FY 2012 Congressionally Directed Funding Request Form (Non-Defense)

Note: Fields marked with an * are required.

Proposed Recipient Information

Primary Contact Information

Organization *

Prefix *

First Name *

Last Name *

Suffix

Title *

Street Address 1 *

Street Address 2

City *

County *

Zip Code *

Phone Number *

Fax Number

Email Address *

Secondary Contact Information

Prefix

First Name

Last Name

Suffix

Title

Street Address 1

Street Address 2

City

State

Zip Code

Phone Number

Fax Number

Email Address

If Applicable, Washington DC Government Affairs Associate and Contact Information

Prefix

First Name

Last Name

Suffix

Title

Street Address 1

Street Address 2

City

State

Zip Code

Phone Number

Fax Number

Email Address

Summary Project Information

Project Name *

County Location of the Project *

Amount of Request *

Purpose of the Request *

Benefit to the Military *

Benefit to the Taxpayer *

Benefit to West Virginia *

Overview of Budget Breakdown (e.g. staffing, construction, etc...) *

If submitting multiple request, this is priority _ of _

Example 2 of 3

Legislative Information

Appropriations Bill for Requested Funding * Agriculture and Rural Development Commerce, Justice, Science Defense Energy and Water Development Financial Services and General Government Homeland Security Interior and Envriorment Labor - HHS MilCon/Va Transportation - HUD UNKNOWN

Federal Department or Agency (if known)

Account (if known)

Request for Report or Bill Language

If so, please provide specific requested language

Jobs Creation

Current Level of Jobs

Anticipated number of jobs to be created *

What type of jobs will be created? (ex: temporary construction or permanent?) *

Average salary of new jobs *

Location of new jobs *

How will these jobs be sustained in the future during the funding period and into the future *

Additional Project and Funding Issues

If these questions do not apply to your project, please indicate 'not applicable'.

Will additional funding in subsequent years be required and, if so, over what duration of time and how much *

Some federal programs such as the State and Tribal Assistance Grant or Save America's Treasures have a mandatory non-federal match requirements. If the program of interest to you has a mandatory non-federal match, has it been secured and from what source *

Amount and source of other matching funds *

Has this project received congressional support in the past? If yes, please respond to the following * :

• Complete funding history (agency, amount, and year)
• What milestone achievements were reached
• Agency contact for verification of merit
• Justification for additional support of the project
• How and when will the project achieve self-sustainability

Detailed Narrative

Detailed Narrative of the Project *

Three Significant Points about the Project *