RECIPIENT REQUEST CERTIFICATION FORM



RECIPIENT REQUEST CERTIFICATION FORM

The Office of Congressman Mike Rogers (Alabama)

▪ None of the funding requested will be used for a new building, program, or project that has been named for a sitting Member of Congress. If the building, program, or project is already named after a sitting Member of Congress, please state when that naming occurred.

▪ None of the funding requested will be used to secure funds for other entities unless the use of funding is consistent with the specified purpose of the earmark.

▪ For requests where the receiving entity is NOT a unit of federal, state or local government, OR where the entity receiving the funding will NOT be providing support to a federal, state, or local government, or will NOT be providing research, the requesting entity is to provide matching funds including in-kind contributions of 5% or more above statutory requirement.

▪ Attachment of detailed finance plan MUST include:

o anticipated sources of the funding for the duration of the project;

o percent and source of required matching fund; and

o justification for use of federal taxpayer dollars. 

Name of person certifying:

Title of person certifying:

Project name:

Legal name of entity making request:

Address:

______________________________ ______________

Signature of person certifying Date

Breakdown of Funding- Detailed Finance Plan- Sample Document

MUST include:

o anticipated sources of the funding for the duration of the project;

o percent and source of required matching fund; and

o justification for use of federal taxpayer dollars. 

Requesting Member: Congressman John Doe

Bill Number: H.R. 9999

Account: Army Corps of Engineers, General Investigations

Legal Name of Requesting Entity: “The City of Anytown” 

Address of Requesting Entity: 123 Main Street, “City of Anytown”, State, USA 

Description of Request: Provide an earmark of $500,000 to complete a flood control study being conducted with the Army Corps of Engineers. Approximately, $100,000 is for hydrology and hydraulics analysis; $200,000 for engineering; $75,000 for economic analysis; $25,000 for environmental assessment and urban restoration; and $100,000 for flood plain risk management. The Army Corps of Engineers approved a final reconnaissance study that determined that there is a federal interest in flood damage reduction measures to protect both people and property. This request is consistent with the intended and authorized purpose of the Army Corps of Engineers, General Investigations account. This is the last year funding will be needed to complete the study.  “The City of Anytown” will provide a minimum of a 50/50 cost share and this funding will come directly from the City.

District Impact Form

Project Name:

Why is this project a good use of taxpayer’s money?

How does this project directly impact the 3rd Congressional District of Alabama?

What is the impact of this project to the State of Alabama?

What is the National impact of this project?

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