Application as of 12-05-24

Kaysinger Basin Regional Planning Commission

Paul Bruhn Historic Revitalization Subgrantee Application
Project Name (include county where the property is located - i.e. "Old Schoolhouse - Benton County)*
Applicant Information

Please refer to the Subgrant Program Guidelines prior to completing this application.
Name*

Applicant First NameApplicant Last Name
Entity Name (city, county, business, organization, etc.):
Applicant Mailing Address:
Street Address*
City*
State*
Zip Code*
County*
Applicant Email Address*
example@example.com
Applicant Phone Number*
Please Answer the Following Mandatory Questions:
Applicant UEI Number*
Does the applicant own the building or is a co-owner*

YESNO
Is the applicant a property tenant*

YESNO
Project Coordinator (may be the same as the applicant or primary contact):
Name*

First NameLast Name
Street Address*
City*
State*
Zip Code*
Email Address*
example@example.com
Phone Number*
Property/Project Information
Property Name*
Street Address*
City*
State*
Zip Code*
Type of Property*

CommercialCommunityResidentialMixed Use
Has the property been individually listed in the National Register of Historic Places, is eligible to be on the National Register of Historic Places, or identified as a contributing element to a district listed in the National Register of Historic Places?*

YESNO
The KBRPC Paul Bruhn Project Director can help you determine whether or not the property is on the National Register of Historic Places, or you can visit the following link - https://mostateparks.com/page/84436/missouri-national-register-listings, or call the MO State Historic Preservation Office at 800-361-4827 or
573-751-7858
Current Use of Property*
Is this property currently occupied?*

YESNO
If you answered "No", please explain the reason for vacancy.

0/500
Provide a narrative that describes the current state of the property, its current use, and the proposed use for the property once renovated.*

0/1000
Why should this project receive grant funds through the KBRPC Paul Bruhn Historic Revitalization Subgrant Program.*

0/1000
What is the intended use of the property after the proposed revitalization work is completed?*

0/1000
How will the completed project contribute to the Kaysinger Basin Regional Planning Commission's priority areas of this grant (economy, tourism, community, workforce)?*

0/1000
If this project is awarded a grant, will the property be ready for occupancy at the completion of the grant period as defined in the subaward agreement?*

YESNO
If you answered "No" to the above question, explain the reason for non-occupancy once the project is completed. If you answered "Yes", please put "N/A".

0/500
Budget Details
Please list in LINE ITEM form all work to be performed with grant funds, including the estimated dollar amount associated with each and a final total at the bottom of the list. Example - Replace all windows - 10 windows x $500.00/each = $5,000.00.*

0/500
Total Project Cost please be sure to include all eligible costs - i.e. design/engineering, etc.*
Will you accept partial funding for this project?*

YesNo
Provide a budget narrative that explains the line items listed above and why the listed work is needed.*

0/500
Project Budget Worksheet. For further guidance, refer to page 20 of the PBHRG Guidelines. Please note: The project budget total will be reflected in line 15 of the form below.*
Scope of Work
Please provide an overall Scope of Work narrative that explains the proposed project and its necessity and beneficial impact as it relates to your community and the Kaysinger Basin Region.*

0/1000
Is your project located in a local historic district?*

YESNO
If you answered "yes" to the above question, does the historic district require a Certificate of Appropriateness?

YESNO
Matching Funds Commitment Documentation
Certified Match Amount:*
The above applicant hereby certifies the above amount, in the form of cash or other eligible in-kind matching funds are available unencumbered, and will be committed if the grant project is awarded. The applicant hereby certifies that these funds are not obligated as matching funds for any other grant and that these matching funds have come from a source OTHER than the Paul Bruhn Historic Revitalization Grant program and are NOT federal funds.
Name of Authorizing Official:*

First NameLast Name
Authorizing Official Title:*
Authorizing Official Signature Certifying Matching Funds:*

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Applicant Signature Requirements
By checking this box, I certify that I have read and understand all the information contained in the Historic Revitalization Subgrant Program Guidelines.
By checking this box, I certify that all figures, statements, and representations made in this application, including any uploaded documents, are true and correct to the best of my knowledge.
By checking this box, I certify that funding is available to proceed with each phase of the project according to the deadlines outlined in Appendix B of the grant guidelines. I understand this is a reimbursement grant unless a request for advancement of funds is approved (on an as-needed basis only).
By checking this box, I certify that I am aware that if this project is selected for funding, the property owner will be required to enter into a preservation easement agreement with Kaysinger Basin Regional Planning Commission.
Application Signature (Authorized Official):*

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Date of Signature*

MonthDayYear
Date
Is the applicant a (check applicable box):*

Local GovernmentCorporationNon-Profit OrganizationPrivate Owner
Required Additional Documents
Please Upload All Required Files Here (as described in the Guidelines and the application checklist) - PLEASE ONLY UPLOAD THE FOLLOWING FILE FORMATS - pdf, jpeg, jpg, png.*

Cancelof
Should be Empty:

Kaysinger Basin Regional Planning Commission

Applicant Information

Applicant Mailing Address:

Property/Project Information

Budget Details

Scope of Work

Matching Funds Commitment Documentation

Applicant Signature Requirements

Required Additional Documents