Applicant:

Tax ID Number:

Contact person/Title:

Address:

City State: IA County Zip Code:

Telephone Number: Fax Number:

E-mail address:

Clean Water SRF NPDES Number:

Drinking Water SRF PWSID Number:

Please write a brief description of the proposed project:

Is the system under any regulatory compliance order? Yes No

What is the expected construction start date?

What is the expected project completion date?

How many people are served by the system?

Planning & Design Cost Breakdown

Administrative & Legal expenses / $
Engineering Planning & Design expenses / $
Land (Drinking Water ONLY) / $
Archaeological/Environmental / $
Other- Specify / $
$
Total Planning & Design Costs / $
Planning & Design Loan Request / $


PROFESSIONAL CONSULTANTS

Project Engineer:

Name of Contact Person:

Mailing Address:

City, State, and Zip Code:

Telephone Number:

E-mail address:

Bond Counsel:

Name of Contact Person:

Mailing Address:

City, State, and Zip Code:

Telephone Number:

E-mail address:

Financial Advisor:

Name of Contact Person:

Mailing Address:

City, State, and Zip Code:

Telephone Number:

E-mail address:

What is the anticipated method or methods of permanently financing the proposed project?

State Revolving Fund Loan (SRF Construction Loan)

Community Development Block Grant (CDBG)

USDA/Rural Development (RD) Grant and/or Loan

Other

System Utilization for the most recent year: / Number of Connections / Annual Revenue / Percentage of System Annual Usage
Residential
Commercial
Industrial
Other
Unmetered
Total

The applicant must enclose (or email) its most recent financial statement with the completed application. (If your financial information is available online, you may just provide a link.)

The undersigned is duly authorized to request this loan on behalf of the Applicant. The Applicant declares under penalty of law that all facts given and information attached are true and correct. The Applicant authorizes IFA to verify all information.

Authorized Signature Date

Typed Name and Title

2