Final Intended Use Plan for the New York State Drinking Water State Revolving Fund

Drinking Water State Revolving Fund (DWSRF) Pre-Application Form
Preliminary Project Schedule and Cost Estimate
For Intended Use Plan (IUP) Listing Purposed
Instructions
DOH Use Only
PWS I.D. No. __________
Project Tracking No. __________
Date Received ___/___/___

Date Prepared: ____/____/____

Project Information
Name of Water System:_______________________________________________________________________________________
Municipality:________________________________________________________________________________________________
County:____________________________________________________________________________________________________
Legislative Districts - Congressional: __________ NYS Senate: __________ NYS Assembly: __________
Project Description/Location:__________________________________________________________________________________
Population Served by Water System:____________________________________________________________________________
Population Served by Project:__________________________________________________________________________________
Has this project been listed in a DWSRF Intended Use Plan (IUP)? Yes or No. If yes, please indicate the DWSRF
project tracking number: __________
Are there other funding sources anticipated for the project: Yes or No. If yes, please attach a separate sheet of paper
and include source of funding, amount of funding, type of funding, and letter of confirmation
Contact Information
Name of Borrower: _______________________ Consulting Engineer: _______________________
Contact Person, Title: _______________________ Contact Person, Title: _______________________
Address: _______________________ Address: _______________________
Phone #: _______________________ Phone #: _______________________
Fax #: _______________________ Fax #: _______________________
E-Mail Address: _______________________ E-Mail Address: _______________________
If applicable, on a separate sheet of paper provide contact information for additional parties who should be included on project mail list, including system owner (if different than borrower) and person responsible for completing subsequent application package.
Project Cost Estimate
Construction Costs $__________
Engineering Fees $__________
Other Expenses $__________
Equipment Costs $__________
Land Acquisition $__________
Contingencies (___% used) $__________
Subtotal Project Costs $__________
Deduct other funding
sources (HUD, RD, etc.)		 $__________
Add Est. Issuance Costs $__________
(Estimated issuance costs are approximately 3% of project costs)
Total Amount to Finance $__________
Project Schedule Dates
(T)Target or (A)Actual
1. Submit Engineering Report. (  )___________
(date)
2. When will all Technical Submittals be completed? (  )___________
 (date)
3. Start of construction date (date Notice to Proceed was issued)? (  )___________
 v(date)
4. Is this project being submitted for Refinancing? Yes or No
If yes, Construction Completion Date (actual date)?		 (  )___________
(date)
Please return completed form to:
New York State Department of Health
Bureau of Water Supply Protection
Empire State Plaza - Corning Tower Room 1110
Albany, New York 12237
Phone: (518) 402-7650
Fax: (518) 402-7659