Document ID: EPA-HQ-OW-2016-0178-0022
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2019-04-23T04:00Z

Introduction: The U.S. Environmental Protection Agency (EPA) will invite selected prospective borrowers to submit this application for Water Infrastructure Finance and Innovation Act (WIFIA) credit assistance. EPA will use the collected information to further evaluate applicants and to develop loan agreement documents. EPA may ask applicants to provide additional supporting materials or to clarify details during the review and negotiation process. The applicant is required to notify and submit to EPA any superseding application materials during the review period. Unsolicited applications will not be considered.
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Purpose: Applicants complete this application to provide EPA with information to assess the creditworthiness of the applicant and project, identify the project's engineering and financial risk, negotiate the terms and conditions of the credit assistance, and calculate the amount of budget authority that will be needed to fund the project(s). 
_____________________________________________________________________________________Format: Applications must include all requested information. Responses to all the questions should be included in this form. If necessary, additional narrative information should be on single-spaced, standard-sized 8 (1/2)" x 11" pages. Page margins should not be less than 1-inch. Font size should not be smaller than 11-point Calibri. 
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Fees: Applicants must submit a non-refundable application fee. The application fee is $25,000 for applications for projects serving small communities (population of not more than 25,000 people). For all other project applications, the application fee is $100,000. An application will not be considered until receipt of the application fee. For further information regarding the application fee, as well as the credit processing fee which will be charged at loan closing, and any other applicable fees, please see the WIFIA fee rule at: https://www.federalregister.gov/documents/2017/06/28/2017-13438/fees-for-water-infrastructure-project-applications-under-wifia.  
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Submission: The applicant should submit an application that includes all components on the application checklist. The applicant may indicate if a requirement is not applicable to its project. If the applicant anticipates a delay in one or more source documents, it may indicate the anticipated date of submitting that document in the application. EPA may request additional items from applicants on a case-by-case basis. 
The documents may be submitted in two ways: 
 Email the documents as attachments to wifia@epa.gov. 
 Upload the documents to EPA's SharePoint site.  To be granted access to the WIFIA SharePoint site, the applicant may email the WIFIA Underwriter assigned to the applicant with the names and emails of all staff that need access. 
Use of Pay.gov to make payments to EPA is the preferred electronic payment method for the Application Fee. In Pay.gov, users can track their payments to EPA and schedule recurring or automatic payments. Although it is not mandatory to register for a user id to access and use Pay.Gov, registration is recommended to have access to all Pay.gov system functionality. To use Pay.gov, follow these instructions:
 Access the Pay.gov system by going to https://www.pay.gov and search for WIFIA or click on the following hyperlink to directly launch the WIFIA Loan Collection & Fees Form.
 Provide the following information on your payment to ensure proper credit:
 Remitter's contact phone number
 Company/Organization Name as it appears on EPA document
 Complete address, including city, state, zip code
 Project Name
 Loan Number: this is EPA WIFIA Loan number, NOT the remitter's number
 From the "Payment Type" drop down menu select "Application Fee (Fee01)" 
 Other Description: please enter your EPA WIFIA Loan number followed by -FEE01, for example 16123DC-FEE01
 Follow the remaining on‐screen instructions to successfully process the payment to EPA.
 Send an email to lvfc-grants@epa.gov and wifia_portfolio@epa.gov informing that a payment has been made.
The application fee may also be paid via FEDWIRE or by check sent to US EPA; Las Vegas Finance Center; 4220 S. Maryland Pkwy, Bldg C, Ste 503; Las Vegas NV 89119. For questions about payments, contact the US EPA Las Vegas Finance Center at (702)798‐2485 or lvfc-grants@epa.gov. For detailed payment instructions, contact the WIFIA program. 
Upon receipt of the application fee and materials, EPA will provide a confirmation email. 
_____________________________________________________________________________________Confidential Business Information:  An applicant may assert a business confidentiality claim covering part or all of the information submitted to EPA as part of its application, in a manner consistent with 40 C.F.R. 2.203, 41 Fed. Reg. 36902 (Sept. 1, 1976), by placing on (or attaching to) the information a cover sheet, stamped or typed legend, or other suitable form of notice employing language such as trade secret, proprietary, or company confidential. The applicant should also state whether it desires confidential treatment until a certain date or until the occurrence of a certain event.  Information covered by a business confidentiality claim will be disclosed by EPA only to the extent and only by means of the procedures set forth under 40 C.F.R. Part 2, Subpart B.  Information that is not accompanied by a business confidentiality claim when it is received by EPA may be made available to the public by EPA without further notice to the applicant. 
More information about CBI is available in the WIFIA program handbook and frequently asked questions (FAQ) available at http://www.epa.gov/wifia.
_____________________________________________________________________________________Burden: The public reporting and recordkeeping burden for this collection of information is estimated to average 150 hours per response.  Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Regulatory Support Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 
_____________________________________________________________________________________Warning: Falsification or misrepresentation of information or failure to file or report information required to be reported may be the basis for denial of financial assistance by the Environmental Protection Agency. Knowing and willful falsification of information required to be submitted and false statements to a Federal Agency may also subject you to criminal prosecution.  See, for example, 18 U.S.C. §1001.
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Additional information is available at https://epa.gov/wifia and by contacting wifia@epa.gov. 
APPLICATION FORM
Provide the following information in this form or as narrative answers. Narrative answers can reference source documents (include the name of the document and relevant pages or sections). Provide any referenced documents as attachments.
Section A: Key Applicant and Loan Information

