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Home My WebLink AboutDDW-2024-007781Data Xfr 8 - Signature 7b - Financial Worksheet 7a - Capacity Assessment 7 - Attachments 6 - Misc 5 - Your System 4 - Funding Sources 3 - Project Info and Costs 2 - Contacts 1 - Introduction Have you received a "Quality Growth Community" certification ? Note to User: There is no user input on this worksheet. Info On "Quality Growth Community" Certification Other Future Projects If YES, please describe the nature of the projects and the timing: End of Tab 6 - MISCELLANEOUS Worksheet QualGrowth gal/mo/conn. Commercial users use X times as much water Commercial users are charged X times as much money OtherProjects 7 - Attachments A Note On Attachments DDW prefers to receive attachments electronically whenever possible. Please send Microsoft Word, Microsoft Excel, PDF or scanned images if possible. If this is not possible, paper submittals are acceptable. Send paper submittals to: Financial Assistance Program Utah Division of Drinking Water Location Address: Salt Lake City, Utah 84116 Post Office Address: P.O. Box 144830 Salt Lake City, Utah 84114-4830 Not On-Line The amount of information which must accompany your application varies with the type of project you are seeking funds for . . . PLANNING or CONSTRUCTION. For all PLANNING Projects . . . * Determination of Water Rights that will fulfill the scope of the project. Capacity Development Water Conservation Plan Source Protection For Water Treatment Plants: Determination of "Maximum Affordable Water Bill" See: For all CONSTRUCTION Projects . . . Please review items below and check the appropriate box. Master Plan or Engineering Report dealing with the proposed project Most Recent Financial Statement Detailed cost estimates for all components of the project Documentation of the Water Rights that will fulfill the scope of the project Description of current water rate structure f. Current Rate and Enforcement Ordinance g. Capacity Assessment Worksheet See DDW's Capacity Development Program h. i. Emergency Response Plan For Your Water System All water systems are encouraged to have emergency response plans. The possiblity of power outages, sabotage, earthquakes, flash floods, equipment failure, etc. should be considered by any water supplier. End of Tab 7 - ATTACHMENTS Worksheet MasPlan FinStmt c CostEst d WatRights e RateStruct f RateEnfOrd g CapAss h i EmerResp 8 - Signature Investigative and administrative costs incurred by the Utah Department of Environmental Quality (DEQ) or the Utah Drinking Water Board will eventually be billed to the project. A budget item for this expense has been calculated on Tab 3. The budget for DEQ Administrative Costs is: (From Tab 3) Please read and acknowledge the following. AGREEMENT: If the project is found not feasible If the application is denied by the Board, If the applicant withdraws the application prior to the Board's authorization. If the applicant decides not to build the project after the Board has authorized the project, all costs accruing after the authorization will be reimbursed by the applicant to the Board. (1) Note: Historically, the Drinking Water Board authorizes up to 20% principle forgiveness if the applicant qualifies as a By typing in the following boxes, I hereby accept the policy and conditions as enumerated above. Furthermore, I also pledge that the information provided in this application form is true and complete to the best of my knowledge. Water System Name: 7b - Financial Worksheet 7a - Capacity Assessment Worksheet End of Tab 7a - Capacity Assessment Worksheet End of Tab 7b - Financial Worksheet Applicant: Prepared By: Date: The Technical Portion of your System Water Supply and Existing Demands Do you know how much water you pump on an average day ? Unknown Amount: Do you know how much water you pump on a peak day ? Have you been able to provide adequate volumes of water during drought cycles ? Please mark the appropriate box (Yes, No, or Unknown) for each section with an "X". Please try to determine the answer to every question. If a section or question does not apply to your system, please write NA for not applicable. Do you have an Emergency Response Plan that will allow you to meet system demand during a drought or shortage, such as the loss of the largest source ? If Yes, please submit a copy Do you have a contract to purchase water? If yes, with whom? Do you know the terms affecting your supply during drought conditions ? Sytem Maintenance Are locations, size, and type of mains and service lines detailed on records ? Unaccounted-for Water Is unaccounted-for water in the water system monitored and analyzed ? Is unaccounted-for water less than 15 percent of the total water delivered to the mains ? List percentage of unaccounted-for water: Do you have a routine leak detection and repair program ? Are all sources of supply and customers metered ? Are the meters calibrated and tested to ensure their accuracy and reliability ? Water Quality in Distribution System Is an annual inspection for cross-connections performed ? Is there a program for installing and testing backflow prevention devices where potential contamination is present ? Distribution System Problems Can you maintain adequte pressure in the distribution system under all conditions of flow ? The Management Portion of your System Operations Staff Does the person operating your system have current water treatment plant and water distribution operator certification credentials from DEQ/DDW? If Yes, list classification: Does your operator receive additional training on an ongoing basis to keep current on new developments in the field ? Future Operational Demands Does your water system obtain any regular or occasional technical assistance from outside sources, such as DDW, your engineer, other utilities or organizations specifically dedicated to providing technical assistance ? If yes, who: Management & Administration Is there a clear plan of organization and control among the people responsible for management and operation of the system ? Are the limits of the operators authority clearly known ? Are all the specific functional areas of operations and management assigned ? Does everyone involved in operations know who is responsible for each area ? Is someone responsible for scheduling work ? Rules and Standards Do you have explicit rules and standards for system