2. Type of Application Circle One of the 3. Address – Following: New Sewer Sewer Rehab Sewer Treatment Potable Water Water for Fire Protection Streets 4. Name of City Clerk or Parish Secretary 5. Email Address Applicant’s 6. Name and Phone Number of Administrative Consultant 7. Name and Phone Number of Preparing Application Engineering/Architectural Firm Preparing Application 8. Administrative Consultant Email Address 9. Engineering/Architectural Firm Email Address 10. Fax Number 11. Parish Applicant’s 12. National Objective Addressed: 13. Total Amount of LCDBG Funds Requested [ ] Slum/Blight [ ] Low/Moderate Income [ ] Urgent Need $ 14. Funds Amount Source of Funds Fund Status State Use Only $ LCDBG $ Local Funds $ Private Funds $ State Funds $ Federal Funds $ Other Funds TOTAL COST $ 15. Signature (Chief Elected Official) 16. Date 17. Typed Name/Title 18. Telephone Number INSTRUCTIONS
2. Type of Application – Circle One of the Following: New Sewer Sewer Rehab Sewer Treatment Potable Water Water for Fire Protection Streets 3. Address 4. Name of City Clerk or Parish Secretary 5. Applicant’s Email Address 6. Name and Phone Number of Administrative Consultant Preparing Application 7. Name and Phone Number of Engineering/Architectural Firm Preparing Application 8. Administrative Consultant Email Address 9. Engineering/Architectural Firm Email Address 10. Applicant’s Fax Number 11. Parish 12. National Objective Addressed: [ ] Slum/Blight [ ] Low/Moderate Income [ ] Urgent Need 13. Total Amount of LCDBG Funds Requested $ 14. Funds Amount Source of Funds Fund Status State Use Only LCDBG $ Local Funds $ Private Funds $ State Funds $ Federal Funds $ Other Funds $ TOTAL COST $ 15. Signature (Chief Elected Official) 16. Date 17. Typed Name/Title 18. Telephone Number INSTRUCTIONS
PF%202016%202017%20Application%20Chapter%204%20Website.docx