HomeMy WebLinkAbout#5270 PWSLP Loan Application K e So LUT i b VU -_A: 502 -7 V -
Illinois Environmental Protection Agency
1021 North Grand Avenue East •. P.O. Box 19276 • Springfield Illinois • 62794-9276 : (217)782-3397
Illinois Public Water Supply Loan Program (PWSLP) for(EPA's use:
Loan Application Loan Number.L17 5828
Date Received::
The Loan Application, plus all accompanying materials,should be submitted to the attention of your
Project Manager at the address below prior to bidding the project and should reflect the latest pre-bid
estimated project costs. Biddable plans and specifications, accompanied by the IEPA Certification of
Pians and Specifications, may be submitted with this package or submitted separately prior to bidding
the project.
Mail threes b fts,ofthe Loan AR 1io cation and,two!,fties of all applicable=attachments:(page 9)to the
attention of your Project Manager at:
Illinois Environmental Protection Agency
Bureau of Water, Infrastructure Financial Assistance Section
1021 North Grand Avenue East
PO Box 19276
Springfield, IL 62794-9276
Please use the guide below to ensure you are including all required materials in your submittal to IEPA.
M Loan Applicant and Project Information-Pages 1 -6.
F71 Comprehensive financial projections, including historical information for the last three(3).
years and projections for the next five (5)years,starting with the current fiscal year(8 years
total). Instructions on page 7.
❑✓ All reauiredla0011cab1e attachments-detailed listing on page 9.
Appendix:Ensure.you,have'filled in all boxes-and-16bluded your signature wherever regdested..
,( Amount and source.of any local funds to be used for project (Pg .,1)
EE Intent Regarding National Flood Insurance(Pg. 2)
✓0 Certification Regarding Project Site, Rights-of-Way, Easements and Permits(Pg. 3)
✓� Taxpayer Identification Number(Pg. 4)
❑E Executive-Compensation Data (5 Officer Form) (Pg. 5)
✓❑ Authorization of a Loan Applicant's Authorized Representative (Pg.6)
✓� Certification of Information on All Previous Pages(Pg. 7),,including
• Debarment, Suspension and Other Responsibility Matters (Pg. 2)
• Use of.American Iron and Steel Products (Pg. 3) .
Refer to Loan Application Instructions for additional information. Questions?Please contact us:
General questions:Your Project Manager or Heidi:AllenAillinoisaov
Financial questions:Jacob.PoescheID-iilihois.gov. BOLL CALL,
Legal questions:Stephanie.'Flowers(Oillino- :go-y
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IL 532-3028 PWS 297 NANI 5 1:
Rev:12/2019 Illinois PWSLP Loan Application M,pN 0-MV-"k
Illinois Environmental Protection Agency
1021 North Grand Avenue East • P.O. Box 19276 •= Springfield •. Illinois • 62794-9276 • (217)782-3397
Illinois Public Water Supply Loan Program (PWSLP) For IEPA's use:
Loan Application Loan Number:L17 5828
Date Received: ,
APPLICANT INFORMATION
Applicant Name: City of Canton
Applicant Address: 2 N. Main Street
City: Canton Zip+4: 61520-2627 County: Fulton
Mailing Address(if different):
City: Zip+4: County:
Applicanttype: Q Municipal 0 County 0 Cooperative 0 Private 0 Other
If Other,enter type here
Public Water System Number IL 0570250
Public Water System Name City of Canton Water System
Data UniversalNumber System(DUNS) Number 142122048
U.S. Congressional District(s) 17
Illinois Representative District 91 Illinois Senate District 46
PROJECT INFORMATION
Project Title: City of Canton-Lead Service Replacements
Project Address:various locations throughout the City
City: Canton Zip+4: 61520 County: Fulton
County or Counties Served by Project: Fulton
U.S. Congressional District(s):17 Same as applicant
Illinois Representative District: 91 Illinois Senate District: 46
Is this a multi-phased project? 0 Yes (2) No
If yes, include previous loan number: L17
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Rev.12/2019 Illinois PWSLP Loan Application Page 1 of 9
CONTACT INFORMATION
Loan Applicant's Authorized Representative(please refer to application instructions)
Name:Kent A. McDowell Title:Mayor
Phone:(309)647-0065 0 Cell (2) Office Email:kmcdowell@cantoncityhall.org
Project Engineer
Name:Keith Plavec Firm:Maurer-Stutz, Inc.
