3-attachment from barbaras email m archive keyword NURFC Submi

8/7/2019 3-attachment from barbaras email m archive keyword NURFC Submi

1/21


2/21

Declaration Regarding Material Assistance/Non-Assistance to a TerroristOrganization form. Complete the attached form. This is required by the Departmentof Homeland Security for those organizations receiving state funds. Governmentalagencies are not required to provide this documentation; IRS Determination letter showing 501(c)(3) status;

Financial Information:

Audited Financials for the last two years. If audited financials are unavailable,submit the last two years of IRS 990s with internal financial reports;

Year-to-Date Financials for the current year; Five-Year Pro forma which forecasts revenues and expenses for your organization,

incorporating any expenses and revenues that result from this project and writtenexplanations of the assumptions used to derive the numbers; and

Full Funding and Local Matching Resources substantiation for the same fundingsources submitted with the project funding model and local match sections in the

Registration and Detail Form. If you are using resources that are not listed on ourRegistration and Detail Form, e.g. property value, please identify those sources andsubmit substantiating documentation (please see page 18 of the PSRG).

Fundraising Information:

Fundraising Plan if this projects funding model relies on completion of a fundraisingcampaign or an already completed fundraising campaign;

Proof of Pledges documentation for confirmed pledges, such as written pledgeletters, pledge cards signed by donors, and/or check copies; and

Cash Flow Schedule of anticipated pledge collection dates.

Facility Information:

Photographs of the Facility for use on our Web site and annual report (at least900x1500 pixels, if digital photo is available);

Facility Lease Agreement if the property is not owned by your organization, or adraft lease if one is not yet signed;

Property Title if you own your facility, in order to ascertain clear title, please providea title insurance commitment letter, title insurance policy, or title opinion letter. If theproperty is owned by someone other than the project sponsor, a Non-Disturbanceand Estoppel Agreement must be entered into with the property owner. Attached isa draft of a sample opinion letter and Non-Disturbance and Estoppel agreement foryour and the property owners review;

Deed & Legal Description of the Property and site survey map if available. These may besubmitted as an exhibit to the title opinion letter, title insurance commitment letter, titleinsurance policy or Non-Disturbance and Estoppel Agreement listed above. If not, pleasesubmit it separately;


3/21

Insurance Accord certificates or other documentation outlining coverage amountsfor Special Form Property Insurance, Employers Liability Insurance , CommercialGeneral Liability Insurance and any other organizational insurance.

Loan Or Mortgage Documents and/or Liens Against the Property identifying anybond documents, letters of credit or security/collateral agreements and a loan pay-

down plan; Environmental Site Assessment Form completed by a facility manager orarchitect/engineer (see attachment). This assessment form includes a list ofyes/no questions. Please provide a cover letter when responding, providingdetails of any items indicated as yes answers. Send copies of any otherenvironmental reports concerning the property;

Farmland Use Report if your project includes new construction on farmland or formerfarmland, complete and submit (see attachment);

National Register of Historic Places: if the facility is listed on the National Register ofHistoric Places, your plans should be reviewed by the Ohio Historic Preservation Office. Ifyou are listed on the National Register of Historic Places and you are receiving a federal

grant or federal funding, you must have the Ohio Historical Preservation Office conduct asection 106 review of your project. Contact their office at (614) 298-2000 for informationand please copy your project manager on any correspondence. Their contact informationis;

Ohio Historic Preservation OfficeResource Protection and Review567 W. HudsonColumbus, Ohio 43211

Description of culture provided if your project involves a local historical facility andthe facility will not be open and operable at the conclusion of this project.

Project Information:

Construction Already Completed documentation such as contract(s), invoice(s), bidtab(s), certification of prevailing wage, for completed portions of this project;

Describe the construction delivery method (i.e. design-bid-build, design-build etc.) Construction Schedule; Design, Construction and other professional contracts; Detailed Cost Estimate inclusive of all hard costs, soft costs, and contingencies.

