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CLEAN WATER STATE REVOLVING FUND PROGRAM
of the
STATE OF CALIFORNIA
acting by and through the
STATE WATER RESOURCES CONTROL BOARD
TAX QUESTIONNAIRE
You have applied for financing from the State Water Resources Control Board (State Water Board) and its Clean Water State Revolving Fund (CWSRF.) The CWSRF utilizes the proceeds of tax-exempt bonds (the "Bonds"). Since the Bonds will be tax-exempt, it is necessary to obtain certain information regarding the project to be funded (the "Project"). This Tax Questionnaire is designed to assist in obtaining such information. Each recipient of a CWSRF financing agreement or other assistance to be financed with Bond proceeds is requested to complete the attached Tax Questionnaire. In addition, you will be asked to execute a certification as to the use of the financial assistance being provided to you and certain other matters that could affect the tax exemption of the Bonds. We will prepare this certification based upon the information furnished by you in this Tax Questionnaire. Your CWSRF financing agreement "Agreement", also known as an Installment Sales Agreement, will also contain tax covenants based in part on your answers to this Tax Questionnaire.
Any questions regarding this Tax Questionnaire may be directed to your project manager. You may also wish to consult with your own counsel. The adopted Reimbursement Resolution is preferred to be submitted with the application or as soon as possible after the application is submitted. However, if the Agency cannot send in the Reimbursement Resolution with the application the latest date of submittal is no later than 60 days after start of construction of the project and before DFA can prepare the CWSRF financing agreement (see the above model resolution).
Please return a hard copy version of the executed, completed Tax Questionnaire and the adopted Reimbursement Resolution to your project manager at State Water Resources Control Board, Division of Financial Assistance, 1001 I Street, 16th Floor, Sacramento, Cal i f o r n i a 9 5 8 1 4 .
A t t a c h m e n t 1 1 C ( A l l P r o g r a m s e x c e p t S C W G )
S T A T E W A T E R R E S O U R C E S C O N T R O L B O A R D
C L E A N W A T E R S T A T E R E V O L V I N G F U N D P R O G R A M
T A X Q U E S T I O N N A I R E
L E G A L N A M E O F A P P L I C A N T
F O R M T E X T P r o j e c t N u m b e r
F O R M T E X T D A T E / T I M E R E C E I V E D B Y W a t e r B o a r d N A M E A N D L O C A T I O N O F P R O J E C T
F O R M T E X T A s u s e d i n t h i s T a x Q u e s t i o n n a i r e , t h e t e r m " P r o j e c t " i s t h e p r o j e c t t h a t y o u d e s c r i b e d i n t h e F i n a n c i a l A s s i s t a n c e A p p l i c a t i o n s u b m i t t e d t o t h e W a t e r B o a r d a n d c o n s t i t u t e s t h o s e c o s t s t h a t will be funded by the Water Board under the Agreement. The phrase "Non-Governmental Entity" constitutes any person, partnership, corporation or other organization that is not organized as a state, city, county, school district, other special district or joint powers authority. The federal government is a Non-Governmental Entity.Instructions: Answer all questions and provide all information and documents requested. Begin typing in the shaded area and the space will enlarge to accommodate the informatio n t h a t i s t y p e d . B r i e f l y d e s c r i b e t h e P r o j e c t , i t s f u n c t i o n s a n d i t s p r i n c i p a l c o m p o n e n t s .
F O R M T E X T
I n d i c a t e b y p r i n c i p a l c o m p o n e n t s y o u r c u r r e n t e s t i m a t e s o f t h e c o s t s o f t h e P r o j e c t , a s f o l l o w s :
a . C o n s t r u c t i o n c o s t s $ F O R M T E X T
b . E q u i p m e n t c o s t s $ F O R M T E X T
c . R e h a b i l i t a t i o n o r r e n o v a t i o n o f f a c i l i t i e s $ F O R M T E X T
d . S i t e p r e p a r a t i o n c o s t s $ F O R M T E X T
e . A r c h i t e c t u r a l / e n g i n e e r i n g , d e s i g n a n d p l a n n i n g c o s t s $ F O R M T E X T
f . E n g i n e e r i n g a n d a d m i n i s t r a t i v e c o s t s d u r i n g c o n s t r u c t i o n $ F O R M T E X T
g . S u r v e y s $ F O R M T E X T
h . L e g a l f e e s $ F O R M T E X T
i . F i n a n c i n g c o s t s $ F O R M T E X T
j . C o m m i t m e n t f e e s a n d d e p o s i t s $ F O R M T E X T
k . O t h e r c o s t s ( p l e a s e s p e c i f y ) $ F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
W i l l a n y p o r t i o n o f t h e f i n a n c i n g p r o v i d e d u n d e r t h e A g r e e m e n t b e u s e d t o r e f i n a n c e e x i s t i n g d e b t r e l a t i n g t o t h e P r o j e c t ?