Address: 1670 E.Ash St. Phone:(309) 647-7831' Q Cell ✓) Office
C_anton, IL 61520
Email:kjplavec@mstutz.com
Attorney
Name:Christopher Jump Firm:Davis&Campbell L.L.C.
Address:401 Main Street, Suite 1600 Phone:(309)673-1681 0 Cell (Z) Office
Peoria ,IL 61602
Email:cjump@cantoncityhall.org
Finance Director
Name:Beka Schultz Firm:Clittonl-arsonAllen LLP
Address:301 S.W.Adams Street, Suite 1000 Phone:(309) 495-6904 0 Cell Q Office
Peoria;,IL 61602
Email:beka.schultz@CLAconnect.com
Other(describe role) City Treasurer
Name:Crystal Wilkinson Firm:City of Canton
Address:2 N. Main Street Phone:(309) 647-6691 0 Cell Q) Office
Canton, IL 61520 - - -
Email:cwilkinson@cantoncityhail.org
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PROJECT SCHEDULE
1. Schedule for bidding and construction
Submit IEPA Certification of 7/1/2020
Plans and Specifications
Advertise for Bids 7/1/2021
Open Bids 8/1/2021
Initiation of Construction 11/1/2021
Completion of Construction 7/1/2022
ESTIMATED PROJECT COSTS AND REQUESTED FINANCING
2.Pre-bid estimate of itemized project costs
Project Planning $12,000.00
Legal/Financial
Design Engineering $36,000.00
Construction Engineering $121,000.00
Construction $1,183,485.00
Other $7,000.00
Construction Contingency(suggested 10%
of total construction costs) $118,348.00
Total Pre-Bid Estimate of Project Costs $1,477,833.00
Construction Period Interest(anticipated $22,167.49
to be 1.5% of total project costs) "
Total Project Cost and
Construction Period Interest $1,500,000.50
"Applicant has the option to add construction period interest to the total
amount .financed or pay construction period interest with local funds.
3. Requested PWSLP loan funding $1,500,000.00
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4. List any other proposed sources of funding in addition to the PWSLP request
Source Amount Applied for Approved Received
0 0 0
0 0 0
0 0 0
LOAN REPAYMENT PERIOD AND PLEDGED REVENUES
5. Pledged.revenues. Federal and state,law requires that a specific source(s)of revenue be dedicated
and pledged to make the loan repayments. Provide a description of the source(s)of revenue pledged
to repay the proposed financing agreement(e.g.,system revenues,sales taxes, property taxes)and
method used to secure collection. Please ensure that the Ordinance Authorizing Debt to be Incurred
names the same pledged revenues as the source of repayment proposed in the comprehensive 5-
,_year financial projections requested in Question 19.
Unfunded project costs will be paid from system revenues collected from monthly invoices.
6. Loan repayment period requested 20 years
SYSTEM INFORMATION
7.Active service connections. Not applicable
Connection Type Number of Connections Current Monthly Projected Monthly
User Charge User Charge
Residential 5,093 $155,933.00 $155,933.00
Commercial 455 $160,039.00 $160,039.00
Industrial
Other
Total 5,548 $315,927.00 $315,927.00
8. User charges. Please provide the following dates:
When did current user charges go into effect?6/3/2014
What is the effective date for the
projected monthly user charges?
6/3/2014
Per the 2014 Rate Ordinance:
The monthly minimum charge increased between 2014 and 2018 from$6.00 to$9.50.
The monthly O&M charge increases$0.10 per month each year.
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9. Is an annual review of the revenue system and other related user charges being performed?
Q Yes Q No
10.When was the most recent revenue system study performed? 2019
11. Largest customers. Provide information on customers accounting for at least 5% of system revenues.
Only include non-residential customers.
Customer Type of Business % of System Revenues
City of Cuba Municipality 6%
Illinois River Correctional Facility Correctional Facility 4%
Village of Dunfermline/St. David Municipality 2%
12.Are other entities substantially benefiting (greater than.5%)from the project?
0Yes ✓) No
If Yes,submit copies of any applicable service agreement(s)with substantial beneficiaries.