 Legal name of prospective borrower:

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 Project name (for purposes of identification assign a short name to the project):

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 Estimated total eligible project costs (in dollars): 

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      ☐	Check here if total eligible project costs have changed since the letter of interest submittal

 Requested amount of the WIFIA loan (in dollars): 

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 Anticipated Closing Date and what is driving date:  Click or tap here to enter text.

 Applicant Contact Information

Team Member
Name
Email
Phone Number
Authorized Signatory
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WIFIA Point of Contact
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Financial Advisor
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Bond Counsel
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Project Manager
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Environmental Review Contact
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Other: Click or tap here to enter text.
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Other:  Click or tap here to enter text.
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 Will your project create pre and post-construction jobs?
   
      
      If yes, provide approximately how many and explain how this number was calculated.	
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 Approximately how much in savings is expected with the WIFIA loan as compared to a bond issuance?

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Section B:  Applicant Background

 For applicants other than Public Entities, provide a project-level organizational chart, include the major parties involved in planning, owning, financing, providing supply and/or offtake, constructing, operating, and/or maintaining the project(s). Include the major service contractors that have been, or will be, retained for the project (e.g., architects, developers, engineers, attorneys, financial advisors and underwriters, environmental consultants). Please also disclose if there is a financial relationship between the project sponsor and any key project partners. 

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 Describe the authorizing actions required by the applicant in order to enter into a loan agreement with the WIFIA program (e.g., board vote, local vote, ordinance). For each action, indicate materials required (i.e. substantially complete term sheet or loan agreement) and potential action dates.
                          Applicant Approval Actions
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                              Materials Required
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 Disclose any current, threatened, or pending litigation involving the applicant related to permitting, public involvement, environmental irregularities, construction defects, securities fraud, conflict of interest, failure to perform under a State or Federal contract, or other charges which may reflect on the applicant's financial position or ability to complete the project(s).
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 Customer Concentration Analysis:  List the historical, if available, or projected breakdown of customers by class and revenue. List the top ten (10) customers by percentage of revenues. 

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 Describe the applicant's capital improvement planning process. Include capital improvement plans, other planning documents, and budgets produced in the current year and last three (3) years as attachments. 

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 Describe accounts receivables outstanding, including the 12-month trailing average of on-time payment amounts as a percentage of amount billed per period. Include a brief description of the process for collections.

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 Describe status of liabilities and funding for pension contributions, defined benefits, and other post-employment benefits. 

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 Describe the information available to assess the condition of the system which supports the dedicated revenue source for repayment.
      