( I f y e s , p l e a s e i d e n t i f y the existing indebtedness to be refinanced, including its name, original issue date, par amount, purpose(s), whether it is immediately prepayable, and whether the interest on such existing debt is federally taxable or tax-exempt. State the amount of the Agreement that is expected to be used for refinancing purposes. Note that existing indebtedness includes all bonds, notes, leases or commercial paper issued by you relating to any portion of the Project.)
FORMTEXT I n d i c a t e t h e a m o u n t o f P r o j e c t c o s t s t h a t a r e e x p e c t e d t o b e p a i d w i t h i n t h e f o l l o w i n g p e r i o d s o f t i m e :
( P l e a s e r e s p o n d t o t h i s q u e s t i o n u s i n g t h e e x p e c t e d i n i t i a t i o n d a t e o f c o n s t r u c t i o n . )
P r o j e c t c o s t s t o b e s p e n t w i t h i n 6 m o n t h s : $ F O R M T E X T
P r o j e c t c o s t s t o b e s p e n t w i t h i n 1 2 m o n t h s : $ F O R M T E X T
P r o j e c t c o s t s t o b e s p e n t w i t h i n 1 8 m o n t h s : $ F O R M T E X T
P r o j e c t c o s t s t o b e s p e n t w i t h i n 2 4 m o n t h s : $ F O R M T E X T
P r o j e c t c o s t s t o b e s p e n t w i t h i n 3 0 m o n t h s : $ F O R M T E X T
P r o j e c t c o s t s t o b e s p e n t w i t h i n 3 6 m o n t h s : $ F O R M T E X T
P r o j e c t c o s t s t o b e s p e n t b e y o n d 3 6 m o n t h s : $ F O R M T E X T
P l e a s e p r o v i d e t h e d a t e s o f e x p e c t e d c o m m e n c e m e n t a n d c o m p l e t i o n o f c o n s t r u c t i o n o f t h e P r o j e c t .
F O R M T E X T
F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
H a v e a n y c o s t s o f t h e P r o j e c t b e e n p a i d p r i o r t o t h e d a t e h e r e o f ?
( F o r e a c h P r o j e c t c o s t t h a t h a s b e e n p r e v i o u s l y p a i d , p r o v i d e a n i t e m i z a t i o n o f t h e ( i ) a m o u n t , ( i i ) p u r p o s e , ( i i i ) d a t e p a i d , a n d ( i v ) s o u r c e o f p a y m e n t o f s u c h c o s t , e . g . , r e v e n u e , F e d e r a l o r S t a t e g r a n t s , o t h e r f i n a n c i n g , o r i n t e r n a l l o a n . )
F O R M T E X T
F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X N o t A p p l i c a b l e
I f y o u a n s w e r e d " y e s " t o Q u e s t i o n 6 a b o v e , h a ve you at any time adopted a resolution or other official action (e.g., a so-called "reimbursement resolution") relating to your intent to finance the Project with financial assistance from the WATER BOARD or other indebtedness?
(If yes, please identify the date of such resolution or other document and attach a copy.)
FORMTEXT
F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
W i l l a n y p o r t i o n o f t h e f i n a n c i n g p r o v i d e d u n d e r t h e A g r e e m e n t b e u s e d t o p a y a d m i n i s t r a t i v e o r e n g i n e e r i n g e x p e n s e s d i r e c t l y r e l a t i n g t o t h e c o n s t r u c t i o n o f t h e P r o j e c t ?
