APPENDIX C Page 1 

### SMALL COMMUNITY AIR SERVICE DEVELOPMENT PROGRAM

**DOCKET OST -**  **2012 -**  **006 9**  **SUMMARY INFORMATION**  All applicants mus t submit this information with their proposal , along with a completed form SF424 on http:// www.grants.gov. 

### A. **APPLICANT INF ORMATION: (CHECK ALL THAT APPLY)**  **⁭ Not a Consortium ⁭ Interstate Consortium**  **⁭ Intrastate Consortium ⁭ Community now receives EAS subsidy**  **⁭ Community (or Consortium member) previously received a Small Community Grant**  **If previous recipient**  **:** Date of Grant: **___________** E xpiration dat e of grant:

**_________ _**  Federal Funds Requested: Carrier(s) Service Obtained: Destination(s) Served: 

### B. **P UBLIC**  **/P RIVATE**  **P ARTNERSHIPS**  **: (L IST ORGANIZATION NAMES**  **) Public**  **Private 1.**  Port of Chelan County **1._____________**

**_________________________ 2.**  Port of Douglas County **2.______________________________________ 3.____________________________________ 3.______________________________________**  **4.__________________________ __________ 4.______________________________________**  **5.____________________________________ 5.______________________________________** 

### C. **P ROJECT**  **P ROPOSAL**  **: (CHECK ALL THAT APPLY)**  **⁭** Marketing ⁭ Upgrade Aircraft ⁭ New Route ⁭ Travel Ba nk ⁭ Service Restoration Subsidy ⁭ Surface Transportation ⁭ Regional Service Revenue Guarantee ⁭ Launch New Carrier Start Up Cost Offset First Service Study ⁭ Secure Additional Carrier Other (explain below )

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### D. **E XISTIN**  **G L**  **ANDING A**  **IDS AT**  **L OCAL**  **A IRPORT:**  **⁭** Full ILS **⁭** Outer/Middle Marker ⁭ Published Instrument Approach **⁭** Localizer **⁭** Other (specify**)** 

### E. **PROJECT COSTS: DO NOT ENTER TEXT IN SHADED AREA**  LI NE DESCRIPT ION SUB TOTAL TO TAL AMOUNT 1 Federal amount requ ested 200,000 2 State cash financial contribution Local cash financial contribution 3a Airport cash funds 3b Non
- airport cash funds 40,000 3 Total local cash funds ( 3a +3b ) 40,000 4 TO TAL CASH FUNDING ( 1+2+3 ) 240,000 In
- Kind contributi on 5a Airport In
- Kind contribution** 5b Other In
- Kind contribution** 5 TO TAL IN
- KIND CONTRIBUTION ( 5a + 5b ) 6 TO TAL PROJECT COST (4+8) 240,000 

### F. **IN -**  **KIND CONTRIBUTIONS  For funds in lines 5a (Airport In
- Kind contribution) and 7b (Other In
- K ind contribution), please describe the source(s) of fund(s) for each.APPENDIX C Page 3 

### G. ** IS THIS APPLICATION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372** **PROCESS?** ⁭ a . This application was made availabl e to the State under the Executive Order 12372 Process for review on

(date) ___________________. ⁭ b. Program is subject to E.O. 12372, but has not been selected by the State for review. ⁭ c. Program is not covered by E.O. 12372
. 

### H. **IS THE APPLICANT D ELINQUENT ON ANY FEDERAL DEBT? (IF “YES”, PROVIDE EXPLANATION)**  ⁭ No ⁭ Yes (explain)

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