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 Describe the process the applicant implements for overseeing scope/schedule/costs of projects. If available provide a Project Management Plan or similar document.
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 For WIFIA loans expected to be secured with drinking water system revenues, provide the following system metrics where data is available. Note the source and data range. If alternative metrics are more readily available, provide them instead.
                                    Metric
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Leaks/100 miles of pipe
Total number of leaks x 100Total miles of distribution piping
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Breaks/100 miles of pipe
Total number of breaks x 100Total miles of distribution piping
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Total O&M Costs of Potable Water Services ($/MG)
Total O&M cost Average daily production x 365 days
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Planned Maintenance Ratio (% of total maintenance time)
Total time for planned maintenance Time for planned mainteance+Time for corrective maintenance
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Water Supply Renewal and Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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Water Treatment Facilities Renewal and Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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Water Pump Stations Renewal and Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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Water Transmission and Distribution Renewal and Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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 For WIFIA loans expected to be secured with wastewater system revenues, provide the following system metrics where data is available. Note the source and data range. If alternative metrics are more readily available, provide them instead.
                                    Metric
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Non-Capacity Sewer Overflow Rate
Number of non-capacity sewer overflowevents annualy x 100Total miles of collection system piping
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Capacity Sewer Overflow Rate
Number of capacity sewer overflowevents annualy x 100Total miles of collection system piping
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Collection System Integrity
Total number of failures x 100Total miles of collection system piping
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Total O&M Costs of Wastewater Services ($/MG)
Total O&M cost Average daily production x 365 days
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Planned Maintenance Ratio (% of total maintenance time)
Total time for planned maintenance Time for planned mainteance+Time for corrective maintenance
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Wastewater Collection Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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Wastewater Pump Stations Renewal and Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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Wastewater Treatment Renewal and Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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Stormwater Collection Renewal and Replacement (%)
Total expenditures or amount of funds reserved for R&RTotal present worth of R&R needs
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Section C: Project Information 

 Provide a general description of all project components. Indicate whether the project involves the construction of new facilities or the renovation or replacement of existing ones. Describe each of the project components including dimensions, quantities, capacities, square footage, etc.

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 Provide design criteria and useful life information for all major project components. Include any supporting technical reports (i.e. Preliminary Engineering Reports, Preliminary Design Reports, or planning documents) as attachments.

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 Describe the location of the project(s); specify if the location is within an existing facility. Include a project map(s) for all project components or sub-projects, if available. Include location address(es), and/or latitude and longitude details for all project components or sub-projects. 

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 Type of project delivery method (i.e., design-build, construction manager at-risk, design-bid-build) that is planned for this project(s):

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 Present the overall project schedule start and end dates for key milestones in the table provided. For WIFIA loans with one project, fill out Row 1. For WIFIA loans with multiple projects, fill out and create as many rows as needed. Provide the detailed project schedule(s) as attachments.

                                   Schedule
Project Name
Planning
Design
Permitting
Construction
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 Present the overall project costs in the table provided. For WIFIA loans with one project, fill out Row 1. For WIFIA loans with multiple projects, fill out and create as many rows as needed. Construction costs should be backed up by a technical document which includes an engineer's estimate or similar, showing quantities, unit prices, and total costs.

                                     Costs
Project Name
Planning
Design
Construction
Other
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 Describe the level of design documentation (including, but not limited to, construction drawings, specifications, construction contract forms, bidding instructions, etc.) available for review and attached with the application. 
      

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 For alternative project delivery methods (i.e., design-build, construction manager at-risk, design-bid-build), describe the level of procurement documentation (including contractor selection materials such as Request for Qualifications and Request for Proposals) available for review and attached with the application.  

      

If one of the options above is not a good fit for the project and/or additional information is available about the procurement documentation, elaborate here: Click or tap here to enter text.

 Describe how the applicant has developed a plan for operating, maintaining, and repairing the project over the useful life of the project. 

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 For loans which include assets to be operated and/or maintained by a third party, provide any contractual arrangements that the applicant plans to execute for the operation and maintenance of the project(s), key performance indicators, insurance policies that may be used to cover the project(s), and reserves that will be set aside for the maintenance of the project(s).
   
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 If applicable, describe community outreach efforts conducted to date and planned for the project(s). Include community meetings, outreach sessions and groups contacted.

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 Describe the risk mitigation strategies implemented for this project. Sample risks might include construction schedule delays, cost escalation, delayed approvals, and litigation.
      
      
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 List any state or local agencies conducting reviews of the project design. Describe any applicable statutory references and expected timelines.

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Section D: Financing Plan

 Provide a sources and uses of funds table for the construction period(s), including the proposed WIFIA assistance. Note any ineligible project costs. More information about eligible costs is available in the WIFIA program handbook.  If other debt is being issued, describe the timing and certainty.

