Arizona Department of Liquor License & Control
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RWIC - Rural Water Infrastructure Committee

Please completely fill out the following information as accurately as possible.

If you prefer, you can download this form and fax it back to us.
Project Information Form - 2007 (19kb)

If you have any questions, please call us (602) 364-1310

I. General Information: (* Indicates a required field)
*1. System ID #:
*2. County:
*3. Name of Facility/System:
*4. Type of Organization:

If Other, Please Explain:

*5. Contact Person *5a. Title:
*6. Phone Number:
7. Fax Number:
8. Address
*9. Email Address:
 

*10. How did you hear about RWIC?

If Other, Please Explain:
II. Demographic & Service Area Information:
11. Type of Project (Select all that apply)
Water
Wastewater
Solid Waste
Other
If Other, Please Identify:
12. Population of Project Service Area:
13. Number of Service Connections or Users:
Complete the following (If you don't have accurate study data, please provide an estimate:
14. Median Income of Service Area:
15. % Poverty Level of Service Area:
III. Description of Project and Applicable Background Information:
16. Provide a description of the problem:
17a. Estimated Project Cost $:
17b. Estimated By: Date:
18. Describe the proposed solution:
19. Please check all that apply to resolving the problem:
a. Not Certain How/Where to Begin b. Public is Unaware of the problem.
c. Need Qualified Consultants d. Lack Financial Options
e. Environmental Issues f. Lack Organization/Cooperation
g. Experiencing Technical Problems h. Regulatory Problems
i. Other-Please Describe: J. Lack Public Support for Solution

If Environmental or Other Issues are applicable, please explain:
     
20. Have you contacted anyone about funding? Yes No
If you answered Yes to question 20, Who have you contacted?
BECC BOR
CDBG GADA
USDA - Rural Development NADBank
WIFA Other-Please Describe below:
     
21. Have you received on-site Technical Assistance? Yes No
Check source(s) of Technical Assistance Received:
AWPCA RCAC
ASUA Other, Please Specify:
     
IV. Financial Rate, Collection & Fund Information
22. Rates: Monthly/Quarterly/Other
Service
Residential Rates
Commercial
Date of Last Increase
Water
 Base: Base:
Use: Use:
Wastewater
 Base: Base:
Use: Use:
Solid Waste
Base: Base:
Use: Use:
23. Are water and wastewater separate funds? Yes No
24. Please complete budget information.
Total Debt
Water Fund
Wastewater Fund
Total Collections
Operation/Maintenance/Replacement
Annual Debt Service
Reserve/Sinking Fund Balance
Available/Uncommitted Balances
Rates by "Uses" - e.g. $1.00 gallons beyond base of 5,000 gallons
25. Please provide the latest summary of your revenues and expenditures.
(If you have audited financial statements, please include a section entitled "Combined Statement of Revenues & Expenditures".)
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