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Forms & Checklists

All documents may be downloaded in Portable Document Format (PDF), which can be viewed using Adobe Acrobat Reader.  Documents generated by the Public Water Supply Section are also available for download in Microsoft Word or Microsoft Excel document format so that the Applicant may enter and save information necessary to complete the associated forms and checklists. Some of the following documents, such as the Application Appendix and the Part B, contain multiple forms. These documents are accompanied by an outline of the forms and checklists contained therein. If you have any problems downloading any of the following documents, contact the Public Water Supply Section at (919) 707-9053.

Application

Document Description / Pages / Version
Application (MSWord) (PDF)
North Carolina Department of Environment & Natural Resources Application Appendix for Drinking Water Funding Programs (MSWord) (PDF) Appendix to the application including checklists, forms, and supplemental information for Drinking Water Loan and Grant Programs (High Unit Cost, Emergency Loans, and Drinking Water State Revolving Fund) / 36 pages / 22 July 2011
Checklist for Required Drinking Water Application Supporting Documents 1 page
Bonus Points Scoring Checklist 2 pages
Resolution by Governing Body of Applicant (Sample) Resolution by governing body of applicant agreeing to the terms of the prospective loan or grant / 1 page
Certification by Recording Officer Certification of governing body resolution by a recording officer / 1 page
Request for Categorical Exclusion from Substantive Environmental Review 2 pages
Water & Sewer Utilities Revenue Form 2 pages
LGC-108A Selected Fiscal Information as Certified by Financial Officer / 2 pages
LGC-108C Projection of Water and Sewer Net Revenues / 2 pages
Checklist for Rate Structures that Support Water Conservation Pursuant to the requirements of NCGS § 143-355.4.(b)(1) / 3 pages
Checklist for Water Loss Reduction Program 1 page
Reclaimed Water Certification Pursuant to the requirements of NCGS § 143-355.4.(b)(6) / 2 pages
Water & Sewer Utilities Revenue Form:  Future Rate Calculations Spreadsheet (MSExcel) (PDF) Spreadsheet tool for calculation of projected average user fees and rates for the Water & Sewer Utilities Revenue Form / 3 pages / May 25, 2011

Construction Bid / Contract and Compliance Documents

Document Description / Pages / Version
Disadvantaged Business Enterprise (DBE) Forms  (Special Conditions Packages) Link to the DBE page
DOL Form WH-347 (PDF) U.S. Dept. of Labor Weekly Payroll Report / 2 pages / (N/A)
DOL Form WH-1321 (English / Spanish PDF) U.S. Dept. of Labor “Employee Rights Under the Davis-Bacon Act” Poster / 1 page / (N/A)
EPA Form 4700-4 (PDF) EPA Preaward Compliance Review Report for All Applicants and Recipients Requesting EPA Financial Assistance / 2 pages / (N/A)
GSA Form SF-1445 (PDF) U.S. General Services Administration Labor Standards Interview / 1 page / (N/A)

Budget Approval

Document Description / Pages / Version
Part B Form 1951B (MSWord) (PDF) Offer and Acceptance of Loan or Grant for Water Supply System Project, Part B / 10 Pages / 13 December 2013
Engineer's Certification of Compliance with NCGS § 133-3 Certification that a specific product was not endorsed as part the project plans and specifications1 page
Site Certificate by Title Counsel 1 page
Clear Site Certification 1 page

Reimbursement and Repayment

Document Description / Pages / Version
Reimbursement Form Link to Division of Water Quality's Funding Assistance Program website
Repayment Schedule Example (MSExcel) (PDF) Example repayment schedule provided by the Local Government Commission1 page / (N/A)