Form DOT F 2326-2 DOT F 2326-2 TIFIA Application Form - Exhibit C

OMB CONTROL NUMBER: 21XX-XXXX

EXPIRATION DATE: mm/dd/yyyy

DOT F 2326-2

U.S. Department of Transportation

TIFIA Credit Program

Fiscal Year 2013 Application

UNITED STATES

DEPARTMENT OF TRANSPORTATION

Fiscal Year 2013 APPLICATION FOR FEDERAL CREDIT ASSISTANCE

Transportation Infrastructure Finance and Innovation Act

Background: This form is to be completed by eligible applicants for Federal credit assistance under the Transportation Infrastructure Finance and Innovation Act (TIFIA), as amended, invited to submit an application by the U.S. Department of Transportation (DOT). The TIFIA statute is codified under 23 U.S.C. 601-609. The DOT will use the collected information to evaluate and select recipients for credit assistance as authorized under TIFIA. Applicants may be asked to provide additional supporting evidence or to quantify details during the review and negotiation process. If any information submitted, or requested to be submitted, changes after the application is submitted, the applicant will update its application accordingly. Pursuant to the recently enacted Moving Ahead for Progress in the 21st Century Act (MAP–21), the DOT announced the availability of $1.75 billion ($750 million in Federal Fiscal Year (FY) 2013 funds and $1 billion in FY 2014 funds (and any funds that may be available from prior fiscal years)) to provide TIFIA credit assistance for eligible projects. Only after a project sponsor has submitted a Letter of Interest and the DOT has determined that a project has met or is likely to meet all statutory eligibility requirements will the project sponsor be invited to submit an application. MAP–21 contains a timeline for assessing applications for credit assistance.

Charges: The DOT may require reimbursement for expenses related to services provided by the DOT’s outside advisors in connection with the evaluation of the TIFIA Letter of Interest, evaluation of the TIFIA application, and negotiation of the TIFIA transaction documents.

Format: Applications must provide all requested information and will not be reviewed if incomplete, which the DOT shall confirm within 30 days after the date of receipt of the application. Applications should be provided in three-hole punch binders with sections and tabs following the sequence shown in the application checklist.

Submission: The completed application (including a computer diskette (CD) containing electronic versions of the entire application with attachments as well as separate working files for Section D and Exhibit VII – but NOT in PDF or “values” format) should be sent to the attention of Mr. Duane Callender, TIFIA Joint Program Office, Federal Highway Administration, HITJ, Room E64-301, 1200 New Jersey Avenue, SE, Washington, DC, 20590. Applicants are advised to utilize an express mail or courier delivery service to ensure delivery confirmation of the package. The application checklist appearing on the next page of this application form specifies the number of copies (plus original) required for each section. The DOT requires one original submission of the complete application package with all supporting exhibits and related documentation. As noted on the checklist on the following page, 11 additional hard copies of the completed application form, without attachments are required. Only after a project sponsor has submitted a Letter of Interest and the DOT has determined that a project has met or is likely to meet all statutory eligibility requirements will the project sponsor be invited to submit an application. Please note that an invitation by the DOT to submit an application does not guarantee that a project will receive TIFIA credit assistance, which remains subject to a project’s continued eligibility. Please check the TIFIA website regularly to identify updated guidance and application materials.

Selection: The DOT’s selection of a project for participation in the TIFIA program does not imply that the DOT has approved all elements proposed in the application. For example, the DOT may require changes in the project’s financial plan proposed in the application. Provision of credit assistance is subject to negotiation of a credit agreement on terms and conditions satisfactory in all respects to the DOT.

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Information Requests: If an applicant desires that any information submitted in its application or any supplement thereto not be released by the DOT upon request from a member of the public or otherwise made publicly available, the applicant must so state and set forth any reasons why such information is confidential and should not be released, including particulars as to any competitive harm which would potentially result from the release of such information. The DOT will keep such information confidential to the extent permitted by law.

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Warning: It is a crime to knowingly make false statements to a Federal agency. Penalties upon conviction can include a fine and imprisonment. For details, see 18 U.S.C. 1001. Misrepresentation of material facts may also be the basis for denial of financial assistance by the U.S. Department of Transportation.

APPLICATION CHECKLIST

An application must include the following items.

