Form 4921 - Economic Vitality Incentive Program Grant Application (Fy 2012 - Round 2) Page 9
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9Michigan Department of Treasury
Instructions for Form 4921
4921 (Rev. 07-12), Page 9
Economic Vitality Incentive Program Grant Application (FY 2012 - Round 2)
The numbers listed below coincide with the numbers on the
PART 4: CERTIFICATION
grant application. Lines not listed are explained on the form.
24. Signature of the Primary Local Unit’s Chief Administrative
Officer (as defined in MCL 141.422b), including printed name,
PART 1: PRIMARY INFORMATION
title, and date of signature.
1. Primary Local Unit Name. The name of the Primary
PART 5: PROJECT DETAILS
Local Unit that has the authority and the responsibility for the
(Attach additional information
if needed)
administration of the project in accordance with the project
conditions. For example, “City of Blank” is acceptable.
25. Project Description. Clearly identify all components of
2. Primary Local Unit Code. The revenue sharing local unit
this project, including but not limited to, the following: detailed
code for the Primary Local Unit.
description of proposed project; what is the desired outcome of
3. Primary Local Unit FEIN. Federal employer identification
this project etc... It is very important to present all substance
of the project in a concise form. This information will be an
number that is issued by the Internal Revenue Service.
important factor in the selection process.
4. Primary Local Unit County. County in which the Primary
Local Unit is located.
26. Shared Service Analysis. Describe the status of any
shared service analysis undertaken to date related to this
5. Mailing Address. Street number and name, including suite
project. Have you performed a service consolidation study?
number if applicable, of the Primary Local Unit.
If yes, briefly describe the status of the study (i.e. has it been
PART 2: PROJECT OVERVIEW
completed, when was it completed? How the study relates to
the proposed project).
9. Project Title. Short name that is descriptive of the work to
27. Current Services. Briefly describe how the services related
be done.
to this project are currently being provided. If the project
10. Project Type. Indicate project type. Merger between two
involves more than one local unit, provide the information for
or more local units; inter-local agreement to share services
all local units.
between two local units; or cooperative efforts within one local
unit.
28. Goals and Business Objectives of this Project.
11. Estimated Start Date. Date the project is slated to begin.
List the goals and business objectives this project will be
accomplishing. Explain the outcomes you hope to achieve and
12. Estimated Completion Date. Date the project is expected
how they will be measured.
to be completed.
13. Estimated Total Project Cost. Estimated cost of the total
29. Cost Savings. Indicate “yes” or “no” and include estimated
savings amount for both short-term (one year or less) and long-
project.
term (greater than one year). For long-term savings, indicate
14. Grant Amount Requested. Amount of funding requested
the estimated annual savings and estimated 5 year savings.
for this grant project. The Department of Treasury reserves the
right to award funds for an amount other than requested.
30. Work Plan and Project Timeline. Describe the
15. Local Units Participating In Project. If the project
implementation steps to make the project successful, including
involves multiple local units, list all local units that will
the estimated stages of project development and a detailed
timeline chart outlining each phase of the project (i.e. list task
participate, including their county and revenue sharing local
and projected task completion date, etc.). It should be written so
unit code.
it is clear what the project deliverables and outcomes will be.
PART 3: PROJECT CONTACT INFORMATION
31. Total Grant Budget Worksheet. Provide categorical
18. Contact Name. Full name of the individual that will be
descriptions and amounts. The total of this worksheet should
equal the Grant Amount Requested (Line 14) in Part 2.
responsible for the project and all reporting requirements.
19. Contact Title. Full title of the individual that will be
32. Additional Information and Comments. Provide any
responsible for the project.
other information or comments you deem pertinent, but not
20. Contact Telephone Number. Complete phone number,
specifically requested elsewhere in the application.
including area code, of the individual that will be responsible
for the project.
FILING INSTRuCTIONS
21. Contact Fax Number. Complete fax number, including
Applications are due July 27, 2012. Completed applications
area code, of the individual that will be responsible for the
must be received by 5 p.m. on Friday, July 27, 2012. Post
project.
mark dates will not be accepted. Incomplete applications and
22. Contact E-mail Address. Complete e-mail address of the
electronic submissions will not be considered.
individual that will be responsible for the project.
The original signed application must be submitted by mail to:
23. Contact Local Unit Name. Name of the Local Unit the
project contact is affiliated with.
Michigan Department of Treasury
Office of Revenue and Tax Analysis
PO Box 30722
Lansing, MI 48909
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