Energy And Mineral Impact Assistance Program Application printable pdf download

Energy And Mineral Impact Assistance Program Application

STATE OF COLORADO

Rev. 7/00

#___________

Department of Local Affairs

(

For Use by State)

ENERGY AND MINERAL IMPACT ASSISTANCE PROGRAM APPLICATION

Public Facilities/Public Services/Community Development Projects

(Refer to back page for application filing information)

A. GENERAL AND SUMMARY INFORMATION

Name/Title of Proposed Project:

Applicant:

(In the case of a multi-jurisdictional application, name of the "lead" municipality, county, special districts or other political subdivision)

In the case of a multi-jurisdictional application, names of other directly participating political subdivisions:

If applying on behalf of a non-profit corporation, the eligible local government must assume responsibility for the

administration of any funds awarded. Name of the non-profit corporation:

Chief Elected Official (In the case of a multi-jurisdictional application, chief elected official of the "lead" political

subdivision):

Name:

Title:

Mailing Address:

Phone:

E-mail Address:

Fax:

Designated Contact Person for the Application:

Name:

Title:

Mailing Address:

Phone:

E-mail Address:

Fax:

Amount requested:_____________ Does the applicant jurisdiction have the ability to receive and spend state grant

If no, please explain.

funds under TABOR spending limitations? Yes

Brief Description of Proposed Project

(100 words or less):

a. Local priority as assigned by county-wide impact team:

. Relative to other applications (e.g., 1

of 2, 2 of 4, etc.) submitted by jurisdictions in the county in current fund cycle.

b. What is the composition of the county-wide impact team? (e.g., energy/mineral industry representation, county

commissioners, municipalities, schools districts, emergency service agencies, etc.).

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Energy And Mineral Impact Assistance Program Application