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NewMarketsTaxCreditProjectIntakeForm

PartIGeneralInformation Today'sDate

ProjectTitle

ProjectStreetAddress

City State ZipCode

County ContactName

ContactPhoneNumber ContactEmail

11DigitCensusTractCode (Ifprojectoccupiestwotractspleaselistboth)

CommunityType(PleaseCheckOne):
MajorUrbanArea(totalurban/suburbanpopulationgreaterthan1million)
MinorUrbanArea(totalurban/suburbanpopulationlessthan1million)
RuralArea(Areasnotcontainedwithinmajorurbanorminorurbanareas)

PartIIProjectDetails

Pleasedescribetheproposedprojectprovidingasmuchdetailaspossible:
BorrowingEntityName ForProfitorNonprofit

NameofEntityOccupyingNMTCProjectSite Doestheprojectincludenewconstruction,
renovation,expansionoffacilities,ormajor
equipmentpurchase?

SquareFootageofFacility PlannedUseofFacility

Yes No NA
Istheprojectsitecontrolorleaseagreementexecuted?
Arearchitecturalplans/drawingscomplete?
IsphaseIenvironmentalstudycomplete?
Isappraisal/othercostbasisdocumentationavailable?
Areallrequiredpermitsappliedfororreceived?
Doesthisprojectinvolveconstruction?
Ifyes,hasaGeneralContractorbeenretained?
EstimatedStartDateofConstruction:

PartIIICommunityGoodsorServicestoLowIncomeCommunities

Iftheprojectwillincreaseaccesstocommunitygoodsand/orservicesforresidentsoflowincome
communitiesorlowincomepersons(healthcare,socialservices,educational,cultural,etc.),please
describethenumberofpeopletobeserved,andhowtheprojectwillservethem.

Willtheprojectbelocatedinaruralcommunitywithapopulationoflessthan20,000,orwillit
provideservicesto51%ormoreclientswhoareresidentsofcommunitieswithpopulationless
than20,000?

Yes No
Willtheprojectprovideanessentialcommunityfacilitycarryingoutafunctioncustomarily
providedbyaunitoflocalgovernment,orbeapublicimprovementneededfortheorderly
developmentofaruralcommunity?[Forexample,anonprofitprovidinghealthservices(hospitals,
medical/dentalclinics,skillednursingorassistedlivingfacilities,etc.);publicservices(townhalls,
courthouses,fireorpolicestations,prisons,etc.);community,socialorculturalservices(childcare
orcommunitycenters,transitionalhousing,librariesorschools,etc.);ortransportationfacilities
suchasstreets,roadsorbridges].

Yes No

Ifyes,pleaseprovideadditionaldetailifnotincludedelsewhere:

PartIVProjectFinancing

TotalEstimatedProjectCost NMTCAllocationRequested

(PleaseCheckOne)
SourcesofFinancingExcludingNMTCandAmount Equity Public Private

Yes No
Aretherecommitmentlettersinplace?
Hasalegalcounselbeenselected?
Ifso,who?
PartVProjectEligibility

InadditiontobeinginaCDFINMTCqualifiedcensustract,projectsmustbelocatedinareasthat
meetONEOFTHEFIRSTFIVEorTWOOFTHEFOLLOWINGELEVENcharacteristicstobeconsidered
anareaofdeeperdistress.Werelookingformaximumimpacttotargetareas.Ifyoubelieve
yourprojectmeetsthebelowcriteriafor"deeperdistressed",pleaseindicateanythatapply.

CensusTractMeetsatLeast1oftheFollowing:
PovertyRategreaterthan30%
MedianIncomethatdoesnotexceed60%ofareamedianincome
Unemploymentrateatleast1.5timesthenationalaverage
LocatedinaNonMetropolitanCountywithrespecttothe2010census
ServesaTargetedPopulationprojectis60%ownedbyLowIncomePersons(LIPs)
OR60%ofemployeesareLIPsORatleast60%ofcustomersareLIPs

ORCensusTractmeetsatleast2ofthefollowing:
PovertyRate>25%,but<30%ORMedianIncome>60%,but<70%OR
unemployment>1.25timesnationalaverage,but<1.5times
SBAdesignatedHUBZone(Note:Projectmustqualifyandreceivecertification)
BrownfieldRedevelopmentArea
EncompassedbyaHOPEVIRedevelopmentPlan
FederallydesignatedNativeAmerican/AlaskanNative/HawaiianHomelandsArea
AreadesignatedasdistressedbytheAppalachianRegionalCommissionorDelta
RegionalAuthority
ColoniasAreaasdesignatedbytheU.SDepartmentofHousingandUrban
Development
FederallydesignatedmedicallyunderservedareaifQLICIwillsupporthealthrelated
services
FederallydesignatedPromiseZones,ImpactedCoalCounties,BaseRealignmentand
Closureareas,StateEnterprisezoneprograms,orothersimilarstate/localprograms
targetedtowardsparticularlyeconomicallydistressedcommunities.
CountywhereFEMAissuedamajordisasterdeclarationandtheinitialinvestment
willbemadewithin36monthsofthedisasterdeclaration.
CensustractsidentifiedasFoodDesertsundertheHFFIdefinition(USDAERS),tothe
extentQLICIactivitieswillincreaseaccesstohealthyfood.

PartVIBorrowingEntityQALICBQualification

AreanyofthefollowingbusinesseseitherproposedoroperatingattheNMTCprojectsite:
massageparlor,hottubfacility,suntanfacility,countryclub,racetrack
orotherfacilityusedforgambling,storewhoseprincipalpurposeisthesaleof
alcoholicbeveragesforconsumptionoffpremises,developmentorholdingof
intangiblesforsale,and/oraprivateorcommercialgolfcourse?

Yes No

Ifyes,pleaseexplain:
WouldanyproposedrevenuesoftheNMTCprojectcomefromtherentalofresidentialproperty
(apartmentsorlive/workunits)?

Yes No

Ifyes,estimatethepercentageforeachbuilding:

PartVIIDeterminationofNeedforNMTC

CouldthisprojectmoveforwardwithouttheexistenceoftheNMTCenhancement?

Yes No

Ifno,pleaseindicatewhatspecificbenefitNMTCswillprovidesotheprojectcanmoveforward
(e.g.LowerLTV,NonTraditionalCollateral,LowerBlendedInterestRate,moreflexibleunderwriting,
financialleverageetc.) :

PartVIIICommunityImpact

Pleasefillinallthatapply:

ExpectedCommunityImpactHousing
Describeanyhousingcomponentoftheproject?

Total#units

Aretheserentalorforsaleunits?

#unitsaffordabletolowincomepeople

ExpectedCommunityImpactIncrementalInvestment
Inwhatwayswillyourprojecthelpspuradditional
privateorpublicinvestmentintheimmediate
vicinityoftheproject?
Estimatethedollarvalueoftheincremental
investmentdescribedabove.

ExpectedImpactNewJobCreation
Numberandtypeoffullandparttimenewjobsto
becreated

Avg.wagesnewjobs (pleaseprovidearangeif
applicable)
Jobbenefitstobeoffered(e.g.insurance,sickpay,
holidays,401k,lifeinsurance,childcareetc.)

Numberandtypesofnewjobsthatwillrequire
onlyahighschooleducation
Willjobtrainingbeoffered?

Willjobshavecareerpaths?

What,ifany,effortswillbemadetotargetjobsto
lowincomecommunityresidentsorotherlow
incomepeople?
Willjobstargetwomen,minorities,veterans,or
thedisabledorothertargetpopulations?

ExpectedImpactJobRetention
Numberandtypesofjobstoberetained

Avg.wagesretainedjobs (pleaseprovidearangeif
applicable)

Jobbenefitsoffered

ExpectedImpactConstructionJobCreation
NumberoftemporaryFTEconstructionjobstobe
created(OneFTEisa35hourormoreworkweek)

Avg.wagesconstructionjobs (pleaseprovidea
rangeifapplicable)
What,ifany,effortswillbemadetoutilize
minority/women/veteranownedbusinesses?

OTHERExpectedImpacts
Describecommercialgoodsorservicestheproject
willprovidetoresidentsofLowIncome
CommunitiesorLowIncomePersons (e.g.access
toretail,restaurants,orpharmacies,etc.)

HowmanyLowIncomePeoplewillbenefitfrom
plannedcommercialgoodsorservices?
DescribethecommunitygoodsorservicestoLow
incomeCommunitiesorLowIncomePersonsthe
projectwillprovide(e.g.,accesstosocial,
educational,healthcare,orcultural,etc.)
HowmanyLowincomePeoplewillbenefitfrom
plannedcommunitygoodsorservices?
Describehowtheprojectremediates
environmentalcontamination,meetsLEED
certificationstandards;and/ordirectlysupportthe
productionordistributionofrenewableenergy
resources(e.g.biomass,hydro,geothermal,solar,
wind,etc.).
Ifapplicable,describehowtheprojectimproves
accesstofreshandhealthyfoods (e.g.retailoutlets
suchasgrocerystores,supermarketsandfarmers
marketsforLowIncomePersonsorLowIncome
Communities)
Doestheprojectprovidespaceand/oranexplicit
setasideforlocallyowned,
minorityorwomenownedbusinessesornon
profittenants?

Doestheprojectcreateenvironmentally
sustainableoutcomesthroughgreen
buildingconcepts,locationnearmasstransit,
adaptivereuseofexistingbuilding
ormaterials,etc.?

Pleasedescribeanyotherimpactstheproject
offerstothecommunity


PartIXAdditionalInformation

Areyouseekingordoyouplantoseekstateorfederaltaxcredits(includingNMTC)withother

Yes No

Ifyes,pleaseindicatewho:

HaveyoureceivedNewMarketsTaxCreditsforpastprojects?

Yes No

Ifyes,pleasenamethetaxcredittype(s)andentity(ies):

Pleaselistanyadditionalinformationyouwishtoprovide:
Ifyouhaveanyquestionspleasecontact: Mr.JasonL.Lee
CommunityVentures
1450NBroadway
Lexington,Kentucky40505
Phone8592310054
Emailjlee@cvky.org

ForInternalUseOnly:
VerifiedNMTCQualifiedLocation(YesorNo)