**U.S. Representative Kendrick B. Meek**

Appropriations Request Form

Tentative Deadline for Submission: COB Feb. 27, 2009

Please return electronically to <Ali.DiMatteo@mail.house.gov>

**[Contact info:]{.underline}**

Please provide contact information for 2 people for questions about the
project. If you are working with a lobbying firm, please provide 1
contact at the lobbying firm and 1 contact in the organization.

  ------------------ --------------------------- -------------------------------
                     **Contact 1**               **Contact 2**

  **Name**                                       

  **Title**                                      

  **Organization**                               

  **Address**                                    

  **Work Phone**                                 

  **Cell Phone**                                 

  **Email**                                      

  **Any additional                               
  relevant info**                                
  ------------------ --------------------------- -------------------------------

**[Project Description]{.underline}**

1.  Name of Project:

2.  Project Description (250 words or less):

3.  What are the anticipated benefits of the project (250 words or
    less)?

4.  Identify the targeted population who will be served by this
    initiative?

5.  Name, address, telephone number, fax number of Requesting
    Organization:

6.  What is the Requesting Organization's main purpose/activities?

7.  Physical location of Project:

8.  Is this project 100% in the 17^th^ Congressional District? If not,
    what percentage of funding will go to the 17^th^ Congressional
    District?

**[Budget]{.underline}**

1.  Amount of Appropriations funding requested?

2.  What is the total project cost? Please include/attach a detailed
    budget of the total project's estimated expenditures:

3.  What is the specific purpose(s) of the funds?

4.  In the table below, pleas indicate the sources and amounts of
    matching funds from state, local, private or in kind contributions
    (please remember that you are more likely to be funded if you
    request no more than 50 percent of the total cost of the project):

  -------------------- ----------------- ----------------- -----------------
  **Sources of         **Dollar Amount   **% of Total      **Is this funding
  Funding**            Requested**       Project Cost**    committed?**

  **\*Appropriations                                       No
  Funding**                                                

                                                           

                                                           

                                                           

                                                           

                                                           

                                                           

                                                           

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

\*(must match Question 2 in this section)

5.  What is the minimum amount in federal funds needed to have the
    project/program move ahead?

**[Background]{.underline}**

1.  Will other organizations or communities benefit from the project? If
    so, please describe:

2.  Supporting organizations and contact information (if applicable):

3.  If applicable, does the project have the support of state/local
    elected officials (especially for infrastructure projects)? Please
    identify and include resolutions of support if available:

4.  Will this request be submitted to any other U.S. Representatives or
    U.S. Senators for consideration? If so, please specify:

5.  Please list the federal departments/agencies, in order of likely
    jurisdiction, for this project, in the chart below. Additionally,
    please include the account within that department or agency. If this
    is a request for Defense (DOD), please include the DOD program title
    as well, account, line number and Program Element line in the second
    chart.

Remember to list in order of likely jurisdiction:

  ----------------------------------- -----------------------------------
  **Agency/Department of              **Account**
  Jurisdiction**                      

                                      

                                      

                                      

                                      

                                      

                                      

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

> For DOD requests only:

  ----------------- ----------------- ---------------- ------------------
  **DOD Program     **DOD Account**   **DOD Line       **DOD Program
  Title**                             Number**         Element**

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

6.  Are there additional materials (e.g. maps or letters of support)
    that are accompanying this questionnaire? If so, please identify:

7.  Have you spoke to a Meek staff member about the project? If so,
    please identify the staff member:

8.  Has the project received Federal funding in the past? If so, please
    fill in the chart below:

  -------------------------- ------------ ------------- --------------------------
  **Federal source of        **Amount**   **Year(s)**   **Any additional info**
  Funding (i.e. Agency and                              
  account)**                                            

                                                        

                                                        

                                                        

                                                        

                                                        

                                                        

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

9.  Please disclose any financial or operational issues -- now or in the
    foreseeable future -- that could place the organization's operation
    at risk of continuing its programs and services, or would jeopardize
    the availability of the local match?

10. Please disclose any foreseeable issues that could cause the project
    to not go forward as planned or could cause funds to get diverted
    out of the 17^th^ Congressional District: