Local Program Review Or Obligation Request Form

LOCAL PROGRAM REVIEW OR OBLIGATION REQUEST FORM

From:Click here to enter text.

Date:Click here to enter a date.

Project Information:

District, Sponsoring Agency and Federal Aid Number (Please include State Number, if applicable)

Project Description

Choose an item.

The sponsor is requesting Choose an item. All applicable clearances, reviews and required modifications have been verified and approved. Please obligate federal funds for the subject project.

Project Information

Proposed Work: Click here to enter text. / Project Location: Click here to enter text.
MPO Area: Choose an item. / TIP Number: Click here to enter text. (attach most current TIP sheet)
Estimated Award Date: Click here to enter date. / Travelway ID:
Beginning Log Point: Ending Log Point:

PE Authorization (ifPE allocation in TIP restricts federal participation, insert federal funds amount here.)

Design ESC Approval Date: Click here to enter a date. / Design PE By Local Forces Approval Date: Click here to enter a date.
ESC PE Contract Maximum: Click here to enter text. / Estimated Local Forces PE Cost: Click here to enter text.

Construction Authorization (Authority to Advertise for Bids)

DBE Goal: Click here to enter text. / Design Approval Date: Click here to enter a date.
Project Match: Choose an item. / Design Approval Date Work by Local Forces: Click here to enter a date.
Railroad Impacts: Choose an item. / Bridge Approval Date: Click here to enter a date.

Clearance Dates

NEPA Date: Click here to enter a date. / NEPA Classification:Choose an item.
Section 106 Clearance Date or leave blank if 106 does not apply: Click here to enter date. / Environmental Final Project Clearance Date: Click here to enter a date.
ROW Clearance: Click here to enter date. / Utility Clearance: Choose an item.

Concurrence in Award

DBE Participation:Click here to enter text. / Low Bidder: Click here to enter text.
Design Concurrence Date: Click here to enter a date. / DBE Verification Date Provided by ECR: Click here to enter a date.
Construction Contract Completion Date: Click here to enter a date.

Project Total Cost per activity requesting obligationbased on Choose an item.:

PE: / $ 0.00 / CE Consultant: / $ 0.00
ROW: / $ 0.00 / CE In-House: / $ 0.00
Roadway: / $ 0.00 / Bridge: / $ 0.00
Signing/Striping/Signals/Lighting: / $ 0.00 / Landscaping/Streetscaping: / $ 0.00
Work by Local Forces (please define): / $ 0.00 / Utilities: / $ 0.00
Bike/Ped Facilities: / $ 0.00 / Non-Infrastructure / $ 0.00
Construction Change Orders: / $ 0.00 / $ 0.00
Other (please define): / $ 0.00 / Total Estimate or Bid Amount: / $ 0.00

Comments: Click here to enter text.

2015 Obligation Request Form includes the original table the only disadvantage is Word doesn’t automatically calculate the equation each time a new entry is keyed within the table. In order to calculate the total, all the cells which are included in the formula need to be highlighted and then press F9.

Revised 4/8/15