modifications ? Do you have rules governing hook-ups ? Do you have a water main extension policy ? Do you have standard construction specifications to be followed ? Do you have measures to assure cross-connection control and backflow prevention ? Do you have policies or rules describing customer rights and responsibilities ? Regulatory Compliance Program Do you fully understand monitoring requirements and have a scheduling mechanism to assure compliance ? Do you have a mechanism to obtain the most recent information on regulatory requirements ? If Yes, please explain how. If No, please explain why not or why not possible: impfail nodemands equipinad Sto90 InadSource Do you know how to obtain clarification or explanation of requirements ? Do you know what to do in the event of a violation ? Emergencies Do you have an Emergency Response Plan ? Is there a contingency for making emergency interconnections to neighboring systems, and do you know they will work if needed ? Does everyone involved in operations know what they are to do in the event of contamination from a toxic hazardous waste spill in your source water or a main break or a tank failure ? Do you have a clear chain-of-command protocol for emergency action ? Is someone responsible for emergency operations, for communications with state regulators, for customer relations, for media relations ? If yes, who (title): Safety Do you have a safety program defining measures to be taken if someone is injured ? Does everyone understand the risks and safety measures involved in system operations ? Do you have written operating procedures for both routine and emergency system operations ? Are you fully aware of Occupational Safety and Health Administration (OSHA) confined space (such as trenches/manholes) regulations ? Maintenance Do you have a planned maintenance management system - a system for scheduling routine preventative maintenance ? Do you have a system for assuring adequate inventory of essential spare parts and back-up equipment ? Do you have records and data management systems for system operating and maintenance data, for regulatory compliance data, and for system management and administration ? Management Capability Are you getting the outside services and technical assistance you need ? Do you have adequate legal counsel, insurance, engineering advice, technical / operations assistance, rate case preperation, and financial advice ? The Financial Portion of your System Financial Planning Mechanisms Do you have an annual budget ? Do you have within the annual budget a seperate reserve account for equipment replacement and/or capitol improvement ? Do you have a capital budget or capital improvement plan that projects future capital investment needs some distance (at least five years) into the future ? Do you have a process for scheduling and commiting to capital projects ? Do you have a capital improvement plan that covers at least the next ten years? Does your planning process take account of all the potential capital needs suggested by all of the preceding questions in these worksheets? Does your long-term planning analysis of alternative strategies that might offer cost saving to customers, such as consolidation with other nearby systems or sharing of operations and management expenses with other nearby systems ? Rates/Billing - Are they Adequate ? Do you regularly review your rates ? How often ? Do you have a plan in place for periodic increases in rates ? Is the rate structure based on metered watered use ? List water rates per 1000 gallons: Do users pay the same or higher rate per 1000 gallons as they use more water ? Do you have procedures for billing and collection ? Is your billing collection rate greater than 95 % ? Do you have collection procedures specifically for delinquent accounts ? Financial Planning Mechanisns - Are they Adequate ? Do you have audited financial statements ? Does your water system presently operate on a break-even basis ? Does your water system keep all the water revenues (i.e., water revenue does not support other municipal departments or unrelated activities)? Do you employ standardized accounting and tracking systems ? Do you track budget performance ? Do you keep records to substantiate depreciation of fixed assets and accounting for reserve funds ? Are financial management record keeping systems organized ? Are controls exercised over expenditures ? Are controls exercised to keep from exceeding your budget ? Are there purchasing procedures ? Financial Spreadsheet Guidelines: This cash flow projection form provides a systematic method of estimating cash receipts, disbursements and balances. The entries listed on the form will not necessarily apply to every PWS, and some entries may not be included which would be pertinent to each PWS. It is suggested, therefore, that the form be adapted to each particular PWS, with appropriate changes in the entries as may be required. Procedure: Most of the entries on the form are self-explanatory; however, the following suggestions are offered to simplify the procedure : Please complete the financial spreadsheet on the following tab using the guidance presented below. (1) First gather the audited financial statements, internally prepared statements or budgets and other information for the current year and the two prior years. Please include the most recent audit financial statement with your self-assessment report. (2) Complete the columns for the prior two years using actual data from your audited financial staements, if available, or your internally prepared financial staements. Keeping in mind that, for purposes of this analysis, it is important to use cash receipts and disbursements. Suggestion: Round the amounts at least to the nearest dollar. (3) Complete the current year's column using the most recent budget information. Include all expenditures incurred by the utility. (4) Complete the form using the suggestions in the partial form below for each entry. Be sure to include any expenditures resulting from planned plant improvement and estimate the impact of inflation on all expenditures. (5) Item #1 (Beginning Cash on Hand ) plus Item #3 (Total Cash Receipts) minus Item #6 (Total Cash Paid Out) should equal Item #7 (Ending Cash Position). (6) Item # 13 (Total Reserves) plus Item #12 (Operating Cash) should equal Item #7 (Ending Cash Position). (7) item #1 (Beginning Cash on Hand) should equal Item #7 (Ending Cash Position) from the prior financial period. (8) Items # 8 & 9 are used together to determine the impact of the rate structure on the equivalent residential user, If industrial or business customers contribute a significant portion of the revenues, these amounts should be looked at seperately. Consideration should be given to design a rate structure so that each category of user pays its proportional share of the costs of operating and maintaining the PWS. (9) Item #11 is used to determine to what extent a PWS's rate structure produces revenues sufficient to cover operating expenses. (10) Item #12 is the operating cash balance at year end. The operating cash balance at the end of any financial period should be adequate to meet the cash requirements for a minimum of one month. If there is too little cash, additional cash may have to be injected or expenditures may have to be reduced. If there is excessive cash on hand, the money should be invested or otherwise deposited into interest bearing accounts (e.g.. set up reserves for replacement or capital improvements, etc.) Putting it all together: Do you have Technical, Managerial, and Financial Capacity ? The Division of Drinking Water will be reviewing these worksheets, and information we have in our files, in order to make a determination whether you have the technical, managerial, and financial capacity to qualify for a Drinking Water State Revolving Fund loan. Remember, even if you do not have the required capacity right now, you may still qualify if the loan is going to be used to obtain capacity. Keep in mind that certain other changes may also have to be made, such as managerial and financial changes, in order to qualify. If you need more information or assistance in using and completing these capacity worksheets, please contact: (801) 536-0069 mgrange@utah.gov Michael Grange, P.E. If it is determined that your system does NOT have the required capacity, you may still qualify for a SRF loan if it is going to be used to ensure that your system will have the necessary capacity. If you have questions while completing the following worksheets, please call our office at (801) 536-4200, and we will be happy to help. Or conctact Michael Grange directly at (801) 536-0069. Presiding Officer: Would You Like To Add Any Additional Information or Comments? Please do so here . . . Who Entered Data Into This Form? Please enter the names, phone numbers and e-mail addresses of all those who helped complete this form. Thank You For Completing This Application Form. End of Tab 9 - SIGNATURE Worksheet Data Transfer Tab 1 Choice DocID Ver DateFormCompleted MeetingDatePreference SystemNumber EIN Tab 2 AppName AppAddress AppZIP AppPhone AppFax AppEmail ConTitle ConAddress ConZIP ConPhone ConFax ConEmail TreasPhone TreasFax TreasEmail EngAdd EngZIP EngPhone EngFax EngEmail FinCompany FinAdd FinZIP FinPhone FinFax FinEmail AttCompany AttAdd AttZIP AttPhone AttFax AttEmail BA_Co BA_Add BA_Zip BA_Phone BA_Fax BA_Email OthRole 3 - Project Information and Costs OthCompany OthAdd OthZIP OthPhone OthFax OthEmail Tab 3 ProjDescrip Where ProjCounty PercentExist 25percentDetails Developers MasPlanDate DWB_AuthDate PubHrngDate EA_Date CommenceDesignDate CompleteDesignDate DDW_PlanDate AdBidsDate BidOpenDate LoanClosDate BeginConsDate EndConsDate ReceiveOP_Date Bonding$ WaterRights$ ROW$ Oth1$ Oth1_Specify Oth2$ Oth2_Specify FinCon$ EnvClear$ Oth3$ Oth3_Specify Oth4$ Oth4_Specify Planning$ Design$ CMS$ Oth5$ Oth5_Specify Oth6$ Oth6_Specify Oth7$ Oth7_Specify Oth8$ Oth8_Specify Oth8a$ Oth8a_Specify WatSrce$ Trans$ Tmt$ Tank$ Pump$ Dist$ Oth9$ Oth9_Specify Oth10$ Oth10_Specify Oth11$ Oth11_Specify Oth12$ Oth12_Specify Contin$ Land$ Oth13$ Oth13_Specify Oth14$ Oth14_Specify EstDate PropOwn ROW_Probs RegionalExplain SrceDescrip WR_Explain Tmt_Descrip StorDescrip PipeDescrip Tab 4 DWB_Loan$ DWB_Loan% DWB_LoanYrs DWB_Grant$ BWR_Loan$ Agency1_Name Agency2_Name Agency3_Name No attachments are required when applying for a PLANNING project. Please note, however, that certain items will be required before the Drinking Water Board will fund any construction project. Thus, it is recommended that the following items be considered during the planning phase: * A preliminary assessment of any environmental issues that may arise due to the construction of a proposed project. (Note: This initial assessment need not be detailed. However, a detailed Environmental Assessment may be required if funds are eventually received from the "FSRF Program") BWR_Loan% BWR_LoanYrs BWR_Grant$ BWR_Status CIB_Loan$ CIB_Loan% CIB_LoanYrs CIB_Grant$ CIB_Status CDBG_Loan$ CDBG_Loan% CDBG_LoanYrs CDBG_Grant$ CDBG_Status RD_Loan$ RD_Loan% RD_LoanYrs RD_Grant$ RD_Status Agency1_Loan$ Agency1_Loan% Agency1_LoanYrs Agency1_Grant$ Agency1_Status Agency2_Loan$ Agency2_Loan% Agency2_LoanYrs Agency2_Grant$ Agency2_Status Agency3_Loan$ Agency3_Loan% Agency3_LoanYrs Agency3_Grant$ Agency3_Status App$ PubMark$ PubMark% PubMarkYrs PubMarkExplain CredEnhanceDescr Tab 5 (added) RBond1Name RBond1% RBond1Yrs RBond1Orig$ RBond1AP RBond1MatDate RBond2Name RBond2% RBond2Yrs RBond2Orig$ RBond2AP RBond2MatDate RBond3Name RBond3% RBond3Yrs RBond3Orig$ RBond3AP RBond3MatDate RBond4Name RBond4% RBond4Yrs RBond4Orig$ RBond4AP RBond4MatDate RBond5Name RBond5% RBond5Yrs RBond5Orig$ RBond5AP RBond5MatDate RBond6Name RBond6% RBond6Yrs RBond6Orig$ RBond6AP RBond6MatDate RBond7Name RBond7% RBond7Yrs RBond7Orig$ RBond7AP RBond7MatDate RBond8Name RBond8% RBond8Yrs RBond8Orig$ RBond8AP RBond8MatDate hardship community, or possibly 50% grant if the applicant qualifies for State SRF funding (subject to available funds) GOBond1Name GOBond1% GOBond1Yrs GOBond1Orig$ GOBond1AP GOBond1MatDate GOBond2Name GOBond2% GOBond2Yrs GOBond2Orig$ GOBond2AP GOBond2MatDate GOBond3Name GOBond3% GOBond3Yrs GOBond3Orig$ GOBond3AP GOBond3MatDate GOBond4Name GOBond4% GOBond4Yrs GOBond4Orig$ GOBond4AP GOBond4MatDate GOBond5Name GOBond5% GOBond5Yrs GOBond5Orig$ GOBond5AP GOBond5MatDate GOBond6Name GOBond6% GOBond6Yrs GOBond6Orig$ GOBond6AP GOBond6MatDate GOBond7Name GOBond7% GOBond7Yrs GOBond7Orig$ GOBond7AP GOBond7MatDate GOBond8Name GOBond8% GOBond8Yrs GOBond8Orig$ GOBond8AP GOBond8MatDate OthObligations OthObligations$ Dep$Yrly Dep$Balance CapRep$Yrly CapRep$Balance OtherFundDescrip OthFundBalance ResConn ComConn OtherConn OtherConnDescribe ResGallons CommOthGallons Purchase$ Maint$ EquipRepl$ Oth51$ Oth51Describe Oth52$ Oth52Describe Oth53$ Oth53Describe Oth54$ Oth54Describe Oth55$ Oth55Describe Income$Res Income$NonRes Income$Taxes SpecifyTaxes Income$ConnFee Income$Impact Income$Interest Income$Sales Income$Permit Income$Oth1 IncomeOth1Describe Income$Oth2 IncomeOth2Describe Income$Oth IncomeOth3Describe ConnFeePerHookup ImpactFeePerNewConn Rbase$ Rgal ROB1$ ROB1Per ROB1ForNext ROB2$ ROB2Per ROB2ForNext ROB3$ ROB3Per ROB3ForNext ROB4$ ROB4Per ROB4ForNext ROB5$ ROB5Per ROB5ForNext Cbase$ Cgal COB1$ COB1Per COB1ForNext COB2$ COB2Per COB2ForNext COB3$ COB3Per COB3ForNext COB4$ COB4Per COB4ForNext COB5$ COB5Per COB5ForNext %onPiped YrlyPipedFee DEA_Current DEA_2 DEA_3 DEA_4 DEA_5 DEA_Comments AppPop_Current AppPop_1 AppPop_2 AppPop_3 AppPop_4 AppPop_5 ConnCurrent ConnPop1 ConnPop2 ConnPop3 ConnPop4 ConnPop5 FutureDevelopments AssesValue BondingCap MAGI MAGI_Comments ExpenseChange IncomeChange IncExpDiff Tab 6 DemoPubSup PubPart DescribeOtherProj Tab 7 Tab 8 WSysName Officer Title AddlComments WhoEntered Providing cost estimates in the format given below will allow us to evaluate applications in a consistent manner. Please fill out the information requested below completely. If you have existing documents which provide detailed project cost estimates, please transmit them to us also (in addition to entering the information requested below). Please Note: The above questions pertain to the project under consideration. For funding, you will eventually need to show that ALL of your water systems facilites, even your existing ones, are under your control by virtue of rights-of-ways, easements or property ownership. Grant $ State law requires that all water systems serving more than 500 connections have a written Water Conservation Plan. The Utah Drinking Water Board has adopted a policy requiring that all applicants for financial assistance (regardless of system size) have an acceptable "Water Conservation Plan Ordinance" in place before funds are released. After your project is constructed, your water system EXPENSES may increase or decrease. You may have new annual loan payments. Your operating costs may decrease because of reduced maintenance demands. Please describe any anticipated changes to your current operating EXPENSES after the project is completed. Consult with DDW's Treatment Speciaists during the planning phase. Certain treatment technologies may require pilot testing. Some of the questions on this worksheet pertain to your system's finances. Please fill out all yellow boxes shown below. In order to verify the financial information you provide below, we also need a copy of your latest financial statement. If, for a given category, there is no limit on use, please enter the word "unlimited" in the gallons blank. For instance, Overage Block 1 could read: $0.50 per 1,000 gallons for the next unlimited gallons. The "bond purchase price" will be the amount of money advanced by the Drinking Water Board to the Sponsor for all costs related to the project, plus the anticipated costs to DEQ and the Board for reviews and other administrative activities. Normal costs incurred by the Department of Environmental Quality or Board during preliminary project investigation and prior to Board Authorization will not become a charge to the applicant . . . Division of Drinking Water Doc ID: Utah Dept. of Environmental Quality Version: UTAH DRINKING WATER BOARD FINANCIAL ASSISTANCE This form applies to both the "State SRF" and the "Federal SRF" financial assistance programs. Detailed information on these programs is available on-line at: Enter today's date: mm/dd/yy What type of project are you seeking funds for ? Click HERE To Activate Choices Note: You MUST make a selection before completing the rest of this application form. The choice you make above will determine which information you are required to provide in the remainder of this workbook. If you have a preference, enter the date of the upcoming Board meeting at which you want to make your initial appearance: mm/dd/yy What is your Utah Division of Drinking Water water system number? (Example: 98765. Leave blank if you don't know your number.) What is your Federal EIN (i.e. Tax ID Number) ? More Info on Federal EIN End of Tab 1 - INTRODUCTION Worksheet Do NOT Type in the Cells Shown Below ProjectType 2 - Contacts Fill In All Boxes Highlighted In YELLOW APPLICANT INFORMATION System Name: This is a: Address: Zip Code: Phone: Fax: Email: PRESIDING OFFICIAL OR CONTACT PERSON Title: TREASURER/RECORDER CONSULTING ENGINEER FINANCIAL CONSULTANT Company: This individual should be able to list possibilities of other financing and evaluate the possibility of credit enhancement, interest buy down or other loan methods available to applicant. CITY ATTORNEY (if applicable) BOND ATTORNEY OTHER Role: Type BRIEF PROJECT DESCRIPTION a. Please provide a brief description of your proposed project in the yellow box shown below. (You will have an opportunity to provide a detailed description later.) Examples: For a PLANNING project - "Engineering study, including a least-cost analysis, of how to provide better service to the northwest side of town. This region now experiences low pressure and inadequate fire flows." b. In what area(s) will the project be constructed? (e.g "Within our town limits and 8 miles south of town.") c. In what county will the project be constructed? ELIGIBILITY FOR "FEDERAL SRF" FUNDS If you answer YES to any of the following questions, your project is NOT eligible for funding from the "Federal SRF" program. Does the project include the construction or rehabilitation of a dam or dams? Is the project needed mainly for fire protection? BENEFICIARIES 4 Year Projections Last Year Current Year Year 2 Year 3 Year 4 Actual Budget Projected Year 1 Projected Enter Year: 1. Beginning Cash on Hand 2. Cash Receipts: a. Unmetered Water Revenue b. Metered Water Revenue c. Other Water Revenue e. Connection Fees f. Interest and Dividend Income g. Other Income i. Transfers in/Additional Rev Needed j. Loans, Grants or other Cash Injection please specify 5. Operating Expenses a. Salaries and wages b. Employee Pensions and Benefits c. Purchased Water d. Purchased Power e. Fuel for Power Production f. Chemicals g. Materials and Supplies h. Contractual Services - Engineering i. Contractual Services - Other j. Rental of Equipment/Real Property k. Transportation Expenses l. Laboratory