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Local Government Limited Gaming Impact Fund Application - Colorado Department Of Local Affairs Page 3

g. Water****

Tap Fee

Avg. Monthly User Charges****

Number of Taps Served by Applicant

Fund Carry Forward (as of 1/1/

)

h. Sewer*****

Tap Fee

Avg. Monthly User Charge****

Number of Taps Served by Applicant

Fund Carry Forward (as of 1/1/

)

------------------------------------------------------

****Fill in only for utility projects.

*****Divide sum of monthly residential revenues by number of residential taps served.

C. PROJECT JUSTIFICATION

1. What was the 1990 Census population of the applicant jurisdiction:

? List the current estimated population

for the applicant jurisdiction

. . (Current most recent lottery distribution estimate is acceptable.) What is the

population projection for the applicant in 5 years?

What was the source of the estimate?

2. Attach to this application form Service Delivery Reports and Cost Recovery Form(s) for the preceding calender year

documenting impacts incurred by the applicant from limited stakes gaming operations in Black Hawk, Central City, Cripple

Creek and/or tribal lands.

3. Cite how the project will mitigate any adverse direct impacts associated with the limited stakes gaming operations.

4. List any expenses applicant has already incurred directly related to the need for this project.

5. Describe and calculate any local tax revenue benefits (property, sales or other) that have occurred within the jurisdiction

attributable directly or indirectly to gaming activities. (Discuss methodology used to determine benefits.)

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Local Government Limited Gaming Impact Fund Application - Colorado Department Of Local Affairs Page 3