Indicates required field Your Contact InformationPrefix:- None -Ms.Miss.Mrs.Mr.Mr. and Mrs.Rev.Dr.The HonorableRabbiFirst Name: Last Name: Requesting Organization Name : AddressAddressAddress 2City/TownState- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingZIP CodeEmail:Contact Phone Number:Phone NumberRequestBrief description of Program Request:One-Page detailed descriptionOne file only.2 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Request Type:- Select -Program FundingBill LanguageReport LanguageLocationSame as entity?Location of project if different from Entity applyingSubcommittee:- Select -AgricultureCommerce, Justice, ScienceDefenseEnergy and WaterFinancial ServicesHomeland SecurityInteriorLabor, Health and Human ServicesLegislative BranchMilitary Construction, Veterans AffairsState and Foreign OperationsTransportation, and Housing and Urban DevelopmentProject total cost: Is there a local match: - None -YesNoIf there is a local match, please elaborate on the amount and funding sources:Have you requested with a another member of congress: - None -YesNoIf yes, which member and district:For Programmatic RequestsSubcommittee and AgencyPlease Select a Committee- Select -AgricultureCommerce Justice ScienceDefenseEnergy and WaterFinancial Services and General GovernmentHomeland SecurityInterior and EnvironmentLabor HHSLegislative BranchMilcon VAState and Foreign OperationsTransportation, Housing and Urban Development Please select an agency:Agriculture- Select -USDA - Staff OfficesUSDA - Research, Education, and EconomicsUSDA - Marketing and Regulatory ProgramsUSDA - Food SafetyUSDA - Farm Production and Conservation ProgramsUSDA - Rural DevelopmentUSDA - Domestic Food ProgramsUSDA - Trade and Foreign Agricultural AffairsFood and Drug AdministrationCommodity Futures Trading CommissionFarm Credit AdministrationGeneral ProvisionsCommerce Justice Science- Select -CommerceJusticeOffice of Science and Technology PolicyNational Space CouncilNASANational Science FoundationRelated AgenciesBill-wideDefense- Select -ArmyNavyMarine CorpsAir ForceSpace ForceDefense-WideOtherEnergy and Water- Select -Army Corps of Engineers (Civil)Department of the InteriorDepartment of EnergyIndependent AgenciesFinancial Services and General Government- Select -Department of the TreasuryExecutive Office of the PresidentFederal JudiciaryDistrict of ColumbiaAdministrative Conference of the United StatesConsumer Product Safety CommissionElection Assistance CommissionFederal Deposit Insurance CorporationFederal Election CommissionFederal Labor Relations AuthorityFederal Permitting Improvement Steering CouncilFederal Trade CommissionGeneral Services AdministrationHarry S. Truman Scholarship FoundationMerit Systems Protection BoardMorris K. Udall and Stewart L. Udall FoundationNational Archives and Records AdministrationNational Credit Union AdministrationOffice of Government EthicsOffice of Personnel ManagementOffice of Special CounselPostal Regulatory CommissionPrivacy and Civil Liberties Oversight Board (050)Public Buildings Reform BoardSecurities and Exchange CommissionSelective Service System (050)Small Business AdministrationUnited States Postal ServiceUnited States Tax CourtGeneral ProvisionsHomeland Security- Select -Office of the Secretary and Executive ManagementManagement DirectorateIntelligence, Analysis, and Operations CoordinationOffice of the Inspector GeneralU.S. Customs and Border ProtectionU.S. Immigration and Customs EnforcementTransportation Security AdministrationCoast GuardUnited States Secret ServiceCybersecurity and Infrastructure Security AgencyFederal Emergency Management AgencyU.S. Citizenship and Immigration ServicesFederal Law Enforcement Training CenterScience and Technology DirectorateCountering Weapons of Mass Destruction OfficeGeneral ProvisionsInterior and Environment- Select -Land and Water Conservation Fund - any agencyWildland Fire Management - all agenciesBureau of Land Management - Management of Lands and ResourcesBureau of Land Management - Oregon and California Grant LandsU.S. Fish and Wildlife ServiceNational Park Service - Operations of the National Park SystemNational Park Service - National Recreation and PreservationNational Park Service - Historic Preservation FundNational Park Service - ConstructionNational Park Service - Centennial ChallengeUS Geological SurveyBureau of Ocean Energy ManagementBureau of Safety and Environmental EnforcementOffice of Surface MiningBureau of Indian Affairs - Operation of Indian ProgramsBureau of