CURRENT AND FUTURE DEBT
13. Debt obligations. For the revenue source(s) pledged to repay the proposed PWSLP loan in#5 above,
list all debt obligations currently being paid by the same revenue source(s). (Use additional pages if
needed.)
Title of Debt Amount Annual Payment Maturity Date
Water Bond $7,685,000.00 $2,199,665.00 12/1/2023
TEPA Loan $500,687.56 $209,086.22 8/28/2022
i
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Rev.12/2019 Illinois PWSLP-Loqt Applicofion Page 5 of 9
14. Planned debt issuance. Please describe current plans for debt issuance over the next three years for
the public water supply system. Include any authorized debt which is not project-related. Indicate
whether the debt will be parity or subordinate to PWSLP financing, if known, and the anticipated
revenue source for repayment.
Within the next 3 years the City of Canton plans to upgrade the water treatment plant(approx. cost=
$2.1 million). It is anticipated that these improvements will be funded by an EDA Grant/Loan, Rebuild
Illinois Grant or by a PWS loan. Loan payments will be made from revenues colleced from user fees..
15. Current bond ratings(if available)
Standard &Poor's Moody's Fitch
G.O. AA(Stable Outlook)
Revenue Baa3(Stable)
PROPERTY TAX INFORMATION
Complete only if General Obligation bond is pledged to repay the loan.
16. Property tax information. Provide valuation and collection data for the most recent three years.
Year
Assessed Value of Property
Market Value of Property
Property Tax Revenues Levied
Property Taxes Collected
Property Tax Collection Rate
SALES TAX INFORMATION
Complete only if sales taxes are pledged to repay the loan
17.Sales tax collection data. Please complete for the most recent twelve (12) months.
Month/Year Amount Collected Month/Year Amount Collected
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FINANCIAL PROJECTIONS
ALL applicants must complete the following.
18. Start of system fiscal year May 1
19. Submit a comprehensive five (5)year financial projection demonstrating that the dedicated source(s)
of revenue is sufficient to cover the PWSLP debt service costs. Projections must begin with the
current fiscal year. Historical information for the last three (3) years must be provided and must tie to
information in audited financial statements.A sample worksheet in Microsoft Excel can be found at
Www2.illinbis..gov/e aP /top_ipi6s/grants-loans/state=revolving-fund/guidance/Pages. You may add rows to
the worksheet to demonstrate additional sources of revenues or expenditures.
If you wish to submit projections using your own worksheets, ensure that they include the following:
• Revenues and expenses, including operations and maintenance expenses, from the previous
three (3) years and projections for the next five(5)years, starting with the current fiscal year(8
years total).
• Projected revenues for the dedicated source of revenues to be used for repaying the PWSLP
loan.
o If system revenues will be pledged for the loan, ensure the revenues include all
applicable service revenues. Ensure that any anticipated rate increases are included.
o If another source of revenues will be pledged for.the loan (e.g., property taxes,sales
taxes, special assessments), demonstrate that sufficient revenues will be raised and
transferred to the water fund for the purposes for repaying the IEPA loan.
o If revenues are insufficient,the applicant will be asked to raise rates or find other capital
toinfuse into the system. .
• Projected expenses. If system revenues will be pledged, ensure that the budget includes
operations, maintenance, and replacement reserves, as well as current and future debt costs.
• Ensure the new amount available for repayment of the SRF loan is included.
• If applicant is a private entity, use Federal tax returns for the previous three (3) years.
• Refer to the IEPA PWSLP Loan Application and Approval Process for additional clarification.
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20. Provide a written narrative detailing the major assumptions used in arriving at the current and
proposed projections(e.g.additional customers, rate increases, other revenues, changes in
operations and maintenance costs, and debt service). If rate increases are anticipated, explain when
those will go into effect, and what the revised rates will be.Any variances greater than 10%-from year
to year must be explained.Attach additional pages if needed.
Assumptions:
*-The City will continue to increase O&M charges by$0.10/100 c.f. each year
*IEPA PWS loan will include 100%forgiveness, since the project is entirely for lead service
replacements..
I
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ATTACHMENTS
Item ' . Complete and submit the following attachments. Please check the box next to each item to
Attached? confirm that the item is attached to your application.
✓❑ Audited financial statements. Please provide the most recent audited financial statement. If
posted online at the entity's website or the State Comptroller's Local Government
Warehouse (http://warehouse.illinoiseomptroller.com), provide links. IEPA may request
additional audit reports. If applicant is a private entity, submit Federal tax returns..
