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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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