HomeMy WebLinkAboutJ - 05 (a) Shared Services Mobile Stage Grant ApplicationPage 1 of 2
STATE AND MUNICIPAL FACILITIES PROGRAM
PRELIMINARY APPLICATION
Project Category: (X ) State and Municipal ( ) Economic Development • ( ) Environmenta,1'
* projects in these categories may require additional information and approval/certification
SECTION 1: DATA SHEET/ GENERAL INFORMATION
A.Project Name:
Project Location:
B.Applicant Organization:
Legally Incorporated Name:
Street (not P.O. Box):
City: Zip: County:
Phone: Ext: Fax: E-mail:
Contact Name & Title:
Federal Taxpayer I.D./Charity Reg.# (Non-profits Only):
1.Type of Organization:( ) Municipality ( ) Local Development Corporation or Industrial Dev. Agency ( ) Not-for-Profit ( ) University/Educational Org. ( ) Business Corporation ( ) Other (please describe)
2.Is the organization currently seeking or receiving any other New York State assistance for this project?( ) No ( ) Yes
If your answer is "yes", please provide a detailed explanation on an attached separate sheet.
3.Name of project beneficiary if not applicant:. .
SECTION 2: PROJECT DESCRIPTION
A.Project Description and Amount
1.Please attach a detailed description of the specific capital project that will be undertaken and funded pursuantto this application.
2.Please list the amount of funding anticipated to be received from the State and Municipal Facilities Program forthis project.
3. Project Start Date: Anticipated Date of Project Completion:
SECTION 3: PROJECT BUDGET, DISBURSEMENT SCHEDULE, & OPERATING COSTS
A.Use of Funds
Complete the following Project Budget detailing the proposed sources and uses of funds (attach additional sheetsif necessary).
Paae 1 of 2
USE OF FUNDS SOURCES TOTAL
In-Kind/ State Equity/Sponsor Other sources Contribution
Direct Costs: $ $ $ $
lndirecUSoft Costs:
B.
C.
D.
E.
Total: $ $
. .
$
Please describe other sources of funds and if they have been secured.
Does the project require environmental or other regulatory permits? Have they been secured?
$
( ) No ( ) Yes
( ) No ( ) Yes (
Has any State or local government agency reviewed the project under the State Environmental Quality Review Act (SEQRA) or is such review necessary to obtain any governmental approvals? ) No ( ) Yes (
) NA
) NA
Please describe the ongoing operating costs required to maintain the proposed project and the sources of these funds.
SECTION 4: ELIGIBILITY FOR TAX-EXEMPT FINANCING
1. Do you believe your project is eligible for tax-exempt financing under the Federal Internal Revenue Service code? ( ) No ( ) Yes
2.Has the applicant or proposed recipient of funds previously received financing from the sale of tax-exemptbonds? If yes, attach a schedule describing the details of such financing. ( ) No ( ) Yes
3.Does the applicant or proposed recipient of funds anticipate applying for financing for this project from the saleof other tax-exempt bonds? ( ) No ( ) Yes
4.Have any funds been expended or obligations incurred to date on that portion of the project for which thisapplication is made? If yes, attach a schedule showing details of such disbursements (date, purpose, payee, etc.). ( ) No ( ) Yes
5.Does the applicant or proposed recipient of funds plan to occupy 100% of the project facility? If no, attach aschedule explaining the planned occupancy. ( ) No ( ) Yes
Signature of Applicant:--�---------------Date: ________ _