PERMANENT COMMUNITY IMPACT FUND

NEW APPLICATION

Revised November 2024

PERMANENT COMMUNITY IMPACT FUND 140 East 300 South ~ 1st Floor SALT LAKE CITY, UTAH 84111 O: 435-660-1382 EMAIL COMPLETE APPLICATIONS TO: CIB@UTAH.GOV	Application DeadlineS June 1; OCTOBER 1; February 1; (5:00 pm)

PERMANENT COMMUNITY IMPACT FUND BOARD APPLICATION

PART A. GENERAL INFORMATION (Please use the tab key)

PROJECT TITLE:
Project Location:	Population:
APPLICANT ATTENDED TUTORIAL: Y N	Application provided to SHPO: Y N N/A
Applicant Agency:
Name:	FEDERAL TAX ID NUMBER:
Address:
City:	County:	Zip:
Contact Name:	Phone:	EMAIL:
Must be with the applicant agency and registered in webgrants	CELL:
PRESIDING OFFICIAL // NAME:	TITLE:
This person shall sign application	PHONE:	EMAIL:
CLERK / RECORDER // NAME:	PHONE:	EMAIL:
APPLICANT SUPPORT:
ENGINEER / ARCHITECT // NAME:	COMPANY:
MAILING ADDRESS:	PHONE:	EMAIL:
CITY:	STATE:	ZIP:	CELL:
BOND COUNSEL // NAME:	COMPANY:
MAILING ADDRESS:	PHONE:	EMAIL:
CITY:	STATE:	ZIP:	CELL:
FINANCIAL CONSULTANT // NAME:	COMPANY:
(OPTIONAL)
MAILING ADDRESS:	PHONE:	EMAIL:
CITY:	STATE:	ZIP:	CELL:

PART B. PROPOSED FUNDING

Note: The CIB may limit its total participation in any given project to a maximum of $5,000,000.
TOTAL CIB Funds Requested	Applicant’s Grant/Loan Package request
One Lump Sum - Round to the nearest $1000
$ total request to CIB	Grant $ amount Loan $ amount @ % for Years
SECURITY FOR LOAN	SOURCE/LESSEE
General Obligation Bond
Revenue Bond
Building Authority Lease Revenue Bond
Class B & C Road Fund Revenue Bond
MINERAL LEASE REVENUE
Other (specify):
TOTAL PROJECT FUNDING	SPECIFY	AMOUNT
Applicant Cash
Applicant In-kind**
Other Local Cash
Other Local In-kind**
Federal Grant
Federal Loan
State Grant (DDW, DWQ, - Not cib)
State Loan (DDW, DWQ, - Not cib)
Total REQUESTED CIB Funds
Total Project Cost Must match PROJECT TOTal (pg. 3)	Please Note this will automatically total the above numbers. Please do not overide.	$0

ADDITIONAL INFORMATION AND QUESTIONS
** In-Kind contributions must have a demonstrable value, such as real property. All applicants must indicate how they propose to finance cost over-runs for the proposed project. Were other funding sources, (e.g., DDW, DWQ, USDA Rural Development) contacted to discuss financing this project? Y N Who?
Will the proposed facility be leased? Y N If yes, provide evidence that it will constitute a true lease. (Pass through public funding for private purpose is statutorily prohibited.) Are there mineral revenue development impacts that affect public infrastructure, public finance, federal land, employment and safety? Describe: Clearly define the public purpose for the project and identify how the project alleviates impacts on public infrastructure, public finance, federal land, employment and safety. What is the percentage of federal land in the county? Who are the prime beneficiaries of this project?

PART C. PROJECT BUDGET

COST ESTIMATES
INDIVIDUAL OR FIRM RESPONSIBLE	DATE OF ESTIMATE
CONSTRUCTION BUDGET Attach detailed budget as part of Attachment #1
CONSTRUCTION
CONTINGENCY
CONSTRUCTION SUBTOTAL Please Note this will automatically total the above numbers. Please do not overide.	$0
PRE-CONSTRUCTION ENGINEERING Preliminary studies, layouts, cost estimates, design drawings, specification & contract documents
SPECIAL ENGINEERING SERVICES Soil investigations, geotechnical studies, land surveys, environmental evaluations, permitting, water rights and other special investigations
CONSTRUCTION ENGINEERING SERVICES Representation during construction, special inspections, materials testing and construction phase services
ENGINEERING SUBTOTAL Please Note this will automatically total the above numbers. Please do not overide.	$0
Planning and Studies SUBTOTAL NEPA, EA, EIS, Feasibility
LAND/EASEMENTS/WATER RIGHT SUBTOTAL
EQUIPMENT & FACILITIES SUBTOTAL
Admin // Legal / BONDING ONLY
ADMIN // Financial Consultant
ADMIN SUBTOTAL Please Note this will automatically total the above numbers. Please do not overide.	$0
PROJECT TOTAL - Must match TOTAL PROJECT COST (pg.2) = $0 (This should be $0 if Page 2=Page 3) Please Note this will automatically total the above numbers. Please do not overide.	$0
ANNUAL PLANNED BUDGET FOR COMPLETED PROJECT	ESTIMATED START DATE
Operations & MaintENance
replacement FUND

