1.	Project Title:	Click here to enter text.
2.	Senate Sponsor:	Click here to enter text.
3.	Date of Request:	Click here to enter a date.
4.	Project/Program Description:
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5.	State Agency to receive requested funds:	Click here to enter text.
State Agency Contacted?	Click here to enter text.
6.	Amount of the Non-Recurring Request for fiscal year 2018-19:
Amount Requested for Operations	Amount Requested for Fixed Capital Outlay	Total Amount of Requested State Funds
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7.	Type, amount and percent of matching funds available for this project for fiscal year 2018-19:
Type	Amount	Percent
Federal:	Click here to enter text.	Click here to enter text.
State (Excluding the amount of this request):	Click here to enter text.	Click here to enter text.
Local:	Click here to enter text.	Click here to enter text.
Other:	Click here to enter text.	Click here to enter text.
8.	Total Project Cost for fiscal year 2018-19 (includes all requested State funds and any other funding sources):	Click here to enter text.
9.	Was the project previously funded by the State? (Optional)
Fiscal Year(s)	Amount	Vetoed
Recurring	Non-Recurring
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10.	Is future-year funding likely to be requested? If yes, indicate non-recurring amount per year.
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11.	Program Performance (if needed, include additional documentation):
a.	What is the specific purpose or goal that will be achieved by the funds requested?
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b.	What are the activities and services that will be provided to meet the intended purpose of these funds?
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c.	How will the funds be expended?
Spending Category	Description	Amount
Administrative Costs:
Executive Director/Project Head Salary and Benefits	Click here to enter text.	Click here to enter text.
Other Salary and Benefits	Click here to enter text.	Click here to enter text.
Expense/Equipment/Travel/ Supplies/Other	Click here to enter text.	Click here to enter text.
Consultants/Contracted Services/ Study	Click here to enter text.	Click here to enter text.
Operational Costs:
Salary and Benefits	Click here to enter text.	Click here to enter text.
Expense/Equipment/Travel/ Supplies/Other	Click here to enter text.	Click here to enter text.
Consultants/Contracted Services/ Study	Click here to enter text.	Click here to enter text.
Fixed Capital Construction/Major Renovation:
Construction/Renovation/Land/ Planning Engineering	Click here to enter text.	Click here to enter text.
d.	What are the direct services to be provided to citizens by the appropriations project?
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e.	Who is the target population served by this project? How many individuals are expected to be served.
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f.	What is the expected benefit or outcome of this project? What is the methodology by which this outcome will be mesasured?
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g.	What are the suggested penalties that the contracting agency may consider in addition to its standard penalties for failing to meet deliverables or performance measures provided for in the contract?
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12.	The owners of the facility to receive, directly or indirectly, any fixed capital outlay funding. Include the relationship between the owners of the facility and the entity.
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13.	Requestor Contact information:
a.	Name and Title:	Click here to enter text.
b.	Organization:	Click here to enter text.
c.	E-mail Address:	Click here to enter text.
d.	Phone Number:	Click here to enter text.
14.	Recipient Contact Information:
a.	Organization:	Click here to enter text.
b.	Municipality and County:	Click here to enter text.
c.	Organization type (check all that apply):
☐	For-profit Entity
☐	Non Profit 501(c) (3)
☐	Non Profit 501(c) (4)
☐	Local Entity
☐	University or College
☐	Other (please specify)	Click here to enter text.
d.	Contact Name and Title:	Click here to enter text.
e.	E-mail Address:	Click here to enter text.
f.	Phone Number:	Click here to enter text.
15.	Lobbyist Contact Information:
a.	Name:	Click here to enter text.
b.	Firm:	Click here to enter text.
c.	Email Address:	Click here to enter text.
d.	Phone Number:	Click here to enter text.
Please complete the questions below for Water Projects only.
16.	Have you applied for alternative state funding?
☐	Waste Water Revolving Loan
☐	Drinking Water Revolving Loan
☐	Small Community Wastewater Treatment Grant
☐	Other (Please describe)	Click here to enter text.
☐	N/A
17.	What is the population economic status?
☐	Financially Disadvantaged Community (ch. 62-552, F.A.C)
☐	Financially Disadvantaged Municipality (ch. 62-552, F.A.C)
☐	Rural Area of Economic Concern
☐	Rural Area of Opportunity (s. 288.0656, Florida Statutes)
☐	N/A
18.	What is the status of construction?
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19.	What percentage of the construction has been completed? What is the estimated completion date?
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The information provided will be posted on the Florida Senate website for public viewing if sponsored by a Senator.