Indian Affairs - Contract Support CostsBureau of Indian Affairs - ConstructionBureau of Indian Affairs - Indian Land and Water Claim SettlementsBureau of Indian Affairs - Indian Guaranteed Loan ProgramBureau of Indian Affairs - Office of the Special TrusteeBureau of Indian Education - Operation of Indian Education ProgramsBureau of Indian Education - ConstructionDepartment of the Interior - Office of the SecretaryDepartment of the Interior - PILTInsular AffairsDepartment of the Interior - Office of the SolicitorDepartment of the Interior - Office of Inspector GeneralDepartment of the Interior - Office of the Special Trustee for American IndiansDepartment of the Interior - Central Hazardous Materials FundDepartment of the Interior - Natural Resource Damage Assessment FundDepartment of the Interior - Working Capital FundDepartment of the Interior - Office of Natural Resources RevenueEnvironmental Protection Agency - Science and TechnologyEnvironmental Protection Agency - Environmental Programs and ManagementEnvironmental Protection Agency - Office of Inspector GeneralEnvironmental Protection Agency - Buildings and FacilitiesEnvironmental Protection Agency - Hazardous Substance SuperfundEnvironmental Protection Agency - Leaking Underground Storage TankEnvironmental Protection Agency - Inland Oil Spill ProgramsEnvironmental Protection Agency - State and Tribal Assistance GrantsEnvironmental Protection Agency - Water Infrastructure Finance (WIFIA)Department of AgricultureForest Service - Forest Service OperationsForest Service - Forest and Rangeland ResearchForest Service - State and Private ForestryForest Service - Capital Improvement and MaintenanceForest Service - Range Betterment FundForest Service - Gifts, DonationsForest Service - Subsistence UsesIndian Health Service - Indian Health ServicesIndian Health Service - Contract Support CostsIndian Health Service FacilitiesNational Institute of Environmental Health SciencesAgency for Toxic Substances Disease RegistryExecutive Office of the President - Council on Environmental QualityChemical Safety and Hazard Investigation BoardOffice of Navajo and Hopi Indian RelocationInstitute of American Indian and Alaska Native Culture and Arts DevelopmentSmithsonian InstitutionNational Gallery of ArtKennedy Center for the Performing ArtsWoodrow Wilson International Center for ScholarsNational Endowment for the ArtsNational Endowment for the HumanitiesCommission of Fine ArtsNational Capital Arts and Cultural AffairsAdvisory Council on Historic PreservationNational Capital Planning CommissionUnited States Holocaust Memorial MuseumPresidio TrustDwight D. Eisenhower Memorial CommissionWomen's Suffrage Centennial CommissionWorld War I Centennial CommissionAlyce Spotted Bear and Walter Soboleff Commission on Native ChildrenLabor HHS- Select -Employment and Training Administration (ETA)Employee Benefits Security Administration (EBSA)Pension Benefit Guaranty Corporation (PBGC)Wage and Hour DivisionOffice of Labor-Management StandardsOffice of Federal Contract Compliance ProgramsOffice of Workers' Compensation ProgramsOccupational Safety and Health Administration (OSHA)Mine Safety and Health Administration (MSHA)Bureau of Labor Statistics (BLS)Office of Disability Employment Policy (ODEP)Labor Departmental ManagementVeterans Employment and Training (VETS)Labor - General ProvisionsHealth Resources and Services Administration (HRSA)Centers for Disease Control and Prevention (CDC)National Institutes of Health (NIH)Substance Abuse and Mental Health Services Administration (SAMHSA)Agency for Healthcare Research and Quality (AHRQ)Centers for Medicare and Medicaid Services (CMS)Administration for Children and Families (ACF)Administration for Community Living (ACL)HHS Office of the Secretary (OS)HHS - General ProvisionsEducation for the DisadvantagedImpact AidSchool Improvement ProgramsIndian EducationInnovation and ImprovementSafe Schools and Citizenship EducationEnglish Language AcquisitionSpecial EducationRehabilitation Services and Disability ResearchSpecial Institutions for Persons with DisabilitiesCareer, Technical, and Adult EducationStudent Aid AdministrationHigher EducationCollege Housing and Academic Facilities Loans Programs (CHAFL)Historically Black College and University Capital Financing Program Account (HBCU)Institute of Education SciencesDepartmental ManagementEducation - General ProvisionsCommittee for Purchase From People Who Are Blind or Severely DisabledCorporation for National and Community Service (CNCS)Corporation