( I f y e s , p l e a s e s t a t e t h e a m o u n t e x p e c t e d t o b e s o u s e d a n d p r o v i d e d e t a i l s a s t o i t s c a l c u l a t i o n ( e . g . , b a s e d o n a c t u a l c o s t s o r a p e r c e n t a g e o f c o n s t r u c t i o n ) . )
F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X N o t A p p l i c a b l e
9 . I f y o u a n s w e r e d " y e s " t o Question 8 above, will any portion of the financing provided under the Agreement be used to pay administrative or engineering expenses incurred by the applicants staff?
(If yes, please state the amount expected to be so used and provide details of the work performed.)
FORMTEXT F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X N o t A p p l i c a b l e
1 0 . I f y o u a n s w e r e d " y e s " t o Q u e s t i o n 9 a b o v e , w i l l t h e c h a r g e s t o b e r e i m b u r s e d b e t r a c k e d b y a n a c c o u n t i n g s y s t e m , s u c h a s a c o s t a c c o u n t i n g s y s t e m , t h a t w i l l a l l o w t h e m t o b e d i f f e r e n t i a t e d f r o m o t h e r c h a r g e s f o r o t h e r w o r k d o n e b y t h e a p p l i c a n t s s t a f f ?
( I f y e s , p l e a s e s p e c i f y h o w c h a r g e s w i l l b e t r a c k e d . )
F O R M T E X T
F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
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l aytWt i n g a n y p o r t i o n o f t h e P r o j e c t a t a n y t i m e ?
( I f y e s , i d e n t i f y t h e N o n - G o v e r n m e n t a l E n t i t y a n d p r o v i d e a l l a v a i l a b l e d e t a i l s w i t h r e s p e c t t o i t s o w n e r s h i p i n t e r e s t . )
F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D o y o u a n t i c i p a t e a n y N o n - G o v e r n m e n t a l E n t i t y c o n t r a c t i n g t o o p e r a t e , m a n a g e o r p r o v i d e a n y e x c l u s i v e s e r v i c e s w i t h r e s p e c t t o t h e P r o j e c t a t a n y t i m e ? ( I f y e s , p l e a s e i d e n t i f y t h e N o n - G o v e r n m e n t a l E n t i t y a n d e x p l a i n t h e a r r a n g e m e n t . I f a n o p e r a t i o n s , m a n a g e m e n t o r e x c l u s i v e s e r v i c e s c o n t r a c t c u r r e n t l y e x i s t s , a t t a c h a c o p y . C o n t r a c t s t h a t r e l a t e s o l e l y t o s e r v i c e s t h a t a r e m e r e l y i n c i d e n t a l t o t h e p r i m a r y u s e o f t h e P r o j e c t n e e d n o t b e l i s t e d . E x a m p l e s o f i n c i d e n t a l s e r v i c e s a r e c o n t r a c t s f o r j a n i t o r i a l s e r v i c e s , o f f i c e e q u i p m e n t r e p a i r s o r b i l l i n g s e r v i c e s . I f y o u a r e u n c e r t a i n a s t o w h e t h e r t h e c o n t r a c t i s i n c i d e n t a l o r n o t , p l e a s e d e s c r i b e t h e c o n t r a c t a n d t h e s e r v i c e s p r o v i d e d t h e r e u n d e r . )
F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
W i l l t h e P r o j e c t p r o v i d e r e c y c l e d w a t e r o r w a s t e w a t e r s e r v i c e s t o n o n - g o v e r n m e n t a l e n t i t i e s o t h e r t h a n o n t h e b a s i s o f s t a n d a r d r a t e s a n d c h a r g e s ? ( I f t h e r e a r e a n y n o n - s t a n d a r d r a t e s a n d c h a r g e s , d e s c r i b e t h e r a t e s t r u c t u r e f o c u s i n g o n a n y s p e c i a l r a t e a g r e e m e n t s o r c h a r g e s f o r s p e c i f i c e n t i t i e s . A n e x a m p l e o f a n o n - s t a n d a r d r a t e i s a l a r g e i n d u s t r i a l u s e r p a y i n g a f l a t f e e i n a s y s t e m w h e r e t h e o t h e r u s e r s p a y a r a t e b a s e d o n u s a g e . )
F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D o y o u a n t i c i p a t e a n y N o n - G o v e r n m e n t a l E n t i t y h a v i n g s p e c i a l p r i o r i t y r i g h t s o r o t h e r p r e f e r e n t i a l r i g h t s t o u s e t h e s e r v i c e p r o v i d e d b y t h e P r o j e c t ? ( I f y e s , i d e n t i f y t h e N o n - G o v e r n m e n t a l E n t i t y a n d d e s c r i b e t h e s p e c i a l p r i o r i t y o r p r e f e r e n t i a l r i g h t ( s ) . )
F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
W i l l t h e e n t i r e P r o j e c t b e a v a i l a b l e f o r u s e b y t h e g e n e r a l p u b l i c ?
( I f n o , p l e a s e e x p l a i n a n d d e s c r i b e t h e p o r t i o n o f t h e P r o j e c t t h a t w i l l n o t b e a v a i l a b l e f o r u s e b y t h e g e n e r a l p u b l i c . F o r e x a m p l e , m u n i c i p a l w a t e r a n d w a s t e w a t e r s y s t e m s u s e d f o r r e s i d e n t i a l , c o m m e r c i a l , g o v e r n m e n t a l a n d b u s i n e s s p u r p o s e s a r e a v a i l a b l e f o r u s e b y t h e g e n e r a l p u b l i c ; a s p e c i a l i z e d p o l l u t i o n c o n t r o l f a c i l i t y i m m e d i a t e l y a d j a c e n t t o a p r i v a t e b u s i n e s s t h a t i s t h e s o l e u s e r o f t h e f a c i l i t y i s n o t a v a i l a b l e f o r u s e b y t h e g e n e r a l p u b l i c . ) F O R M T E X T F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
W i l l a n y N o n - G o v e r n m e n t a l E n t i t y g u a r a n t y o r o t h e r w i s e b e d i r e c t l y o b l i g a t e d t o r e p a y t h e f i n a n c i a l a s s i s t a n c e p r o v i d e d u n d e r t h e A g r e e m e n t ?
( I f y e s , i d e n t i f y t h e N o n - G o v e r n m e n t a l E n t i t y a n d d e s c r i b e t h e g u a r a n t y a r r a n g e m e n t t h e r e w i t h . )
F O R M T E X T A P P L I C A N T A C K N O W L E D G E M E N T A N D S I G N A T U R E
I h e r e b y c e r t i f y t h a t I a m a n a u t h o r i z e d r e p r e s e n t a t i v e o f t h e A p p l i c a n t , a n d t h a t I a m a u t h o r i z e d b y t h e A p p l i c a n t t o e x e c u t e t h i s T a x Q u e s t i o n n a i r e . I a m c h a r g e d w i t h t h e r e s p o n s i b i l i t y t o p e r f o r m s u c h a c t s a s a r e n e c e s s a r y a n d p r o p e r f o r t h e f i n a n c i n g , c o n s t r u c t i o n , a c q u i s i t i o n a n d / o r i m p r o v e m e n t o f t h e P r o j e c t , a n d a m a c t i n g f o r a n d o n b e h a l f o f t h e A p p l i c a n t i n e x e c u t i n g t h i s T a x Q u e s t i o n n a i r e . I c e r t i f y t h a t I a m f a m i l i a r w i t h t h e P r o j e c t a n d t h a t a l l i n f o r m a t i o n c o n t a i n e d h e r e i n i s t r u e , c o r r e c t a n d c o m p l e t e t o t h e b e s t o f m y k n o w l e d g e . I a m n o t a w a r e o f a n y f a c t s o r c i r c u m s t a n c e s t h a t w o u l d c a u s e m e t o q u e s t i o n t h e a c c u r a c y o r r e a s o n a b l e n e s s o f a n y i n f o r m a t i o n c o n t a i n e d i n t h e s e r e s p o n s e s o r a t t a c h e d d o c u m e n t a t i o n . I u n d e r s t a n d t h a t t h e f o r e g o i n g i n f o r m a t i o n a n d a t t a c h e d d o c u m e n t a t i o n w i l l b e r e l i e d u p o n b y t h e W a t e r B o a r d a n d t h e i r c o u n s e l , i n p r o v i d i n g f i n a n c i n g w i t h r e s p e c t t o t h e P r o j e c t .
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