Financial Hardship Analysis Form

Centennial Clean Water Fund State Revolving Fund (Revolving Fund State Fiscal Year 2012 (SFY12) Applicant Purpose: The information provided on this form is used by Ecology to determine if a water pollution control facilities (WPCF) construction project will cause financial hardship for residential sewer ratepayers. Financial hardship assistance may be available to loan and grant recipients when a WPCF construction project results in a residential user charge of two percent or greater of the applicable median household income. If financial hardship exists, Ecology may offer funding recipients reduced interest rates, repayment terms to 20 years, or grant funding. Please direct any questions or comments to the staff of the Financial Management Section of Ecology’s Water Quality Program.

I. NAME OF PERSON COMPLETING THIS FORM

Title:

Address:

Phone Number:

Email Address:

II. ROLES AND RESPONSIBILITIES

This section is intended to summarize the key management agencies, the roles they will be assigned, and the agreements that will be needed to provide for continued cooperation in the management of the facility.

A. Will any other agencies or jurisdictions, beside the applicant, be responsible for the facility in terms of:

1. Ownership:

2. Operation:

3. Financing:

B. If so, please describe:

1. The type and amount of the contributions(s):

ECY 040-32 (Rev. 08/10) 1 2. The nature of the cooperative agreement(s):

III. COST ESTIMATE AT TODAY’S PRICES This section is intended to provide a realistic picture of all costs that will be incurred, including management, overhead, outside services, and equipment related to the project. A. Construction Cost Estimates for Facilities  Treatment Plants $  Pump Stations $  Interceptor Sewers $  Combined Sewer Overflow Reduction Measures $  Collection Sewers $  Land Acquisition $  Other (Specify) Stormwater $

 Total Construction Costs $

B. Estimated Annual Operation, Maintenance, and Equipment Replacement Costs for the Proposed Facilities. (Do not include depreciation on equipment or buildings.)  Labor $  Utilities $  Materials and Supplies $  Outside Services $  Miscellaneous Expenses $  Equipment Replacement (e.g., pumps, vehicles) $  Other (Specify) $

 Annual Operation, Maintenance and Equipment Replacement $ Costs

2 Fiscal Year 2004 Guidelines, Volume 1 Appendix G IV. FINANCING A. Breakdown of Funding Committed or Anticipated for the Project, including Ecology funding.

System Components Estimated Local Ecology Other Other Cost Contributions Share Grants Loans (Specify) (Specify)  Facilities $ $ $ $ $ Planning  Facilities Design $ $ $ $ $

 Treatment Plant $ $ $ $ $

 Pump Stations $ $ $ $ $

 Interceptors $ $ $ $ $

 Collectors $ $ $ $ $

 Land Acquisition $ $ $ $ $

 Other $ $ $ $ $ Stormwater

Totals $ $ $ $ $

B. Source of Loan Financing from Other Lenders, if Any (from IV A). Only include secured/committed funds.

Year Financing Method Amount Interest Term of Annual Debt Borrowed Rate Maturity Service Payments

Revolving Fund Loan $ $ $ $

CCWF Loan $ $ $ $

General Obligation Bond $ $ $ $

Revenue Bond $ $ $ $

PWTF $ $ $ $

USDA/RD $ $ $ $

Other Loan(s) (specify) $ $ $ $

Totals $ $

ECY 040-32 (Rev. 08/10) 3 C. Estimated Annual Water Pollution Control Facilities Costs

Existing annual operation, maintenance and equipment replacement costs. (Do not include depreciation on equipment or buildings.)  Labor (+)$

 Utilities (+)$

 Materials and Supplies (+)$

 Outside Services (+)$

 Miscellaneous Expenses (+)$

 Equipment Replacement (e.g., pumps, vehicles) (+)$

 Other (City and State taxes, permits and interest) (+)$ Total existing annual operating, maintenance and equipment replacement costs = $ 1. Discontinued portion (savings) of above costs as a result of proposed project (–)$ 2. Estimated annual operation and maintenance and equipment replacement costs for proposed facilities (from III-B) (+)$ 3. Annual debt service on existing wastewater facilities not associated with this project (+)$ 4. Existing annual debt service on this wastewater facility, if any (from IV-B) (+)$ Total estimated annual water pollution control facilities costs = $ 5. Non-residential share of total annual costs

V. DEMOGRAPHIC INFORMATION A. Population Estimates

1. Population in 2000 2. Current Population 3. Estimated Population in 2010 4. Planning Year 5. Planning Year Population 6. Number of Households

4 Fiscal Year 2004 Guidelines, Volume 1 Appendix G Source of Estimates

B. Median Household Income (MHI)

(1) 2000: (2) 2011 MHI:

(See the 2012-13 Funding Guidelines, Appendix H, Median Household Income Table for information on 2011 estimated median household income.

C. Sewer Users: a. Number ERU*s b. % of Total ERUs Residential Customers: Industrial & Institutional Customers Growth

What was the monthly sewer rate for a single family household using 1000 cubic feet of water in

2007? 2008? and 2009?

MHIs are updated from 2000 census levels for many communities in the state. If a funding applicant/recipient can show that the updated census do not reflect existing circumstances, Ecology may accept a valid survey to accurately determine the MHI.

VI. SIGNATURE

The Financial Hardship Analysis Form will not be reviewed without complete signatures and the phone number of the person completing this form.

ECY 040-32 (Rev. 08/10) 5 Signature of Person Responsible for Completing This Form.

(Date) Signature of Authorized Representative.

(Date)

6 Fiscal Year 2004 Guidelines, Volume 1 Appendix G