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Community Project Funding Request

Section One

Organization Name: *

Street Address: *

Street Address: (Continued)

City: *

State: *

Zip Code: *

Work Phone: *

Are you a nonprofit or government entity? Note: you must be a non-profit or government entity to be eligible for CPF funding * Yes No

Primary Point of Contact *federal lobbyists cannot be the primary point of contact
First Name: *

Last Name: *

Title: *

Email: *

Phone: *

Alternate Point of Contact
First Name:

Last Name:

Title: *

Email: *

Phone: *

EIN / Federal Identifier: *

Has this organization received federal Community Project Funding (CPF) before? * Yes No Not Sure

Section Two: Project Overview

Project Title:

Project Summary:

How will this project benefit your community and Nebraska's Second District?

Will the project, if funded, become self-sustaining after a defined period? Yes No

City/Town:

Has this project request been submitted to Congressman Bacon or another congressional office in prior fiscal years? Yes No

Has this project received Community Project Funding (CPF) in the past? Yes No

Is your project included in a state, county, or city plan? Yes – Please specify below No

Explain how your project is included in a state, county, or city plan:

Does your project meet all the criteria listed in the CPF guidance? Yes No

Section Three: Community Project Funding Request

What type of project is this?

What federal department or agency does your project fall under?

Subcommittee:

Does this project entail or include: New Construction Renovation/Rehabilitation Neither

Has this project completed design, engineering, or permitting? Yes Partially complete No / Early concept or planning Not Applicable

Section Four: Budget and Readiness

Note: The Build America, Buy America Act requires federally funded infrastructure projects use only iron, steel, construction materials, and manufactured products produced in the United States. This requirement applies to articles, materials, and supplies that are consumed in, incorporated into, or affixed to an infrastructure project. If you are submitting a CPF request for an infrastructure project, please take this into account.

CPF Amount Requested: $

What will the funds be used for?

What is the total project cost?

Itemized Budget:

Expected Project Timeline/Milestones:

If the date depends on enactment or grant execution, please explain:

Does this project comply with Build America, Buy America (BABA)? Yes No Not sure

Can the project proceed if the Appropriations Committee cannot fully fund the request? Yes No

Please provide any federal, local/state government, and private or non-profit funding this project has already received along with the status of the funding:

Federal Nexus Statement *This statement serves as the legal justification for why federal tax dollars should be spent on a local project.

Section Five: Other

If applicable, list any member of Congressman Bacon's staff whom you have discussed this CPF request:

Section Six: Community Support and Attachments

Please email any letters of support and supplemental documents such as project budgeting forms or engineering/map schematics to Theresa.Thibodeau@mail.house.gov. When emailing materials include organization, project name, and date application submitted in the subject line.

Section Seven: Certification

I certify that the information provided is accurate and the project will comply with all federal transparency and reporting requirements

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Office Locations

Washington, DC Office 2104 Rayburn HOB
Washington, DC 20515
Phone: (202) 225-4155
Toll-Free: 888-221-7452
Omaha Office 13906 Gold Circle
Suite 101
Omaha, NE 68144
Phone: (402) 938-0300
Saunders County Office 543 Linden Street
Wahoo, NE 68066
Phone: (402) 607-0077

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