Section 1: Applicant Information

Agency Name
Location of Project (i.e. Benton Township)
Contact Name	Title
Phone Number	Email

Section 2: Project Proposal and Funding Request
Project Name
Project Limits (i.e. Napier to Britain)	Proposed Year(s) of Project Funding	2017 2018 2019 2020 Not Sure
Project Length	(in miles, to the nearest hundredth)	Was this project already scheduled for 2017 in the TwinCATS 2014-2017 TIP?	Yes No
Improvement Type	Reconstruction Preventative Maintenance Resurfacing Overlay "Mill and Fill" Non-Motorized Only
Project Description (please provide major work items including any sidewalks, utility work, and ADA upgrades)
Project Funding: (Remember, TwinCATS receives $871,925 in federal STP funds per year)
Funding Type	Source (i.e. STP, Village)	Amount
Federal	STP	$
Local	$
TOTAL	$
Does your agency have the financial capacity to Advance Construct all or part of this project if necessary? If yes, what is the maximum dollar amount your agency is willing to Advance Construct (AC)?	Yes No Maximum Dollar Amount you can AC? $
A local match equal to 18.15% of the construction cost is required. Is your agency committing a local match percentage that is 30% or greater of the construction cost?	Yes No If yes, what percentage?

Section 3: Safety
How will this project improve safety?	Convert one way to two way or vice versa Install or upgrade ADA ramps where they connect to sidewalks Install new marked crosswalks New designated facilities for bicyclists Better driving surface ONLY (i.e. fewer potholes or bumps in the road after project is done) Other (please specify in the box below)
Please describe the safety improvements you intend to make with this project:
Have you applied for federal safety funds for the safety elements in this project in the past three years and been rejected by the state because your crash thresholds are too low?	Yes No What was applied for? Year of application?
Have you had multiple crashes (of any type) at this location in the last three years (2013-2015)? (Note: SWMPC staff will do this analysis based on Michigan Crash Facts data)	Yes No Not Sure

Section 4: Complete Streets
Does this project meet the TwinCATS Complete Streets Policy, approved in 2014?	Yes No, I will seek an exemption
If you answered “No” above, please state the reason why this project should be exempt from the TwinCATS Complete Streets Policy. Please cite one of the listed exemptions in the Policy.
Existing and Proposed Design of Road
Existing	Proposed
Number of Vehicle Lanes	Through Traffic Lanes	Center Turn Lanes	On Street Parking Yes No	Through Traffic Lanes	Center Turn Lanes	On Street Parking Yes No
Shoulder Surfacing	Paved Unpaved	Width? ft	Paved Unpaved	Width? ft
Sidewalk/ path information	Placement One Side Both Sides Intermittent None	Type Shared Use (≥ 8 Ft) Sidewalks(≤ 8 ft)	Placement One Side Both Sides Intermittent None	Type Shared Use (≥ 8 Ft) Sidewalks(≤ 8 ft)
On road bicycle facilities	Bike Lane Other (specify) Sharrows Wide Shoulders None	Bike Lane Other (specify) Sharrows Wide Shoulders None
Utilities, Sewer and Water	Utilities Upgrades Needed Sewer and water line work needed	Replaced Utilities Relocating Utilities Sewer and Water Line Work
Please describe any improvements being made as part of this project to crosswalks, signage or signals, or streetscape elements not discussed in project description
Does this project connect to an existing pedestrian/bicycle facility or one that is planned to be completed from 2017-2020?	Yes No If yes, which facility?
Does this project enhance connectivity of pedestrian or bicyclists to fixed route or Dial-A-Ride transit?	Yes No If yes, how?
Section 5: System Preservation
Provide the most current PASER rating for the area involving this project.	Year : Rating 1-2 Rating 3-4 Rating 5-7
What is the state of current drainage?	Adequate Minor and tolerable drainage problems Occasional drainage problems with some maintenance required Inadequate drainage, frequent flooding, excessive maintenance required
What is the expected useful life of the project?	0-3 years 4-6 7-9 10-14 15-20 PM projects use MDOT Approved Maintenance Techniques for Useful Life

Section 6: Project Readiness and Targeting Investments Strategically
Is project mentioned or implied in any of the following plans approved by your governing board?	Asset Management Plan Capital Improvement Plan Infrastructure Plan Please cite plan and page number :
Is the project identified in another local planning document such as a parks and recreation plan or master plan?	Yes No If yes: Indicate name of plan and page number below:
Project crosses over jurisdictional boundaries and is being bid as a single project?	Yes No If yes: Indicate name of jurisdiction.
Does this project coordinate with other local projects (i.e. utility or sewer/water line improvements) in order to minimize inconvenience to users?	Yes No If yes: Indicate the project type and construction year.
How many water main breaks have you had at this location in the past five years?	None Some (enter number here)
Have you completed a utilities assessment and televised the sewers in the project area?	Yes No
What is the most current daily traffic count for the limits of this project?	Less than 2000 2000-5000 5000-10,000 Above 10,000 Year of count: Source:
What is the National Functional Classification for this Roadway?	Interstate Other Principal Arterial Minor Arterial Major Collector Minor Collector
Will this project require environmental mitigation, purchase of ROW, or railroad permits?	Yes No Not Sure Which? (Please identify any items listed here in the project schedule )
Does this project perform Resurfacing, Reconstruction or Preventative Maintenance on a segment adjacent to a segment where a federally-funded project was done during the 2014-2017 TwinCATS TIP cycle or RTF cycle?	Yes No What segment was the PREVIOUS project done on?

Please attach the following documents to your application when you email it:

1. Include a project schedule with at least the anticipated program application submission, grade inspection, obligation, letting, construction start, construction completion and any project readiness item (ROW acquisition, RR permits, Environmental permits) completion dates. We recognize that these are estimates, but your agency should be planning for these items.

2. Any maps or diagrams that help detail the project scope and location.

3. Any documentation of public support for the project. If your project is selected for funding, you will be required to submit a resolution of support for your project certifying that your agency will be able to provide the local match in the fiscal year your project is funded.