Sources Category
Estimated Dollar Value 
1. WIFIA Loan
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2. Revenue Bonds
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3. SRF Loan
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4. Borrower Cash
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6. Other (please specify) Click or tap here to enter text.
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TOTAL SOURCES
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Uses Category
Estimated Cost
1.  Construction 
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2.  Design 
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3.  Planning 
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4.  Land Acquisition
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5.  Other Capital Costs
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6.  Contingency
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7.  Total Capital Costs
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8. Ineligible Costs (if applicable) 

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10. Other (please specify)  Click or tap here to enter text.
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TOTAL USES
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 Describe the proposed credit terms of the WIFIA assistance.  Complete the following table and include additional text below.  
Credit Term
Proposed
Lien Priority

Security Pledge
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WIFIA Loan Maturity Date 
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Distribution of Excess Cashflow
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Additional Bonds-Test
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5. Other (please specify) Click or tap here to enter text.
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6. Other (please specify) Click or tap here to enter text.
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 For applicants other than Public Entities, please identify the amount and source(s) of project equity, other sources of debt, guarantees from the sponsor or project partners, letters of credit, grants and monetized tax incentives.   

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 Preliminary Rating Letter:  Submit a preliminary rating letter from a nationally recognized statistical rating organization opining on the proposed WIFIA financing and describing the applicant's ability to obtain an investment grade rating on the project's senior obligations. If available, provide any recent rating agency reports for the dedicated repayment source and the lien position for the WIFIA loan.

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 Provide the year-end audited financial statement for the past three (3) years, as an attachment. 

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 Attach the cash flow pro forma(s) for the project(s). All amounts should be expressed on a cash (year-of-expenditure) basis and should include a narrative describing assumptions used to arrive at such estimates.  A sample pro forma can be found here. The pro forma(s) should include:
 Projected cash flows, including separate line items for each category of revenue (such as taxes and user fees) and expenditure (at a minimum, construction, operations and maintenance, contributions to reserves and capital replacement funds, debt service, repayments of the WIFIA credit assistance, and repayment of other borrowed funds, sharing the same security structure as the WIFIA credit assistance, if any);
 Estimated debt service coverage, (addressing, as applicable, senior and junior lien debt), and illustrating projected combined coverage, as applicable;
 The following ratios: (i) Average customer combined water and sewer rates as a percentage of Median Household Income, (ii) Debt to Operating Revenue (Debt being defined as total short- and long-term borrowings (including current maturities), adjusted by adding material debt equivalents, such as operating leases, (iii) Capital Adequacy Ratio ((Fixed Assets less Accumulated Depreciation)/ Annual Depreciation). 
 Disbursement and amortization schedule for all debt sharing the WIFIA security structure, (addressing, as applicable, senior- and junior-lien debt), and combined components; 
 Key assumptions, supported by project and financing documents, including revenue, construction cost, construction schedule, operating expenses, capital expenditures and other debt terms.  Also include assumptions on estimated interest rates, inflation, and macroeconomic information.  Include referenced project and financing documents as attachments.
 Anticipated repayment schedule illustrating the disbursement and repayment of the requested WIFIA credit assistance.

Additional notes for pro forma(s):  Click or tap here to enter text.

 Indicate if the applicant has identified adequate revenues to satisfy increases in operating, maintaining, and repairing expenses for the project over the useful life of the project. 

 Describe all revenue sources to be used to repay project financing. Specify the nature of the revenue source (dedicated or not dedicated), the expected rate(s), the base to which such rates will be applied (e.g. average monthly consumption), projected revenues from each source, and projected increases or decreases in such revenues over time. Include rate covenant requirements that may affect these revenue sources. 

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 Describe the rate setting process, including regulations governing rate setting, approval requirements, timing for implementation, etc. If available, include rate studies and rate schedules for the applicant from the last ten (10) years. Additionally, include historical rate changes for at least five (5) and preferably ten (10) years. Specify if recommended rate increases have ever not been approved.

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 Provide an existing or anticipated flow of funds schedule and summarize key obligations in the flow of funds.

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 Describe any restrictions that may limit the ability to pursue additional funding or transfer funds from the applicant, such as additional bonds tests. 
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 Describe whether the template term sheet is included as an attachment:
      
      

 Describe what document(s) will be the starting point for the WIFIA loan agreement:
      
      
      
      Additional notes for loan agreement: Click or tap here to enter text.
Section E: Federal Requirements Compliance

 Describe the status of the environmental review in accordance with the National Environmental Policy Act (NEPA), including submission of the Programmatic Environmental Assessment (PEA) Questionnaire form, if applicable: 

      
      
Additional NEPA support information: Click or tap here to enter text.

 Describe the status of the SRF environmental review, as applicable

      
      
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 If the environmental review for the project is underway or complete, complete the following table to identify the anticipated impacts and mitigations. Mark a "X" in the appropriate column to identify the impacts anticipated for each resource type and, if applicable, provide a short explanation of the mitigations.

