Local Share Account Application

Company

Company Name*

Company Entity Type*

Charitable organization?*

NAICS Code*

FEIN/SSN* Please enter FEIN/SSN as 9 digits, no dashes

UEI Number*

Top Official/Signing Authority*

Title*

SAP Vendor Number* xxxxxx or xxxxxx-xxx

Contact

GrpID: 1067

GrpID: 1068

Contact Name*

Contact Title*

GrpID: 1069

Phone*

GrpID: 1070

Ext.

GrpID: 1071

Fax

E-mail*

GrpID: 1051

GrpID: 1072

Mailing Address*

GrpID: 1054

City*

GrpID: 1055

State*

GrpID: 1056

ZIP*

Business Specifics

PageID: 124

Employees

Current # of Full time Employees in Pennsylvania*

Current # of Full time Employees World Wide*

Minority Owned*

Ethnicity

Woman Owned*

Sales

Total Sales*

Total Export Sales*

Investments

R&D Investment* (% of Budget)

Employee Training Investment* (% of Budget)

Enterprise Type* Indicate the types of enterprises that describe the organization listed above.

Project Overview

PageID: 125

Project

Project Name*

Is this project related to another previously submitted project?*

If yes, indicate previous project name

Contacts

Have you contacted anyone at DCED about your project?*

If yes, indicate who

Certification

Is your community certified through Sustainable Pennsylvania?* https://www.sustainablepacommunitycertification.org

If yes, what level

How many Site Locations are involved in the project?*

Project Site Location(s)

PageID: 126

Site Locations

GrpID: 1073

GrpID: 1074

Address*

ZIP*

GrpID: 1075

Designated Areas*

Municipality*

GrpID: 1076

PA House*

PA Senate*

Add Another (Max: 255)

Project Narrative

PageID: 127

Adequate answers to the Project Narrative questions below are required. Uploaded attachments or mailed documents are no longer permitted in this section of the application. If a more detailed narrative is required for the Program selected, instructions will either be provided in the Addenda section or the Program Guidelines.

Project Narrative

What do you plan to accomplish with this project?* Identify the problem(s) that need to be resolved.

How do you plan to accomplish it?* Include expected outcomes that are measurable, obtainable, clear and understandable, and valid. Examples of measurable outcomes include jobs created or retained, people trained, land or building acquired, housing units renovated or built, etc.

How do you plan to use the funds?* Should include specific use of funds and reflect the budget provided with the application.

Projected Schedule and Key Milestones and Dates* A detailed schedule of activities, including key milestones and dates, must accompany this application if applicable to the project.

Project Budget

PageID: 128

Project Budget Narrative

Basis of Cost*

Appraisals

Bids/Quotations

Budget Justification

Contractor Estimates

Engineer Estimates

Sales Agreements

Provide the basis for calculating the costs that are identified in the Project Budget.

Budget Narrative* This narrative must specifically address each of the cost items identified in the budgets below. If an amount is placed in any of the "Other" categories, then you must specify what the money will be used for. NOTE: Some programs have specific guidelines regarding the narrative necessary to qualify for that particular resource. Please read the Program Guidelines for details.

Local Share Account Fund (Gaming Funds) - Budget

GrpID: 1083

Acquisition

GrpID: 1086

GrpID: 1095	GrpID: 1096 Amount
GrpID: 1098 Land	GrpID: 1099 Land - Amount
GrpID: 1101 Buildings	GrpID: 1102 Buildings - Amount

General Construction

GrpID: 1087

GrpID: 1105	GrpID: 1106 Amount
GrpID: 1108 New Construction	GrpID: 1109 New Construction - Amount
GrpID: 1111 Renovations	GrpID: 1112 Renovations - Amount

Infrastructure / Site Preparation

GrpID: 1088

GrpID: 1115	GrpID: 1116 Amount
GrpID: 1118 Roads/Streets	GrpID: 1119 Roads/Streets - Amount
GrpID: 1121 Parking	GrpID: 1122 Parking - Amount
GrpID: 1124 Water/Sewer	GrpID: 1125 Water/Sewer - Amount
GrpID: 1127 Utilities	GrpID: 1128 Utilities - Amount
GrpID: 1130 Demolition	GrpID: 1131 Demolition - Amount
GrpID: 1133 Excavation/Grading	GrpID: 1134 Excavation/Grading - Amount
GrpID: 1136 Environmental Cleanup	GrpID: 1137 Environmental Cleanup - Amount