Please indicate the source of these estimates; Construction Cash Flow Schedule showing cash-out corresponding with the

construction schedule and cash-in corresponding with cash-out; Construction Bridge Financing Documentation for the current project (if applicable); Bid Specifications for the current project; Bid Tabulations for the current project; Construction Drawings for the current project; Project Team organizational chart including resumes for each person on your

project team. Please describe how each individual/organization was selected andeach individuals and each organizations qualifications including the individualrepresenting your organization, architect, contractor, construction manager, and/or


4/21

owners representative. Indicate the person who is responsible for prevailing wageadherence and the person responsible for submitting reimbursement requests to usand their qualifications;

Proof of Builders Risk and Design Professional Liability Insurance includingcoverage amounts;

Change Order Process for managing construction change orders.

This information assists us in the assessment of your project; however, the materialyou submit may generate subsequent questions and you may be asked to provideadditional information.

As previously discussed, the earliest meeting for which your project could beconsidered is May 14th, 2009. This will depend on your timeliness in submitting therequested information, the results of our on-going assessment and your ability toresolve any additional issues or questions.

Attachments:Sample Authorizing ResolutionDeclaration Regarding Material Assistance/Non-Assistance to a Terrorist Organization.

(completed and returned)Sample Title Opinion LetterSample Non-Disturbance and Estoppel AgreementEnvironmental Site Assessment (completed and returned)Farmland Use Determination (completed and returned)


5/21

http://ocfcsp/project/General Information/LPS Resolution Template CUA (Owner).doc

Sampl e Res ol ut i on t o be enact ed by t he Sponsor,

Bond Funded Local Const ruct i on Admi ni st rat i on

Memorandum of Unders t andi ng, Cooperat i ve Use Agreement and

Const ruct i on Admi ni s t rat i on and Fundi ng Agreement

RESOLUTION AUTHORIZING THE [ fill in the SPONSORS LEGAL

NAME] TO SIGN AND EXECUTE THE MEMORANDUM OFUNDERSTANDING, THE COOPERATIVE USE AGREEMENT, THE

CULTURAL FACILITIES CONSTRUCTION ADMINISTRATION AND

FUNDING AGREEMENT AND ANY OTHER NECESSARY LEGAL

DOCUMENTS AND TO TAKE CERTAIN OTHER ACTI ONS

RESOLVED it is the intention of[fill in the sponsor name]to enter into theMEMORANDUM OF UNDERSTANDING, THE COOPERATIVE USEAGREEMENT, THE CULTURAL FACILITIES CONSTRUCTIONADMINISTRATION AND FUNDING AGREEMENT and ANY OTHER NECESSARYLEGAL DOCUMENTS in connection with the funding of a certain cultural project for

[fill in the sponsor name], specifically [short description of the cultural project];

BE IT FURTHER RESOLVED that the [fill in the sponsor name]will raise anyadditional funds or provide the additional resources to complete the cultural project; and

BE IT FURTHER RESOLVED that the [fill in the position title]of[fill in the sponsorname]hereby is authorized and directed to do, or cause to be done, all such acts andthings and to execute and deliver or cause to be executed or delivered the Memorandumof Understanding, the Cooperative Use Agreement and the Cultural FacilitiesConstruction Administration and Funding Agreement and all such other agreements,documents, instruments or certificates, in the name and on behalf of[fill in the sponsorname], as the [fill in the position title]of[fill in the sponsor name]may deem necessaryor appropriate to carry out the intent of the foregoing resolution. The execution thereofby the [fill in the position title]of[fill in the sponsor name]or the taking of such actionshall be conclusive evidence of the exercise of discretionary authority conferred herein.

IN WITNESS WHEREOF, the undersigned hereby certifies that the foregoing resolution

was adopted by the [voting body]of[fill in the sponsor name]at a meeting held on

[date.]

____________________________________

[Name and Title]

Secretary


6/21

Ohio Department of Public SafetyDivision of Homeland Security

http://www.homelandsecurity.ohio.gov

GOVERNMENT BUSINESS AND FUNDING CONTRACTSIn accordance with section 2909.33 of the Ohio Revised Code

DECLARATION REGARDING MATERIAL ASSISTANCE/NONASSISTANCE TO A TERRORIST ORGANIZATION

This form serves as a declaration of the provision of material assistance to a terrorist organization or organization thatsupports terrorism as identified by the U.S. Department of State Terrorist Exclusion List (see the Ohio Homeland SecurityDivision website for a reference copy of the Terrorist Exclusion List).

Any answer of yes to any question, or the failure to answer no to any question on this declaration shall serve as adisclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion Listhas been provided. Failure to disclose the provision of material assistance to such an organization or knowingly makingfalse statements regarding material assistance to such an organization is a felony of the fifth degree.