                                 Resource Type
                              Anticipated Impacts
                                  Mitigations

                                   No Impact
                         Less Than Significant Impact
                        Potentially Significant Impact
                                       
Water
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Biological
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Cultural
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Others as Applicable
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 Identify any agencies with which cross-cutter consultations have been undertaken for the project and include supporting documentation as attachments. (Check all that apply)

      ☐	State Historic Preservation Officer
      ☐	Fish and Wildlife Service
      ☐	National Marine and Fisheries Service 
      ☐	Coastal Zone Management Agency
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 Describe the status of any additional permits and approvals that the project(s) may require. Add additional rows as needed.
      
Major Permits or Approvals Required
Approving Authority
Status
Expected Approval Date
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 If applicable, specify if a new or relocated discharge to surface or groundwater is expected or new or relocated water intakes are expected.

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 Indicate which federal requirements are addressed in final or draft bid specifications (or project procurement documents) and drawings developed for the project(s): (Check all that apply and include documents as attachments)

      ☐	Davis-Bacon and Related Acts, Included as attachments are bid specifications or project procurement documents.
      
      ☐	American Iron and Steel (AIS) Requirements.  Included as attachments are bid specifications and contract drawings or project procurement documents.
      
      ☐	Disadvantaged Business Enterprises (DBE) Requirements. Included as attachments are bid specifications or project procurement documents.
      
      ☐	Debarment and Suspension Requirements. Included as attachments are bid specifications or project procurement documents.
      
      ☐	Equal Employment Opportunity (EEO) Requirements. Included as attachments are bid specifications or project procurement documents.
      
      ☐	 New Restrictions on Lobbying. I Included as attachments are bid specifications or project procurement documents.
      
 If draft or final bid specifications (or procurement documents) have not yet been developed, is the applicant aware of how to comply with the federal requirements identified in Section E, Question 7?
      

 Provide a narrative of the good faith efforts used during procuring construction, equipment, services and supplies for the project(s) to comply with DBE requirements or include a DBE plan as an attachment.
   
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 Additional forms attached with the application for compliance with Federal Requirements: (Check all that apply)

      ☐	 EPA Form 5700-52A for DBE Requirements
      
      ☐	 EPA Form 6600-06 for New Restrictions on Lobbying
      
      ☐	 EPA Form 4700-4 and supporting evidence for compliance with Civil Rights Laws
      
 Does the project include acquisition of real property? If so, identify how the project complies or will comply with Uniform Relocation Assistance and Real Property Acquisition Policies Act (Uniform Act):
      
      

 For project(s) in construction, identify if the applicant has manufacturer's certifications available for review for compliance with AIS Requirements.

CERTIFICATIONS 

 National Environmental Policy Act:  The applicant acknowledges that any project receiving credit assistance under this program must comply with all provisions of the National Environmental Policy Act of 1969 (42 U.S.C. 4321 et seq.)
 American Iron and Steel:  The applicant acknowledges that any project receiving credit assistance under this program for the construction, alteration, maintenance, or repair of a project may only use iron and steel products produced in the United States and must comply with all applicable guidance.
 Prevailing Wages:  The applicant acknowledges that all laborers and mechanics employed by contractors or subcontractors on projects receiving credit assistance under this program shall be paid wages at rates not less than those prevailing for the same type of work on similar construction in the immediate locality, as determined by the Secretary of Labor, in accordance with sections 3141-3144, 3146, and 3147 of Title 40 (Davis-Bacon wage rules).
 Credit Ratings:  This applicant has received a preliminary rating opinion letter(s) on the project's senior debt instrument, from one or more rating agencies. These letters or ratings are attached.
 Credit Processing Fees:  The undersigned certifies that it will reimburse EPA for its costs incurred in negotiating the credit agreement, irrespective of whether the credit agreement is executed.
 Lobbying:  Section 1352 of Title 31, United States Code provides that none of the funds appropriated by any Act of Congress may be expended by a recipient of a contract, grant, loan, or cooperative agreement to pay any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, or an employee of a Member of Congress in connection with the award or making of a Federal contract, grant, loan, or cooperative agreement or the modification thereof. EPA interprets this provision to include the use of appropriated funds to influence or attempt to influence the selection for assistance under the WIFIA program.
WIFIA applicants must file a declaration: (a) with the submission of an application for WIFIA credit assistance; (b) upon receipt of WIFIA credit assistance (unless the information contained in the declaration accompanying the WIFIA application has not materially changed); and (c) at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the information contained in any declaration previously filed in connection with the WIFIA credit assistance.
The undersigned certifies, to the best of his or her knowledge and belief, that:
 No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
 If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
 The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
         This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
 Debarment: The undersigned further certifies that it is not currently: 1) debarred or suspended  from participating in any Federal programs; 2) formally proposed for debarment, with a final determination still pending; or 3) indicted, convicted, or had a civil judgment rendered against it for any of the offenses listed in the Regulations Governing Debarment and Suspension (Governmentwide Nonprocurement Debarment and Suspension Regulations: 2 C.F.R. Part 180 and Part 1532).
 Default/Delinquency:  The undersigned further certifies that neither it nor any of its subsidiaries or affiliates are currently in default or delinquent on any debt or loans provided or guaranteed by the Federal Government.
 Other Federal Requirements:  The applicant acknowledges that it must comply with all other federal statutes and regulations, as applicable.  A non-exhaustive list of federal cross-cutting statutes and regulations can be found at : https://www.epa.gov/wifia/wifia-resources#complianceanchor.

