Introduction: The U.S. Environmental Protection Agency (EPA) will invite selected State infrastructure financing authorities, herein referred to as "State Revolving Fund Programs," to submit this application for Water Infrastructure Finance and Innovation Act (WIFIA) credit assistance. EPA will use the collected information to further evaluate applicants and develop loan agreement documents. EPA may ask applicants to provide additional supporting materials or to clarify details during the review and negotiation process. The applicant is required to notify of and submit to EPA any updated application materials during the review period. Unsolicited applications will not be considered.
___________________________________________________________________________________
Purpose: Applicants complete this application to provide EPA with information to assess the creditworthiness of the applicant, identify engineering and financial risk, negotiate the terms and conditions of the credit assistance, and calculate the amount of budget authority that will be needed for the loan. 
_____________________________________________________________________________________Format: Applications must include all requested information. Applicants must provide electronic files of the entire application and all attachments via email to wifia@epa.gov, on a USB drive or CD, or uploaded to EPA's SharePoint site.
_____________________________________________________________________________________
Fees: Applicants must submit a non-refundable application fee. The application fee is $100,000. An application will not be considered until receipt of the application fee. For further information regarding the application fee, as well as the credit processing fee which will be charged at loan closing, and any other applicable fees, please see the WIFIA fee rule at: https://www.federalregister.gov/documents/2017/06/28/2017-13438/fees-for-water-infrastructure-project-applications-under-wifia.  
_____________________________________________________________________________________
Submission: The applicant should submit an application that includes all components on the application checklist. The applicant may indicate if a requirement is not applicable to its loan. If the applicant anticipates a delay in one or more source documents, it may indicate the anticipated date of submitting that document in the application. EPA may request additional items from applicants on a case-by-case basis. 
The electronic files (if not provided via email or SharePoint) should be sent to the attention of Director, WIFIA Program; US EPA William Jefferson Clinton West Building‐room 6210 A; 1301 Constitution Ave, NW; Washington, DC 20004. The applicant must use an overnight or courier delivery service (e.g. UPS, FedEx, DHL) to ensure proper delivery of the package. Upon receipt, EPA will provide a confirmation email. 
Use of Pay.gov (https://www.pay.gov) to make payments to EPA is the preferred electronic payment method for the Application Fee. The application fee may also be paid via FEDWIRE or by check sent to US EPA; Las Vegas Finance Center; 4220 S. Maryland Pkwy, Bldg C, Ste 503; Las Vegas NV 89119. For questions about payments, contact the US EPA Las Vegas Finance Center at (702)798‐2485 or lvfc-grants@epa.gov. For detailed payment instructions, contact the WIFIA program. 

Upon receipt of the application fee and materials, EPA will provide a confirmation email.
_____________________________________________________________________________________Selection: EPA's invitation of a prospective borrower to submit an application for the WIFIA program does not imply that EPA has approved all elements proposed in the letter of interest. However, EPA will only select those prospective borrowers that it expects to achieve financial closing.  As such, EPA may require changes in the applicant's financial plan and other factors proposed in the letter of interest. Credit assistance is subject to a determination of creditworthiness, readiness to proceed and negotiation of a credit agreement satisfactory to EPA. 
_____________________________________________________________________________________Confidential Business Information:  An applicant may assert a business confidentiality claim covering part or all of the information submitted to EPA as part of its application, in a manner consistent with 40 C.F.R. 2.203, 41 Fed. Reg. 36902 (Sept. 1, 1976), by placing on (or attaching to) the information a cover sheet, stamped or typed legend, or other suitable form of notice employing language such as trade secret, proprietary, or company confidential. The applicant should also state whether it desires confidential treatment until a certain date or until the occurrence of a certain event.  Information covered by a business confidentiality claim will be disclosed by EPA only to the extent and only by means of the procedures set forth under 40 C.F.R. Part 2, Subpart B.  Information that is not accompanied by a business confidentiality claim when it is received by EPA may be made available to the public by EPA without further notice to the applicant. 
More information about CBI is available in the WIFIA program handbook and frequently asked questions (FAQ) available at http://www.epa.gov/wifia.
_____________________________________________________________________________________Burden: The public reporting and recordkeeping burden for this collection of information is estimated to average 150 hours per response.  Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Regulatory Support Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. 
_____________________________________________________________________________________Warning: Falsification or misrepresentation of information or failure to file or report information required to be reported may be the basis for denial of financial assistance by the Environmental Protection Agency. Knowing and willful falsification of information required to be submitted and false statements to a Federal Agency may also subject you to criminal prosecution.  See, for example, 18 U.S.C. §1001.
_____________________________________________________________________________________
Additional information is available at https://epa.gov/wifia and by contacting wifia@epa.gov. 
APPLICATION FORM FOR STATE REVOLVING FUND PROGRAMS
Provide the following information in this form or as narrative answers. Narrative answers can reference source documents (include the name of the document and relevant pages or sections). Provide any referenced documents as attachments.
Section A: Loan Information

    Legal name of prospective borrower:

   Click or tap here to enter text.

    Other names under which the prospective borrower does business: 

   Click or tap here to enter text. 
      
    Business street address: 

   Click or tap here to enter text.

    Program website: 

   Click or tap here to enter text.

    Employer/taxpayer identification number (EIN/TIN):

    Click or tap here to enter text.

    Dun and Bradstreet Data Universal Number System (DUNS) number:

    Click or tap here to enter text.

    Requested amount of the WIFIA loan (in dollars): 

   Click or tap here to enter text. 

    Estimated total eligible costs (in dollars): 

   Click or tap here to enter text.
   
   
    Indicate the requested loan structure (select only one): 
☐ WIFIA program adopts SRF program's existing indenture
☐ SRF program accepts WIFIA program's standard terms


Section B: Applicant Information

 Describe the applicant's legal structure. Include a copy of the statutory authority under which the entity was created as an attachment, if applicable.
   Click or tap here to enter text.
 Describe the legal authority of the applicant to carry out proposed activities described in the application packet, including, issuing debt, charging fees, and/or receiving dedicated funding from another entity. Provide documentation as an attachment, if applicable.
   Click or tap here to enter text.
 Identify what governmental entities (other than the applicant) approved the submission of this application and must approve incurrence of WIFIA debt. Explain the approval process and timeline.
   Click or tap here to enter text.
 Disclose any current, threatened, or pending litigation involving the applicant. 
   Click or tap here to enter text.
 Describe how the applicant assesses project designs and reviews plans and specifications. 
   Click or tap here to enter text.
 Describe how the applicant assesses proposed project costs for eligibility and reasonableness.
   Click or tap here to enter text.
 Describe how the applicant assesses the reasonableness and achievability of the proposed development schedules, including the critical path schedule. Include information about how pending actions (e.g., permits, resolutions, documents) that have the potential to delay the implementation of a project on time and within budget are identified.
   Click or tap here to enter text.
 Describe how the applicant evaluates the expected useful life of a project.
   
    Click or tap here to enter text.
   
 Describe the construction monitoring protocols for projects, including the frequency of construction sites visits.
   Click or tap here to enter text.
 Describe how the applicant determines Federal cross-cutter (American Iron and Steel, Davis-Bacon, etc) compliance for its financed projects.
   Click or tap here to enter text.
 Describe how the applicant confirms substantial completion for a project.
   Click or tap here to enter text.
 Describe how the applicant assesses operations and maintenance plans.
   
   Click or tap here to enter text.
   
 Describe the contingency plans for financing and completion of a project if it is significantly delayed and/or over budget.
   Click or tap here to enter text.
 Provide the following documents as attachments:
 Engineering review and construction monitoring procedures
 Programmatic Environmental Assessment Questionnaire for WIFIA Credit Assistance SRF Programs available at https://www.epa.gov/wifia/wifia-programmatic-environmental-assessment-questionnaires
         

Section C: Financing Plan

 Complete the following sources and uses of funds table, including the proposed WIFIA assistance. Note:  Total sources and uses should be equal to one another and equal the estimated total eligible costs. All estimates should be expressed in year-of-expenditure dollars.
Sources and Uses of Funds Table
Sources Category
Estimated Dollar Value 
1. WIFIA Loan
Click or tap here to enter text.
2. Revenue Bonds
Click or tap here to enter text.
3. Borrower Cash
Click or tap here to enter text.
4. Federal Grant
Click or tap here to enter text.
5. Interest
Click or tap here to enter text.
6. Principal Repayments
Click or tap here to enter text.
7. Other (please specify) Click or tap here to enter text.
Click or tap here to enter text.
8. Other (please specify) Click or tap here to enter text.
Click or tap here to enter text.
TOTAL SOURCES
Click or tap here to enter text.
Project Name
Estimated Cost
Click or tap here to enter text.
Click or tap here to enter text.
 Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
TOTAL USES
Click or tap here to enter text.
   
