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HomeMy WebLinkAbout2020.11.23 Council Remote Special Meeting Packet AGENDA Remote Special Meeting 7:00 PM - Monday, November 23, 2020 GoToWebinar Page 1. REMOTE MEETING INSTRUCTIONS: Governor Inslee's Proclamation No. 20-28, made in response to the COVID-19 emergency, prohibits members of the public from attending City meetings in-person but requires agencies to provide options for the public to participate in remotely. To best comply, the City asks all members of the public that would like to comment regarding items on the agenda, where the public is allowed to speak, to fill out a form via the City’s website (www.pasco-wa.gov/publiccomment) to obtain access information to comment. Requests to comment in meetings must be received by 4:00 p.m. on the day of each meeting. To listen to the meeting via phone, call (213) 929-4212 and use access code 555-318-622. City Council meetings are broadcast live on PSC-TV Channel 191 on Charter/Spectrum Cable in Pasco and Richland and streamed at www.pasco-wa.gov/psctvlive and on the City’s Facebook page at www.facebook.com/cityofPasco. 2. CALL TO ORDER: 3. ROLL CALL: (a) Pledge of Allegiance 4. NEW BUSINESS: 3 - 51 (a) Two Rivers Behavioral Health Recovery Center - Lee Kerr, Two Rivers Health District Superintendent MOTION: I move to approve the City of Pasco’s support of the Two Rivers Health District’s efforts to secure funding and development a Behavioral Health Recovery Center to serve the Tri-City region and authorize the Mayor to sign the letter of support on behalf of the City Council. Page 1 of 66 52 - 66 (b) Approval for DWSRF Loan application for West Pasco WTP MOTION: I move to approve the submittal of a Drinking Water State Revolving Fund Loan Application for the West Pasco Water Treatment Plant Expansion project for a loan amount of up to $5 million. 5. ADJOURNMENT: (a) (RC) Roll Call Vote Required * Item not previously discussed Q Quasi-Judicial Matter MF# “Master File #....” (b) This meeting is broadcast live on PSC-TV Channel 191 on Spectrum/Charter Cable in Pasco and Richland and streamed at www.pasco-wa.gov/psctvlive. Audio equipment available for the hearing impaired; cont act the Clerk for assistance. Servicio de intérprete puede estar disponible con aviso. Por favor avisa la Secretaria Municipal dos días antes para garantizar la disponibilidad. (Spanish language interpreter service may be provided upon request. Please provide two business day's notice to the City Clerk to ensure availability.) Page 2 of 66 AGENDA REPORT FOR: City Council November 20, 2020 TO: Dave Zabell, City Manager Remote Special Meeting : 11/23/20 FROM: Adam Lincoln, Deputy City Manager Executive SUBJECT: Two Rivers Behavioral Health Recovery Center - Lee Kerr, Two Rivers Health District Superintendent I. REFERENCE(S): 1. PowerPoint Presentation: Two Rivers Behavioral Health Recovery Center 2. Feasibility Study – Two Rivers Behavioral Health Recovery Center 3. Request for Endorsement 4. Draft Letter of Support II. ACTION REQUESTED OF COUNCIL / STAFF RECOMMENDATIONS: MOTION: I move to approve the City of Pasco’s support of the Two Rivers Health District’s efforts to secure funding and development a Behavioral Health Recovery Center to serve the Tri-City region and authorize the Mayor to sign the letter of support on behalf of the City Council. III. FISCAL IMPACT: N/A IV. HISTORY AND FACTS BRIEF: The Two Rivers Health District (TRHD) is seeking the City’s endorsement of a Behavioral Health Recovery Center to serve the Tri-City region. The project is based upon the attached Feasibility Study to address behavioral health issues impacting Pasco and the other Tri-Cities communities. The requested endorsement is to demonstrate the City's support for the District’s efforts to secure State and Federal capital funding for the aforementioned Center. Currently, there is no request for financial assistance from the City. The TRHD is also seeking endorsements from other community leaders and agencies to demonstrate broad community support. Page 3 of 66 The City Council has adopted the goal of supporting Mental Health Funding as a part of their 2021 Legislative Priorities, which states: “The Pasco community is experiencing increased homelessness, rising crime rates, and other public safety and health concerns. As such, the City requests increased funding for mental health services, including but not limited to additional local option tools, to best meet the community’s needs.” The TRHD proposal and their intended effort to pursue a capital request in the upcoming legislative session is consistent with the aforementioned legislative goal. The TRHD presented to the Franklin County Commission on November 17, 2020 and is scheduled to present to Kennewick City Council November 24, 2020. V. DISCUSSION: Lee Kerr, Two Rivers Health District