Item	Page Limit	Copies (Plus Original)
Section A: Contact Information	1	12
Section B: Project Information ___1. Project Name ___2. Location ___3. Project Description ___4. Rural Project Description (If Applicable) ___5. Project Purpose (quantitative/qualitative details) ___6. Project Cost and TIFIA Credit Assistance Request ___7. Project Management and Compliance Monitoring Plan ___8. Maintenance and Operations	8	12
Section C: Satisfaction of Eligibility Requirements ___1. Creditworthiness (rate covenant, coverage requirements, investment grade rating(s)) ___2. Foster Partnerships that Attract Public and Private Investment ___3. Enable Project to Proceed at an Earlier Date or with Reduced Lifecycle Costs ___4. Reduce the Contribution of Federal Grant Assistance ___5. Environmental Review (NEPA) ___6. Permits and Approvals ___7. Transportation Planning and Programming Process Approvals (STIP and TIP) ___8. Construction Contracting Process Readiness ___9. Project Schedule	20	12
Section D: Financial Plan (include Executable Electronic – NOT PDF – files) ___1. Estimated Capital Project Cost, Amount and Type of Credit Assistance Requested ___2. Amount of TIFIA Assistance Requested ___3. Summary Table: Sources and Uses of Funds ___4. Cash Flow Pro Forma ___5. Supplementary Narrative: Other Borrowed Funds ___6. Supplementary Narrative: Revenue Sources (including pledged repayment source) ___7. Proposed Terms for the Requested TIFIA Credit Instrument ___8. Reasons for Selecting the Proposed Type(s) of Credit Instrument ___9. Flexibility in Financial Plan to Support a Reduced Percent of TIFIA Credit ___10. Risks and Mitigation Strategies	20	12
Section E: Applicant’s Organizational Structure	10	12
___1. Background Information and Legal Authority ___2. Organization and Management ___3. What Entity will Serve as Applicant (public-sector agency or private-sector firm) ___4. Is the Applicant the Same Entity as the Borrower (detail project team members) ___5. Prior Experience ___6. Financial Condition ___7. Litigation and/or Conflicts
Section F: Certifications	3	12
___Exhibit I: Project Map		1
___Exhibit II: Supporting Documentation: Project Purpose		1
___Exhibit III: Supporting Documentation: Financing Documents		1
___Exhibit IV: Preliminary Rating Opinion Letter(s)/Creditworthiness		1
___Exhibit V: Supporting Documentation: Public-Private Partnerships		1
___Exhibit VI: Supporting Documentation: Other Anticipated Funds		1
___Exhibit VII: Cash Flow Pro Forma (include electronic files)		1
___Exhibit VIII: Supporting Documentation: Revenue and Cost Projections		1
___Exhibit IX: Proposed Terms for the Requested TIFIA Credit Instrument		1
___Exhibit X: Supporting Documentation: Legal Authority		1
___Exhibit XI: Organizational Chart		1
___Exhibit XII: Audited Financial Statements (Three Years)		1

SECTION A: Contact Information

Provide the following information and include this sheet as the first page of the application. If the Applicant is different from the expected Borrower, please provide information for both parties.

1. Applicant’s Legal Name:

2. Other Names under Which Applicant Does Business:

3. Federal Tax Identification Number (to be used to determine whether the applicant is delinquent or in default on any Federal debt, in accordance with 31 U.S.C. 3701, et seq. and 5 U.S.C. 552a at note):

4. Business Address:

5. Mailing Address (if different from above) – include both U.S. mailing address and courier (i.e., no P.O. Box) address:

6. Contact Person Name:

7. Contact Person Title:

8. Mailing Address for Contact Person (if different from above):

9. Telephone:

10. Fax:

11. E-mail:

SECTION B: Project Information

This section requests narrative information and two exhibits. The list below should be included in the application packet with responses attached and numbered to correspond to the relevant item. Total narrative supporting Section B should not exceed 8 pages, excluding the exhibits.

1. Project Name. Assign a short name to the project, for purposes of identification.

2. Location. Describe the location of the project, including major intersecting highway and rail routes, and attach a map as Exhibit I. Include the name(s) of the counties that the project will serve.

3. Project Description. Describe the need for the project, its basic design features, and what it will accomplish. Include an assessment of the current condition of all transportation facilities relating to the project. If the project’s current scope differs from what is described in its environmental documents, please explain.

