P re-application. North Dakota Community Development Block Grant Program Lake Agassiz Regional Council, Region 5 FY 2018

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1 P re-application rth Dakota Community Development Block Grant Program Lake Agassiz Regional Council, Region 5 FY 2018 For Public Facilities (including ROAB & ESB) and Housing Projects All Applications must be received by May 21, 2018 (pre-applications submitted by or fax must be followed by original) Name of Applicant: Tax ID Number: DUNS Number: Is the applicant SAM.gov registered? Mayor/Chairperson: Auditor: Point of Contact (if different from mayor/chairperson): If the applicant is a nonprofit organization, has the city/county agreed to sponsor this pre-application and to accept the responsibilities of being the grantee? Engineer/Architect/Contractor: Name: Contact Person: Type of Project: City Wide Project Area Public Facilities, LI & VLI Benefit Public Facilities, Urgent Need Housing Rehabilitation/Other Housing Projects Architectural Barrier Removal

2 Elimination of Slum and Blight Public Facilities, Urgent Need Will the proposed project COMPLETELY remedy the problem? Housing Rehabilitation/Other Housing Projects How many individual housing units (e.g. apartment units, single-family homes) will be rehabilitated? How many of those housing units are occupied by Low and Moderate Income (LMI) households, according to income limits as set forth by the Division for Community Services for each county? Have you submitted alongside this pre-application the completed and signed Multi-Family Housing Program Application Data Collection for each housing unit? Does the community undertake any of the following activities? (Mark all that apply) Enforcement of Building Code Community Clean-up/Fix-up Enforcement of Nuisance Ordinance Prior or Existing Housing Rehabilitation Program (e.g. city-funded loan or grants for LMI households, city partnership with non-profit program, etc.) Is the building older than 1978? If yes, has the property had a lead-based paint inspection conducted since March 2000? Please submit the results of the inspection, which must have been conducted with an X-ray Fluorescence (XRF) device by a trained certified inspector. Has a Housing Quality Standards (HQS) inspection been conducted? (This must be conducted before the pre-application is submitted to LARC. The costs of the inspection are to be borne solely by the applicant). Please submit the results of the HQS inspection along with pre-application. Elimination of Slum and Blight Projects How many structures will be affected? Residential: Commercial/Industrial: Public/Institutional: Will the structures be renovated or demolished?

3 If demolished, what is the intended future use of the land? Project Location (legal description lot, block, township, range, section, etc. or city address) Anticipated Project Duration Length: months Can the beginning of the project wait until spring/summer of 2019? Has any on-site construction and/or rehabilitation work been conducted thus far that would have altered the physical conditions of the project site? Is the project: Entirely within the city limits? Entirely outside the city limits? Some features within and some features outside? Is the project located in a floodplain? Attach Floodplain map showing the location of the project, if applicable. Maps must come from the FEMA Flood Map Service Center (msc.fema.gov/portal). LARC staff can obtain this map if requested by applicant. Is the project on the National Register of Historic Places and/or older than 50 years? Will any part of the project benefit a church-owned property or an organization with a religious purpose or affiliation?

4 If yes, provide an explanation. Is an Income Survey needed to verify Low/Very Low Income Benefit? If yes, applicant must arrange for an income survey acceptable to the CDBG Program. Contact LARC for further instructions. Income survey must be submitted to LARC by June 9, Brief Description of Project: (public facilities applicants, attach Preliminary Engineering Report) Need for Project:

5 Project Cost: Local Funds: CDBG Funds: Other Funds: Total Cost: *Costs to publish notices are local costs that cannot count towards scoring points for matching *Engineering costs are local responsibility if the city is using its contracted engineering firm *Please add CDBG administration costs to local share according to LARC s administrative charge policy (found at under Community Development tab) * Contingency costs are not an allowable expense category per CDBG regulations How will local share be funded? Cash on hand Revenue bond Special assessment bond Bank of rth Dakota loan Other What are the sources of Other Funds? Foundation grants EDA grant Clean/Drinking Water State Revolving Loan Fund Tax Increment Financing Community Facilities Loan Program (USDA Rural Development) USDA Rural Development grant Other Provide evidence that all other funding sources have been secured, if only conditionally at this point in time. Acceptable proof includes but is not limited to commitment letters from funders, balance sheet and income statements, or financial statements showing the city or organization s reserves. All Applicants, attach: Copy of Detailed Cost Estimates Floodplain map, indicating project location, if available Project Location Map, including legal description and/or street address Preliminary Engineering Report (see attached format) Public Facilities Applicants, attach: ADA Applicants, attach: Signature: Signature: Current Water and Sewer Rate Schedule (if water or sewer project) ADA/504 Plan Preliminary Architect Report (see attached format) Mayor/Chairman Date: Auditor or Point of Contact Date: