I.  Legal Applicant

Applicant Name

Address

City

County

ZIP

Local Government Contact Person

Phone Number

Fax Number

Person who completed application

Phone Number

Fax Number

Population for last official census

Area population

2.  Type of Request

  Planning

  Public Facilities

  Housing Opportunities

  Housing Rehabilitation

Pre-application           

Final application

3.  National Objective

Low/Moderate Income Benefit

Slums/Blight Elimination

Alleviation of Urgent Need

4.  Title of Project and Brief Summary Description

5.  Use of CDBG Funds

Construction

Relocation

User Fees

Acquisition

Special Assessments

Other

6.  Proposed Funding

a.  CDBG Cost               

b.  CDBG Administration

c.  Local Funds               

d.  Other Funds              

e.  Other Administration  

f.   Total Cost                 

7.  Project Start Date 

8.  Project Duration (max 18 months) 

9.  Applicant Certifies That

To the best of my knowledge and belief, data in this application are true and correct, and the document has been duly authorized by the governing body of the applicant.

 

Name             Title