   
   

 Select the revenue source(s) that will be used to repay the WIFIA loan:
      ☐ Principal and interest loan repayments
      ☐ Investment earnings
      ☐ SRF program equity
      ☐ Other (Please explain): Click or tap here to enter text.
      
         
 Is the revenue source(s) identified in question C-2 pledged to anything other than SRF debt service? If yes, explain.
   
   Click or tap here to enter text.
   
 Identify the following proposed terms for the requested WIFIA credit assistance:

 Origination date: Click or tap here to enter text.
 Final maturity date: Click or tap here to enter text.
 Timing of disbursements: Click or tap here to enter text.
 Pledged security: Click or tap here to enter text.
 Repayment sources: Click or tap here to enter text.
 Amortization schedule: Click or tap here to enter text.
 Lien position: Click or tap here to enter text.

 Describe any restrictions that may limit the SRF's program's ability to pursue additional funding or transfer funds from the applicant, such as Additional Bonds Tests or closed indentures. 
   Click or tap here to enter text.	
 Discuss the existing ratings, repayment schedules, and weighted average default ratings of the underlying borrowers?
   Click or tap here to enter text.	
 Provide the Default Tolerance.
   Click or tap here to enter text.	
 Describe the portfolio size and concentration.
   Click or tap here to enter text.	


Section D: Supporting Documents
Provide the most recent versions of the following documents as attachments. The document is required unless otherwise noted:
 Attachment 1: Intended Use Plan
 Attachment 2: Annual Report to EPA Region
 Attachments 3-5: Audited program financials for the previous 3 years
 Attachment 6: SRF Sample loan agreement
 Attachment 7:  Projected Revenue Certificate, which includes pledged loan repayments, annual debt service, and debt service coverage for all outstanding debt until maturity (for SRF programs with existing debt) OR the projected revenue from loan repayments for the life of the SRF loan (for SRF programs with no debt).
 Attachment 8: Existing rating agency reports (if available)
 Attachment 9: Procedures for reviewing project's Preliminary Engineering Report (PER)
 Attachment 10: Procedures for the conducting the state environmental review
 Attachment 11: Documentation of SRF program's priority setting system
 Attachment 12: Bond Indenture (if applying for OPTION 1)
 Attachment 13: Most recent Official Statement (if applying for OPTION 1)
 Attachment 14: A preliminary rating letter from a Nationally Recognized Statistical Rating Organization, describing the applicant's ability to obtain an investment grade rating. 
 Attachment 15:  The underwriting criteria that will be applied to the loans pledged to the WIFIA loan
Section C: Project List
Complete the following table for the projects that are included in the total eligible project costs. Add or delete rows as needed. Alternatively, this information may be provided in Excel spreadsheet marked as attachment 14.
No.
Borrower
Project Name
Brief Description (1-2 sentences)
City
County
Population
Loan Amount
Status and Finding of State Environmental Review
Design Start and End Date
Construction Start and End Date
Estimated Loan Closing Date
1