❑. Single Audit report. If a Single Audit has been completed within the last 3 years, provide the
most recent one. If posted online, provide links.
Projected revenues, expenses and debt coverage for pledged revenue. Provide 5 year
projected revenues, beginning with the current fiscal year. See#19 above for guidance.The
projections must show that there are sufficient revenues to offset relevant costs and SRF
debt service. See the IEPA PWSLP Financial Capability Review Criteria instructions for
additional information.
❑ If any other entities are substantially benefiting (more than 5%)from the project, provide
copies of applicable service agreement(s)with these beneficiaries.
Amortization schedules for all debt obligations listed in#13.
Q Copy of a certified ordinance (bond ordinance) authorizing the debt to be incurred and
identifying a dedicated source of repayment. Required for publicly owned entities. Sample
ordinances can be found at www2.illinois.goy/epa'/topio/grants-lbans/state-revolvfng-fund/
guidance/Pages. The applicant may use an ordinance developed by its bond counsel. Refer
to the Loan Application and Approval Process for more information on this requirement,and
for requirements for nonpublic applicants. If an applicant is not using the IEPA sample
ordinance, it is highly encouraged to submit the draft ordinance for pre-approval to
Stephanie Flowers at Stephanie.FlbwerSffl-)illinoiazpvto avoid delays in loan closing. Please
ensure that the ordinance authorizing debt to be incurred names the same pledged revenues
as the source of repayment that is proposed in the comprehensive 5-year financial
projections requested in#19.
0 Water rate ordinances defining user charges.Alternatively, provide the website address.
0 Signed tax certificate and agreement(www2.illinois.gov/tea/topics/grants-loans%state-
.revolving=fund/Pages/state:revolving-fund-forms.aspx).
❑ Corporate resolution to apply, borrow, and to grant security(required for corporations).
❑ Federal non-profit certification (required for non-profit applicants).
❑ If the system is involved in a lawsuit or pending litigation that is in excess of$10,000, attach
a statement from the system's attorney describing the situation.
✓❑ Loan program certifications and related forms(Appendix). The applicant must agree to the
loan certifications and related forms listed in the appendix starting on the next page.
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APPENDIX: LOAN PROGRAM CERTIFICATIONS
Loan Applicant's Authorized Representative shall.complete and sign in all areas indicated. .
• The loan applicant hereby agrees to pay all project costs not covered by the loan. If the project
costs provided by the applicant exceed the lesser of 5% of the total project cost or$100,000,
please provide the following information:
Amount to be provided by applicant:
Source of funds:
• The loan applicant hereby certifies that it has analyzed the costs and the financial impacts of the
proposed project and that it has the legal, institutional, managerial and financial capability to
insure adequate building,operation,-maintenance and replacement of the treatment works
project.
• The loan applicant hereby certifies that no unlawful or corrupt practice has taken place in the
planning or design of the proposed project.
• The loan applicant hereby certifies that it has complied with all applicable State and Federal
statutory and regulatory requirements in regard to the proposed project.
• The loan applicant hereby certifies that it is not barred from being awarded a_contract or
subcontract under Section 10.1 of the Illinois Purchasing Act.
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CERTIFICATION REGARDING DEBARMENT, SUSPENSION
AND OTHER RESPONSIBILITY MATTERS
The prospective participant to the best of its knowledge and belief that it and its principals:
a. Are not presently debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded from covered transactions by any Federal department or agency;
b. Have not within a three-year period preceding this proposal been convicted of or had a civil
judgment rendered against-them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a'public(Federal, State or local)transaction or
contract under a public transaction;violation of Federal or State antitrust statutes or commission _
of embezzlement,theft,forgery, bribery,falsification or destruction of records, making false
statements or receiving stolen property.
c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(Federal, State or local)with commission of any of the offenses enumerated in paragraph (b) of -
this certification; and
d. Have not within a three-year period preceding this application/proposal had one or more public
transactions(Federal, State or local)terminated for cause or default.
I understand that a false statement on this certification may be grounds for rejection of this proposal or
termination of the award. In addition, under 18 USC Sec. 1001,.a false statement may result in fine of up
to$10,000 or imprisonment for up to 5 years, or both.
