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Letter of Support Request Form

Applicant

Applicant Name - Please provide the name of the ELIGIBLE applicant who is applying for funding and will serve as the recipient of the funds.

Is the eligible applicant applying on behalf of another organization?

Yes No

Contact Person - Please include the name of the primary contact person for this request.

Support Letter Contact Person Role

Applicant Engineer/Consultant Other

If Other, please specify

Address

City

State

Zip Code(5-Digit)

Contact Person Phone Number

Contact Person Email Address

Grant/Loan

Funding Department, Agency, Bureau, etc. (e.g. DCED, PennDOT, etc.)

Funding Program (e.g. Local Share Account, Multimodal Transportation Fund, etc.

Type of Funding

Grant Loan Tax Credit Other

If Other, please specify

Project Name

Application ID Number, if application submitted

If application has been submitted, please provide a copy of your application here.. (Accepted file types: doc, pdf, jpg, docx, Max. file size: 4 MB.)

Municipality

County

Requested Amount

Total Project Cost

Brief Description of the Project

Brief Impact of the Project

Will the ELIGIBLE applicant be requesting another support letter under the same funding department and program but for a different project?

Yes No

Support Letter Handling

To whom should the letter be addressed/directed? (first name, last name)

Please provide the title of the above addressee

Please provide the organization/department/agency of the above addressee

Please provide the mailing address of the above addressee

Address

Address (line 2)

City

State

Zip Code

Support Letter Extra Copies

Please provide the names and Mailing addresses (if hardcopy) or email addresses of where support letter extra copies should be sent.

Support Letter Due Date(MMDDYYYY)

Please allow at least two fully operational business days.

If submitting more than one project, please designate which project name is the highest priority here:

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Email*

ZIP Code

Office Locations

CRESSON

7447 Admiral Peary Highway
Cresson, PA 16630
814-886-1055
Weekdays 9 a.m.-4:30 p.m.

FERNDALE

1021 Ferndale Ave.
Johnstown, PA 15905
814-536-9818
Weekdays 9 a.m.-4:30 p.m.

SOMERSET COUNTY

1914 Graham Ave.
(next to Leone’s Market)
Windber, PA 15963
1-814-509-6942
Tuesdays & Thursdays
9 a.m. to 4:30 p.m.

CAPITOL

403 Irvis Office Building
PO Box 202071
Harrisburg, PA 17120
(717) 772-9924

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71st District
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