Superintendent, will provide a presentation and further detail. Page 4 of 66 BEHAVIORAL HEALTH RECOVERY CENTER Update Lee Kerr, Superintendent, Kennewick Public Hospital District November 2020 Page 5 of 66 BACKGROUND ➢Tri-Cities is only major metropolitan area in WA State with no detoxification facility or inpatient treatment facility for Mental Health Disorders & Substance Use Disorder (SUD) ➢Tri-Cities has overdose, opiate use, drug- trafficking & suicide rates above state averages ➢Residents of Tri-Cities languish on long waiting lists for mental health and detox services and often miss windows of opportunity to get help ➢Tri-Cities needs a Recovery Center to provide essential mental health & SUD services to our communityPage 6 of 66 BENEFITS OF A COMPREHENSIVE BEHAVIORAL HEALTH RECOVERY CENTER Reduce crime & recidivism Efficient access for law enforcement Lower local law enforcement costs & burdens Increase public safety & hygiene Reduce repeat visits to hospital Emergency Departments by persons in crisis Assist physicians and health care providers by providing a place to send patients who need SUD & mental health care Provide timely treatment to persons in crisis Allow families to participate in all treatment programs Page 7 of 66 BENEFITS CONTINUED Provide support for employers in attracting high-quality workers to Tri-Cities area Keep treatment dollars in Tri-Cities Provide substantial Return on Investment (ROI) to employers currently sending employees & their family members to treatment centers throughout U.S. Attract highly qualified medical & mental health providers to Tri-Cities region Raise profile & pride of Tri-Cities as place of medical excellence in all fields Add mental health crisis resources Provide regional resource to help meet shortages in: Secure withdrawal management (civil commitment) Correctional diversion to treatment instead of jail where appropriate Transitional recovery housing Care of chemically-using pregnant women Page 8 of 66 PUBLIC ACCEPTABILITY •No negative feedback in extensive public presentations •All comments indicate enthusiastic support Page 9 of 66 TWO PART FEASIBILITY STUDY 1. BUSINESS PLAN BY ASCENSION 2. REPURPOSE CONSTRUCTION COSTS OF THE 900 AUBURN FACILITY BY ARCULUS Executive Summary addressing additional mental health servicesPage 10 of 66 HIGHLIGHTS OF THE ASCENSION BUSINESS PLAN •24/7/365 No Wrong Door Access •Referral point for local providers, hospital Emergency Departments, law enforcement, families, individuals •Comprehensive Services •Assessments, Evaluation & Treatment (E&T) services for behavioral health crises, Secure & non-secure detoxification, Inpatient SUD treatment, Chemically-using pregnant (CUP) program, Group & Family counseling, Co-occurring mental health services •Potential for transitional sober housing, wraparound services such as job assistance, research •New employment opportunities within our community •Cooperation with existing local providers •Financially self sustaining Page 11 of 66 HIGHLIGHTS OF THE REPURPOSE COST BY ARCULUS Capital Costs to Repurpose Facility purchase cost $1,600,000 A&E fees (includes project management & inspection)1,120,000 Construction costs (includes ancillary costs)11,200,000 Sales tax 963,200 Total Capital Costs to Repurpose $14,883,200 Page 12 of 66 NEXT STEPS: PURCHASE OF EXISTING CAMPUS AT 900 S AUBURN •One-year agreement to acquire the facilities for $1.6 million •The district has $600,000 to put towards purchase Page 13 of 66 NEXT STEPS CONTINUED •Fund Raising Plan •Presentation to Counties •Presentation to Cities •State: Engaged in positive discussions with Governor’s Office of Financial Management for a line item in the State’s capital budget for 2021. Additionally have had discussions and positive support with state legislators for a line item to the capital budget. •Federal: Pursuing federal funding and resources. •Fund raising campaign: Have a proposal from a firm that has had positive results in the Tri Cities. •Have secured the services of a grant writer Page 14 of 66 QUESTIONS?Page 15 of 66 CONCLUSION •What We Need from You: •Endorsement of the Project •Financial assistance •Pledge from local governments will enhance likelihood of state funding Page 16 of 66 Page 17 of 66 Table of Contents Executive Summary ......................................................................................page 2 Vision ..........................................................................................................page 3 Highlights of Two Rivers Center .................................................................page 4 Repurpose and Conversion costs of the 10th and Auburn Campus to a Behavior Health Facility .................................page 5 Ascension Feasibility Study Business Plan ..................................................................................page 6 Proforma ..........................................................................................page 22 Arculus Design and Technical Services Feasibility Study ..............................................................................page 25 1 Page 18 of 66 EXECUTIVE SUMMARY The recent Community Health Needs Assessment dramatically showed that tragically absent from our community is any detoxification or residential rehabilitation facility necessary to combat the opioid epidemic. The Kennewick Public Hospital District in consultation with the Benton Franklin Recovery Coalition are seeking to address this public healthcare crisis. The message from our community and the Commissioners and Sheriffs of our two Counties was that Substance Abuse Disorder is inextricably intertwined with mental health needs, collectively treated as Behavioral Health. LifePoint’s has committed to the sale of the Trios Auburn Campus to the District. This will provide the unique opportunity to gather all these services under one roof and offer “no wrong door” to anyone in crisis. The project will incorporate appropriate changes to that building to meet all State requirements. This Feasibility Study incorporates the Business Plan and Proforma prepared by Ascension Recovery Services and the conversion analysis prepared by Arculus Technical Design and Services. The results of the Studies performed are: The Ascension Feasibly Study determined there are sufficient numbers of potential guests with sufficient reimbursement sources to assure financial viability. The Arculus Feasibility Study determined the costs of conversion are significantly less than the costs of constructing a new facility with the existing facility and with significant room for expansion of services and number of guests. Originally the vision focused on Substance Use Disorder treatment and has expanded to address the more inclusive Behavior Health. Conclusion The Recovery Center will meet an urgent public need. The facility once constructed will be self-sufficient or require less public and private support than creating a new publicly or privately owned facility. The facility will use local service providers and regional providers for a no wrong door behavior health Recovery Center. 2 Page 19 of 66 VISION No Wrong Door Behavioral Health and Recovery Services for Anyone, Anywhere and Anytime Campus of Connections Clients stay in a welcoming facility with a bi-cultural approach. Connections for each level of recovery offer support to individuals living with behavioral health challenges. Our goal is to provide our clients with hope and recovery through individual, group and peer services demonstrating recovery is possible for everyone, no matter the circumstances. Community Referral Point Referral point for local business, local providers, including hospital emergency departments, physicians and other healthcare providers. A 10-minute drop-off for all law enforcement agencies will be available. Additionally, the Center will accept self and family referrals, as well as from drug courts, day report centers and other justice system and correction-oriented programs. Secured and Unsecured Withdrawal Management and Residential Treatment Secure withdrawal management and stabilization services will be provided to individuals to assist in the process of withdrawal from psychoactive substances in a safe and effective manner, or to medically stabilize the individual after acute intoxication, in accordance with ASAM1 criteria. The facility will also offer “Inpatient/Residential Substance Use Treatment Services”, including diagnostic evaluation and face-to-face individual or group counseling using therapeutic techniques directed toward individuals who are harmfully affected by the use of mood-altering chemicals or have been diagnosed with a SUD. Techniques have a goal of assisting individuals with SUDs in their recovery. Services will be offered in accordance with the following ASAM criteria. •ASAM 3.7 Medically Monitored Intensive Inpatient Services Withdrawal Management •ASAM 3.5 Clinically Managed High-Intensity Residential Services •ASAM 3.2 Clinically Managed Residential Withdrawal Management Evaluation and Treatment Center A secured evaluation and treatment (E&T) center for those experiencing severe behavioral health incidents will be the center-point of the facility with a 16-bed residential treatment facility that offers an alternative to hospitalization (24/7, 365 days per year) for persons experiencing behavioral health incidents. (Footnotes) 1 ASAM - American Society of Addiction Medicine 3 Page 20 of 66 Highlights of the Two River Behavioral Health program will include: •Residential inpatient SUD treatment •Medically Managed Withdrawal (detoxification) •Crisis stabilization •Integrated, bi-directional care •Individualized treatment plans •Individual counseling •Group counseling •Family