INTENT REGARDING NATIONAL FLOOD INSURANCE
•_ Whereas application provisions for loans from the Public Water Supply Loan Program require
compliance with the National Flood Insurance Act 1968, as amended,-and
• Whereas the costs of securing and maintaining flood insurance are eligible for loan participation
during the approved construction period, and
• Whereas failure to secure flood insurance for eligible construction located in designated flood
hazard areas will,cause this construction to become ineligible for loan funds:
• Now therefore, be it resolved that theCUC of Canton will cooperate and coordinate with the
National Flood Insurance Program to acquire and maintain any flood insurance made available
for Project,1_17 5828 for the entire useful life of the insurable construction pursuant to the Flood
Insurance Act of 1968, as amended, and that it will secure said flood insurance for each
insurable structure, as soon as said insurance is available-and will notify the Illinois .
Environmental Protection Agency in writing that the National Flood Insurance requirement has
been satisfied.
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Rev.1212019 PWSLP Loan Application Appendix Page 2 of 7
CERTIFICATION REGARDING PROJECT SITE, RIGHTS-OF-WAY, EASEMENTS AND PERMITS
1. The applicant has investigated and ascertained the location of the site or sites, rights-of-way and
easements being provided for the facilities in its application for loan assistance. In my opinion,
the applicant has a sufficient legal interest in the said site or sites, rights-of-way and easements
to permit the building of.such facilities thereon and to permit the operation and maintenance of
such facilities thereon during,the estimated life of the facility by the applicant after the completion
of construction.
2. The loan applicant has compiled with the provisions of 49 CFR 24 as required by the Uniform
Relocation Assistance and Real Property Acquisition Policies Act of 1970 as amended (42 USG
4601 et seq.).
3: The loan applicant has obtained all the necessary permits as indicated below: .
Type of Permit Permit Number Date Issued
Army Corps of Eng.404
IL Dept. of Trans. Pending
County Highway
Other
LOAN APPLICANT ACKNOWLEDGEMENT OF THE USE OF
AMERICAN IRON AND STEEL PRODUCTS REQUIREMENT
1. I an!aware that all iron and steel products used for this project must be produced in the United
States per Federal appropriations;
2. I.understand the term '"iron and steel products"refers to 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;
3. 1 am aware that loan recipients must be able to verify that products used in their State Revolving
Fund (SRF) projects comply with the AIS requirements;
4. lam aware that this requirement applies to all portions of the project.
Information regarding the American Iron and Steel Requirements is available on IEPA's website,
www2 illinois;gov 60'.at o !atra6ts looms/state revblui6g fund/guidance/Pagers; or by calling the
Infrastructure Financial Assistance Section at(217)782-2027.
IL 532-3028 PWS 297
Rev,,12/2019 PWSLP Loan Application Appendix Page 3 of 7
TAXPAYER IDENTIFICATION NUMBER
certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for
a number to be issued to me),and
2. l am not subject to backup withholding because: (a) I am.exempt from backup withholding, or(b)
I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup
withholding as a.result of a failure to report all interest or dividends, or(c)the IRS has notified me
that I am no longer subject to backup withholding,and
3. 1 am a U.S. person (including a U.S. resident alien).
• If you are an individual, enter your name and SSN as it appears on your Social Security
Card.
• If you are a sole proprietor, enter the owner's name on the name line followed by the
name of the business and the owner's SSN or EIN.
• If you are a single-member LLC that is disregarded as an entity separate from its owner,.
enter the owner's name on the name_ line and the d/b/a on the business name line and
enter the owner's SSN or EIN.
• If the LLC is a corporation or partnership, enter the entity's business name and EIN and
for corporations, attach IRS acceptance letter(CP261 or CP277).
• For all other entities, enter the name of the entity as used to apply for the entity's EIN
and the EIN.
Name:: City of Canton
Business Name: Municipality
Taxpayer Identification Number.
