House Republicans Preliminary Bond Request Form

Please use the form below to submit information about your request for project funding. Some questions may not apply to your project request. If you do not have information available or a question does not apply to your project, please enter “N/A” in that field. This request should only be submitted by legislators or their staff. Any supplemental information (budget breakdown, blueprints, design plans, etc.) should be emailed to Sarah.Maloney@cga.ct.gov AND Benjamin.Borecki@cga.ct.gov.

Name of Person Completing Form(Required)

Email of Person Completing Form(Required)

Name of Project(Required)

Project Description(Required)

Legislator(s) Requesting (if multiple legislators, please include all names)(Required)

Legislator(s) House District(Required)

Legislator Email(s) (if multiple legislators on request, please include all email addresses)(Required)

Address of Project (Street, Address, City, Zip Code)(Required)

Legal Name of Entity Receiving Funds? (Legal name of organization)(Required)

Entity Type:(Required)

Project Contact Name(Required)

Project Contact Email(Required)

Project Contact Phone(Required)

Total Amount Requested for Bonding(Required)

Total Cost of Project(Required)

Other Sources of Funding(Required)

Amount from Other Sources of Funding (please indicate what other sources and the amount, if there is more than one source, please list all)(Required)

Status of Other Funding(Required)

Project Status (i.e. current phase, permits received, designed, federal or local approval, ready for construction)(Required)

Please indicate the status level of project plans and construction(Required)

Job Creation(Required)

Temporary (Construction jobs limited during time period of project)

Permanent (Employees/staff operating in a project after completion)

Benefits from this project (who does this project impact? serve? how? why is this important?)(Required)

Request Also Submitted in Senate?(Required)

Yes

TIMELINE OF PROJECT

This project is anticipated to begin upon receiving bond request (check one)(Required)

Anticipated completion date(Required)

Please provide any additional information that describes readiness.(Required)

A copy of your responses will be emailed to the address you provided.

House Republicans Preliminary Bond Request Form

TIMELINE OF PROJECT

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