FEDERAL TRANSIT ADMINISTRATION

SECTION 5310 PROGRAM

ENHANCED MOBILITY OF SENIORS AND

INDIVIDUALS WITH DISABILITIES

Federal Fiscal Year 2017 Grant Cycle

NONTRADITIONAL GRANT APPLICATION – CAPITAL FUNDS

State of Connecticut

Department of Transportation

1FFY 2017

Table of Contents

Table of Contents

I. General Information

II. Proposal

III. Transportation Budget

IV. Applicant Signature

Section 5310 Application Checklist

1FFY 2017

Section 5310 A Applicants Only

I. General Information

Project Request:
Legal Name of Applicant Organization:
Primary Street Address:
P.O. Box #:
City:
Town: / Zip code:
County:
Organization Website:
Name of Program Contact:
Title of Program Contact:
Email Address of Program Contact:
Telephone Number: --
Fax Number: --
Federal Employer Identification Number: -

Type of Agency/Organization:

☐Private non-profit

☐State or local governmental

☐Operator of public transportation services (including public or private operators)

☐Other:

Is your organization incorporated?*☐Yes☐No

*If yes, a copy of your organization's Articles of Incorporation MUSTbe attached.

(All applicants,except municipalities, must attach Articles of Incorporation to this application if their organization is incorporated, even if the organization is a prior recipient of Section 5310 funding. Municipalities are exempt from this requirement.)

1FFY 2017

Nontraditional Section 5310 Capital Application

II. Proposal

Equipment, Physical Access Improvements or Mobility Management

  1. Describe your organization’sproposed project in detail.
  1. What gap or strategy identified in the Locally Coordinated Public Transit Human Service Transportation Plan (LOCHSTP) does your organization’s proposal address? Information on LOCHSTP may be found on page 13 of the Application Instructions, Section 5310 Program Guidelines.
  1. How will this project be managed by your organization? I.e., How will program compliance and reporting be addressed?
  1. List all towns to be served by the project. Indicate which is (are) theprimary service location(s).
  1. Estimate number of individuals in the following groups to receive service:

Black Pacific Islander White

Hispanic American Indian Other

Asian Alaskan Native

  1. Explain how these figures were determined:
  1. How does your organization’s project go above and beyond the requirements of the Americans with Disabilities Act of 1990?
  1. Describe transportation now being provided to seniors and/or persons with disabilities by other public and nonprofit organizations in your proposed service area, including days and hours of operation, areas, types of passengers, etc.
  1. How does this proposal help make the most of available local, state and federal public transportation resources?
  1. Does your organization plan to coordinate and/or combine your proposed service with the existing transportation services in your proposed service area? Yes No
  2. If yes please elaborate and indicate any efforts made toward regional coordination of service.
  1. If no, please indicate why.
  1. How does your organization resolve complaints? Please explain the complaint procedure in detail.
  1. Does your organization have the contact information of the regional Mobility Manager?

☐ Yes☐ No

  1. If yes, has your organization ever utilized or coordinated with the regional Mobility Manager?

☐ Yes☐ No

  1. If yes, please explain:

III. Transportation Budget

Capital Equipment Costs
Itemize and describe below capital equipment requests and costs.
1) / $
2) / $
3) / $
4) / $
5) / $
6) / $
7) / $
TOTAL CAPITAL EQUIPMENT COST / $
Capital Funds
a. Capital Funds Requested from CTDOT[1] / $
TOTAL CAPITAL FUNDS REQUESTED FROM CTDOT / $

1FFY 2017

Nontraditional Section 5310 Capital Application

IV. Applicant Signature

Signature Required: By signing or typing my name on the signature line below, I confirm that I have completed this application to the best of my knowledge on behalf of my organization, and that I have read and understand the application instructions associated with this Section 5310 application. I have made a copy of the completed application packet for my records.

Grant Applicant Signature[2]:______Date:______

1FFY 2017

Nontraditional Section 5310 Capital Application

Section 5310 Application Checklist

Applications must be received by 4:00 p.m. on Friday, March 2, 2017. Please ensure each question has been answered.Refer to the Application Instructions packet for information on how to submit the application.

We suggest you review your application for accuracy. If you are selected as a grant recipient, this application will become part of your agreement with the State of Connecticut.

Do not submit information beyond what is requested for the application. It will be discarded.

Did you remember to:

☐Answer all questions in the application?

☐Sign the application?

☐Submit the application to CTDOT?

☐Submit the application to your local RPO?

1FFY 2017

[1]TheFTA will pay 80% of the total capital equipment cost. Remaining cost must be funded by the awarded recipient.

[2]Name of person who completed the grant application.May differ from the program contact.