For the purposes of this declaration, material support or resources means currency, payment instruments, other financiasecurities, funds, transfer of funds, and financial services that are in excess of one hundred dollars, as well ascommunications, lodging, training, safe houses, false documentation or identification, communications equipmentfacilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine

or religious materials.

LAST NAME FIRST NAME MIDDLE INITIAL

HOME ADDRESS

CITY STATE ZIP COUNTY

HOME PHONE

( )

WORK PHONE

( )

COMPLETE THIS SECTION ONLY IF YOU ARE A COMPANY, BUSINESS OR ORGANIZATION

BUSINESS/ORGANIZATION NAME

BUSINESS ADDRESS

CITY STATE ZIP COUNTY

PHONE NUMBER

( )

DECLARATIONIn accordance with division (A)(2)(b) of section 2909.32 of the Ohio Revised Code

For each question, indicate either yes, or no in the space provided. Responses must be truthful to the best of your knowledge.

1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List?

Yes No

2. Have you used any position of prominence you have with any country to persuade others to support an organizationon the U.S. Department of State Terrorist Exclusion List?

Yes No

HLS 0038 2/06


7/21

GOVERNMENT BUSINESS AND FUNDING CONTRACTS - CONTINUED

3. Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of StateTerrorist Exclusion List?

Yes No

4. Have you solicited any individual for membership in an organization on the U.S. Department of State Terroris

Exclusion List?Yes No

5. Have you committed an act that you know, or reasonably should have known, affords "material support or resourcesto an organization on the U.S. Department of State Terrorist Exclusion List?

Yes No

6. Have you hired or compensated a person you knew to be a member of an organization on the U.S. Department ofState Terrorist Exclusion List, or a person you knew to be engaged in planning, assisting, or carrying out an act oterrorism?

Yes No

In the event of a denial of a government contract or government funding due to a positive indication that materiaassistance has been provided to a terrorist organization, or an organization that supports terrorism as identified by theU.S. Department of State Terrorist Exclusion List, a review of the denial may be requested. The request must be sent tothe Ohio Department of Public Safetys Division of Homeland Security. The request forms and instructions for filing can befound on the Ohio Homeland Security Division website.

CERTIFICATIONI hereby certify that the answers I have made to all of the questions on this declaration are true to the best of myknowledge. I understand that if this declaration is not completed in its entirety, it will not be processed and I will be

automatically disqualified. I understand that I am responsible for the correctness of this declaration. I understand thafailure to disclose the provision of material assistance to an organization identified on the U.S. Department of StateTerrorist Exclusion List, or knowingly making false statements regarding material assistance to such an organization is afelony of the fifth degree. I understand that any answer of yes to any question, or the failure to answer no to anyquestion on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.SDepartment of State Terrorist Exclusion List has been provided by myself or my organization. If I am signing this on behalfof a company, business or organization, I hereby acknowledge that I have the authority to make this certification on behalfof the company, business or organization referenced on page 1 of this declaration.

X Signature Date


8/21


9/21

NON-DISTURBANCE AND ESTOPPEL AGREEMENT

This Non-Disturbance and Estoppel Agreement (the Agreement), made effectiveas of the _____ day of ___________, 200_, by and between the Ohio Cultural Facilities

Commission (the Commission), duly created, existing and operating by virtue of OhioRevised Code (O.R.C.) Chapter 3383 (hereinafter referred to as the Act), a bodycorporate and politic, an agency of state government and an instrumentality of the Stateof Ohio (Ohio), performing essential governmental functions of the State, having anoffice located at 20 East Broad Street, Suite 200, Columbus, Ohio 43215-3416; [ProjectSponsor Name], with its principal offices at [address], (the Project Sponsor); and[owner name], with its principal offices at [address] (the Fee Simple Owner).