Social Security Number.
or
Employer Identification Number.37-6000876
Legal Status(check one):
0 Individual Q Governmental
0 Sole Proprietor 0 Nonresident alien
0 Partnership 0 Estate or trust
0 Legal Services Corporation 0 Pharmacy(Non-Corp.)
0 Tax-exempt 0 Pharmacy/Funeral Home/Cemetery(Corp.)
0 Corporation providing or billing medical Limited Liability Company
and/or,health care services (select applicable tax classification):
0 Corporation NOT providing or billing 0 D=disregarded entity
medical and/or health care services 0 C=corporation
0 P=partnership
$innatnrg• �• fA J A�'
VY �.�. Date:
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EXECUTIVE COMPENSATION DATA(5 OFFICER FORM)
DUNS number: 142122048 CCR/Cage Number: 3Q3c8
Loan Recipient Name: City of Canton
Name of Project: City of Canton-Lead Service Replacements
Federal Reporting Contact Information:
Name:Kent A. McDowell Phone:(309)647-0065 Email:kmcdowell@cantoncityhall.org
Requirements to report five most highly compensated officers:
When all three of the following conditions are met in the previous fiscal year, you must report the five most highly compensated
officers of the entity.
1. The recipient received 80 percent or more of its annual gross revenues in Federal awards, and
2. The recipient received $25,000,000 or more in annual gross revenue from Federal awards, and
3. The public does not have access to information about the compensation of the senior executives of the entity through
periodic reports filed under section 13(a)or 15(d) of the Securities Exchange Act of 1934(15 U.S.C. §78m(a),78o(d)) or
section 6104 of the Internal Revenue Code of 1986(26 U.S.C.§6104).
Check either box A or B below and complete the requested information.
✓Q A. I certify that in the preceding fiscal year, 2019 City of Canton
(Fiscal year) (Loan recipient name)
✓❑ 1. DID NOT receive 80 percent or more of its annual gross revenues in Federal awards, or
✓./ 2. DID NOT receive$25,000,000 or more in annual gross revenue from Federal awards, or
3.The public DOES have access to information about the compensation of the senior executives of the entity
✓./ through periodic reports filed under section 13(a) or 15(d) of the Securities Exchange Act of 1934(15 U.S.C.
§78m(a), 78o(d))or section 6104 of the Internal Revenue Code of 1986(26 U.S.C. §6104).
And is therefore not required to report the names and compensation of the five most highly compensated officers.
Mayor
Signature Title Date
Q B.The five most highly compensated officers of are:
Name Compensation Amount 1
1 Compensation includes: (1)Salary and bonus. (2)Awards of stock,stock options,and stock appreciation rights. Use the
dollar amount recognized for financial statement reporting purposes with respect to the fiscal year in accordance with FAS
123R.(3)Earnings for services under non-equity incentive plans. Does not include group life, health, hospitalization or
medical reimbursement plans that do not discriminate in favor of executives,and are available generally to all salaried
eiipioyeas. (4)Change io preseni value or denned beneR and actuanai pension pians. (6)Above-market earnings on
deferred compensation that is not tax-qualified. (6)Other compensation. For example: severance,termination payments,
value of life insurance paid on behalf of the employee, perquisites or property if the value for the executive exceeds$10,000,
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Rev.12/2019 PWSLP Loan Application Appendix Page 5 of 7
AUTHORIZATION OF A LOAN APPLICANT'S AUTHORIZED REPRESENTATIVE
TO SIGN PWSLP LOAN APPLICATION DOCUMENTS
Whereas, application provisions for loans from the Public Water Supply Loan Program require that the
City of Canton of Canton. IL authorize a representative to sign the loan application forms and supporting
documents;therefore, be it resolved by the City Council of the City of Canton of Canton. IL that Mayor
Kent A. McDowell is hereby authorized to sign all loan application forms and documents.
Resolved this day of 2020
ture Date
Kent A. McDowell Mayor
Printed Name Title
Certified to be a true and accurate copy, passed and adopted on the above date.
-
'OFFICIAL SEAL.
CAROL E KOHLER
NOTARY PUBLIC-STATE OF ILLINOIS
o Cpt1�4fIS$ION EXf'IRES:10(02122
Signature&Stamp/Seal of Notary Public
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CERTIFICATION OF INFORMATION ON ALL PREVIOUS PAGES
BY LOAN APPLICANT'S AUTHORIZED REPRESENTATIVE
I, Kent A. McDowell, hereby verify that the above information is,to the best of my knowledge,true and
correct.
Signature of Au �.Repr sentative Date
Kent A. McDowell Mayor
Printed Name Title
Attested by . riicipality Official or Notary
Ap
Signature&Stamp/Seal
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Rev.1 M019 PWSLP Loan Application Appendix Page 7 of 7