programs •Self-help support groups •Peer recovery support services •Trauma-informed care •Mindfulness-based cognitive therapy •Holistic approaches to care •Relationships with quality aftercare providers •Referrals to Quality Aftercare •Medication-assisted treatment (MAT) •Intensive Out Patient Services •Chemically Using Pregnant (CUP) Womens’s Program 4 Page 21 of 66 5 Page 22 of 66 6 Page 23 of 66 Page 24 of 66 Page 25 of 66 Page 26 of 66 Page 27 of 66 Page 28 of 66 Page 29 of 66 Page 30 of 66 Page 31 of 66 Page 32 of 66 Page 33 of 66 Page 34 of 66 Page 35 of 66 Page 36 of 66 Page 37 of 66 Page 38 of 66 22 Page 39 of 66 Page 40 of 66 Page 41 of 66 25 Page 42 of 66 Page 43 of 66 Page 44 of 66 Page 45 of 66 Page 46 of 66 Page 47 of 66 Page 48 of 66 Page 49 of 66 Page 50 of 66 MAYOR • (509) 545-3404 • FAX (509) 545-3403 P.O. Box 293 • 525 North 3rd Ave. • Pasco, WA 99301 www.pasco-wa.gov November 20, 2020 Two Rivers Health District P.O. Box 6974 Kennewick, WA 9336 RE: Two Rivers Behavioral Health Recovery Center Letter of Support To Whom It May Concern: On behalf of the Pasco City Council I am pleased to convey the Council’s support of the proposed Two Rivers Behavioral Health Recovery Center. This center would provide patients and families in our region much needed services to assist those suffering from substance use disorder (SUD – addiction) as well as other mental health disorders. The City Council has adopted the goal of supporting mental health funding as a part of our 2021 Legislative Priorities, which states: “The Pasco community is experiencing increased homelessness, rising crime rates, and other public safety and health concerns. As such, the City requests increased funding for mental health services, including but not limited to additional local option tools, to best meet the community’s needs.” The proposed center would bring along with it several community benefits: • Reduce crime and recidivism, lower local law enforcement costs and burdens, and increase public safety and hygiene • Reduce repeat visits to hospital Emergency Departments by addicted persons in crisis as well as decrease the burden placed on emergency medical providers like firefighters and paramedics • Assist physicians and other health care providers by providing a place to send patients who cannot be otherwise helped in more traditional medical facilities The Pasco City Council unanimously endorses the effort to create this facility and urges the provision of State, Federal, and other grant funding to help establish the Center. Sincerely, Saul Martinez, Mayor Page 51 of 66 AGENDA REPORT FOR: City Council November 17, 2020 TO: Dave Zabell, City Manager Remote Special Meeting : 11/23/20 FROM: Steve Worley, Public Works Director Public Works SUBJECT: Approval for DWSRF Loan application for West Pasco WTP I. REFERENCE(S): Drinking Water State Revolving Fund (DWSRF) Application Form II. ACTION REQUESTED OF COUNCIL / STAFF RECOMMENDATIONS: MOTION: I move to approve the submittal of a Drinking Water State Revolving Fund Loan Application for the West Pasco Wat er Treatment Plant Expansion project for a loan amount of up to $5 million. III. FISCAL IMPACT: Maximum award of $5 Million per jurisdiction, 1.75% interest rate, 20-year loan term. IV. HISTORY AND FACTS BRIEF: The 2019 Comprehensive Water System Plan identified needed improvements to the West Pasco Water Treatment Plant (WPWTP) in order to incre ase water filtration capacity from 6 Million Gallons per Day (MGD) to 12 MGD. The exact scope and estimated cost of the WPWTP capacity project associated improvements are currently being refined through the design process. Funding for the improvements are anticipated by bond proceeds, however an opportunity exists through the Washington State Department of Health (DOH), Drinking Water State Revolving Fund (DWSRF) program for a low-interest construction loan. DWSRF exists to provide such loans for drinking water system infrastructure improvements to publicly- and privately-owned drinking water systems. This program includes both federal and state money subject to state laws and additional federal regulations. These loans are intended for capital improvements that increase public health and compliance with drinking water regulations. As currently advertised, DWSRF 20-year Construction loans have a 1.75% interest rate, with a maximum award of $5 Million per jurisdiction. Applications are due by November 30, 2020. Page 52 of 66 Even in a favorable bond market, a 1.75% DWSRF is an attractive alternative to a revenue bond. Application for a DWSRF loan requires authorization of the legislative body. V. DISCUSSION: Staff recommends Council approval for the submittal of a DWSRF low-interest loan Application to the Department of Health for the West Pasco Water Treatment Plant improvement project. Council action, in the form of a motion, is sufficient. Page 53 of 66 2020 Drinking Water State Revolving Fund (DWSRF) Construction Loan Application Worksheet DOH Worksheet (Updated November 2020). 