WITNESSETH:

1. WHEREAS, by a certain lease agreement dated _______________, 200_(hereinafter referred to as the Facility Lease Agreement), the Fee Simple Ownerleased and rented to the Project Sponsor the real property, the appurtenances andfixtures thereto, commonly known as [facility name], a legal description of which isattached hereto as Exhibit A (the Property);

2. WHEREAS, pursuant to Section 3383.04(K) and (L) of the Act, the Commission maymake and enter into all contracts, commitments and agreements, and execute allinstruments necessary or incidental to the performance of its duties and theexecution of its rights under the Act and do anything necessary or appropriate tocarry out the purposes of and exercise the powers granted under the Act;

3. WHEREAS, the Project Sponsor has obtained or will obtain moneys from theCommission for use in a Cultural Project as the same is defined Chapter 3383 of theAct, and as a condition of receiving such appropriated funds, the Project Sponsormust provide the Commission with certain rights, safeguards, obligations, andpriorities with respect to its interest in the Cultural Project including, but not limitedto, a Cooperative Use Agreement with the Commission whereby the ProjectSponsor grants to the Commission the right to use and occupy the Cultural Projectfor the term of the Cooperative Use Agreement (the Commissions Use Interest);and

4. WHEREAS, the Commission, the Project Sponsor and the Fee Simple Owner desirehereby to establish certain rights, safeguards, obligations and priorities with respectto their respective interests by means of the following agreement.

NOW THEREFORE, for and in consideration of the premises and of the mutualcovenants and promises herein contained, and other good and valuable consideration,the receipt and sufficiency of which are hereby acknowledged, the parties hereto agreeas follows:


10/21

2

Section 1. So long as the Facility Lease Agreement is in full force and effect and theProject Sponsor shall not be in default under any provision of the Facility LeaseAgreement or this Agreement, and no event has occurred which has continued to exist for

a period of time (after notice, if any, required by the Facility Lease Agreement) as wouldentitle the Fee Simple Owner to terminate the Facility Lease Agreement or would causewithout further action by the Fee Simple Owner, the termination of the Facility LeaseAgreement or would entitle the Fee Simple Owner to dispossess the Project Sponsorthereunder:

(a) The Commissions Use Interest shall not be terminated or disturbed by anysteps or proceedings taken by the Fee Simple Owner in the exercise of any ofits rights under the Facility Lease Agreement.

(b) The Commissions Use Interest shall not be terminated or affected by said

exercise of any remedy provided for in the Facility Lease Agreement, and theFee Simple Owner hereby covenants that any sale by it of the Property shallbe made subject to the Commissions Use Interest and the rights of theCommission under the Cooperative Use Agreement.

Section 2. The Project Sponsor and/or the Fee Simple Owner agree to give promptwritten notice to the Commission of any default by either the Project Sponsor or the FeeSimple Owner under the Facility Lease Agreement which would entitle The ProjectSponsor or the Fee Simple Owner to cancel the Facility Lease Agreement or abate therent payable thereunder, and both parties agree that notwithstanding any provision ofFacility Lease Agreement, no notice of cancellation or termination thereof shall beeffective unless the Commission has received notice of the aforesaid and the defaultingparty has failed, within 30 days of the date of receipt thereof, to cure such default, or if thedefault cannot be cured within 30 days, has failed to commence and to pursue diligentlyto cure the default which gave rise to such right of cancellation or termination.

Section 3. The Project Sponsor agrees to certify in writing to the Commission, uponrequest, whether or not any default on the part of the Fee Simple Owner exists under theFacility Lease Agreement and the nature of any such default. The Project Sponsor statesthat as of this date there is no default that, whether currently or with the passage of time,would permit the Project Sponsor to terminate or cancel the Facility Lease Agreementand that the Facility Lease Agreement is in full force and effect, without modification, acopy of said Facility Lease Agreement being attached hereto as Exhibit B. The ProjectSponsor further states as follows:

(a) The Project Sponsor is the tenant under the Facility Lease Agreement forspace in the above-referenced Property. The monthly base rent presently is$_____________ per month.


11/21

3

(b) The Project Sponsor has accepted possession of the Premises pursuant tothe Facility Lease Agreement. The Facility Lease Agreement termcommenced on [commencement date]. The termination date of theFacility Lease Agreement term, excluding renewals and extensions, is

[termination date]. The Project Sponsor has the right to extend or renewthe Facility Lease Agreement for: [number of __ year extensions].

(c) Any improvements required by the terms of the Facility Lease Agreement tobe made by the Fee Simple Owner have been completed to the satisfactionof the Project Sponsor in all respects, and the Fee Simple Owner hasfulfilled all of its duties under the Facility Lease Agreement.

