ࡱ> %` 3bjbjNN t<,,F5$ ,j,j,jP|jPk ((n:bn(nnneo0oo$߄hGnireoeorrnnqwwwr|nnwrwwwnn '.,jswNx 0wsww4ov7pTwpDpooovdooorrrr  ahd  h    Clean Water Revolving Funds APPLICATION for Financial Assistance Michigan Department of Environmental Quality Jennifer M. Granholm, Governor Steven E. Chester, Director  http://www.michigan.gov/deq Administered by: The Water Bureau Revolving Loan and Operator Certification Section Chip Heckathorn, Chief Mailing Address: Delivery Address: P.O. Box 30273 Constitution Hall 3rd Floor South Lansing, MI 48909 525 W. Allegan St. 517-373-2161 Lansing, MI 48933 Department of Treasury Michigan Municipal Bond Authority Thomas Letavis, Executive Director 430 W. Allegan St. Lansing, MI 48922 517-335-0994 The Michigan Department of Environmental Quality (MDEQ) will not discriminate against any individual or group on the basis of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. Questions or concerns should be directed to the MDEQ Office of Human Resources, P.O. Box 30473, Lansing, MI 48909. Printed by authority ofof Part 53, 1994 PA 451 FORMTEXT      Total number of copies printed:50Total Cost: $ 57.96Cost per copy: $1.16Michigan Department of Environmental Quality (EQP 3524 Rev. 04/08) State Revolving Fund (SRF) & Strategic Water Quality Initiatives Fund (SWQIF) Loan Application PART I - FINANCIAL INFORMATION Questions about Part I should be directed to the Michigan Municipal Bond Authority at 517-335-0994. Project Name ___________________________________________________________________________ SRF Project Number ____________________ SWQIF Project Number ____________________ A. Legal Name of Applicant __________________________________________________________ The legal name of the applicant may be different than the name of the project. For example, a county may be the legal applicant for bonding purposes, while the project may be named for the particular village or township it serves. B. Address of Applicant ________________________________________________________________________________ (Street, P.O. Box) ________________________________________________________________________________ (City, State & Zip) ________________________________________________________________________________ (Area Code and Telephone Number) (Fax Number) C. Designated Contacts for this Project 1. Authorized Representative Name __________________________________________________________________________ Title ___________________________________________________________________________ ________________________________________________________________________________ (Street, P.O. Box) ________________________________________________________________________________ (City, State & Zip) ________________________________________________________________________________ (Area Code and Telephone Number) (Fax Number) ________________________________________________________________________________ (E-mail Address) If the authorized representative or legal applicant is different from that designated in the resolution submitted with the project plan, another resolution will be required. 2. Primary Contact Name _________________________________________Title _____________________________ 3. Applicants Chief Administrative Officer Name _________________________________________________________________________ 4. Applicants Chief Financial Officer Name _________________________________________________________________________ 5. Applicants Bond Counsel Name __________________________________________________________________________ Firm ___________________________________________________________________________ ________________________________________________________________________________ (Street, P.O. Box) ________________________________________________________________________________ (City, State & Zip) ________________________________________________________________________________ (Area Code and Telephone Number) (Fax Number) ________________________________________________________________________________ (E-mail Address) 6. Applicants Financial Advisor Name __________________________________________________________________________ Firm ___________________________________________________________________________ ________________________________________________________________________________ (Street, P.O. Box) ________________________________________________________________________________ (City, State & Zip) ________________________________________________________________________________ (Area Code and Telephone Number) (Fax Number) ________________________________________________________________________________ (E-mail Address) 7. Consulting Engineer Name __________________________________________________________________________ Firm ___________________________________________________________________________ ________________________________________________________________________________ (Street, P.O. Box) ________________________________________________________________________________ (City, State & Zip) ________________________________________________________________________________ (Area Code and Telephone Number) (Fax Number) ________________________________________________________________________________ (E-mail Address) D. Authorizing Statute Please identify the statute(s) under which you will be