3. Rural Project Description (If Applicable). If invited to apply for consideration as a rural infrastructure project, describe how the project meets MAP-21’s definition of a rural infrastructure project. Please also describe whether the project is located outside of an urbanized area as defined under title 23.

3. Project Purpose. Describe the project’s purpose, including quantitative or qualitative details on public benefits the project will achieve. Supporting documentation may be attached as Exhibit II.

3. Project Cost and TIFIA Credit Assistance Request. Provide a cost estimate for both the entire project and the eligible project costs under the TIFIA program. Specify the TIFIA credit instrument(s) (i.e., secured loan, loan guarantee, and/or standby line of credit) requested and the amount of TIFIA credit assistance requested for each credit instrument. If requesting a secured loan, please provide a brief explanation of how the plan of finance for the project would be impacted if TIFIA credit assistance was instead provided in the form of a loan guarantee. Please also indicate whether the applicant intends to use a Master Credit Agreement with contingent commitments for purposes of carrying out a program of projects. If requesting a Master Credit Agreement, please provide the expected timing and amount of credit assistance requested for each of the projects in the program. Note that Section D of this application requests a financial plan; information furnished under this item may be cross-referenced to materials provided in Section D, and in all instances, including but not limited to dollar amounts, must be consistent with those materials.

3. Project Management and Compliance Monitoring Plan. Provide a comprehensive project management and monitoring plan that will assure the DOT of the applicant's ability to deliver the project as planned, fulfill all project commitments, and ensure compliance with all terms of the credit agreement, including all applicable regulations and provisions of law. The plan should provide: (a) information on the roles and responsibilities of all entities with decision making authority for the project; (b) status reporting processes that document not only the status but changes and potential risks; and (c) coordination processes that provide for advance notification of potential issues to all appropriate agencies and timely resolution.

3. Maintenance and Operations. Describe the maintenance and operations plan for the project.

SECTION C: Satisfaction of Eligibility Requirements

This section allows the applicant to describe the extent to which the project satisfies the eligibility requirements specified under 23 U.S.C. 602(a). The applicant should provide relevant quantitative or qualitative data to support its assertions and to justify the benefits to be derived from TIFIA assistance in satisfying these requirements and advancing the proposed project. The list below should be included in the application packet with responses and supporting documents attached and numbered to correspond to the relevant item. Total narrative supporting Section C should not exceed 20 pages, excluding the three exhibits.

1. Creditworthiness. Describe the creditworthiness of the project as noted below.

1. Detail the project’s ability to satisfy applicable creditworthiness standards. Provide information to support the project’s creditworthiness, such as: the project’s market position; the history of user-based repayments for other obligations; the economic outlook for related commerce; qualifications of the project team; proposed risk mitigation strategies, etc. The applicant may refer to other portions of its application, as applicable.

2. Describe the rate covenant, if applicable. Provide a copy of existing financing documents, such as a trust indenture agreement, including any rating agency credit reports, for other creditors of the project or a term sheet indicating the proposed features of the anticipated financing documents, as Exhibit III. The information should indicate the Federal credit instrument’s status in relation to pledged security, coverage, and treatment under an additional bonds test. Applicants should be aware that when prior financing based on the proposed TIFIA security is already in place difficult inter-creditor issues often arise in the negotiation of the TIFIA credit instrument.

3. Demonstrate that adequate coverage requirements are in place to ensure repayment. Provide information concerning the ability of the applicant (or any significant public or private partners that pledge to repay or provide funding) to repay all borrowed funds, including any obligations to the Federal Government. Describe the extent to which the project includes security features, such as a rate covenant and an additional bonds test, to ensure repayment of the Federal credit instrument.

4. Provide one preliminary rating opinion letter with an investment grade rating on senior debt and a rating on the TIFIA debt, as Exhibit IV. This letter is a conditional credit assessment from a nationally recognized statistical rating organization (NRSRO) that must indicate the potential for the senior debt obligations funding the project to achieve an investment grade rating and also must provide a rating on the TIFIA credit instrument. (The senior debt has a lien senior to that of the TIFIA credit instrument on the pledged security; if there are no debt obligations senior to the TIFIA credit instrument, then the TIFIA credit instrument itself must be shown to have the potential to obtain an investment grade rating). This preliminary assessment by the rating agencies will be based on the financing structure proposed by the applicant. The letter should provide a preliminary rating assessment of the financial strength of the overall project and the default risk (i.e., without regard to recovery potential) of the requested TIFIA instrument. This includes a demonstrated capacity to repay the federal credit assistance as well as a determination that the project has appropriate security features, such as proper coverage ratios, rate covenants and reserves as applicable.

