| To assist you with your proposed project please complete and submit the following information |
| Date | 05/16/2012 | Name | * | Title | Street Address | (Street or P.O. Box, City, State, Zipcode) |
Mailing Address | (Street or P.O. Box, City, State, Zipcode) |
| * | Business Phone | * (###) ###-#### | |||
| Fax Number | (###) ###-#### | County | * | ||
| Name of Entity | Type of Entity | * | Name of Project | Type of Project | * |
| Tribe/Nation/Pueblo? | YesNo | ||||
| Is this a Drinking Water State Revolving Fund project? | YesNo | ||||
| Is this a Tribal Infrastructure Fund project? | YesNo | ||||
| If yes, what category of project is this? | |||||
| If no, what category of project is this? | |||||
| Description of Proposed Project | (400 Char. max) | Population to be served by the proposed project? | |||
| Population currently served by the system | Has the proposed project's Preliminary Engineering Report (PER) been completed? | YesNo | If yes, date of completion | 
mm/dd/yyyy | |
| Has any environmental work been completed in connection with this proposed project? | YesNo | If yes, date of completion |
mm/dd/yyyy | ||
| Do you believe that this proposed project is eligible for a NEPA Categorical Exclusion? | YesNo | ||||
| What is the total estimated cost anticipated for this proposed project? | |||||
| What is the amount of funding being requested at this time for this proposed project? | |||||
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Please enter the exact text in the box. Text is case-sensitive. | |
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* - Required field | |