bonding to finance this project. ( PA 3 (1895)( PA 94 (1933)( PA 233 (1955)( PA 342 (1939)( PA 7 (1967)( PA 116 (1923)( PA 235 (1947)( Part 43, PA 451 (1994)( PA 34 (2001)( PA 129 (1943)( PA 278 (1909)( Part 47, PA 451 (1994)( PA 35 (1951)( PA 185 (1957)( PA 279 (1909)( Part 119, PA 451 (1994)( PA 40 (1956)( PA 188 (1954)( PA 312 (1929)( PA 76 (1965)( PA 202 (1943)( Public Act ________ of ___________ Your bond counsel or financial advisor can assist you in determining the statute under which your bonding should proceed. Some of the referenced statutes will require the publication of a notice of intent and/or require the holding of a public referendum, which may need to occur several months before bonds are issued. E. Project Estimates The estimated cost of the project should include all costs, whether eligible for loan assistance or not. The amount to be borrowed from the program should equal the amount necessary to cover eligible costs plus a 6% contingency less any amount to be secured from another source. The estimated cost should be rounded to the nearest $5,000. The estimated amount of debt to be refinanced should be the amount of existing debt obligations that will be refinanced by the loan. Estimated Total Cost of Project: $ ___________________________________________________ Estimated Amount to Be Borrowed from the SRF/SWQIF: $ ______________________________ Estimated Amount of Debt (if any) to Be Refinanced by the SRF/SWQIF Loan: $ _____________ F. Principal Payment Dates Annual principal payments will be due each year until the debt is retired. Principal payments must commence in April or October but no later than one year after the targeted date of the initiation of operation that has been agreed to by the MDEQ and the applicant. Principal payments may not be made in more than 20 annual installments.  FORMCHECKBOX  20 Annual Payments Preference for Payment  FORMCHECKBOX  April  FORMCHECKBOX  October Proposed First Principal Payment Will Occur On ____________________________________ Proposed Last Principal Payment Will Occur On ____________________________________ G. Investment Grade Rating The applicant municipality is required to provide evidence of an investment grade rating before financing can be completed. The investment grade rating that you intend to utilize to satisfy this requirement must be for the bonds you intend to issue or for bonds that have the same security pledged for bond repayment. Your bond counsel or financial advisor can assist you with assessing options to bring your loan to an investment grade level. Please refer to the Quarterly Financing Schedule for applicable dates. Please check the appropriate box below and provide the requested information: ( The applicant municipality has obtained an investment grade rating, as detailed below: Fitchs Long-Term Rating __________ Date _____________________________ Type of Borrowing _________________________________________________________ Moodys Long-Term Rating __________ Date _____________________________ Type of Borrowing _________________________________________________________ Standard & Poors Long-Term Rating ________ Date _____________________________ Type of Borrowing _________________________________________________________ ( The applicant municipality will achieve an investment grade rating, as detailed below: ________________________________________________________________________________ ________________________________________________________________________________ H. Project Funding from Other Sources Your SRF or SWQIF loan cannot be used to pay for project costs which have been or will be covered by another source of funding, either public or private (e.g., grants or loans from other state or federal agencies or cash reserves already on hand). Please list your anticipated project costs which are to be covered by another source of funding and the source(s) of that funding. ________________________________________________________________________________ ________________________________________________________________________________ I. Capitalized Interest for New Systems (SRF Only) Interest payments on an SRF loan are due semi-annually until the debt is retired. For a qualifying municipality, the amount of interest due during the construction of a new wastewater collection and treatment system can be included in its loan (i.e., capitalized). This option is available only if the applicant municipality is constructing a new system and no current utility system exists to produce revenue for bond payments during the construction period. If you check the box below, MMBA will confirm your qualification and your MDEQ project manager will compute the appropriate amount of capitalized interest to include in your loan. ( The applicant municipality qualifies for and wishes to capitalize interest during construction. J. Sewage Services Information 1. Population of Applicant Municipality 1990 Census _________________________ 2000 Census _________________________ Current Estimate ______________________ 2. Service Provider Please check the appropriate boxes below. If a service is funded by the applicant but contracted out, mark the "OTHER" box in first column and the "APPLICANT" box in the second. SERVICE SERVICE PROVIDED BY: SERVICE FUNDED BY: Sewage ( Applicant ( Other ( Applicant ( Other If sewage