CPA Eligibility Determination Form

CPA Eligibility Determination Form FY24

City of Somerville Community Preservation Act Fund
Please contact Community Preservation Act Manager, Roberta Cameron, with questions about this form. rcameron@somervillema.gov
Project Name:
Project Location:
Property Owner:
Applicant Name/Organization:
Contact Person:
Mailing Address:
Phone:
Email:
Approximate amount of funds to be requested:
Please provide “ballpark” estimate – contractor/vendor estimates not required at this stage.

Does your project...

	Yes	No	Maybe
Acquire, create, or preserve open space and natural resources?
Acquire, create, preserve, or rehabilitate land used for outdoor recreation?
Acquire, preserve, or restore a historic asset?
Acquire, preserve, create, or support affordable housing?

Check if this project is for historic preservation

Yes
Does your project pertain to a physical asset such as a building, structure, land, or object?

YesNoMaybe
Would the public be able to view and/or access the asset?

YesNoMaybe
Who owns the property or asset?

I, or my organization owns it.The City of Somerville is the owner and the applicant.I have the owner's agreement to apply for a grant together. (Attach documentation: owner's signature as co-applicant or letter of consent)
Is the property currently protected under a deed restriction, Article 97, or other form of permanent protection?

Yes (please attach documentation)No
Narrative Questions
Project Summary:
Please provide a brief description of the proposed project.
Project Status:
What community need is this trying to address and what level of planning has already been undertaken to inform the proposed project, including stakeholders engaged to date?
Acknowledgement of Grant Agreement Requirements and Conditions
The CPA Application Supplement provides sample forms and specifications which will be required of all projects which receive CPA grants before funds will be disbursed.

Please review the following list and check each box to acknowledge that you have reviewed this material and consent to sign these forms if applicable, and agree to CPA conditions if your grant is approved.
CPA Grant Agreement*

Grant Agreement General ConditionsDisbursement Guidelines
City of Somerville Standard Contract Forms*

General Grant AgreementCertificate of AuthorityEvidence of InsuranceCertificate of Good Standing (MA and Somerville)Side Guard Ordinance AcknowledgementTax Exemption AcknowledgementCampaign Contribution DisclosureSomerville Living Wage Ordinance Acknowledgement
Sample Restrictions*

Preservation RestrictionConservation RestrictionPublic Access Agreement
Please print, sign and submit the following Signature Form using the window below.
Submit Signature Form here.

Cancelof
If applicable, submit documentation of owner's consent here.

Cancelof
Should be Empty:

CPA Eligibility Determination Form FY24

Narrative Questions

Acknowledgement of Grant Agreement Requirements and Conditions