APPLICANT INFORMATION
ORGANIZATION/AGENCY NAME	PROJECT LOCATION(CITY/COUNTY/TOWNSHIP)	HIGHWAY DISTRICT
ADDRESS	CITY	STATE
ZIP	PHONE	FAX
POINT OF CONTACT	CONTACT E-MAIL
PROJECT NAME AND/OR LOCATION
FUNDING PROGRAM Surface Transportation Block Grant (STBG) Program Transportation Alternatives (STBG Set-Aside Program) Congestion Mitigation Air Quality (CMAQ) – Ohio	PROJECT TYPE Roadway Planning Study Transit Bicycle/Pedestrian/Multimodal Intermodal Other
Is this a new project or a continuation of a project? Yes No If yes, Project Name:
PROJECT DESCRIPTION Please provide a detailed project description and attach an 8 ½” x 11” location map. Project description should include but not be limited to: targeted letting dates, purpose and need, any work completed to date, incurred cost to date, etc. If you require additional space for the Project Description please attach separate sheet labeled with the heading – “Project Description – continued”.
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Is the project included in KYOVA’s current Metropolitan Transportation Plan (MTP)? Yes No
If yes, please identify the location (page number) and project identification number. Page #: MTP Project ID:
Is the project included in KYOVA’s current Transportation Improvement Program (TIP)? Yes No
If yes, please identify the location (page number) and project Identification number. Page #: TIP Project ID:
NOTE: Please include, as an attachment, a Resolution and/or Letter of Commitment signed by the agency chief official approving application of this project. The Resolution and/or Letter must state the project title, total project cost, committed match and the projected project timeline.

ESTIMATED PROJECT COST
IMPORTANT: KYOVA uses the cost estimate to determine the amount of funding; therefore, the estimates for each phase of the project must be as accurate as possible.
INFRASTRUCTURE (CONSTRUCTION) PROJECTS
PHASE	COST
Preliminary Engineering/Detailed Environmental
Design
Design/Build Project
Right of Way (ROW)
Utilities
Construction
Construction Engineering/Inspection
Total Construction Funds	$0.00
*Contingency ( of Total Construction Funds)
TOTAL PROJECT COST – INFRASTRUCTURE	$0.00
NON-INFRASTRUCTURE (NON-CONSTRUCTION) PROJECTS
ACTIVITY	COST
Total Non Infrastructure Funds	$0.00
*Contingency ( of Total Non Infrastructure Funds)
TOTAL PROJECT COST – NON-INFRASTRUCTURE	$0.00
LOCAL PUBLIC AGENCY (LPA) MATCH – Projects require a 20% match
ITEM/SOURCE	AMOUNT
TOTAL MATCH PROVIDED	$0.00
TOTAL PROJECT COST – ESTIMATED
Infrastructure (Construction) Funds	$0.00
Non-Infrastructure (Non-Construction) Funds	$0.00
TOTAL PROJECT COST	$0.00
Match – 20% Minimum Required ( )	$0.00
TOTAL FUNDS REQUESTED	$0.00

*Contingency: It is advised to have 10% contingency for your project. However, if that is not available please state the amount your agency believes will be reasonable in the shaded COST block. The Percent Block under the ACTIVITY column will populate once the dollar amount is completed.

FINANCIAL FEASIBILITY
Will the funds requested in this application fully fund the project? Yes No
If no, provide the gap amount and how the difference will be covered. If more space is required attach a separate sheet with the heading “Financial Feasibility – continued”.
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Name/Title:	Signature: ______________________________	Date: