HomeMy WebLinkAbout2020.11.23 Council Remote Special Meeting Packet
AGENDA
Remote Special Meeting
7:00 PM - Monday, November 23, 2020
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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.)
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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.
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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
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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
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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
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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
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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
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22
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25
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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.)
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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
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text.
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text.
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text.
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text.
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text.
Total Number of
Active
Commercial
Connections
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enter text.
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text.
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text.
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text.
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text.
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text.
Total Number of
Other or Vacant
Connections
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enter text.
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text.
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text.
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text.
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text.
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text.
Total Number of
Connections
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text.
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text.
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text.
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text.
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text.
*Water Rate Information (Provide Water Rate Information per residential connection.)
Average monthly
residential rate
per connection
(base rate)
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here to
enter text.
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here to enter
text.
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text.
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text.
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text.
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text.
Additional
residential rate
per 100 cubic
feet (CF)
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enter text.
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text.
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text.
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text.
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text.
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text.
Average monthly
cubic feet
consumption per
connection
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here to
enter text.
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text.
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text.
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text.
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text.
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text.
Current average
rate per
connection
before this
project
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here to
enter text.
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text.
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text.
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text.
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text.
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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
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to enter text.
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here to
enter text.
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text.
☐Weekly
☐Monthly
☐Quarterly
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here to enter
text.
☐Fixed
☐Variable
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here to enter
text.
Click or tap here
to enter text.
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enter text.
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text.
☐Weekly
☐Monthly
☐Quarterly
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here to enter
text.
☐Fixed
☐Variable
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here to enter
text.
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to enter text.
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enter text.
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text.
☐Weekly
☐Monthly
☐Quarterly
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text.
☐Fixed
☐Variable
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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
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to enter text.
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enter text.
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text.
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text.
☐Fixed
☐Variable
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text.
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text.
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to enter text.
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enter text.
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text.
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text.
☐Fixed
☐Variable
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here to enter
text.
Click or tap
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text.
Click or tap here
to enter text.
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enter text.
Click or tap
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text.
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text.
☐Fixed
☐Variable
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text.
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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:
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