1 It is important that you read and understand the 2020 DWSRF Construction Guidelines before you complete this application worksheet. All applications must be submitted using the DWSRF online portal, WALT. Fields marked with an asterisk (*) are required fields. Submittals must be received by November 30, 2020. Submit questions to dwsrf@doh.wa.gov. Registration - Organization Information *Applicant Organization *Address 1 Address 2 *City State *Zip Code +4 (Link to USPS Zip Code Lookup) *County *Phone Number *Email *Federal Tax ID # Organization Website Address Registration - Contact Information *First Name *Last Name *Phone Number *Email Address 1 Address 2 *City State *Zip Code +4 (Link to USPS Zip Code Lookup) Page 54 of 66 DOH Worksheet (Updated November 2020). 2 Applicant Organization Information *Water System Name: *Water System ID#: *Data Universal Numbering System (DUNS) #: *Statewide Vendor #: *Central Contractor Registration (CCR) Expiration Date: Click here to enter a date. *UBI#: 123 nowhe Initial Eligibility ATTENTION: Answering NO to any of the following six questions or not providing documents requested will make you ineligible. Please contact your regional planner or engineer if you have questions. *Is your Water System Plan (WSP) or Small Water System Management Program (SWSMP) approved and current? ☐YES ☐ NO *Have you uploaded a copy of the approval letter for applicant’s WSP or SWSMP? ☐YES ☐NO Provide copy with application submittal *Have you uploaded a copy of the page in the WSP or SWSMP that has the proposed project included? ☐YES ☐NO Provide copy with application submittal *If your project requires Water Rights (such as a new source) have you secured your Water Rights? ☐YES ☐ NO ☐N/A Provide copy of applicable information with application submittal. *Applicant owns project site or has ability to control site through easement or lease for at least the duration of the loan? ☐YES ☐ NO Provide copy of applicable information with application submittal. *Applicant has NO outstanding audit findings related to technical, managerial, or financial capacity? ☐YES ☐ NO Project Information *Project Name: *Brief Project Description (Max 500 Words): Page 55 of 66 DOH Worksheet (Updated November 2020). 3 *Legislative District (1-49): *Congressional District (1-10): Project Site Name Project Site Street Address City State Zip Code +4 Latitude Longitude *Project County *Main focus of the project (Select One): ☐Construction-Transmission & Distribution ☐Construction-Source ☐Construction-Treatment ☐Land Acquisition ☐Planning & Design Only ☐Purchase of Systems ☐Restructuring/Consolidation/Receivership ☐Other If other (public health concerns), please provide comments: *Actions proposed to address public health concerns (Check all that apply): ☐New Source ☐Source reconstruction or rehabilitation ☐Disinfection ☐Filtration ☐Other treatment ☐Treatment replacement or upgrade ☐Lead component or service line replacement ☐Security measures ☐Seismic improvements ☐Resiliency ☐Intertie ☐Redundancy ☐Reservoir interior rehabilitation ☐New reservoir ☐Consolidation or restructuring ☐Cross connection control ☐Pressure reducing station ☐New pump station ☐Pump Station improvements ☐Meters as part of bigger project ☐Water main installation or replacement ☐Treatment plant discharge improvements ☐Telemetry or controls ☐Other *If Other actions proposed, please Page 56 of 66 DOH Worksheet (Updated November 2020). 4 *Is this a restructuring/consolidation/receivership project? ☐YES ☐NO *If YES, provide general description of the final outcome of restructuring/consolidation/receivership activities and provide a copy of the signed transfer of ownership agreement or court order for receivership: *Upload signed transfer of ownership agreement or court order for receivership. *Does this project address a compliance issue in a department issued correspondence? ☐YES ☐NO *If YES, what issue(s)? ☐Compliance Order ☐Boil Water Advisory ☐Sanitary Survey Finding ☐Other *Upload Department Issued Compliance Document(s) *Exceeding a maximum contaminant level (MCL), secondary MCL, or action level or within 80% of nitrate or arsenic MCL? ☐YES ☐NO *If YES, what type of contaminant(s)? ☐Arsenic (As) ☐Copper (Cu) ☐Iron (Fe) ☐Manganese (Mn) ☐Lead (Pb) ☐Nitrate (as N) ☐Disinfection by-products ☐Radionuclides ☐Organic chemicals ☐Total Coliform ☐Other *If Other, please describe: Page 57 of 66 DOH Worksheet (Updated November 2020). 