(d) The Facility Lease Agreement has not been assigned, modified,supplemented or amended in any way by the Project Sponsor. The FacilityLease Agreement constitutes the entire agreement between the parties and

there are no other agreements concerning the Property, and the ProjectSponsor is not entitled to receive any concession or benefit (rental orotherwise) or other similar compensation in connection with renting theProperty other than as set forth in the Facility Lease Agreement.

(e) The Facility Lease Agreement is valid and in full force and effect, and, to thebest of the Project Sponsors knowledge, no party thereto, their successorsor assigns is presently in default thereunder. The Project Sponsor has nodefense, set-off or counterclaim against the Fee Simple Owner arising outof the Facility Lease Agreement or in any way relating thereto, and no eventhas occurred and no condition exists, which with the giving of notice or thepassage of time, or both, will constitute a default under the Facility LeaseAgreement.

Section 4. The Fee Simple Owner agrees to certify in writing to the Commission, uponrequest, whether or not any default on the part of the Project Sponsor exists under theFacility Lease Agreement and the nature of any such default. The Fee Simple Ownerstates that, as of the date of this Agreement, there is no default that, whether currently orwith the passage of time, would permit the Fee Simple Owner to terminate or cancel theFacility Lease Agreement, and that the Facility Lease Agreement, attached hereto asExhibit B, is in full force and effect and without modification. The Fee Simple Ownerfurther states as follows:

(a) The Fee Simple Owner is the landlord under the Facility Lease Agreementfor space in the above-referenced Property.

(b) Any improvements required by the terms of the Facility Lease Agreement tobe made by the Project Sponsor have been completed to the satisfaction ofthe Fee Simple Owner in all respects, and the Project Sponsor has fulfilledall of its duties under the Facility Lease Agreement.


12/21

4

(c) The Facility Lease Agreement has not been assigned, modified,supplemented or amended in any way by the Fee Simple Owner. TheFacility Lease Agreement constitutes the entire agreement between the

parties and there are no other agreements concerning the Property, and theFee Simple Owner is not entitled to receive any concession or benefit(rental or otherwise) or other similar compensation in connection withrenting the Property other than as set forth in the Facility Lease Agreement.

(d) The Facility Lease Agreement is valid and in full force and effect, and, to thebest of the Fee Simple Owners knowledge, no party thereto, theirsuccessors or assigns is presently in default thereunder. The Fee SimpleOwner has no defense, set-off or counterclaim against the Project Sponsorarising out of the Facility Lease Agreement or in any way relating thereto,and no event has occurred and no condition exists, which with the giving of

notice or the passage of time, or both, will constitute a default under theFacility Lease Agreement.

(e) To the best of its knowledge, the Fee Simple Owner has good andmarketable title to the Property, there are no easements or restrictions onthe Property, and no agreement with the Fee Simple Owners lender(s), ifany, or any other party, that will interfere with the rights or obligationsbetween the Project Sponsor and the Commission as provided in theCooperative Use Agreement.

Section 5. The Commission, the Project Sponsor and the Fee Simple Owneracknowledge and agree that for purposes of the Cooperative Use Agreement, tenant isdefined as the Project Sponsor, and the Project Sponsor shall be solely responsiblefor the obligations and liabilities under the Cooperative Use Agreement. The FeeSimple Owner shall have no obligation to fulfill the obligations of the Project Sponsorunder the Cooperative Use Agreement and the Fee Simple Owner shall not be liable forany action or inaction of the Project Sponsor under such agreement.

Section 6. The agreements herein contained shall be binding upon and shall inure to thebenefit of the parties hereto, their respective successors, successors-in-interest andassigns, and, without limiting such, the agreements between the parties hereto shallspecifically be binding upon any purchaser of the Property at foreclosure or otherwise.

Section 7. This Agreement may not be modified other than by an agreement in writingsigned by the parties hereto or their respective successors-in-interest.

Section 8. The parties hereto warrant and represent that: (a) they have all requisitepower and authority to enter into, deliver and perform this Agreement; (b) the execution,delivery and performance of this Agreement has been duly authorized by all necessary


13/21

5

action on the part of each of the parties hereto, if any is so required; and (c) thisAgreement has been duly executed and delivered by the parties and constitutes theirvalid and legally binding obligation, enforceable against them in accordance with itsterms.

