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Municipal Application
	Municipality Business Information : Legal Name of Municipality/ Obligor: * Federal ID Address Address Line 1 City State Zip Code County Phone Fax Email Email Confirm Email Gross Annual Revenue State Organization ID Contact Name * First Last Contact Title Contact Phone * Contact Email Email Confirm Email Alternate Contact First Last Alternate Contact Title Alternate Contact Phone Alternate Contact Email Email Confirm Email Type of Municipality City Township State School District Town County Solid Waste District Other Population Households Department/Agency Fiscal Officer Name First Last Fiscal Officeer Title Fiscal Officer Phone Fiscal Officer Fax Date Municipality Entity Was Established Does the obligor self-insure for property & liability insurance? Yes No Within the current calendar year, we or will not issue $10,000,000 or more total debt including all bonds, loans and leases. We Will We Will Not Equipment Information (Attach separate sheet if necessary) Equipment Description Manufacturer Model Year Quantity Equipment Cost $ Total Cost $ Equipment Location Address Line 1 City State Zip Code Equipment Equipment is Additional Equipment is Replacement New Used Soft Costs Included? Yes No Amount of soft costs included (shipping, software, and sales tax) Buyout Included? Yes No Amount of buyout included: Describe the essential use of the equipment: Is the project a building? Yes No If yes, who owns the land? What is the physical address of the new building/project? Address Line 1 City State Zip Code Lease Terms Desired: Length of Lease Term 3 Years 4 Years 5 Years Other Payment Mode Monthly 4 Quarterly Semi-Annual Annual First Payment Due Upon Delivery Other Other Requests/ Requirements: Vendor Information (Attach separate sheet if necessary) Vendor Company Vendor Contact email Email Confirm Email Vendor Contact Name First Last Vendor Contact Phone Vendor City State Zip Name

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