m. Insurance n. Regulatory Commission Expenses o. Advertising p. Miscellaneous r. Replacement Expenditures t. Loan Principal/Capital Lease Payments u. Loan Interest Payments v. Transfers Out w. Capital Purchases (specify): x. Other 8. Number of Customer Accounts 9. Average Annual User Charge per 10. Coverage Ratio (2h-5s)/(5t+5u) 11. Operating Ratio (2d/5s) 13. End of Year Reserves: a. Debt Service Reserve b. Bond Retirement Reserve c. Capital Improvement Reserve d. Replacement Reserve e. Other Directions For the prior period and the current year budget, use the actual cash balance. For all other years, cash on hand should equal item #12 from previous period. All cash received/estimated for water supplied to residential, commercial, industrial and public customers where the customer charge is not based on quantity, i.e., its based on diameter of service pipe, room, foot of frontage or other type units. all cash received/estimated for water supplied to residential, commercial, industrial and public customers where the charge is based on quantity of water delivered. Other cash received/estimated from sale of water, e.g., sales for irrigation, sales for resale, inter- municipal sales, advalorem taxes (OM&R portion) etc. d. Total Water Revenues (2a thru 2c) Self-explanatory All cash received/estimated for connection of customer service during the year. Illness2 Illness3 Illness4 Illness5 LowCapacity2 All cash received/estimated on interest income from securities, loans, notes, etc., whether the securities are carried as investments or included in sinking or reserve accounts. Other revenues collected/estimated during the period (e.g., disconnection or change in service fees, profit on materials billed to customers, servicing of customer lines, late payment fees, rents, sales of assets, advalorem taxes (infrastructure portion) etc.). h. Total Cash Revenues (2d thru 2g) Includes transfers from other funds w/i the municipality or can be used as a "plug" figure when determining the additional cash needed to cover cash needs. Includes loans or grants from financial institutions, inter-municipal loans, state or federal sources. 3. Total Cash Receipts (2h thru 2j) 4. Total Cash Available (1+3) Use actual amounts paid when completing the prior year. Estimate the amounts for projected years based on prior year amounts, trends and other known variables (including those related to needs identified in the self-assessment). Cash expenditures made/estimated for salaries, bonuses and other consideration for work related to the O&M of the facility, including administration, and compensation for officers, directors, etc. Paid vacations, paid sick leave, health insurance, unemployment insurance, pension plan, etc. Amounts paid/estimated for cost of water purchased for resale. Amounts paid/estimated for all electrical power for the utility. Amounts paid/estimated for fuel purchased for the production of power to operate pumps, etc. Amounts paid/estimated for chemicals used in the treatment and distribution. Amounts paid/estimated for materials and supplies used for O&M of the PWS other than those under contractual services. h. Contractual Services - Engineering Amounts paid/estimated to outside engineers to perform ongoing engineering work for the facility. Amounts paid/estimated for costs of outside accounting, legal, managerial, and other services. Amounts paid/estimated for costs associated w/the rental of equipment, buildings and real property. Amounts paid/estimated for automobile, truck, equipment, and other vehicle use and maintenance. m. Insurance Amounts paid/estimated for vehicle, liability, workers' compensation and other insurance. Amounts paid/estimated for rate cases and other activities with a regulatory commission Amounts paid/estimated for informational, instructional and other advertising. Amounts paid/estimated for all expenses not included elsewhere (e.g. permit fees, training, etc.). q. Total Cash 0&M Expenses (5a thru 5p) Total of lines 5a thru 5p. Amounts paid/estimated for replacement of equipment to maintain system integrity. s. Total OM&R Expenditures (5q+r) Include cash payments made/estimated for principal on all loans, including vehicle and equipment purchases on time payments and capital lease payments. Include cash transfers made/estimated to funds or entities outside the PWS. Amount of cash outlays/estimates for items such as equipment, building, vehicle purchases, and leasehold improvements that were not a part of the initial design of the PWS infrastructure. 6. Total Cash Paid Out (5s thru 5x) 7. Ending Cash Position (4 - 6) Use most recent system data or expected increases. 9. Ave User Charge per Customer (2d/8) Self-explanatory Measure of the sufficiency of net operating profit to cover the debt service requirements of the system. A bond covenant might require this to meet or exceed certain limits (e.g. 1.25) Measure of whether operating revenues are sufficient to cover OM&R expenses. An operating ratio of 1.0 is the bare minimum for a self-supporting facility. With debt service requirements, the operating ratio would have to be higher. 12. End of Year Operating Cash (7 - 13) All non-reserved cash. Do not include depreciation as a reserve unless there is actually a "depreciation' reserve that has cash set-aside for future expansion. Funds specifically set-aside to meet debt service requirements or requirements set forth in a loan convenant/bond indenture. Funds specifically set aside to retire debt as it is scheduled. Funds specifically set aside to meet long-term objectives for major facility expansion, improvement and/or the construction of a new facility. Funds specifically set aside for the future replacement of equipment needed to maintain the integrity of the facility over its useful life. d. Total Water Revenues (2a thru 2c) h. Total Cash Revenues (2d thru 2g) 3. Total Cash Receipts (2h thru 2j) 4. Total Cash Available (1+3) q. Total Cash 0&M Expenses (5a thru 5p) s. Total OM&R Expenditures (5q+5r) 6. Total Cash Paid Out (5s thru 5x) 7. Ending Cash Position (4 - 6) account (2d/8) 12. End of Year Operating Cash (7 - 13) Total Reserves (13a thru 13e) What percentage of your existing water system connections will benefit from this construction project? To what extent is this project being driven by anticipated future growth? (Select the statement which best characterizes the project.) If the project results in additional water supply, will more than 25% of the new water be devoted to commercial or industrial users? If YES, please provide details. d. Describe the extent to which private developers or subdividers will benefit from the project. JUSTIFICATION FOR THE PROJECT Please describe the type of investigation which led you to conclude the proposed project is justified. If your proposed project is part of a Master Plan, or resulted from a formal Engineering Investigation, please transmit the document to the Division of Drinking Water. Indicate the date the document was published below: Date of Report Rule R309-700 Rule R309-705 TENTATIVE PROJECT SCHEDULE TotalProjectCost Please provide an anticipated timetable for the following milestones. Complete Master Plan or Engineering Report (For PLANNING Project) Final Public Hearings Advertise Environmental Assessment (FONSI) . . . If Applicable Commence Design Complete Design Receive DDW Plan Approval Advertise for Bids Bid Opening Loan Closing Begin Construction Complete Construction Receive DDW Operating Permit ESTIMATED PROJECT COST Legal: Bonding Water Rights Rights of Way & Easements Other Specify: Legal Subtotal Administrative: Financial Consultant Environmental Clearances Administrative Subtotal Engineering: Planning Design Construction Management Services Engineering Subtotal Construction: Water Source(s) Transmission Line(s) Treatment Facility(s) Storage Tank(s) Pump Station(s) Distribution Lines Facility Construction Subtotal Facility Construction Contingency AppCity AppSt ConFirstName ConLastName ConCity ConSt TreasFirstName TreasLastName EngFirstName EngLastName EngCompany EngCity EngState FinFirstName FinLastName FinCity FinState AttFirstName AttLastName AttCity AttSt BA_FirstName BA_LastName BA_City BA_State OthFirstName OthLastName OthCity OthSt EC_FirstName EC_LastName EC_Co EC_Add EC_City EC_State EC_ZIP EC_Phone EC_Fax EC_Email % of Facility Const Subtotal Land Acquisition Subtotal of All Construction Items TOTAL PROJECT COST: Legal Administrative Engineering Construction SUBTOTAL (For Info See Tab 8) TOTAL e. The cost estimates shown above were made on: PROPERTY OWNERSHIP AND RIGHTS OF WAY Federal SRF Data Transfer State SRF Data Transfer Briefly describe who currently owns the property on which the project will be constructed (e.g. federal, state, private, etc.) REGIONALIZATION PLAN If the project is authorized by the Board, all costs incurred by the Utah Department of Environmental Quality (DEQ) or the Utah Drinking Water Board from the beginning of the application process will be charged to the project and paid by the applicant as a part of the total project cost. Utah Drinking Water Board Financial Assistance End of Tab 2 - CONTACTS Worksheet Is the project creating, enhancing, or in compliance with a regionalization plan? If YES, please explain. PROJECT DETAILS Source-Related Projects 1. Provide a detailed description of any components of the project which are related to source development. 2. What issues will the source-related project(s) address? (Check all that apply.) 3. Water Rights Issues Is a water right change required for the project? Please Note: For funding, you will eventually need to provide an attorney's opinion that the water rights for the project under consideration AND the water rights for your entire system are valid. For further information on water rights see: Utah Div. of Water Rights - Contact Information Treatment-Related Projects Provide a detailed description of any components of the project which are related to water treatment. ` What issues will the treatment-related project(s) address? (Check all that apply.) Balance Remaining Storage-Related Projects Provide a detailed description of any components of the project which are related to water storage. What issues will the storage-related project(s) address? (Check all that apply.) D PROPOSED FUNDING PACKAGE Loan/Grant mix $ Transmission and Distribution Projects Provide a detailed description of any components of the project which are associated with the construction or renovation of water transmission or distribution facilities What issues will the transmission/distribution project(s) address? (Check all that apply.) End of Tab 3 - PROJECT INFORMATION AND COSTS Worksheet 2a Dams 2b FireProt 2c Future 3b GrowthDriven 3c 25percent A Justification 8a Regional 9a2 Illness 9a3 UDI 9a4 LowCapacity 9a5 Micro 9a6 Chem 9a7 9a8 Oth15 9a9 Oth15_Specify WR_Change 9b2 City: State: First Name: Last Name: ENVIRONMENTAL CONSULTANT NoLog InadDis InadTmt Oth16 Oth16_Specify 9c2 StoFail StoOld StoInad StoContact StoPress Oth17 Oth17_Specify 9d2 PipeUnsafe PipeDeteriorate Pipe5yr PipeHiBackflow PipeDynamic PipeLeak Oth18 Oth18_Specify 4 - Funding Sources Loan $ Loan % Loan Yrs Describe STATUS of Funding: Funding From Other Sources: Utah Board of Water Resources Utah Community Impact Board Utah Community Development Block Grants USDA Rural Development Other Agency 1 - Specify: Other Agency 2 - Specify: Other Agency 3 - Specify: Subtotal Loans Grants Total of Loans and Grants from All Agencies Applicant's Contribution Describe Below: Total Funds Available For Project DO FUNDS EQUAL THE PROJECT COST ? FILL IN ALL BOXES HIGHLIGHTED IN YELLOW. When typing in dates, be sure to include the forward slashes. Complete Tabs 1 through 8. ORANGE boxes contain formulas which automatically do calculations for you. TIP: Work your way through each worksheet by hitting the TAB key, not the ENTER key. Total Project Cost (From Tab 3 - Project Info and Costs) Total Funds Available (From Above) Difference (Should be Zero) Do funds from all sources equal the total cost of the project? ALTERNATIVE FUNDING METHODS ImportTime If you have a financial advisor please answer these questions. The following questions pertain only to the funds you are seeking from the Utah Drinking Water Board. a Could the amount you are seeking from the Drinking Water Board be financed, in whole or in part, on the public market? If YES, estimate the amount that could be financed on the public market. If NO, explain: b Could a credit enhancement agreement be utilized for the public market bonds? List types of credit enhancements investigated and describe why they are feasible or unfeasible. End of Tab 4 - FUNDING SOURCES Worksheet 1b App$Type SpecifyInKind PubMark CredEnhance 5 - Your System FINANCIAL STATEMENT If your system is a "political subdivision", your