Section 9. All notices, statements and other communications to be given under the termsof this agreement shall be in writing and delivered by hand against written receipt or sentby certified or registered mail, return receipt requested, postage prepaid and addressedas provided in the first paragraph of this Agreement, or at such other address as fromtime to time designated by the party receiving the notice.

IN WITNESS WHEREOF, the parties have caused this instrument to be executed as ofthe day and year first above written.

PROJECT SPONSOR:Signed and delivered asto the Project Sponsor in the presence of: ________________________________

[Insert Project Sponsor Name]

___________________________ By:Witness___________________________Printed Name Printed Name

___________________________ Title: ____________________________Witness___________________________Printed Name

STATE OF OHIOCOUNTY OF__________________________ :

The foregoing instrument was acknowledged before me the ______day of ___________,20__, by ________________________________, the ___________________________of __________________________________________________________, on its behalf.

Notary Public


14/21

6

FEE SIMPLE OWNER:

Signed and delivered asto the Fee Simple Owner in the presence of: ________________________________[Insert Fee Simple Owner Name]

___________________________ By :Witness___________________________Printed Name Printed Name

___________________________ Title: ____________________________Witness

___________________________Printed Name


The foregoing instrument was acknowledged before me the ______day of ___________,20__, by _________________________________, the __________________________of __________________________________________________________, on its behalf.

Notary Public


15/21

7

Signed and delivered as to the STATE OF OHIO, by and through theCommission in the presence of: OHIO CULTURAL FACILITIES

COMMISSION

________________________________ By: _____________________________Witness Kathleen M. Fox, Executive Director________________________________Printed Name

________________________________Witness________________________________Printed Name


The foregoing instrument was acknowledged before me the ______day of ___________,20__, by Kathleen M. Fox, the Executive Director of the Ohio Cultural FacilitiesCommission, on its behalf.

Notary Public

Approved as to form:

Marc Dann, Ohio Attorney GeneralOn attached approval form dated: _____


16/21

8

EXHIBIT A

[Attach Legal Description]


17/21

9

EXHIBIT B

[Attach Facility Lease Agreement]


18/21

S:\PROJECT MANAGEMENT\0-General Info\Aides, Scripts, Templates\Document Templates\materials for project

sponsors\Environmental Site Assessment.rtf Page 1 of 3

Project:

Environmental Site Assessment Transaction Screening

Environmental Site Assessment Transaction Screening (TS) is a process used to evaluate the potential for a

building or a site to have an environmental contamination or other condition. It is usually performed prior

to purchasing a property, although on occasion it may be undertaken after purchase but before remodelingconstruction activities or demolition is started. The TS process is often performed by a person familiar

with buildings and construction but not necessarily an environmental professional. The screening process

involves going to the site with a checklist and answering a series of questions and reviewing a limited

database search of regulatory activities associated with the site. The answers to these questions will lead to

the determination of whether there is a need for additional study.

The Transaction Screening can be used to determine if a Phase I ESA is indicated. In projects involving

the rehabilitation of existing housing, a Transaction Screen may satisfy a lender if it can demonstrate that

the property has always been used for residential purposes. Undeveloped urban sites, infill sites and former

commercial or industrial properties will probably require the greater level of inquiry provided by a Phase I

ESA.

A variety of environmental screening protocols have been developed. Some lending institutions have

developed and may require the use of their own screening and assessment methods. The American Society

of Testing and Materials (ASTM) has developed a Transaction Screen Guide and sells forms which lead the

assessor through the screening process (ASTM may be reached at (610) 832-9585). This method is an

excellent guidance tool.

The purpose of any screening method is to determine if there is a sufficient reason to proceed with a more

involved Environmental Site Assessment. This is achieved by direct observation at the site to determine

the presence of conditions or factors that indicate further investigation would be appropriate. Screening

methods are limited in scope and are not a definitive assessment of the property. The typical types and

range of questions considered in a simple environmental screening can be viewed in the sample outline

below.