 Name: 
Title:  
Organization:
Street Address: 
City/State/Zip: 
Phone: 
E-mail: 

Name: 
Title:  
Organization:
Street Address: 
City/State/Zip: 
Phone: 
E-mail: 

Signature:  By submitting this application, the undersigned certifies that the facts stated and the certifications and representations made in this application are true, to the best of the applicant's knowledge and belief after due inquiry, and that the applicant has not omitted any material facts. The undersigned is an authorized representative of the applicant.
Signature:  _________________________________________________________________________
Date Signed: ________________________________________________________________________

APPLICATION CHECKLIST
WIFIA applications must include the following   
Item
                                Attachment(s)*
                                   Included
Section A:  Key Applicant and Loan Information* (No attachments)
Section B:  Applicant Background
 Organization Chart
    Organization Chart
                                      ☐
 Authorizing Actions
    NA
                                      ☐
 Litigation
    NA
                                      ☐
 Customer Concentration Analysis
    NA
                                      ☐
 Capital Improvement Planning Process
    Last 3 Capital Improvement Plans
                                      ☐
 Outstanding Receivables
    NA
                                      ☐
 Liabilities
    NA
                                      ☐
 System Condition
    System Master Plans
    Condition Assessments
                                      ☐
                                      ☐
 Project Management Process
    Project Management Plan
                                      ☐
 Water System Metrics
    NA
                                      ☐
 Wastewater System Metrics
    NA
                                      ☐
Section C:  Project Information
 Detailed Project Description 
    NA
                                      ☐
 Design Criteria (Include as many as applicable)
    Preliminary Engineering Report*
    Preliminary Design Report*
    Planning Document*
    Other: Click or tap here to enter text.
                                      ☐
                                      ☐
                                      ☐
                                      ☐
 Location
    Project Map
                                      ☐
 Project Delivery Method
    NA
                                      ☐
 Project Schedule
    Detailed project schedule(s)*
                                      ☐
 Project Cost
    Engineer's Cost Estimate associated with detailed project scope*
                                      ☐
 Design Documentation (Check one and include most recent documents available)
    Executed Contract Documents
    Final Contract Documents
    Draft Contract Documents
    Planning Documents
                                      ☐
                                      ☐
                                      ☐
                                      ☐
 Alternate Project Delivery Procurement Documentation (Check one and include most recent documents available)
    Executed Contract Documents
    Final Procurement Documents
    Draft Procurement Documents
    Planning Documents
                                      ☐
                                      ☐
                                      ☐
                                      ☐
 Operations and Maintenance Plan (Include as many as applicable)
    Existing Operation and Maintenance Plan
    Existing Operation and Maintenance Plan, to be updated
    Professional Service Contract or similar evidence of new Operation and Maintenance Plan to be developed
                                      ☐
                                      ☐
                                       
                                      ☐
                                      ☐
 Operations and Maintenance Contracts (Include as many as applicable)
    Operation and Maintenance Contract
    Other: Click or tap here to enter text.
                                      ☐
                                      ☐
 Community Outreach Efforts
    NA
                                      ☐
 Risk Mitigation Plan (Include as many as applicable)
    Risk Mitigation Plan/Matrix
    Project Management Plan
    Evidence of Experience with Similar Projects
                                      ☐
                                      ☐
                                      ☐
 State/Local Design Reviews
    NA
                                      ☐
Section D:  Financing Plan
 Sources and Uses Table
    NA
                                      ☐
 Credit Terms
    NA
                                      ☐
 Plan of Finance
    NA 
                                      ☐
 Preliminary Rating Letter
    Preliminary Rating Letter*
    Rating Agency Report(s)
                                      ☐
                                      ☐
 Audited Financial Statements 
    Audited Financial Statements (3 years)*
                                      ☐
 Cash flow pro forma(s)
    Cash flow pro forma(s)*
    Other Financing Agreements
                                      ☐
 Operation & Maintenance Revenue
    NA
                                      ☐
 Revenue Source Description
    Rate Covenants*
    Other: Click or tap here to enter text.
                                      ☐
                                      ☐
 Rate Setting Process
    Rate Studies
    Rate Schedules
                                     ☐ 
                                      ☐
 Flow of Funds
    Flow of Funds
                                      ☐
 Additional Financial Documentation
    Click or tap here to enter text.
    Click or tap here to enter text.
    Click or tap here to enter text.
                                      ☐
                                      ☐
                                      ☐
 Term Sheet
    Draft Term Sheet
                                      ☐
 Loan Agreement
    Master Indenture
    Bond Ordinance
                                      ☐
                                      ☐
Section E:  Federal Requirements
 National Environmental Policy Act 
    Environmental Assessment (Draft or Final)
    Environmental Impact Statement (Draft or Final)
    Programmatic Environmental Assessment Questionnaire
    Supporting Documentation
                                      ☐
                                      ☐
                                      ☐
                                       
                                      ☐
                                       
 SRF Environmental Review
    SRF Findings
    SRF Consultation Documentation
                                      ☐
                                      ☐
 Environmental Impacts
    NA
                                      ☐
 Cross-Cutter Consultation Agencies
    State Historic Preservation Officer
    Fish and Wildlife Service
    National Marine and Fisheries Service 
    Coastal Zone Management Agency
    Other: Click or tap here to enter text..
                                      ☐
                                      ☐
                                      ☐
                                      ☐
                                      ☐
 Additional Permits
    Click or tap here to enter text.
    Click or tap here to enter text.
    Click or tap here to enter text.
                                      ☐
                                      ☐
                                      ☐
 New Discharge or Intake
    NA
                                      ☐
 Draft or Final Bid Specifications with required language
    Draft or Final Bid Specifications for Project(s)
                                      ☐
 Sample Bid Specifications with required language
    Sample Bid Specifications with required language
                                      ☐
 Disadvantaged Business Enterprise*
    Good Faith Effort Narrative
    DBE Plan
                                      ☐
                                      ☐
 Additional Forms*
    EPA Form 5700-52A
    EPA Form 4700-4
    EPA Form 6600-06
                                      ☐
                                      ☐
                                      ☐
 Uniform Act
    Narrative of Compliance
                                      ☐
 American Iron and Steel
    NA
                                      ☐
Certifications
                                      ☐
 *Required Attachment
KEY DEFINITIONS

 Administrator means the Administrator of EPA.
   
 Applicant means the entity submitting the application for WIFIA credit assistance. Only prospective borrowers that are invited to submit a WIFIA application become applicants. The following entities are eligible to receive credit assistance: a corporation, a partnership, a joint venture, a trust, a Federal, State, or local government, a tribal government or consortium of tribal governments, and a State infrastructure financing authority. 

 Community water system has the meaning given the term in section 1401 of the Safe Drinking Water Act (42 U.S.C. 300f).

 Credit assistance means a secured loan or loan guarantee under WIFIA.

 Credit agreement means a contractual agreement between EPA and the project sponsor (and the lender, if applicable) that formalizes the terms and conditions established in the term sheet (or conditional term sheet) and authorizes the execution of a secured loan or loan guarantee.
   
 Eligible project costs mean amounts, substantially all of which are paid by, or for the account of, a prospective borrower in connection with a project, including the cost of:
 Development-phase activities, including planning, feasibility analysis (including any related analysis necessary to carry out an eligible project), revenue forecasting, environmental review, permitting, preliminary engineering and design work, and other preconstruction activities;
 Construction, reconstruction, rehabilitation, and replacement activities;
 The acquisition of real property or an interest in real property (including water rights, land relating to the project, and improvements to land), environmental mitigation (including acquisitions pursuant to section 33 U.S.C. §3905(7)), construction contingencies, and acquisition of equipment; and
 Capitalized interest necessary to meet market requirements, reasonably required reserve funds, capital issuance expenses, and other carrying costs during construction.
         
