Economic Development Entity Information Name of Entity (required) Address (required) City (required) State (required) Zip Code (required) County (required) Contact Person (required) Email Address (required) Phone Number (required) Federal ID Number (required) Tax Exempt (required) Yes No Entity Type (required)Corporation Partnership Sole Proprietor Non-profit Other If other please specify Corporate Charter Number State Incorporated (required) Is Corporation a Subsidiary? Yes No If Yes, who is the parent entity? Number of Years in Business (required) City/County where funds are to be used (required) Description of service or product manufactured (required) Provide Name of executive officers and board of directors (required) Eligible Recipients (required)Community/City County General and special law district Institution of higher education Private Enterprise Customer Serviced by LNVA Council of Government (COG) Other governmental entity If Other please specify Is this entity within the Neches River and Neches-Trinity Coastal Basin? (required) Yes No Is entity requesting fund in violation or delinquent on any city, county, state, or federal regulations, laws, or taxes? (required) Yes No Does entity own, lease, or rent the property that funds are to be used for? (required)Own Lease Rent If property is leased or rented, who is the landlord? Will the entity be requesting water from the Lower Neches Valley Authority? (required) Yes No How many new jobs will be created? (required) Have any other grants or gifts been requested for the same purpose? (required) Yes No If yes describe Project Description Provide a brief description of the project and how the funds will be used. Additional Sheets may be added if needed. (required) Attachment Project Category Private Enterprise Projects Water/Wastewater Infrastructure Improvement Assistance Water/Wastewater Infrastructure Improvement Assistance Community Distress - does this project improve a serious water-related health problem or move an “out of compliance” system into state or federal regulation compliance? Project Impact - is this project a new system or expansion of an existing system? Does this project meet long-term needs and how will it be maintained? Match to LNVA mission - does this project match LNVA’s mission to improve the water availability, water quality and water management of the Neches River Basin and the Neches-Trinity Coastal Basin? Local Commitment - does this project show local commitment of the community or service area involved? How many local resources are being committed? Grant Status - what is the status of the federal or state grant application that these funds support? Funding Request Grant Request: (Maximum $50,000) Loan Request (Maximum $100,000) Local Commitment (Amount of Local Funds) In-kind Services (Describe and value) Other Funding Sources (Describe) Total Project Costs: Printed Name and Title of Applicant’s Authorized Representative Date There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
