Economic DevelopmentEntity InformationName 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)YesNoEntity Type (required)CorporationPartnershipSole ProprietorNon-profitOtherIf other please specifyCorporate Charter NumberState Incorporated (required)Is Corporation a Subsidiary?YesNoIf 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/CityCountyGeneral and special law districtInstitution of higher educationPrivate EnterpriseCustomer Serviced by LNVACouncil of Government (COG)Other governmental entityIf Other please specifyIs this entity within the Neches River and Neches-Trinity Coastal Basin? (required)YesNoIs entity requesting fund in violation or delinquent on any city, county, state, or federal regulations, laws, or taxes? (required)YesNoDoes entity own, lease, or rent the property that funds are to be used for? (required)OwnLeaseRentIf property is leased or rented, who is the landlord?Will the entity be requesting water from the Lower Neches Valley Authority? (required)YesNoHow many new jobs will be created? (required)Have any other grants or gifts been requested for the same purpose? (required)YesNoIf yes describeProject DescriptionProvide a brief description of the project and how the funds will be used. Additional Sheets may be added if needed. (required)AttachmentProject CategoryPrivate Enterprise ProjectsWater/Wastewater Infrastructure Improvement AssistanceWater/Wastewater Infrastructure Improvement AssistanceCommunity 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 RequestGrant 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 RepresentativeDateThere was a problem saving your submission. Please try again later.Please wait while your submission is being saved...Submitting...SubmitThank you, your submission has been received.