5 *Treatment technique issue? ☐YES ☐NO *If YES, select rule(s): ☐Ground Water Rule ☐Revised Total Coliform Rule ☐Surface Water Treatment Rule ☐Other *If other treatment technique issues, please describe: *Are you experiencing water shortage due to a declining aquifer in one of the following communities: Connell, Ephrata, Kahlotus Lind, Mesa, Moses Lake, Othello, Quincy, Ritzville, Washtucna. A Water Shortage response plan will be reuired as part of the project. If yes, upload documentation such as well water measurements, water saving measures *Do you have meters on all existing water sources? ☐YES ☐ NO *Does the water system have service meters on all existing services? ☐YES ☐ NO Page 58 of 66 DOH Worksheet (Updated November 2020). 6 Readiness to Proceed Points Is the engineering report and/or project report approved? ODW regional office staff must approve your completed engineering/design report. ☐YES ☐NO *If YES, upload DOH approval of engineering or project report Are the construction and/or bid documents complete and approved by DOH? ODW regional office staff must approve your completed construction and/or bid documents. ☐YES ☐NO *If YES, upload DOH approval letter Indicate status of project permits You must have appropriate permits in place to begin construction. Upload approved project permits Has your water system completed the SEPA and/or NEPA process for this project? ☐YES ☐NO Completion of SEPA/NEPA includes issuing a final determination and publishing the determination for the proposed project. Full completion receives full allowable points. In-process status will receive partial points. ☐YES ☐NO Has your water system completed the cultural/historical review process under Section 106 or Governor’s Executive Order 05-05? Completion of the Cultural Review includes a final determination made and published based on the National Historic Preservation Act (NHPA) requirements. Full completion receives full allowable points. Determinations made under Washington State Executive Order 05-05 and projects part way through the NHPA process will receive partial points ☐YES ☐NO *If YES, upload completed cultural/historical review Does this funding complete a previous DWSRF construction or DWSRF emergency loan project? This project completes a previous partially funded DWSRF construction or DWSRF emergency loan project. ☐YES ☐NO *If YES, provide DWSRF Application number and explain why it’s incomplete: Does this funding complete a previous preconstruction loan? This project completes a previous preconstruction loan project. ☐YES ☐ NO *If YES, provide application number: For consolidation projects, did this project receive a consolidation grant? ☐YES ☐ NO *If YES, provide application number: Does this loan complete the funding package for this project? ☐YES ☐NO For multi-funded projects, these points will be awarded if other funding sources are secured for the project and the DWSRF funding will complete the package. Letters of commitment from other funders must be attached to receive these points. Page 59 of 66 DOH Worksheet (Updated November 2020). 7 Bonus Points Do you want to be considered for Restructuring or Consolidation Bonus Points? If YES, list the names and PWSID #’s being taken over and restructured. If uncertain, check Sentry Internet. ☐YES ☐NO Name: PWSID #: Name: PWSID #: Name: PWSID #: Name: PWSID #: Do you want to be considered for Regional Benefit Bonus Points? If YES, list the names and PWSID #’s that benefit from the project. ☐YES ☐ NO Name: PWSID #: Name: PWSID #: Name: PWSID #: Name: PWSID #: Has your staff attended asset management training session? If you participated in an asset management training provided by DOH, RCAC or other technical provider between September 1, 2018 and November 30, 2020, you are eligible for bonus points. To receive points in this category, you must provide the training date, location, title, and sponsor information along with the names of staff who attended the training. ☐YES ☐NO If YES, provide who, where, and when: Does your system have an asset inventory? To receive points in this category, you must provide an asset inventory that includes the list of water system assets, age of assets, expected life of the assets, replacement cost of assets, and criticality. See Appendix G for an example ☐YES ☐NO If YES, upload a copy of your asset inventory *Does this project require coordination with other infrastructure project (Smart Projects)? Water main replacement projects that coincide with a transportation improvement project, fish passage barrier removal project, sewer main replacement, or other infrastructure projects will receive bonus points. Provide documentation of the other infrastructure project and construction schedule. ☐YES ☐ NO If YES, Please list other infrastructure projects and scheduling issues and upload documentation for other infrastructure project. Does this project address water loss, reduce pumping or treatment costs, or result in reduced energy consumption. Provide documentation (put in upload) ☐YES ☐ NO *If yes, please provide Green Infrastructure documentation Page 60 of 66 DOH Worksheet (Updated November 2020). 