Machinery & Equipment

GrpID: 1089

GrpID: 1140	GrpID: 1141 Amount
GrpID: 1143 New Equipment Purchase	GrpID: 1144 New Equipment Purchase - Amount
GrpID: 1146 Used Equipment Purchase	GrpID: 1147 Used Equipment Purchase - Amount
GrpID: 1149 Upgrade Existing	GrpID: 1150 Upgrade Existing - Amount
GrpID: 1152 Installation/Building Modification	GrpID: 1153 Installation/Building Modification - Amount
GrpID: 1155 Vehicles	GrpID: 1156 Vehicles - Amount

GrpID: 1084

Operating Costs / Working Capital

GrpID: 1090

GrpID: 1159	GrpID: 1160 Amount
GrpID: 1162 Working Capital	GrpID: 1163 Working Capital - Amount
GrpID: 1165 Salary/Fringe Benefits	GrpID: 1166 Salary/Fringe Benefits - Amount
GrpID: 1168 Training/Technical Assistance	GrpID: 1169 Training/Technical Assistance - Amount
GrpID: 1171 Consumable Supplies	GrpID: 1172 Consumable Supplies - Amount
GrpID: 1174 Travel	GrpID: 1175 Travel - Amount
GrpID: 1177 Promotion	GrpID: 1178 Promotion - Amount
GrpID: 1180 Office Equipment	GrpID: 1181 Office Equipment - Amount
GrpID: 1183 Space Costs	GrpID: 1184 Space Costs - Amount
GrpID: 1186 Audit	GrpID: 1187 Audit - Amount
GrpID: 1189 Indirect Costs	GrpID: 1190 Indirect Costs - Amount

Related Costs

GrpID: 1091

GrpID: 1193	GrpID: 1194 Amount
GrpID: 1196 Professional Services/Consultants	GrpID: 1197 Professional Services/Consultants - Amount
GrpID: 1199 Engineering	GrpID: 1200 Engineering - Amount
GrpID: 1202 Inspections	GrpID: 1203 Inspections - Amount
GrpID: 1205 Fees	GrpID: 1206 Fees - Amount
GrpID: 1208 Insurance	GrpID: 1209 Insurance - Amount
GrpID: 1211 Environmental Assessment	GrpID: 1212 Environmental Assessment - Amount
GrpID: 1214 Legal Costs	GrpID: 1215 Legal Costs - Amount
GrpID: 1217 Closing Costs	GrpID: 1218 Closing Costs - Amount
GrpID: 1220 Contingencies	GrpID: 1221 Contingencies - Amount

Miscellaneous

GrpID: 1092

GrpID: 1224	GrpID: 1225 Amount
GrpID: 1227 Other Specify	GrpID: 1228 Other - Amount

Total for Local Share Account Fund

GrpID: 1229

GrpID: 1232	GrpID: 1233 Amount
GrpID: 1235 Total	GrpID: 1236 Total - Amount*

Other Sources - Budget

GrpID: 1085

Funding Source Name

Funding Source Type

GrpID: 1237

Acquisition

GrpID: 1239

GrpID: 1250	GrpID: 1251 Amount
GrpID: 1253 Land	GrpID: 1254 Land - Amount
GrpID: 1256 Buildings	GrpID: 1257 Buildings - Amount

General Construction

GrpID: 1240

GrpID: 1260	GrpID: 1261 Amount
GrpID: 1263 New Construction	GrpID: 1264 New Construction - Amount
GrpID: 1266 Renovations	GrpID: 1267 Renovations - Amount

Infrastructure / Site Preparation

GrpID: 1241

GrpID: 1270	GrpID: 1271 Amount
GrpID: 1273 Roads/Streets	GrpID: 1274 Roads/Streets - Amount
GrpID: 1276 Parking	GrpID: 1277 Parking - Amount
GrpID: 1279 Water/Sewer	GrpID: 1280 Water/Sewer - Amount
GrpID: 1282 Utilities	GrpID: 1283 Utilities - Amount
GrpID: 1285 Demolition	GrpID: 1286 Demolition - Amount
GrpID: 1288 Excavation/Grading	GrpID: 1289 Excavation/Grading - Amount
GrpID: 1291 Environmental Cleanup	GrpID: 1292 Environmental Cleanup - Amount