PART D. APPLICANT AGENCY FINANCIAL INFORMATION

Current Year 2024
ANNUAL Budget
General Fund Budget
PROPERTY TAX YEAR (LAST 5 YRS)	TAX RATE	TAX COLLECTED
2023
2022
2021
2020
2019
CURRENT DEBT STRUCTURE
Assessed Valuation
G.O. Debt Capacity*
Outstanding G.O. Debt
Remaining G.O. Debt Capacity (SuBTRACT OUTSTANDING debt from DEBT Capacity)	$0
*G.O. DEBT LIMITS: COUNTIES 2% of ASSESSED VALUE CITIES, TOWNS SCHOOL DISTRICTS 4% OF ASSESSED VALUE CITIES (1st & 2nd class) +4% for water, lights, sewers OF ASSESSED VALUE CITIES (3rd class) & TOWNS +8% for water, lights, sewers OF ASSESSED VALUE
TOTAL OUTSTANDING DEBT
TOTAL CURRENT ANNUAL DEBT SERVICE
USER FEES (if applicable)
Provide user fee structures for all related projects. Population. cost of project divided by Population = cost per capita. $
Number of users (or estimate)

Bonded Debt Summary

Bonded debt information must be submitted in the format shown below. The submission of bonded debt information in an alternative format will not be accepted, since it precludes easy reference to the actual debt structure of applicant agencies. Please attach additional pages in the same format if there are insufficient columns to list all bonded debt issues.

BOND ISSUE #1	BOND ISSUE #2	BOND ISSUE #3	BOND ISSUE #4	BOND ISSUE #5	BOND ISSUE #6	BOND ISSUE #7
PURPOSE
$ ISSUED
INTEREST RATE
DATE ISSUED
DATE DUE
BOND HOLDER
ANNUAL DEBT SERVICE
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054

PART E. PRE-SUBMISSION ATTACHMENT CHECKLIST

Note: Please refer to CIB PROGRAM SUMMARY (jobs.utah.gov/housing/cib/index.html). Incomplete applications will be held pending completion of all requirements.

Registration (*one time only) To be eligible for funding, the applicant must be registered in WebGrants 3 (https:/webgrants.utah.gov/home.do). The applicant will receive an email with their login ID and password. If applicant has submitted an application previously, they should already have a login and password. DO NOT REGISTER AGAIN. Contact Heather Poulsen 435-660-1382. PROJECT DESCRIPTION WHO - the applicant agency including the problem, situation, condition or need to be addressed by the proposed project and the number of persons, land area, governmental facilities, services or operations impacted by the problem. SCOPE OF WORK- a description of the proposed project including size, location, development timetable, etc. Include explanation of projected benefits to public infrastructure and alternatives considered and include a detailed construction budget estimate. Include 8½ X 11 maps, floor plans, site plans, prepared estimates, etc. WHY – has the applicant investigated other sources of funding for this project and an explanation of why the applicant agency requires financial assistance from CIB? Specify. CAPITAL IMPROVEMENT LIST The ‘Project’ must be on the current consolidated county Capital Improvement List of the Housing & Community Development Division. CIB WILL NOT consider projects not identified on the current list, except in the case of a bona fide public safety or health emergency, or other compelling reason. Water & Sewer Applications ALL WATER AND SEWER APPLICATIONS REQUIRE A DEPARTMENT OF ENVIRONMENTAL QUALITY REVIEW Utah Department of Environmental Quality (DEQ) staff act as technical advisors to the CIB on drinking water and waste water projects. Applicants for proposed drinking water and waste water funding MUST COMPLETE AND SUBMIT the Drinking Water & Waste Water Project Supplement to DEQ with the CIB application. DEQ Supplemental form is located on CIB website: https://jobs.utah.gov/housing/community/cib/index.html Street and Road applications Requires a completed street and road addendum, located on: jobs.utah.gov/housing/community/cib/documents/streetsandroadsaddendum.doc	Planning Applications Small Planning grant applications (under $50,000) are processed separately from other CIB funding. For more information on planning requirements: https://jobs.utah.gov/housing/community/cib/index.html CONSTRUCTION APPLICATIONS // STATE HISTORIC PRESERVATION OFFICE (SHPO) REVIEW Applications which include building, altering or disturbing properties fifty (50) years of age or older, or which may include new site excavation to include road realignments shall be submitted to SHPO and include photographs, map and address of the proposed project for review and comment by SHPO. Association of Governments Notification Provide a copy of current application to the applicable AOG two (2) weeks prior to submission. Affordable Housing Plan Attach a brief summary (and date of adoption if applicable) of the applicant’s efforts to comply with the requirements of Section 10-9a-403 UCA (municipalities) and Section 17-27a-403 UCA (counties). DO NOT SUBMIT THE ENTIRE HOUSING PLAN. Public NOTICE and Participation The CIB requires a vigorous public participation effort. Applicants shall hold AT LEAST one formal public hearing to solicit comments concerning the size, scope, nature of any funding request PRIOR to its submission to the board. The minutes must reflect a discussion of all financing scenarios including the possibility of loan funding. Complete and detailed information regarding the project scope and it’s financing, including expected financial impact, potential repayment terms, potential costs to the public as user fees, special assessments, or property taxes shall be discussed. A copy of the public notice for any public hearings and the official transcript / minutes from the hearing must be attached. (NOTE: The board may require additional public hearings if it determines the applicant did not adequately disclose the impact to the public, or if it offers a substantially different financial package than from what was originally proposed.) Current Audited Financial Report Provide a copy of most recent audited financial report.
PRESIDING OFFICIAL SIGNATURE

I,	, the	of
(TYPED NAME)	(TYPED TITLE)	(TYPED ORGANIZATION)
do hereby certify the information presented in this application is accurate and correct to the best of my knowledge and this application has been authorized by the applicant agency. Furthermore, I certify that this project will comply with all applicable laws as outlined in R990-8-3 (M) prohibiting discrimination on the basis of race, religion, color, or national origin; sex, age, and disability. This project, when complete, will comply with the Americans with Disabilities Act (ADA).
ORIGINAL SIGNATURE	DATE