8 Financial Information *Project Budget (Enter date and amount for each activity included in your budget. If not listed, add below.) Activity Date (Estimated) Loan Request (Costs) Amount Engineering Report (preliminary engineering) Click here to enter a date. Environmental Review Click here to enter a date. Cultural Review Click here to enter a date. Land/Right-of-Way Acquisition Click here to enter a date. Permits Click here to enter a date. Public Involvement/Information Click here to enter a date. Bid Documents (design engineering) Click here to enter a date. Construction Click here to enter a date. Contingency (should be at least 10% of Construction cost) Click here to enter a date. DOH Review/Approval Fees Click here to enter a date. Other Fees: (sales or use taxes) Click here to enter a date. Service Meters (purchase and installation) Click here to enter a date. Audit Costs Click here to enter a date. Subtotal Other (describe): Click here to enter a date. Other (describe): Click here to enter a date. Other (describe): Click here to enter a date. Funding Request TOTAL Loan Fee TOTAL FUNDING REQUEST (add the two lines above) Page 61 of 66 DOH Worksheet (Updated November 2020). 9 *Will you be using any other funding sources for your project? If YES, please list funding sources and amounts below. ☐YES ☐ NO Funding Source: Amount: Funding Source: Amount: Funding Source: Amount: Funding Source: Amount: *If the water system is a nonprofit corporation serving a non-community, upload a copy of the federal nonprofit certification to this application. *Applicant’s relationship to the water system (Select one type): ☐Water Manager ☐Parent and/or subsidiary ☐Owner ☐Satellite System ☐Attend to Absorb/Restructure With *Years in business as a water system: *Number of years under current management: *List your System’s Reserve Accounts Amount Operating cash reserve balance Click or tap here to enter text. Emergency reserve balance Click or tap here to enter text. Capital reserve balance Click or tap here to enter text. Equipment reserve balance Click or tap here to enter text. TOTAL Click or tap here to enter text. Does your water system have managerial capacity? *Are all of your water system board positions filled? ☐YES ☐NO *Does your board meet regularly? ☐YES ☐NO If YES, When? *Are your board meeting minutes available for review? ☐YES ☐NO *Upload meeting minutes approving submittal of the DWSRF application for the proposed project and proposed funding amount. Does your water system have technical capacity? *Do you have a certified operator? ☐YES ☐NO If YES, list operator name and certification number *Do you keep the following records and are they available for review? ☐YES ☐NO Operating (example: source and service meter reading) Maintenance (example: how often is the pump replaced or serviced?) *Connection Totals (List number of active residential, commercial, and other or vacant connections.) Page 62 of 66 DOH Worksheet (Updated November 2020). 10 Connections Current Year Future Year 1 Future Year 2 Future Year 3 Future Year 4 Future Year 5 Total Number of Active Residential Connections Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Total Number of Active Commercial Connections Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Total Number of Other or Vacant Connections Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Total Number of Connections Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. *Water Rate Information (Provide Water Rate Information per residential connection.) Average monthly residential rate per connection (base rate) Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Additional residential rate per 100 cubic feet (CF) Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Average monthly cubic feet consumption per connection Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Current average rate per connection before this project Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Was an income survey conducted on your system, jurisdiction, or project area? ☐YES ☐NO If YES, upload a copy of the final report of the income survey and MHI determination. Will the water system increase rates to repay this loan? ☐YES ☐NO *Did or will the water system adopt rates to include the DWSRF loan repayment? ☐YES ☐NO If YES, when will the new rates be effective? Upload meeting minutes of the rate increase How much annual revenue does this system expect this source to generate? Page 63 of 66 DOH Worksheet (Updated November 2020). 