOCUMENT: The WRDD will perform an environmental review of the proposed project based on the information provided in the engineering report and environmental information document (EID).

B.PROJECT PERFORMANCE WORKPLAN: The WRDD must approve a workplan detailing the services that will be provided by the engineering consultant during the one year project performance period.

For the Clean Water RLF Program only:

A.INFILTRATION/INFLOW ANALYSIS: The WRDD will review the condition of the collection system to determine if Infiltration/Inflow (I/I) is considered to be excessive. Depending on the result of that analysis, a Sewer System Evaluation Survey may be required.

B.SEWER SYSTEM EVALUATION SURVEY: The WRDD may require an in depth survey of the collection system to determine if repairs to the system will be required as part of the project.

VII.ASSURANCES IN CONFORMANCE WITH ANRC, STATE & FEDERAL REQUIREMENTS

I, , as the authorized representative of ,

(Name of Signatory Authority)(Name of Borrower)

hereinafter referred to as the Borrower, certify that the Borrower agrees to comply with the laws, regulations, policies and conditions related to the specific funding programused for this project. I further agree that the Borrowerhas and will continue to:

1.Meet financial capability requirements set by ANRC to assure that sufficient revenues are generated to operate and maintain the facility for its useful life and pay all debt service costs. Maintain aReplacement Reserve or Depreciation Fund to cover equipment replacement and major maintenance activities.

2.Maintain adequate financial records and obtain independent audits annually that conform to Generally Accepted Government Accounting Standards and submit the audits to the Water Resources Development Division.

3.Pledge sufficient revenues as a legal dedicated source of repayment for the ANRC loan in its entirety.

4.Not enter into any construction contracts until all property necessary to construct the project has been acquired and acceptable certification has been furnished to and approved by ANRC.

5.Have the right of eminent domain and will take condemnation action, if necessary, to acquire all land, easements, and right-of-way required to construct the project. Condemnation expenses are ineligible for funding from the Drinking Water SRF Program.

6.Provide a full time Resident Inspector under the supervision of the Consulting Engineer at the construction site to ensure that the completed work conforms to the approved plans and specifications and will furnish progress reports and other information as may be required by ANRC from time to time.

7.Initiate procurement action for building all significant elements of the project immediately after loan closing and diligently pursue the completion of the project.

8.Submit for prior approval all project changes and will complete the project in accordance with the application, approved engineering report and the approved plans and specifications.

9.Operate and maintain the system in accordance with the minimum standards as required by cognizant federal, state and local agencies for the maintenance and operation of such facilities and in accordance with the Arkansas Department of Health Permit for water systems or the National Pollutant Discharge Elimination System (NPDES) Permit for sewer systems.

10.Acquire all goods and services used in this project in accordance with the Arkansas laws regarding procurement of Professional Services, Construction Services and Goods and Equipment.

11.Assure that if the loan is for extension of service, the existing population in the new area will connect to the system within one year after construction completion.

For the Federal Funding Programs, I also agree that the Borrowerhas and will continue to:

1.Obtain annual independent audits of the System that conform to Office of Management and Budget, Circular A-133 audit standards (Single Audits) as long as funds are disbursed and will submit the audit to the Water Resources Development Division.

2.Not enter into any contracts until applicable procurement requirements are met and will comply with Executive Order 11738 which states that no goods or services shall be procured from persons or facilities that have been convicted of violations of either Section 306 of the Clean Air Act or Section 508 of the Clean Water Act.

3.Acquire all property necessary to construct the project in accordance with the rules and regulations of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.

4.Comply with the Equal Employment Opportunity Law (Exec. Order 11246).

5.Comply with the requirements of the EPA State Revolving Fund Program Implementation Regulation found at 40 CFR Part 35, Subpart K (Clean Water State Revolving Fund) or 40 CFR Part 35, Subpart L (Drinking Water State Revolving Fund).