The rating opinion letters should not reflect the use of bond insurance or other credit enhancement that does not also secure the TIFIA instrument. The assessment of the senior obligations’ investment grade potential and the TIFIA instrument’s default risk should be based on the underlying ratings of debt obligations and the project’s fundamentals. The DOT will not consider applications without such letters.

Note that Section D of this application requests a financial plan; information furnished under this item may be cross-referenced to materials provided in Section D, and in all instances must be consistent with those materials.

2. Foster Partnerships that Attract Public and Private Investment to the Project. Describe the extent to which the project fosters innovative public-private partnerships and attracts debt and/or equity investment from private capital. Identify private partners and provide evidence of commitments, joint venture agreements, lease, or other supporting documents for the public-private partnerships as Exhibit V. Also, describe the extent to which the project’s debt repayment depends on user charges.

2. Enable the Project to Proceed at an Earlier Date or with Reduced Lifecycle Costs. Estimate and explain the effect of TIFIA assistance on the project’s start and completion dates, the extent to which TIFIA assistance would help the project to proceed at an earlier date than would otherwise be possible, and any effects of an accelerated project timeline (e.g., reduced costs or increased benefits). Document how applicant has been unable to obtain credit assistance from private sources on reasonable terms. Demonstrate the costs of traditional financing would constrain their ability to deliver the project, or that delivery of this project through traditional financing approaches would constrain their ability to deliver additional components of their capital programs.

2. Reduce the Contribution of Federal Grant Assistance for the Project. Estimate and explain how TIFIA assistance would reduce the project’s need for Federal grant assistance. Indicate the percentage of the total project costs that will be funded by Federal grants, Federal credit assistance, and other sources.

2. Environmental Review. Provide a draft Environmental Impact Statement and Record of Decision unless the project has received Categorical Exclusion or Finding of No Significant Impact in connection with the project’s compliance with the National Environmental Policy Act (NEPA). Provide a timeline that illustrates the estimated start and completion dates for each major phase or milestone of the environmental review documentation and a brief summary of how the project intends to reach a final agency decision, including (if necessary) a Record of Decision prior to financial close. Please note the DOT will not obligate funds for a project until the project has done so.

2. Permits and Approvals. List all major permits and approvals necessary for construction of the project and the date, or projected date, of the applicant’s receipt of such permits and approvals. The list should include permits and approvals required under local, regional, state, and Federal laws and regulations. In particular, indicate when outstanding approvals by state or local government entities are expected. Copies of major permits and approvals will be required upon execution of a credit agreement with the DOT.

2. Transportation Planning and Programming Process Approvals. Provide a brief summary as well as certification that the project is included in both the long-range transportation plan and the approved State Transportation Improvement Programs (STIP) of each state affected by the project. Describe how the project satisfies planning and programming requirements of §134 ("Metropolitan Planning") and §135 ("Statewide Planning") under 23 U.S.C. For projects in metropolitan areas, describe how the project is or can be included in the metropolitan transportation plan.

2. Construction Contracting Process Readiness. Briefly describe how the project is prepared to proceed with the construction contracting process within 90 days of executing the TIFIA credit instrument.

2. Project Schedule. Provide a timeline that illustrates the estimated start and completion dates for each major phase or milestone of project development, construction and/or acquisition, including, for example: major investment study, Federal transportation planning requirements, preliminary engineering and environmental documentation, final design, right-of-way acquisition, construction, and vehicle acquisition. Indicate the applicant’s current status on this timeline.

SECTION D: Financial Plan

The following items concern the project’s updated financial plan, incorporating preliminary feedback from the DOT in connection with the Letter of Interest. This section requests narrative information and four exhibits. Note: For the purposes of this application, applicants should propose a single financing structure, representing the scenario deemed to have the greatest likelihood of occurring. While the DOT will evaluate the proposed financial plan, the DOT’s selection of the project for TIFIA assistance does not imply that the DOT has approved the proposed financial; the DOT may require modifications to the financial plan after selection and before execution of the credit agreement. For the financial plan, any combination of the three types of credit assistance offered under TIFIA may be used, provided that the total TIFIA credit amount is capped at 33 percent of eligible project costs for loan guarantees and lines of credits. In certain circumstances, projects requesting a direct loan may be eligible for credit assistance up to 49 percent of eligible project costs. The DOT may ask applicants to develop alternative scenarios, as necessary.

The financial plan should be prepared in accordance with recognized financial reporting standards such as the “Guide for Prospective Financial Information” of the American Institute of Certified Public Accountants (AICPA). The narrative descriptions for the financial projections should include the sources of information for the forecasts and the methodology used for developing the forecasts as well as describe any changes to the project and financial projections since the submission of the Letter of Interest. The discussion should also identify whether there has been any independent validation of the forecasts or sensitivity testing. Any documentation that provides the basis for the projected costs/revenues (e.g., revenue studies, feasibility studies, economic forecasts) should be included as attachments to the plan.

The list below should be included in the application packet with responses attached and numbered to correspond to the relevant item. Items 1, 2, and 3 below must also be provided on a CD in a spreadsheet format. The DOT must be able to review and adjust the assumptions in these files; i.e., PDF or “values” copies of the spreadsheet are not acceptable. Total narrative supporting Section D should not exceed 20 pages. The pro forma(s) and supporting documentation requested under items 4, 6, and 7 (Exhibits VII, VIII, and IX, respectively) do not count toward the page limit.

1. Estimated Capital Project Cost.

1. Provide a detailed capital cost estimate for the project. Distinguish between total and “eligible project costs” as defined under TIFIA; and describe any costs or activities that may not be TIFIA-eligible.

2. For TIFIA-eligible costs, provide an activity breakdown, as applicable, for: feasibility studies, preliminary engineering, environmental assessment, right-of-way-acquisition, vehicle acquisition, construction, construction engineering and inspection, project management, contingencies, and capitalized financing costs (including reserves, capitalized interest, and capital issuance costs for other project financing). Include other cost categories as necessary.

Note: All cost estimates should be expressed on a cash (year-of-expenditure) basis and should include a narrative describing assumptions used to arrive at such estimates.

2. Provide the total amount and type of TIFIA credit assistance requested, including the percentage of total reasonably anticipated eligible project costs.

3. Summary Table: Sources and Uses of Funds.

1. Sources should include separate line items, as applicable, for Federal grants, state grants, local grants, private investment (equity or debt); any other contributions, market value of right-of-way dedications, bond proceeds (general obligation, revenue, and others), other borrowing (specify), investment income, revenues, and Federal credit assistance proceeds. For each line item, describe the status of the source (e.g., requested, committed, and received). Provide supporting documentation to evidence the status of these funds in Exhibit VI.

2. Uses should include separate line items, as applicable, for feasibility studies, preliminary engineering, design, environmental assessment and mitigation, right-of-way-acquisition, vehicle acquisition, construction, construction engineering and inspection, insurance, project management, contingency funds, and capitalized financing costs (including debt service reserve funds, capitalized interest, and capital issuance costs for other project financing). Include other categories as necessary.

Note: Total sources and uses should be equal to one another and equal the estimated total project costs. All estimates should be expressed in year-of-expenditure dollars.

4. Cash Flow Pro Forma. Attach the pro forma for the project as Exhibit VII. The pro forma should include both a statement of sources and uses and a projection of monthly or quarterly cash flows during the construction period and annual cash flows thereafter. All amounts should be expressed on a cash (year-of-expenditure) basis and should include a narrative describing assumptions used to arrive at such estimates. The pro forma should include:

1. Projected cash flows through such time as all project debt is repaid, including separate line items for each category of revenue (such as sales tax proceeds, fares, toll receipts) and expenditure (at a minimum, construction expenditures, operations and maintenance, contributions to reserves and capital replacement funds, debt service, repayments of the TIFIA credit instrument, and repayment of other borrowed funds as well as equity dividends or proceeds (as applicable), if any);

2. Estimated debt service coverage, separated into Federal, non-Federal (addressing, as applicable, senior and junior lien debt), and illustrating projected combined coverage, as applicable;

