Economic Development

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)

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)

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)

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

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

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?

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

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