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