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= Rice Creek Watershed District 2012 <br /> RCWD Urban Stormwater Remediation Cost -Share Program <br /> f Application Form <br /> N- - ` `may, Incomplete applications will be returned to the applicant. <br /> I. APPLICANT INFORMATION <br /> Organization (to be named as Grantee): <br /> Street Address: <br /> City, State, Zip: <br /> Email: Website: <br /> 0. PROJECT CONTACTS <br /> Project Officer: Financial Officer: <br /> Telephone: Telephone: <br /> Fax: Fax: <br /> Email: Email: <br /> Tax Status: Tax ID #: <br /> (e.g., local government, non - profit 501(c)(3), private business, etc.) <br /> 01. PROJECT INFORMATION <br /> Project Name: <br /> Location(s) of Project: <br /> City: State: County: <br /> Project Start Date: Project Completion Date: <br /> Project Type (check only those that directly apply): <br /> J Redevelopment Project ❑ Storm Sewer / Stormwater Treatment Project <br /> ❑ Roadway / Street Project 0 Other <br /> IV. COST -SHARE REQUEST <br /> Cost -Share Funds Requested: $ <br /> Local Matching Contributions: $ (cash) <br /> $ (in -kind) <br /> Total Estimated Project Cost: $ 0.00 <br /> Would you be willing to accept cost -share funding in an amount Tess than requested? Eri YES 0 NO <br /> V. SIGNATURE OF APPLICANT (An original signature page must be received with this application) <br /> I certify that the information contained within this application is true and accurate. <br /> Signature of Executive Director or Project Officer Date <br /> Name, Title <br /> Page 1 of 4 <br /> 57 <br />