2











3











4











5











6











7











8











9











10











11











12











13











14











15













CERTIFICATIONS 

 National Environmental Policy Act:  The undersigned acknowledges that EPA will not approve a loan until a final agency determination, such as a Categorical Exclusion (CATEX), Finding of No Significant Impact (FONSI), or a Record of Decision (ROD), has been issued.
 American Iron and Steel:  The applicant acknowledges that any project receiving credit assistance under this program for the construction, alteration, maintenance, or repair of a project may only use iron and steel products produced in the United States and must comply with all applicable guidance.
 Prevailing Wages:  The applicant acknowledges that all laborers and mechanics employed by contractors or subcontractors on projects receiving credit assistance under this program shall be paid wages at rates not less than those prevailing for the same type of work on similar construction in the immediate locality, as determined by the Secretary of Labor, in accordance with sections 3141-3144, 3146, and 3147 of Title 40 (Davis-Bacon wage rules).
 Credit Ratings:  This applicant has received a preliminary rating opinion letter describing its ability to obtain an investment grade rating. This letters or ratings are attached. 
 Credit Processing Fees:  The undersigned certifies that it will reimburse EPA for its costs incurred in negotiating the credit agreement, irrespective of whether the credit agreement is executed.
 Lobbying:  Section 1352 of Title 31, United States Code provides 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. EPA interprets this provision to include the use of appropriated funds to influence or attempt to influence the selection for assistance under the WIFIA program.
WIFIA applicants must file a declaration: (a) with the submission of an application for WIFIA credit assistance; (b) upon receipt of WIFIA credit assistance (unless the information contained in the declaration accompanying the WIFIA 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 WIFIA credit assistance.
The undersigned certifies, to the best of his or her knowledge and belief, that:
 No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
 If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
 The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
         This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
 Debarment: The undersigned further certifies that it is not currently: 1) debarred or suspended  from participating in any Federal programs; 2) formally proposed for debarment, with a final determination still pending; or 3) indicted, convicted, or had a civil judgment rendered against it for any of the offenses listed in the Regulations Governing Debarment and Suspension (Governmentwide Nonprocurement Debarment and Suspension Regulations: 2 C.F.R. Part 180 and Part 1532).
 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.
 Other Federal Requirements:  The applicant acknowledges that it must comply with all other federal statutes and regulations, as applicable.  A non-exhaustive list of federal cross-cutting statutes and regulations can be found at: www.epa.gov/wifia. 
 Name: 
Title:  
Organization:
Street Address: 
City/State/Zip: 
Phone: 
E-mail: 

Name: 
Title:  
Organization:
Street Address: 
City/State/Zip: 
Phone: 
E-mail: 

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.
Signature:  _________________________________________________________________________
Date Signed: ________________________________________________________________________

KEY DEFINITIONS

 Administrator means the Administrator of EPA.
   
 Applicant means the entity submitting the application for WIFIA credit assistance. Only prospective borrowers that are invited to submit a WIFIA application become applicants. The following entities are eligible to receive credit assistance: a corporation, a partnership, a joint venture, a trust, a Federal, State, or local government, a tribal government or consortium of tribal governments, and a State infrastructure financing authority. 

 Credit assistance means a secured loan or loan guarantee under WIFIA.

 Credit agreement means a contractual agreement between EPA and the applicant (and the lender, if applicable) that formalizes the terms and conditions established in the term sheet (or conditional term sheet) and authorizes the execution of a secured loan or loan guarantee.

 Investment-grade rating means a rating category of BBB minus, Baa3, bbb minus, BBB (low), or higher assigned by a nationally recognized statistical rating organization (NRSRO) to project obligations offered into the capital markets.
   
 Iron and steel products means the following products made primarily of iron or steel: lined or unlined pipes and fittings, manhole covers and other municipal castings, hydrants, tanks, flanges, pipe clamps and restraints, valves, structural steel, reinforced precast concrete, and construction materials.

 Nationally Recognized Statistical Rating Organization (NRSRO) means a credit rating agency identified and registered by the Office of Credit Ratings in the Securities and Exchange Commission.
   
 Prospective borrower means an entity that is contemplating or is in the process of undertaking the WIFIA application process, or an entity that has undertaken these activities on behalf of another entity. The following entities are eligible to receive credit assistance: a corporation, a partnership, a joint venture, a trust, a Federal, State, or local government, a tribal government or consortium of tribal governments, and a State infrastructure financing authority. Prospective borrowers become applicants when they are invited to apply for WIFIA credit assistance.
         
 State infrastructure financing authority means the State entity established or designated by the Governor of a State to receive a capitalization grant provided by, or otherwise carry out the requirements of, title VI of the Federal Water Pollution Control Act (33 U.S.C. 1381 et. seq.) or section 1452 of the Safe Drinking Water Act (42 U.S.C. 300j - 12).

 WIFIA means the Water Infrastructure Finance and Innovation Act of 2014, Pub. L. 113-121, 128 Stat, 1332, codified at 33 U.S.C. §§ 3901-3914.