latest financial statement may be available at: Please check one of the following: EXISTING WATER SYSTEM DEBT (BEFORE NEW PROJECT) List all outstanding WATER REVENUE BONDS and attach amortization schedules. Revenue Bond Name Interest Rate Years Original Amount App_Id App_ID Maturity Date Total Current Annual Payments for Water Revenue Bonds What existing water rights are pertinent to the project ? Please provide water rights numbers, quantities and time periods. List all outstanding GENERAL OBLIGATION BONDS related to WATER and attach amortization schedules. G.O. Bond Name Total Current Annual Payment for Water-related General Obligation Bonds Describe any other financial obligations which encumber the water system. What is the current Annual Payment for these other financial obligations ? DEPRECIATION Please select the statement which best describes how depreciation is handled in your water system budget. If you actually fund depreciation, how much do you collect yearly for this item? If you actually fund depreciation expenses, what is the current fund balance ? CAPITAL FACILITIES REPLACEMENT FUND Are funds currently being deposited into any "capital facilities replacement fund" on an annual or monthly basis? If YES, how much do you collect yearly for this item ? If YES, what is the current fund balance ? Annual Payments on Current Debt (Total of Items 2a, 2b and 2c, above) Are you planning any other capital improvement projects for your drinking water system? DEA_6 OTHER CASH-ON-HAND, INVESTMENTS, ETC. Besides any Depreciation Fund, or Capital Facilities Replacement Fund, does your water system have any other financial resources (e.g. cash-on-hand, investments, etc) ? If YES, please describe. If YES, what is the combined balance of these additional financial resources ? Population What is the current population of your service area ? Connections Number of Commercial Connections Number of Other Connections Describe: Total Connections Equivalent Residential Connections If you have water use data for your system, please complete the following: In a typical year, how much water do ALL of your RESIDENTIAL connections consume? gallons In a typical year, how much water do ALL of your COMMERCIAL and OTHER connections consume? Equivalent Residental Connections (ERC) Analysis Residental Connections ERC of "Commercial" and "Other" Connections Total Equivalent Resident Connections for Entire System Please enter your annual expenses in the format given below. The information you enter below should be consistent with your latest financial statement. Purchase of Water B For a CONSTRUCTION Project - "New spring; 5,000 ft of 8-inch transmission line; 500,000 gal concrete tank" Yes Pumping Maintenance/Labor Treatment/Utilities/Materials "Quality Growth Community" Certification (optional) Equipment Replacement Depreciation (from Item 3, above) Funding of Capital Facilities Replacement Fund (from Item 4, above) Total Expenses Please enter your annual income in the format given below. The information you enter below should be consistent with your latest financial statement. From Residential Customers Technical Capacity - the physical infrastructure of the water system, including but not limited to the source water adequacy, infrastructure adequacy, and technical knowledge. In other words, does your treatment system work the way it is supposed to? Are you providing the safest and cleanest water possible and required by law to your customers right now, and will you be able to in the future? Managerial Capacity - the management structure of the water system, including but not limited to ownership accountability, staffing and organization, and effective linkages. In simpler terms, do you have a capable and trained staff? Do you have an effective management structure? Because you are in the process of applying for a State Revolving Fund (SRF) loan, it is necessary for you to complete the following worksheets. The Safe Drinking Water Act requires that a system applying for a SRF loan must demonstrate that it has financial, managerial, and technical capacity. What exactly does that mean? Financial Capacity - the financial resources of the water system, including but not limited to revenue sufficiency, credit worthiness, and fiscal controls. Basically, does your system have a budget and enough revenue coming in to cover costs, repairs and replacements? We will be studying these worksheets and information located in our files to make a determination whether or not your public water system has the technical, managerial, and financial capacity to be eligible to apply for a SRF loan. A final report will be available upon completion of the analysis. From Non-Residential Customers From Taxes Specify tax(es): From Connection Fees From Impact Fees From Interest Earned From Sales to Other Water Systems From Permit and Inspection Fees Total Annual Income DOES YOUR CURRENT INCOME EQUAL YOUR CURRENT EXPENSES ? Current Income From Item 8, above Current Expenses from Item 7, above Difference If there is a significant difference between your INCOME and your EXPENSES please explain: Note: Master Plans and Engineering Reports should include project alternatives, reason and justification for chosen alternative, and a possible financing plan. (These evaluations are called for in: R309-700-4(2) and/or R309-705-5(2) ). Furthermore, Master Plans and Engineering Reports should also include a preliminary overview of any environmental issues that may arise due to the construction of a proposed project. (Note: This initial assessment need not be detailed. However, a detailed Environmental Assessment may be required if funds are eventually received from the "Federal SRF Program") Drinking Water Board Authorization DDW Administrative Expenses No Connection Fee per hookup Impact Fee per new connection Residential Rate Structure If your residential rate structure cannot be described in the format given below, send us an attachment which describes it. Base Rate For up to gallons Overage Block 1 per gallons for the next Overage Block 2 Overage Block 3 Overage Block 4 Overage Block 5 Commercial Rate Structure C If your commercial rate structure cannot be described in the format given below, send us an attachment which describes it. PIPED IRRIGATION SYSTEMS Are there any PIPED irrigation systems within your current service area ? If YES . . . What percentage of your culinary connections