Priority Infrastructure Project - Grant Application

complete one for each project (Page 1 of 2)

PART A – Project Overview

Participating Entity/
Special District:
If applying for more than one project, please prioritize (1 of etc.):
Is this a matching project? / Contact:
Matching Source #1: / Title:
Matching Source #2: / Phone:
Project Current Status (%): / Email:
Project Title:
Project Description:
Tie Back to the disaster:
(Project documented in BCC’s PAP?)
Scope of Work:
Project Location:
(Including Longitude /Latitude)
Service Area Boundary:
(Including Census Tract and Block Group)
CDBG- DR Amount Requesting:
Reimbursement Project? / Advance Project?
Davis-Bacon Required? / Davis-Bacon Followed?

Project Budgets Implementation Timelines

Design/Engineering: / Environmental Review:
Construction Costs: / Procurement:
Project Delivery Costs: / Contracting:
Other Funding Source #1: / Construction Start:
Other Funding Source #2: / Construction End:

Pre-Application Costs

Activity / Date Incurred / Amount
Architectural / Engineering
Environmental Assessment
Real Property / Easements Acquisition
Permits / Surveys
Legal / Bonding / Insurance
Construction Costs
Construction Administration
Other (Please Specify)

PART B – Project Document Checklist

Uploaded / N/A / Document Type
☐ / ☐ / FEMA Project Worksheet or other federal agencies documentation.
☐ / ☐ / Force Account Labor, Equipment and Materials backup documentation (timesheets/payrolls/equipment logs or usage records, invoices, receipts, work orders).
☐ / ☐ / Contractor/Sub-Contractor Invoices and proof of payments.
☐ / ☐ / Weekly certified payrolls from contractor if Davis Bacon was followed.
☐ / ☐ / Proof of payment received from FEMA or other federal agencies.
☐ / ☐ / Proof of payment received from State.
☐ / ☐ / Proof of payments from other funding sources (insurance, donation, etc.).
☐ / ☐ / Environmental Review completed by FEMA or other federal agencies.
☐ / ☐ / Map of service area boundaries including census tract and block group.
☐ / ☐ / If LMI percentage was determined by survey, provide documentation of survey results/methodology.
Other Documents (Please list below)
☐ / ☐
☐ / ☐
☐ / ☐

Certifications:

The undersigned participating government (collaborative member) assures fulfillment of all requirements of the Boulder County CDBG-DR Collaborative Infrastructure Program as contained in the program guidelines and that all information contained herein is true and correct to the best of my knowledge. The Participating Entity and Special District understands that the project may proceed ONLY AFTER the Request for Release of Funds has been issued.

Approved for Submittal by (Signature)TitleTelephone Number

Print Name of Authorized Collaborative Partner/Special DistrictDate Signed