3. Amortization schedule for all project debt, separated into Federal, non-Federal (addressing, as applicable, senior- and junior-lien debt), and combined components; and

4. Anticipated repayment schedule illustrating the disbursement and repayment of the requested TIFIA credit instrument.

5. Supplementary Narrative Information on Sources of Funds: Other Borrowed Funds.

1. Provide information on the other types of borrowing, including the form of borrowing (e.g., types of bonds to be issued), the pledged security for such borrowing, its priority with respect to the security pledged to the TIFIA instrument, details on structuring, rating assumptions, and anticipated timing of receipt of such funds. Information on amortization schedules, expected interest rates, and coverage calculations should be included in the cash flow pro forma requested under item D. (4), above.

2. For bond issuances, discuss the anticipated tax-status of the bonds, whether an IRS or bond counsel opinion has been sought, and contingency plans in the event that the tax-status differs from that which is anticipated.

6. Supplementary Narrative on Revenue Source(s).

1. Describe all revenue sources to be used to repay project financing. Specify the nature of the revenue source (dedicated or not dedicated), the expected rate(s), the base to which such rates will be applied (e.g., retail sales, average daily traffic), projected revenues from each source, and projected increases or decreases in such revenues over time.

2. Elaborate on existing or anticipated pledges/claims on revenues and provide a brief summary of all claims on the flow of funds.

3. Attach documentation (e.g., revenue studies, feasibility studies, traffic studies, and economic forecasts) as Exhibit VIII to provide the basis for projected revenues and their respective anticipated rates of change. If independent revenue projections have not yet been obtained, state when such independent projections will be completed and identify the consultant engaged to perform the analysis.

7. Proposed Terms for the Requested TIFIA Credit Instrument. Identify the type(s) of TIFIA credit instrument being requested (secured loan, loan guarantee, standby line of credit) and, at a minimum, the following proposed terms and conditions for each proposed credit instrument: amount, origination date, final maturity date, estimated interest rate, timing of disbursements, pledged security, repayment sources, amortization schedule, and lien position. The proposed TIFIA credit facility, which must be senior or parity lien in the event of bankruptcy, liquidation or insolvency, can be subordinate as to cash flows absent such an event. Please describe whether a waiver of the nonsubordination requirement is requested and how the applicant meets the applicable requirements. The proposed terms and conditions should be submitted as Exhibit IX.

8. Reasons for Selecting the Proposed Type(s) of Credit Instrument. Describe why you are requesting the specific type(s) of TIFIA credit instrument. If you are requesting only a direct loan and/or a line of credit, specify the project’s financial structure if the TIFIA credit assistance was instead in the form of a loan guarantee, including the amount of guaranteed loan assistance that would be required. If applicable, describe why the project intends to use a Master Credit Agreement.

9. Flexibility in the Financial Plan to Support a Reduced Percentage of TIFIA Credit Assistance. Explain the flexibility in the financial plan to finance the project with a reduced percentage of TIFIA credit assistance.

10. Risks and Mitigation Strategies. Identify risks to project completion and sufficiency of revenues. Sample risks might include cost escalation, approvals, litigation, construction schedules, ridership and traffic levels, availability of grant funding, and market access. Identify all mitigation strategies and any proposed cost-containment approaches (e.g., design-build, value engineering, guaranteed maximum price and/or completion date, warranties, or other incentive/disincentive clauses).

SECTION E: Applicant’s Organizational Structure

This section requests narrative information and three exhibits. The list below should be included in the application packet with responses attached and numbered to correspond to the relevant item. Total narrative supporting items for Section E should not exceed 10 pages, excluding exhibits.

1. Applicant’s Background Information and Legal Authority.

1. Describe the applicant’s history, ownership, and legal structure (e.g., state governmental agency, local governmental agency, corporation, or partnership). Include a copy of the statutory authority under which the entity was created as part of Exhibit X, if applicable.

2. Describe the legal authority of the applicant to carry out proposed project activities described in the application packet, including levying taxes, issuing debt, charging tolls or other fees, and/or receiving dedicated funding from another entity. Provide documentation as part of Exhibit X.

3. Identify whether governmental entities (other than the applicant) must approve the submission of the application packet, the funding of activities, or the carrying out of activities in the application (other than permits). Provide documentation as part of Exhibit X.