for Public Broadcasting (CPB)Federal Mediation and Conciliation Service (FMCS)Federal Mine Safety and Health Review Commission (FMSHRC)Institute of Museum and Library Services (IMLS)Medicaid and CHIP Payment and Access Commission (MacPAC)Medicare Payment Advisory Commission (MedPAC)National Council on Disability (NCD)National Labor Relations Board (NLRB)National Mediation BoardOccupational Safety and Health Review CommissionRailroad Retirement Board (RRB)Social Security Administration (SSA)LHHS bill-wide - General ProvisionsLegislative Branch- Select -House of RepresentativesJoint ItemsCapitol PoliceOffice of Congressional Workplace Rights (OCWR)Congressional Budget OfficeArchitect of the CapitolLibrary of CongressGovernment Publishing OfficeGovernment Accountability OfficeOpen World Leadership CenterJohn C. Stennis Center for Public Service Training and DevelopmentOtherMilcon VA- Select -Department of Defense (DOD)Veterans Affairs (VA)Title III (Related Agencies)Title IV (OCO)Title V (General Provisions)State and Foreign Operations- Select -Title I - State Department Operations and International CommissionsTitle II - USAID OperationsTitle III - Bilateral Economic AssistanceTitle IV - Security AssistanceTitle V - UN and International Financial InstitutionsTitle V - Multilateral AssistanceTitle VI - Export, Investment, and Trade AssistanceTitle VII - General Provisions: Regions and SectorsTransportation, Housing and Urban Development- Select -DOT - Office of the SecretaryDOT - Local Transportation PrioritiesDOT - Federal Aviation AdministrationDOT - Federal Highway AdministrationDOT - Federal Motor Carrier Safety AdministrationDOT - National Highway Traffic Safety AdministrationDOT - Federal Railroad AdministrationDOT - Federal Transit AdministrationDOT - Saint Lawrence Seaway Development Corp.DOT - Maritime AdministrationDOT - Pipelines and Hazardous Materials SafetyDOT - Office of Inspector GeneralHUD - Management and AdministrationHUD - Public and Indian HousingHUD - Community Planning and DevelopmentHUD - Housing ProgramsHUD - Federal Housing AdministrationHUD - Government National Mortgage AssociationHUD - Policy Development and ResearchHUD - Fair Housing and Equal OpportunityHUD - Office of Lead Hazard Control and Healthy HomesHUD - Cybersecurity and Information Technology FundHUD - Office of Inspector GeneralHUD - Economic Development InitiativesRelated AgenciesGeneral ProvisionsProgram Funding Level- Select -Support amount indicated in response to the following questionSupport the enacted levelSupport the President’s budget requestGeneral support for the programFunding should be increasedFunding should be decreasedEliminate the programExact Language Request:Justification for Language RequestCommunity support Community engagement and support is crucial in determining which projects are worthy of Federal funding. Only projects with demonstrated community support will be considered.Do you have any of the following? If answer yes please attach with the form Letters of support from elected community leaders (e.g. mayors or other officials)- None -YesNoIf yes please elaborate below:Document UploadOne file only.2 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Press articles highlighting the need for the requested Community Project Funding- None -YesNoIf yes please elaborate below:Document UploadOne file only.2 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Support from newspaper editorial boards- None -YesNoIf yes please elaborate below:Document UploadOne file only.2 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Projects listed on State intended use plans, community development plans, or other publicly available planning documents- None -YesNoIf yes please elaborate below:Document UploadOne file only.2 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Resolutions passed by city councils or boards. - None -YesNoIf yes please elaborate below:Document UploadOne file only.2 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Please provide a justification for why it is an appropriate use of taxpayer fundsFinancial disclosure for community project fundingDo you or any of your associates have any personal connection to Rep. Beth Van Duyne and/or her family?- None -YesNoWill you or any of your associates personally benefit financially from the inclusion of the Community Project Funding?- None -YesNoPlease select all that apply to the entity making the requestFor Profit recipientState, local or Tribal entity Non-profit recipientLobbyist