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2. Point of Contact for Application
4. Name:*
5. Title:*
7. Email Address:*
8. Phone Number:*
12. About the Project
14. Parcel Number:*
16. Property Address:*
18. City/Village/Township:*
    -- Select One --City of DowagiacVillage of CassopolisVillage of EdwardsburgVillage of MarcellusVillage of VandaliaCalvin TownshipHoward TownshipJefferson TownshipLaGrange TownshipMarcellus TownshipMason TownshipMilton TownshipNewberg TownshipOntwa TownshipPenn TownshipPokagon TownshipPorter TownshipSilver Creek TownshipVolinia TownshipWayne Township
20. Amount Requested:*
22. Condition Assessment:*
24. Ownership Information:*

    Refer to Section I, page 2 of RFP 2023-001.

26. Describe post-demolition/stabilization use of the land.*
28. Is the property part of a Historic District/National Register of Historic Places?*

    1. Yes
    2. No
30. Known Environmental Hazards:*
32. Map of Subject Property:
33. Photos of Structure:
35. Are you requesting:

    1. Demolition
    2. Stabilization
    3. Rehabilitation (publicly owned properties only)
    4. Environmental Remediation (requires matching or gap funds)
37. Previous uses and potential contaminants or Recognizes Environmental Conditions (RECs):
39. Contaminant Exposure Pathways of Concern:

    Check all that apply.

    1. Unknown
    2. Drinking Water
    3. Direct Contact
    4. Volatilization to Indoor Air
    5. Groundwater/Surfacewater Interface
    6. Ambient Air
41. Map of Known Contamination:
42. Environmental Site Assessments:
44. Project Narrative:*

    Provide a narrative summary description of the proposed project, eligible properties, and eligible activities.

48. Itemized Budget
50. Vendor:
51. Activity:
52. Cost:
53. Anticipated Start Date:
55. Vendor:
56. Activity:
57. Cost:
58. Anticipated Start Date:
60. Vendor:
61. Activity:
62. Cost:
63. Anticipated Start Date:
65. Vendor:
66. Activity:
67. Cost:
68. Anticipated Start Date:
70. Vendor:
71. Activity:
72. Cost:
73. Anticipated Start Date:
75. Vendor:
76. Activity:
77. Cost:
78. Anticipated Start Date:
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit

* indicates a required field