2. Organization and Management.

1. Describe the applicant’s organizational structure and the applicant’s relationship to any subsidiaries or affiliates. Include the legal names of key principals and staff (e.g., project manager and chief financial officer) and any recent or proposed changes to the organizational structure.

2. Provide an organizational chart as Exhibit XI, to include the major parties involved in planning, owning, financing, constructing, operating, and/or maintaining the project. Include the major service contractors that have been, or will be, retained for the project (e.g., architects, developers, engineers, attorneys, financial advisors and underwriters, environmental consultants). Note: The DOT may request additional documentation from major parties other than the applicant as part of the project evaluation and selection process.

3. Applicant. Describe the entity that will serve as the applicant (i.e., public-sector agency/authority or private-sector firm).

3. Applicant/Borrower. Will the applicant and borrower be the same? Explain the relationship between the applicant and the borrower, if they are not the same entities.

3. Prior Experience. Describe the applicant’s prior experience as it relates to carrying out projects similar to that being proposed.

4. Financial Condition. Provide year-end audited financial statements for the past three years, as available, as Exhibit XII.

4. Litigation and/or Conflicts. Disclose any current, threatened, or pending litigation involving the applicant related to permitting, public involvement, environmental irregularities, construction defects, securities fraud, conflict of interest, failure to perform under a state or Federal contract, or other charges which may reflect on the applicant’s financial position or ability to complete the project.

SECTION F: Applicant Certifications

The following items require certification by an authorized representative of the applicant requesting TIFIA assistance. The list below should be included in the application packet with responses attached and numbered to correspond to the relevant item. The DOT may require that applicants provide documentation of these certifications.

1. Federal Requirements. This project complies with, and/or will comply with, the requirements of (check all that apply):

Title 23 of the U.S. Code, and implementing regulations._____

Chapter 53 of title 49 of the U.S. Code, and implementing regulations. _____

Section 5333(a) of title 49 of the U.S. Code. _____

If the applicant intends to request waivers to any requirements included in the preceding citations, explain on an attached sheet.

2. National Environmental Policy Act. The project complies with, and/or will comply with, all provisions of the National Environmental Policy Act of 1969 (42 U.S.C. 4321 et seq.).

Yes _____ No ______ If no, explain on an attached sheet.

The project has (check all that apply):

Yes _____ No ______ Received a Categorical Exclusion.

Yes _____ No ______ Received a Finding of No Significant Impact (FONSI).

Yes _____ No ______ Circulated a Draft Environmental Impact Statement.

Yes _____ No ______ Circulated a Final Environmental Impact Statement.

Yes _____ No ______ Received its Record of Decision. (If no, provide on an attached sheet the estimated date for receipt of the Record of Decision.)

3. Uniform Relocation. This project complies with, and/or will comply with, all provisions of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.C. 4601 et seq.).

Yes _____ No ______ If no, explain on an attached sheet.

4. Civil Rights. This project complies with, and/or will comply with, all provisions of Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.).

Yes _____ No ______ If no, explain on an attached sheet.

5. Other Requirements as Applicable that apply to projects which receive Federal assistance such as the Federal Water Pollution Control Act as amended by the Clean Water Act (33 U.S.C. 1251 et. seq.), and the Endangered Species Act, (16 U.S.C. 1531 et. seq.). This project complies with, and/or will comply with, all other applicable provisions of Federal law.

Yes _____ No ______ If no, explain on an attached sheet.

5. State Transportation Planning and Programming Process. This project is consistent with the long-range state transportation plan(s) of the affected state(s).

Yes _____ No ______ If no, explain on an attached sheet.

If located in a metropolitan planning area, this project is included on the metropolitan transportation plan.

Yes _____ No ______ If no, explain on an attached sheet.

This project is listed within the State Transportation Improvement Program (STIP) of the affected state(s).

Yes _____ No ______ If no, explain on an attached sheet and provide estimated date for project listing on the STIP.

7. Credit Ratings. This applicant has received preliminary rating opinion letter(s) and investment grade ratings on the senior debt instrument, and if TIFIA is not the senior debt, on the TIFIA credit instrument, from one or more Nationally Recognized Statistical Rating Organizations. The letter(s) and rating(s) are attached as Exhibit IV.