 Federal credit instrument means a secured loan or loan guarantee authorized to be made available under WIFIA with respect to a project.
   
 Investment-grade rating means a rating category of BBB minus, Baa3, bbb minus, BBB (low), or higher assigned by a nationally recognized statistical rating organization (NRSRO) to project obligations offered into the capital markets.
   
 Iron and steel products means the following products made primarily of iron or steel: lined or unlined pipes and fittings, manhole covers and other municipal castings, hydrants, tanks, flanges, pipe clamps and restraints, valves, structural steel, reinforced precast concrete, and construction materials.

 Nationally Recognized Statistical Rating Organization (NRSRO) means a credit rating agency identified and registered by the Office of Credit Ratings in the Securities and Exchange Commission.
   
 Project means:
 1 or more activities that are eligible for assistance under section 603(c) of the Federal Water Pollution Control Act (33 U.S.C. 1383(c)), notwithstanding the public ownership requirement under paragraph (1) of that subsection.
 1 or more activities described in section 1452(a)(2) of the Safe Drinking Water Act (42 U.S.C. 300j - 12(a)(2)).
 A project for enhanced energy efficiency in the operation of a public water system or a publicly owned treatment works.
 A project for repair, rehabilitation, or replacement of a treatment works, community water system, or aging water distribution or waste collection facility (including a facility that serves a population or community of an Indian reservation).
 A brackish or sea water desalination project including chloride control.
 A managed aquifer recharge project, a water recycling project, or projects to provide alternative water supplies to reduce aquifer depletion.
 Acquisition of real property or an interest in real property -- 
 If the acquisition is integral to a project described in paragraphs (1) through (5); or
 Pursuant to an existing plan that, in the judgment of the Administrator or the Secretary, as applicable, would mitigate the environmental impacts of water resources infrastructure projects otherwise eligible for assistance under this section.
 A project to prevent, reduce, or mitigate the effects of drought, including projects that enhance the resilience of drought-stricken watersheds.
 A combination of projects, each of which is eligible under paragraph (1) or (2), for which a State infrastructure financing authority submits to the Administrator a single application.
 A combination of projects secured by a common security pledge, each of which is eligible under paragraph (1), (2), (3), (4), (5), (6), or (7), for which an eligible entity, or a combination of eligible entities, submits a single application.
         
 Prospective borrower means an entity that is contemplating or is in the process of undertaking the WIFIA application process, or an entity that has undertaken these activities on behalf of another entity. The following entities are eligible to receive credit assistance: a corporation, a partnership, a joint venture, a trust, a Federal, State, or local government, a tribal government or consortium of tribal governments, and a State infrastructure financing authority. Prospective borrowers become applicants when they are invited to apply for WIFIA credit assistance.
         
 Public entity means:
 a Federal, State, or local Governmental entity, agency, or instrumentality; or
 a Tribal Government or consortium of Tribal Governments.
         
 Publicly sponsored means the prospective borrower can demonstrate, to the satisfaction of the Administrator that it has consulted with the affected State, local or Tribal Government in which the project is located, or is otherwise affected by the project, and that such government supports the proposed project. Support can be shown by a certified letter signed by the approving municipal department or similar agency, mayor or other similar designated authority, local ordinance, or any other means by which local government approval can be evidenced.
   
 Small Community means a community with a population of no more than 25,000 individuals.
   
 State means any one of the fifty states, the District of Columbia, Puerto Rico, or any other territory or possession of the United States.
   
 State infrastructure financing authority means the State entity established or designated by the Governor of a State to receive a capitalization grant provided by, or otherwise carry out the requirements of, title VI of the Federal Water Pollution Control Act (33 U.S.C. 1381 et. seq.) or section 1452 of the Safe Drinking Water Act (42 U.S.C. 300j - 12).

 Term sheet means a contractual agreement between EPA and the project sponsor (and the lender, if applicable) that sets forth the key business terms and conditions of a Federal credit instrument. Execution of this document represents a legal obligation of budget authority.

 Treatment works has the meaning given the term in section 212 of the Federal Water Pollution Control Act (33 U.S.C. 1292).
   
 WIFIA means the Water Infrastructure Finance and Innovation Act of 2014, Pub. L. 113-121, 128 Stat, 1332, codified at 33 U.S.C. §§ 3901-3914.