PA State Rep. Jim Rigby

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 *

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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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Letter of Support Request Form