service is provided by a separate authority, another municipality, or a private entity, please name the provider and describe its service area. Name of Provider ________________________________________________________________ Service Area ____________________________________________________________________ 3. Sewage System Users Please provide the number of sewage system users for each of the past five years, the projected number of users for each of the next five years, and data on the five largest sewage system users. This information should reflect only customers of the service area from which revenues for operation, maintenance, and replacement (OM&R) and debt will be derived. (Current Year) ____________ (Number of Users) _________________ (Year) ____________ (Number of Users) _________________ (Year) ____________ (Number of Users) _________________ (Year) ____________ (Number of Users) _________________ (Year) ____________ (Number of Users) _________________ (Year) ____________ (Projected Number of Users) _________________ (Year) ____________ (Projected Number of Users) _________________ (Year) ____________ (Projected Number of Users) _________________ (Year) ____________ (Projected Number of Users) _________________ (Year) ____________ (Projected Number of Users) _________________ NAMES AND ADDRESSES OF THE FIVE LARGEST SEWAGE SYSTEM USERSESTIMATED % OF TOTAL SYSTEM USE1. 2. 3. 4. 5.  K. Tax Base Information Sections K and L are intended to provide credit information about the issuer of the bonds. If the applicant municipality is issuing the bonds directly, the information you provide should be for that municipality. If instead your municipality is issuing the bonds through the county, the information you provide should be for the county. If the applicant municipality is issuing the bonds, an official statement for a general obligation bond which you have issued within the past 12 months may be submitted instead and Sections K and L do not have to be filled out. If the county is issuing the bonds, an official statement for a general obligation bond which the county issued within the past 12 months may be submitted instead and Sections K and L do not have to be filled out. ( Official Statement Included (Sections K and L do not have to be filled out.) 1. Five Largest Employers in your Community: EMPLOYER TYPE OF BUSINESSNUMBER OF EMPLOYEES 1. 2. 3. 4. 5. 2. Five Largest Taxpayers in your Community: PRIVATE  TAXPAYER ASSESSED VALUATION ASSESSED % OF TOTAL VALUATION 1. 2. 3. 4. 5. L. Tax History Information 1. Tax History for the Two Preceding Fiscal Years TAX HISTORY Two Preceding Fiscal Years:  20____ - 20____ 20____ - 20____ AMOUNT AMOUNT Millage: Operating Allocated mills mills Millage: Operating Voted mills mills Millage: Capital Improvements mills mills Millage: Debt mills mills Millage: Other mills mills Taxable Value$$ Tax Levies: Total$$ Tax Collections to Date$$ Delinquent Taxes$$ Tax Collections as % of Total Tax Levy % % 2. Tax History for the Current Fiscal Year TAX HISTORY Current Fiscal Year: 20____ - 20____ AMOUNT MILLAGE LIMIT MILLAGE EXPIRES Millage: Operating Allocated mills mills Millage: Operating Voted mills mills Millage: Capital Improvements mills mills Millage: Debt mills mills Millage: Other mills mills Taxable Value$ Tax Levies: Total$ Tax Collections to Date$ Delinquent Taxes$ Tax Collections as % of Total Tax Levy % 3. Property Tax Information COMPOSITION OF Taxable Value AMOUNT PERCENT Residential Property  % Industrial Property  % Commercial Property  % Agricultural Property  % Other Property  % Industrial/Commercial Facilities$ Total Taxable Value$ M. Sewage System Funding Sources Please identify the sources of funding for system capitalized costs and debt retirement, both current and after completion of the project. ANNUAL FUNDING SOURCECURRENT AFTER COMPLETION 1. Debt Retirement Revenue$$ 2. Annual Connection Fees $_________X_________ connections$$ 3. Special Assessments $_________X_________ connections$$ 4. Other Assessments or Fees _______________________________$$ _______________________________$$ _______________________________$$ 5. Transfers from Other Funds _______________________________$$ _______________________________$$ _______________________________$$ 6. Total Annual Revenue$$ N. Other Required Documents Please check the appropriate boxes and attach the following items to your Part I submittal. All attachments must be included. Attached 1. Current year budget and audited financial statements for the three most recent years. An applicant that is serving as a conduit issuer for a local unit of government need only attach the general fund and enterprise fund portions of its financial audits. Attached 2. Most recent official statement or prospectus, if applicable. N/A Attached 3. Direct and overlapping debt schedules and a list of future debt that has No Debt been authorized but unissued. Attached 4. Explanation of payment default on any security, if applicable. No Default Attached 5. Disclosure of any pending litigation or legislation that is material to your None financing or that could have an adverse impact on the financial condition of the borrower. Attached 6. Total system revenue and expense projections for the first two years after the proposed project is initiated. Attached 7. 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