Application No.__________

Date Received: __________

APPLICATION FOR FINANCIAL ASSISTANCE

UTAH STATE BOARD OF WATER RESOURCES

The applicant is referred to the Board of Water Resources' Policy and Guidelines for use in Water Conservation Projects for information concerning the completion of this form and the project application process.

1. Applicant: (Irrigation Company, Municipality, Improvement District, Special Service District, Flood Control District, etc.).

Name of Applicant ____________________________________________

Address ____________________________________________

Zip Code

2. Presiding Officer:

Name and Title _____________________________________________

Address _____________________________________________

Phone Number ___________________________ Zip Code

3. Project Location:

Distance and direction from nearest community ________________________________________

County ________________________________

4. Brief description of proposed project and explanation of why it is needed:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

5. Estimated Project Cost ______________________________

6. Financing Plan (Proposed project cost sharing):

Applicant _____________________________________

Board of Water Resources _____________________________________

Other (specify agency) ________________________________________

7. Water Rights (Identify by court decree, application number or other appropriate explanation):

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

8. Attach any available technical information pertaining to the project.

BOARD OF WATER RESOURCES' POLICY

regarding

ENGINEERING AND INVESTIGATION COSTS

1. The project cost is the amount of money advanced by the Board to the applicant for all costs related to the project, plus the costs incurred by the Division of Water Resources for investigation, administration, engineering, and construction inspection. These two elements of the project cost are paid to the Board according to the terms set by the Board at the committal of funds.

2. Normal engineering, investigation, and administrative costs incurred by the Division of Water Resources during preliminary project investigation will not become a charge to the applicant if the project is found infeasible, denied by the Board, or if the applicant withdraws the application.

PROJECT COST AGREEMENT

We have been authorized to sign this form and make application for assistance on behalf of the applicant. We have read the "Guidelines for Applicants Seeking Financial Assistance from the Board of Water Resources", accept the policy and conditions enumerated therein and above, and request assistance in constructing the project described.

________________________

Date Presiding Officer

MEMBER OF THE BOARD OF WATER RESOURCES

I have reviewed this application and forward it for consideration by the Board. Comments (if any):

__________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

__________________ _______________________

Date Board Member