7. Charges: The undersigned certifies that it will reimburse the DOT for costs incurred related to services provided by the DOT’s outside advisors in connection with the evaluation of the TIFIA Letter of Interest, evaluation of the TIFIA application, and negotiation of the TIFIA transaction documents, irrespective of whether the credit agreement is executed.

9. Lobbying. Section 1352 of Title 31, United States Code and 49 C.F.R. §20.100, provide that none of the funds appropriated by any Act of Congress may be expended by a recipient of a contract, grant, loan, or cooperative agreement to pay any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, or an employee of a Member of Congress in connection with the award or making of a Federal contract, grant, loan, or cooperative agreement or the modification thereof. The DOT interprets this provision to include the use of appropriated funds to influence or attempt to influence the selection for a secured loan, loan guarantee, or line of credit under the TIFIA program.

TIFIA applicants must file a declaration: (a) with the submission of an application for TIFIA assistance; (b) upon receipt of a TIFIA credit instrument (unless the information contained in the declaration accompanying the TIFIA application has not materially changed); and (c) at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the information contained in any declaration previously filed in connection with the TIFIA assistance.

A declaration filed in connection with the TIFIA assistance shall contain:

1. The name of any registrant under the Lobbying Disclosure Act of 1995 who has made lobbying contacts on behalf of the TIFIA applicant.

2. A certification by the person making the declaration that none of the funds appropriated by any Act of Congress has been or will be expended to pay any person for influencing or attempting to influence an officer or employee of the DOT or any Federal agency, a Member of Congress, an officer or employee of Congress, or employee of a Member of Congress with regard to the TIFIA assistance.

In addition, any person or entity that requests or receives a subcontract from a TIFIA applicant is required to file a declaration, which shall contain the name of any registrant under the Lobbying Disclosure Act who has made lobbying contacts and a certification that the person or entity has not made or will not make prohibited payments.

The undersigned certifies, to the best of his or her knowledge and belief, that: (i) no federally appropriated funds have been paid or will be paid by or on behalf of the undersigned to influence or attempt to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with an award of TIFIA assistance; and (ii) if non-federally appropriated funds have been or will be paid for the above purposes, the undersigned will disclose such payments through the completion and submission of Standard Form LLL (“Disclosure Form to Report Lobbying”). The applicant shall file Standard Form LLL in accordance with its instructions. Submission of this statement with the TIFIA application is a prerequisite for obtaining TIFIA assistance.

Any person who makes an expenditure of appropriated funds prohibited by 31 U.S.C. 1352(a) or fails to file the required statement or amended statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure in accordance with 31 U.S.C. 1352(c).

10. Debarment. The undersigned further certifies that neither it nor its principals is currently, or has been in the preceding three years: 1) debarred, suspended or declared ineligible from participating in any Federal program; 2) formally proposed for debarment, with a final determination still pending; 3) voluntarily excluded from participation in a Federal transaction; or 4) indicted, convicted, or had a civil judgment rendered against it for any of the offenses listed in the Regulations Governing Debarment and Suspension (Government-wide Nonprocurement Debarment and Suspension Regulations: 49 C.F.R. Part 29.

11. Default/Delinquency. The undersigned further certifies that neither it nor any of its subsidiaries or affiliates are currently in default or delinquent on any debt or loans provided or guaranteed by the Federal Government.

Signature: By submitting this application, the undersigned certifies that the facts stated and the certifications and representations made in this application are true, to the best of the applicant’s knowledge and belief after due inquiry, and that the applicant has not omitted any material facts. The undersigned is an authorized representative of the applicant.

Applicant: _____________________________________________________________

Signed: _____________________________________________________________

Name and Title: _____________________________________________________________

Date: _____________________________________________________________

END OF FORM

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 21XX-XXXX. Public reporting for this collection of information is estimated to be approximately 100 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

All responses to this collection of information are voluntary; if an applicant desires that any information submitted in its letter of interest or application or any supplementary material not be released by the Department upon request from a member of the public or otherwise made publicly available, the applicant is directed to state so and directed to provide reasons why such information is confidential and should not be released, including particulars as to any competitive harm which would potentially result from the release of such information.. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

Page 3 of 17 7/13 FY 2013 Application-TIFIA Credit Program