Machinery & Equipment

GrpID: 1242

GrpID: 1295	GrpID: 1296 Amount
GrpID: 1298 New Equipment Purchase	GrpID: 1299 New Equipment Purchase - Amount
GrpID: 1301 Used Equipment Purchase	GrpID: 1302 Used Equipment Purchase - Amount
GrpID: 1304 Upgrade Existing	GrpID: 1305 Upgrade Existing - Amount
GrpID: 1307 Installation/Building Modification	GrpID: 1308 Installation/Building Modification - Amount
GrpID: 1310 Vehicles	GrpID: 1311 Vehicles - Amount

GrpID: 1238

Operating Costs / Working Capital

GrpID: 1243

GrpID: 1314	GrpID: 1315 Amount
GrpID: 1317 Working Capital	GrpID: 1318 Working Capital - Amount
GrpID: 1320 Salary/Fringe Benefits	GrpID: 1321 Salary/Fringe Benefits - Amount
GrpID: 1323 Training/Technical Assistance	GrpID: 1324 Training/Technical Assistance - Amount
GrpID: 1326 Consumable Supplies	GrpID: 1327 Consumable Supplies - Amount
GrpID: 1329 Travel	GrpID: 1330 Travel - Amount
GrpID: 1332 Promotion	GrpID: 1333 Promotion - Amount
GrpID: 1335 Office Equipment	GrpID: 1336 Office Equipment - Amount
GrpID: 1338 Space Costs	GrpID: 1339 Space Costs - Amount
GrpID: 1341 Audit	GrpID: 1342 Audit - Amount
GrpID: 1344 Indirect Costs	GrpID: 1345 Indirect Costs - Amount

Related Costs

GrpID: 1244

GrpID: 1348	GrpID: 1349 Amount
GrpID: 1351 Professional Services/Consultants	GrpID: 1352 Professional Services/Consultants - Amount
GrpID: 1354 Engineering	GrpID: 1355 Engineering - Amount
GrpID: 1357 Inspections	GrpID: 1358 Inspections - Amount
GrpID: 1360 Fees	GrpID: 1361 Fees - Amount
GrpID: 1363 Insurance	GrpID: 1364 Insurance - Amount
GrpID: 1366 Environmental Assessment	GrpID: 1367 Environmental Assessment - Amount
GrpID: 1369 Legal Costs	GrpID: 1370 Legal Costs - Amount
GrpID: 1372 Closing Costs	GrpID: 1373 Closing Costs - Amount
GrpID: 1375 Contingencies	GrpID: 1376 Contingencies - Amount

Miscellaneous

GrpID: 1245

GrpID: 1379	GrpID: 1380 Amount
GrpID: 1382 Other Specify	GrpID: 1383 Other - Amount

Total for Source

GrpID: 1246

GrpID: 1386	GrpID: 1387 Amount
GrpID: 1389 Total	GrpID: 1390 Total - Amount

Add Another (Max: 3)

Addenda

PageID: 129

Ownership Notice

In accordance with program guidelines, the project will be owned and maintained by an eligible applicant or nonprofit organization.

Ownership* The name of entity that will own the proposed project.

Maintenance* The name of entity that will maintain the proposed project.

E-Signature Authorized Individuals

DCED has implemented an electronic contracting procedure for awarded funds using an e-signature process. Please provide the name, title, and email address of two authorized individuals who will execute a contract (as identified in Exhibit 4: Resolution), if awarded. Staff will verify the accuracy of information prior to contracting, as necessary.

Authorized Individual Name 1*

Title*

Email*

Authorized Individual Name 2*

Email*

Local Share Account Application

Company Information

Company

Contact

Business Specifics

Employees

Sales

Investments

Project Overview

Project

Contacts

Certification

Project Site Location(s)

Site Locations

Project Narrative

Project Narrative

Project Budget

Project Budget Narrative

Local Share Account Fund (Gaming Funds) - Budget

Acquisition

General Construction

Infrastructure / Site Preparation

Machinery & Equipment

Operating Costs / Working Capital

Related Costs

Miscellaneous

Total for Local Share Account Fund

Other Sources - Budget

Acquisition

General Construction

Infrastructure / Site Preparation

Machinery & Equipment

Operating Costs / Working Capital

Related Costs

Miscellaneous

Total for Source

Addenda

Ownership Notice

E-Signature Authorized Individuals

Warning