Typical Environmental Site Screening Questions:

YES NO N/A

Is the property located in an industrial area? ______ ______ ______

Has the property ever been used for industrial activities? ______ ______ ______

Are the properties adjacent to the site industrial? ______ ______ ______

Does storm water from industrial properties flow onto the site? ______ ______ ______

Is the property used to store materials in commercial quantities? ______ ______ ______

Has the site been used for commercial purposes? ______ ______ ______

Are materials disposed of or treated prior to disposal on the site? ______ ______ ______

Are there areas of unexplained fill? ______ ______ ______

Are there areas of dead or stressed vegetation? ______ ______ ______

Are there visibly stained soils on the site? ______ ______ ______

Is the building located in a historic district? ______ ______ ______Are there wetlands or flood plains on the property? ______ ______ ______

Are there electrical utilities such as transformers or transmission lines? ______ ______ ______

Are materials stored in drums on the site? ______ ______ ______

Are there sumps or floor drains in the building? ______ ______ ______

Are there any underground storage tanks on the site? ______ ______ ______

Is there evidence of under ground tanks such as vents of fills? ______ ______ ______

Are there above ground storage tanks of the site? ______ ______ ______

Are there any visible signs of leakage/spills? ______ ______ ______

Are there any transformers on the property? ______ ______ ______


19/21



Is there any equipment stored on the property? ______ ______ ______

Has the site ever been used as a service or repair station, print shop, dry

cleaner, paint shop, furniture refinisher or similar types of commercial

activity?

______ ______ ______

Has the site been remodeled using fire resistant plywood or urea foam

insulation?

______ ______ ______

Has the site been used for activities other than residential? ______ ______ ______

If there are buildings on the site, has a radon test been completed? ______ ______ ______

Is there any evidence of moisture damage in ceilings, walls or floors? ______ ______ ______

Is there visual or olfactory evidence of mold or latent moisture within the

building, including the attic or basement spaces, if any? ______ ______ ______

Were the buildings on the site built prior to 1978? ______ ______ ______

If yes, please answer the next set of questions?

1. Is there any peeling paint? ______ ______ ______2. Is there sprayed-on fire retardant/insulation on or

In the walls or ceiling spaces that remain from construction/

Renovation prior to 1978? ______ ______ ______

3. Does pipe insulation remain from construction/Renovation prior to 1978? ______ ______ ______

4. Is there exposed tile flooring (vinyl) from prior to 1978? ______ ______ ______

5. Have you abated or encapsulated lead-based paintOr any forms of asbestos-containing construction materials? ______ ______ ______

If you have answered a YES to any of these questions, it may be necessary to do additional investigation

and possibly undertake a Phase I Environmental Site Assessment (ESA). Many lenders will require a

Phase I ESA as part of the due diligence process in evaluating a loan. Prior to contracting with an

environmental professional, you should consult with a prospective lender to learn if there are any unique

requirements necessary to meet their review procedures.

Has an ESA ever been completed for any portion of the site?

yes (if so, please provide copies) noDid the evaluator check any yes boxes on the Environmental Site Assessment Transaction Screening?

yes no

If yes was checked for any of the boxes on the Environmental Site Assessment Transaction

Screening, provide a detailed explanation in a written letter as to why it was checked yes.

The explanation will aide in determining if a Phase I ESA should or should not be

completed.

Projects using funds from various federal programs should determine if there are special assessment

requirements as well. For example, an ASTM Phase I Environmental Site Assessment does not include the

collection of samples for asbestos, or lead based paint, but for projects involving remodeling orconstruction of residential properties it may be prudent to determine whether these materials are present,

and under some funding programs these tasks would be required.


20/21



This Environmental Site Assessment Transaction Screening is executed and certified as accurate this _____

day of ______________, ________.

_______________________________________ ___________________________________

Witness Signature Signature

_______________________________________ ___________________________________

Printed Name Printed Name

_______________________________________ Title: ______________________________

Witness Signature

_______________________________________

Printed Name


21/21

FARMLAND USE DETERMINATION

Project Name:____________________________________________________________

Project Manager:__________________________________________________________

Project Sponsor: __________________________________________________________

Description of Selected Site:

1. Owner:_______________________________________________________________

2. Site location:__________________________________________________________

County:_____________________________________________________

3. Number of acres:_______________________________________________________

4. Cost of land: $_________________________________________________________

Is Site Enrolled in CAUV (Current Agricultural Use Valuation):

(Check with the County Recorder to determination enrollment status)

Yes (Fill out Farmland Use Report) No (Continue filling out this report but no further action required)

Comments:______________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________ _____________Project Sponsor Signature Date