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9 <br />North Carolina Depar#ment of Environment & IVatural Resources <br />Apptication Appendix for Clean Water ~unding Pragrams <br />Please see our website for applicatian materials and guidance. http;//portal.ncdenr.or~/web/wq/c~ls <br />Indicate the DENR Clean Water Program you are applying ta: <br />Clean Water S#ate Revol~ing Fund {SRF): <br />~ <br />is the intent of this application to receive principal forgiveness? Yes ~ i~o t' <br />(Please note, an appiicant must have a mintmum of 6 combtned points En guestions 22 and 23 to be eiigibie for principal <br />forgiveness as described in section D.3. of the Intended Use Pian) <br />If the answer to the above question is "yes", wiEl the project proceed if it does nofi receive principal <br />forgiveness? Yes ~ No ~ <br />If this is an application for a Green project, will the project proceed if it does not receive 0% interest <br />~nancing7 ~ Yes ^ No ~ <br />Narth Carolina ttevolving loan and Grant Program: <br />Revo{ving Loan Fund (SRt) ^ <br />Emergency Loan Fund (SEL) ^ <br />High Unit Cost Grant ^ <br />Technital Assistance Grant ^ <br />The follow~ng forms, in addition to the common application farm, canstitute a complete application package: <br />~.: Camplete DENR Appendix: This page, signed, with appropriate boxes checked above, ResoEution with <br />Certifcatian of Recorcling Officer.and Water and Sewer Rate Form (iV/A for Stormwater Projectsj <br />• Priority Rating Sheet with all supporting documentation far xhe program checked above ~SRF, SRL, etc.) <br />ci'~ Form LGC 108A (Downtoad ati LGC forms separateEy from the DENR website) <br />~: } Form LGC 10$ C(Wastewater Projects) or LGC 108D or 108E (Stormwater Projects) <br />PI.EASE NO'fE ~ an En~ineerin~ Report wiq onlv be required if vour proiect is ap~sroved for fundin~. A <br />iVotiee af Intent to Fund wifl be maited to afl success#ul applicants with aN pertinent deadlines as <br />outlined in the CWSRF Intended Use Plan, including the deadfine for Engineering Report submission. <br />Send one (1) origina! and ane (1) capy of the common application pages and ihe forms in this appendix to: <br />Mailing Address <br />Canstruction Grants & Laans Section <br />1633 Mail Service Center <br />Raleigh, North Carolina 27699-1633 <br />Physicai Address {FedEx, UPS) <br />Construction Grants & Loans Section <br />2728 Capital Blvd. Suite 1F <br />Raleigh, North Carolina 27604 <br />Certifica#ion far DEPIR Clean Water Applications ' <br />The undersigned, representing the appticant, hereby acknowledges: <br />1. AI! announced funding awards are subject to approval by the Local Government Commission. <br />2. Funding awar8s are subject ta the timelines as outlined in the Intended Use Pfan. Funding will be <br />rescinded if these time[ines are not met. <br />3. If Priority Po9nts were received for committing to impfementing an Asset Management Plan, funding will <br />be rescinded i the Plan is not impfemented by the time 6ids are recei~ed. <br />~-- <br />l ~ ~' ~L 7' ~~'`' ~tZ~r~1r lf~ CL{~~~,J~ T(.~~~ i I~r~A~t'~-, ~PAr1~~au~Y <br />..-------~ . - - ------- ---- ---- -•------------------•--• . <br />Signa ~ Date Print Name and TiUe Unit of G6vernment <br />f Rev 7/16/2010 <br />