11 Current Outstanding Long Term Debt (For each obligation, list the annual principle and interest debt service, interest rate, maturity date and collateral, if any.) Lender Outstanding Balance Payment Amount Payment Schedule (Select One) Interest Rate Percent Interest Rate (Select One) Maturity Date Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. ☐Weekly ☐Monthly ☐Quarterly Click or tap here to enter text. ☐Fixed ☐Variable Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. ☐Weekly ☐Monthly ☐Quarterly Click or tap here to enter text. ☐Fixed ☐Variable Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. ☐Weekly ☐Monthly ☐Quarterly Click or tap here to enter text. ☐Fixed ☐Variable Click or tap here to enter text. Open Lines of Credit (List total amount available, current balance, and interest rate for each.) Lender Available Credit Current Balance Interest Rate Percent Interest Rate (Select One) Maturity Date Collateral Securing Debt Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. ☐Fixed ☐Variable Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. ☐Fixed ☐Variable Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. ☐Fixed ☐Variable Click or tap here to enter text. Click or tap here to enter text. List all entities where the applicant system has overlapping debt (Please indicate the amount and percent of outstanding debt for which your system is liable. Include 100% of debt if fully guaranteed by your system and 100 % of debt your system's parent company is obligated for as the parent of other subsidiary entities.) Entity Name Outstanding Debt Percent Share of Outstanding Debt Click or tap here to enter text. enter text. Click or tap here to enter text. Click or tap here to enter text. enter text. Click or tap here to enter text. Click or tap here to enter text. enter text. Click or tap here to enter text. Does the system have the ability to raise rate for loan repayment? ☐YES ☐NO Is there a pending motion (or resolution) to limit the water system’s ability to raise rates or expend from revenue the funds needed to repay a loan? ☐YES ☐ NO Has the applicant experienced severe fiscal distress resulting from a natural disaster (example: Governor-declared emergency, or emergency public works need in the past 12 months)? ☐YES ☐ NO Has the applicant received past or present technical assistance from the Rural Community Assistance Corporation (RCAC), Evergreen Rural Water of Washington (ERWOW), or any other consultant? ☐YES ☐ NO If YES, please provide comments: Page 64 of 66 DOH Worksheet (Updated November 2020). 12 Did technical staff help you complete this form? ☐YES ☐NO If YES, identify activities the technical staff provided for your water system or your board: ☐Asset Management Training ☐Rate Setting ☐Assistance Completing Applications ☐Income Survey ☐Other If other (activities), please provide comments: Identify all events listed below that your water system experienced in the last five years. Is the water system involved in any lawsuits or pending litigation that is in excess of $10,000? ☐YES ☐ NO If YES, upload a statement from your attorney describing the lawsuit. Have company assets been sold? ☐YES ☐ NO Will company assets be sold in the future? ☐YES ☐NO Is the system under any regulatory or court compliance order? ☐YES ☐ NO If YES, please explain: Upload documentation Business References for privately owned systems only, list the names and contact information of at least three references you did business with during the past year. Business Organization Contact Person Phone (xxx-xxx-xxxx) Business account # enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. Authorization of DOH by Borrower for privately owned systems only. To facilitate processing of this application, the borrower hereby authorizes DOH staff to request business and/or personal credit reports for all proposed responsible parties for the debt obligation. (List name of person(s) who give DOH authority to check credit history.) Name of Authorized Person(s) Title Date enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. enter text. Page 65 of 66 DOH Worksheet (Updated November 2020). 13 We certify that the applicant has not defaulted on any payment of matured principal and/or interest. ☐YES ☐NO If NO, provide details: *To fully evaluate the financial status of the applicant, the DWSRF program requires the applicant upload the following items: ☐All applicants; Balance Sheet Statements for last three years and current year if available. ☐All applicants; Book Asset Details or complete Fixed Assets Inventory List and Depreciation schedule. ☐All applicants; Income Statements for last three years and current year if available. ☐All applicants; Adopted Water Rate Structure for last three years and current/future year(s) if available. ☐Privately owned water system only; filed Tax Returns for last three years. ☐Privately owned water system only; copy of bank statements ending December 31 for the last three years. ☐Privately owned water system only; copy of bank statements ending December 31 for the last three years. ☐Privately owned water system only; Copy of Bylaws and Articles of Incorporation. enter text. *Attachment Checklist: ☐EZ1 ☐Map ☐Other Other Documentation Comments: Page 66 of 66