PennDOT Home
Pennsylvania Transportation Infrastructure Bank
Project Loan Application
SECTION I
APPLICANT INFORMATION
Name of Applicant (Organization):__________________________________________
Type of Applicant (check one):
ο Local Government ο County Government
ο Transportation Authority ο Regional/Local Authority
ο Private Corporation/Organization ο State Agency
ο Other, please specify: ______________________________________________
Address of Applicant: ____________________________________________________
City: ____________________________ State: ________ Zip Code: _______
Telephone Number: _________________ Fax Number: _______________________
Contact Person & Title: ___________________________________________________
Contact E-Mail Address: _________________________________
Contact’s Telephone Number: ___________________ Fax Number:__________
PA Revenue Tax Box No.: _________________________________
Federal Identification Number: ______________________________
PENNDOT Use Only:
Date Complete Application Received _____________ Interest Rate ____________ Loan Approval Date __________
Application Forwarded to DCED ______________ DCED Review Completed _______________
SECTION II
PROJECT DESCRIPTION
Type of Project
ο Highway/Bridge Project ο Transit Project ο Aviation ο Rail Freight
This Loan Request is for (check all that apply)
ο Environmental Studies/Preliminary Engineering
ο Final Design/Rights-of-Way Acquisition
ο Construction
ο Transit Related Acquisition
ο Non-highway Construction
ο Other, please specify _________________________________________
Project Location (Attach a location map)
County: _________________________ Municipality: ___________________
Project Description (Please include as much detail about the project as possible including description, purpose, status, projected let date and so on. Attach additional information to this application, if necessary):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
SECTION III
PROJECT PROGRAMMING, STATUS & LAND USE CONSISTENCY
Transportation Improvement Program or Twelve Year Program status of the project. Please indicate the project phases and programmed year within the Transportation Improvement Program or Twelve Year Program.
Phase Program Year
Engineering ___________________________
Right-of-Way/Utilities ___________________________
Construction ___________________________
If applicable (non-government applicants only), is your project a permitted use by right, as specifically authorized in the applicable zoning ordinance, or have you obtained formal zoning approval? If yes, please provide the zoning information and approvals.
ο Yes ο No ο No Zoning
SECTION IV
PROJECT COST ESTIMATE
| | | |
|Type of Cost |Amount |Year(s) of Expenditure |
| | | |
|Feasibility Studies | | |
| | | |
|Preliminary Engineering | | |
| | | |
|Environmental Review | | |
| | | |
|Right-of-Way/Utilities | | |
| | | |
|Construction | | |
| | | |
|Construction Engineering/Inspection | | |
| | | |
|Non-highway Acquisitions | | |
| | | |
|Other | | |
| | | |
|Total Project Costs |$ | |
SECTION V
PROJECT FINANCING PLAN
Sources of Project Funding
| | |
|Source |Amount |
| | |
|Private Contributions | |
| | |
|Federal Contributions | |
| | |
|State Contributions | |
| | |
|Local Contributions | |
| | |
|PIB Assistance (How much do you wish to | |
|borrow?) | |
| | |
|Other Financing (Include source) | |
| | |
|Other | |
SECTION VI
PROJECT IMPACTS
Congestion Reduction and Environmental Benefits. Describe and quantify the proposed project’s impact on congestion reduction, traffic flow, single occupancy vehicle reduction, air quality, etc. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Safety Benefits. Describe and quantify the proposed project’s impact on safety. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Economic Benefits. Describe the proposed project’s economic development benefits. Describe and quantify the number of new jobs to be created, municipal and school district and state tax revenues, etc. __________________________________________________________________________________ ___________________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________
___________________________________________________________________________________
SECTION VII
LOAN INFORMATION
What loan term to you desire? (Maximum term is 10 years.) _______
Indicate payment frequency. Monthly, Semi-Annual, Annual __________
SECTION VIII
CERTIFICATION
State/Local Government or Public Authority Applicant
By: _______________________ Title: ___________________ Date: __________
Print Name: ________________________________________________
Address:____________________________________________________
Corporate Applicant
Corporate Name: _______________________________________________________
By: _______________________ Title: ___________________ Date: __________
Print Name: ________________________________________________
Address:____________________________________________________
Attested By: ______________________________ (Signature of Corporate Secretary)
✓ As part of this application, please submit two copies of the two most recent financial audits. Applications can not be processed without this information.
✓ Municipal Applicants: Please include a completed MS-329 Project Approval Form with this application. Please consult your PennDOT District Municipal Services representative if you have any questions.
✓ Local Government Unit Applicants: All local governments must comply with the Local Government Unit Debt Act before the loan is disbursed.
Please submit 2 copies of the completed application and the supporting documentation to:
U.S. Mail Address Only:
Mr. Hugh McGowan
Pennsylvania Department of Transportation
Center for Program Development & Management
P.O. Box 3365
Harrisburg, Pennsylvania 17105-3365
Overnight Delivery Address Only:
Mr. Hugh McGowan
Pennsylvania Department of Transportation
Center for Program Development & Management
400 North Street – 6th Floor
Harrisburg, Pennsylvania 17120
(Please contact Mr. Hugh McGowan at (717) 787-5798 or hmcgowan@state.pa.us if you have any questions or need assistance with this application.)
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