THE MISSISSIPPI ALTERNATIVE FUEL SCHOOL BUS AND MUNICIPAL MOTOR VEHICLE REVOLVING LOAN FUND LOAN APPLICATION

Transcription

1 THE MISSISSIPPI ALTERNATIVE FUEL SCHOOL BUS AND MUNICIPAL MOTOR VEHICLE REVOLVING LOAN FUND LOAN APPLICATION

2 Please Return Form to: MDA ENR Division Post Office Box 849 Jackson, Mississippi The information required on this form is necessary to determine the eligibility of your project for financing under the Alternative Fuel School Bus and Municipal Motor Vehicle Loan Fund. Please answer all questions. Insert NONE or NOT APPLICABLE where necessary. If an estimate is given, put EST. after the figure. Attach additional sheets if more space is needed. Return the original and one (1) copy of this application to MDA- Energy and Natural Resources Division. If you have questions or need additional information, contact the Energy and Natural Resources Division of MDA at (601) APPLICANT INFORMATION 1. Applicant Information: Name of Entity: Principal Address (including Zip +4): County: Congressional District: Federal tax identification number: Address where vehicles will be located (if different from above): Address: County: 2. Responsible Officer: Name: Title: Address: Telephone number: 1

3 3. Project Contact: Applicant must identify a local prime contact Name: Title: Address: Telephone number: Fax number: address: 4. Consultant, if applicable: Name: Title: Address: Telephone number: 5. Local Attorney: Name: Title: Name of Firm: Address: Telephone number: Fax number: 6. Applicant Type: Public School District K-12 Municipal Government 2

4 DEBT INFORMATION 7. List all debt of the Applicant wherein tax revenue has been pledged as collateral: (other bank loans, state programs or other financings) PROGRAM NAME DATE ORIGINAL LOAN AMOUNT LOAN BALANCE 8. Provide the following information on the Applicant s indebtedness: Assessed Valuation: City County If joint application Total Debt Capacity : Outstanding debt that Produces Income (user fees, water or sewer systems, etc.) Other Outstanding General Obligation Debt 9. What type of revenue is the Applicant pledging to the repayment of the loan? 3

5 FUNDING REQUEST 10. Amount requested: ACTIVITY Activity 1: New OEM Purchases Activity 2: Repower/Recharge/Retrofits/Conversions Activity 3: Refueling System AMOUNT OF FUNDS REQUESTED* LEVERAGED FUNDS TOTAL PROJECT COST TOTAL PROJECT TYPE 11. Number of vehicles currently part of the fleet: 12. Number of new vehicles to be purchased, if funded: 13. Number of existing vehicles to be converted, if funded: 14. Check all that apply. Alternative fuel technology to be used for this project CNG LNG LPG Attach page if necessary 15. What policies and or trainings will be implemented to ensure that drivers will choose the alternative fuel as its primary source? 16. What is the expected life of new and/ or converted vehicles? 4

6 The following gasoline prices obtained from the U.S. Energy Information Administration must be used in all calculations. GULF COAST AREA RETAIL GASOLINE AND DIESEL PRICES Regular Mid-Grade Premium Diesel $3.299 $3.471 $3.638 $ Use this space to estimate savings: 18. Use the following formula to estimate return on investment: ROI= (Savings-Cost)/Cost 19. Use this space for a Proposed Project Schedule: 5

7 ACTIVITY 1 NEW OEM VEHICLES 20. In the following table, describe the proposed new vehicles to be purchased. Attach a separate sheet, if necessary. Vehicle Model Model Year Est. Annual Mileage Vehicle Cost Incremental Cost Alternative Fuel Type Used* Est. Annual Alternative Fuel Use Est. Annual Alternative Fuel Cost ($) Estimate Petroleum Use ** (Gal) Estimate Petroleum Cost** ($) TOTAL * Please input CNG, LNG or LPG **Please input D for Diesel or G for Gasoline 6

8 ACTIVITY 2 REPOWER/RECHARGE/RETROFITS/CONVERSIONS 21. In the following table, describe the proposed currently owned vehicles to be retrofitted with project funds. Attach a separate sheet, if necessary. Vehicle Model Model Year Annual Mileage Vehicle Conversion Cost Incremental Cost Alternative Fuel Type Est. Annual Alternative Fuel Use (Gal.) Estimate Annual Alternative Fuel Cost ($) Est. annual Petroleum Use * (Gal.) Est. annual Petroleum Cost* ($) TOTAL * Please input CNG, LNG or LPG **Please input D for Diesel or G for Gasoline 7

9 ACTIVITY 3 Refueling System 22. In the following table, describe the proposed purchase of refueling system Type of Equipment Quantity Cost Fuel Type Upgrade (U) or New Install (N) 8

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11 REQUIRED ATTACHMENTS FOR ALL APPLICANTS: 1. Please show that retrofit kits are EPA certified. 2. Please attach a letter of support from any third party financiers. 3. Provide a copy of the most recent audited financial statement. 4. Provide a detail description of the revenue to be pledged. 5. Provide an opinion or opinions of counsel addressing the authority to borrow loan funds and to pledge the revenue reflected in question Certified Proof of Publication of the Resolution of Intent. 7. Certified copy of the Resolution of No Protest. 9

12 EXHIBIT A Application Certification For the Applicant I, hereby certify that I am the Responsible Local Officer designated by the Local Applicant to request funding. Further, as the Responsible Local Officer, I certify that the Application and attached documentation are true and accurate, and contain no misrepresentations, falsifications, omissions or concealment of material facts. I further agree to timely advise MDA of any changes in such information and documentation and will answer any such further questions regarding same. On behalf of the Applicant I hereby certify to the following: Name of Entity: Name of Responsible Local Officer (Print): Signature of Responsible Local Officer: 10