are also on a piped irrigation system ? What is the average fee, approximately, that each of those on the piped irrigation system pays yearly ? per year, per irrigation system connection WATER CONSERVATION PLAN Utah DWR - Water Conservation Plans Please characterize your status with repect to your Water Conservation Plan and associated ordinance: GROWTH PROJECTIONS Current Population: If you have any comments on DEA's estimates, please enter them below. What are YOUR population and connection estimates for your service area ? Current What expansions (or reductions) in residential and industrial connections do you anticipate? Are there potential developments, commercial ventures or industrial projects which may significantly impact the demand on your water system? MISCELLANEOUS INFO ABOUT YOUR SERVICE AREA Median Adjusted Gross Income (MAGI) DDW staff uses the MAGI to determine the "maximum affordable water bill" for your service area. The higher the MAGI, the higher the water bill your customers should be able to afford. MAGI data originates from Federal tax forms. See line 37 of . . . Federal Income Tax Form 1040 The MAGI for your service area is simply the "median" of the "adjusted gross incomes" for your residents. "Median" means half are above, and half are below, the published figure. The latest MAGI figures are available on DDW's web site. Click the link shown below and browse to the heading "Maximum Affordable Water Bill". Please determine the MAGI for your service area from the web site and enter it below: If you have any comments on the published MAGI, or if you are unable to find data for your service area, please note below: ANTICIPATED SYSTEM EXPENSES AND INCOME AFTER PROJECT IS COMPLETED If your water system expenses change, you may need to increase (or decrease) your water system INCOME. If so, please describe how you will accomplish this. Will you modify your water rate structure? End of Tab 5 - YOUR SYSTEM Worksheet 1a FinStmtOnLine Depreciation 4a CapRepFund 5a OtherFund 10a PipedIrr 11a WCP 6 - Miscellaneous Public Support How will public support for the project be demonstrated? How will public participation be achieved (meetings, fact sheets, referenda, etc.)? 195 North 1950 West MAKE SURE THAT MACROS ARE ENABLED FOR THIS FILE. When you first open this file, choose to to Enable Content. If you have problems with check boxes being unresponsive, goto File/Help/Options and then Trusted Center. Then click Trusted Center Settings, then choose "Disable all macros with notification" and reopen your file. You may print a copy of this entire workbook by selecting File>Print>Print Entire Workbook Electronic Application Form (Microsoft Excel 2010) If you wish to add additional comments or information while completing this form, please go to Tab 8 - Signature. On this tab you will find a box which you can use to add additional information. You may also attach documents to your eMail when submitting your completed form. When completed, save this file for your own records. Then send a copy of this file, and required attachments, to: Will the project finance the expansion of a drinking water system to attract future population growth? Describe potential rights-of-way or easement issues for the project. (required for construction) (required for construction) (required for construction) Other: Political Subdivision What collateral will be used to secure the loan? The value of the pledged collateral must be equal to or in excess of the amount of the loan. % of SUBTOTAL: **Number of Year Round Connections Number of Residential Connections** Important, please note: The completed application and all required attachments must be received by the Division of Drinking Water at least 60 days before the Board meeting at which the application will be considered. The Board's meeting schedule can be viewed at: This file has been saved as Excel 2010 version. Let us know if you have any problems. https://deq.utah.gov/drinking-water/drinking-water-construction-assistance-programs https://deq.utah.gov/boards/utah-drinking-water-board-meetings Utah State Auditor - Local and State Government Reports DDW Construction Assistance Risk Assessments and Emergency Response Risk Assessment and Emergency Response Plan Tab 5, Item 13a, Median Adjusted Gross Income America's Water Infrastructure Act of 2018 requires community water systems serving more than 3,300 people to complete a risk and resilience assessment and develop an emergency response plan. Certification of completion must be submitted to the U.S. EPA. For more information, see: Please click on the statement which best describes the status of your Risk Assessment and Emergency Response Plan: E 3.11 ddwsrf@utah.gov COLLATERAL (Required for Private Systems) List real property and include an appraisal or value report List water rights and include an appraisal or value report Required Annual Payment CURRENT ANNUAL WATER SYSTEM INCOME (Required) CURRENT ANNUAL WATER SYSTEM EXPENSES (Required) CURRENT SERVICE AREA (Required) CURRENT RATE AND FEE STRUCTURES (Required) The Utah Division of Water Resources (DWRe) is the lead state agency for reviewing Water Conservation Plans. A sample plan, including a sample Water Conservation Plan Ordinance, is available at: For the most current Utah subcounty population projections see: Utah Population Projections (City Area) Please browse this website and attempt to determine WFRC population projections for your service area. Enter this data below. 2025 (WFRC estimate) 2030 (WFRC estimate) 2035 (WFRC estimate) 2040 (WFRC estimate) 2045 (WFRC estimate) (5 year estimate) (10 year estimate) (15 year estimate) (20 year estimate) (25 year estimate) Asset Management Plan Master Plan Hydraulic Model For Sources (Required for source projects) If you have any questions or difficulties using this electronic form please contact us at 801-536-4200. You may also contact us via e-mail: (1.0% of final Loan Amount) (Ignore) Page of 700.00 3.11 12:00:00 AM Construction 12:00:00 AM 0.00 0.00 0.00 0.00 0.00 Political Subdivision 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 No No No 0.00 D No 0.00 0.00 C 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM 12:00:00 AM $0.00 $0.00 $0.00 $0.00 0.00 $0.00 0.00 $0.00 $0.00 $0.00 0.00 $0.00 0.00 $0.00 $0.00 $0.00 $0.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 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