FY 2012 Congressionally Directed Funding Request Form (Military Construction)

Note: Fields marked with an * are required.

Please email a copy of the 1391 Form to Suzanne Bentzel after submitting this form

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 *

Amount of Request *

Service, Agency, or Department *

Service - Assigned Project Number

County Location of the Project *

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

Military Branch *

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'.

Is this project included in the current Future Years Defense Program? *

Yes or No

What percentage of the project is designed? *

Is the project mission critical? *

Is the project a top priority of the base commander where the project is located? *

Has the site for the project been selected? *

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

• Complete Funding history (agency, amount, and year)
• Justification for additional support of the project.

Detailed Narrative

Detailed Narrative of the Project *

Three Significant Points about the Project *