OFFICE OF CONGRESSMAN DANIEL B. MAFFEI
APPROPRIATIONS REQUEST FORM
FISCAL YEAR 2010

Please be aware that information provided on this form may be made available to the public.

All applications are due by 6pm on Friday, February 27, 2009.

All submissions must be made electronically by emailing this completed form (without alterations) to 
maffei.appropriations@mail.house.gov.

Please limit all open-ended questions to a paragraph answer.

Project Information
1.	This request best fits into the _________________________ Appropriations bill.

2.	Agency and Account

3.	Name of project

4.	Brief project description

5.	Will the project occur in New York's 25th congressional district?  Yes____/No____  Please 
specify the location of the project.

6.	If the project is NOT located in the 25th congressional district, please describe the impact on the 
district.

7.	Are other Members of the House and Senate also submitting this request?  If so, please list Member 
and appropriate staff with their telephone number and email.

8.	This request is our organization's 1st____ 2nd____ 3rd____ priority.

9.	What is the current status of the project?  What is the estimated completion date of the project?

10.	What measurable outcome will result from the project?  How many and what type of jobs will be 
created or retained due to this funding?

Organizational Information
11.	Name of submitting organization

12.	Describe your organization's mission.  Please include whether it is a public, private or non-profit 
entity.

13.	How many people are currently employed by the organization?_____  How many people are 
employed in New York's 25th?______

14.	Is your organization located in New York's 25th congressional district? Yes____/No____
Funding Details
15.	Amount of funding requested:  $_____________

16.	Please provide a brief budget for the project, listing exactly what the funding is requested for and 
placing an amount by the individual line item.

17.	What is the total cost of the project?

18.	Please list ALL anticipated sources of funding for the project and the amount you have received or 
expect to receive from each source.

19.	Is this project included in the President's budget?  Yes____/No____  If yes, please include amount, 
title and account.

20.	Is the project authorized?  Yes____/No____  If so, please provide the authorization language and 
reference.

21.	Has an application for funding ever been submitted to a federal agency?  Yes____/No____  If yes, 
what was the outcome of the request?

22.	If you have previously received funding, please list the amount of money this project received over 
the past four appropriations cycles.
       FY08:					FY06:
	Member:				Member:

	FY07:					FY05:
	Member:				Member:

23.	Has an application for funding ever been submitted to a Member of Congress for this project and 
NOT received funding?  If yes, what was the Member, year and funding amount?

24.	If required by the federal program you have selected, is the local match available?

Contact Information
25.	Address of submitting organization

26.	County

27.	Highest level person at the organization (who may the Congressman contact?)
   Name:
   Phone:
   Email:
   
28.	Staff contact at the organization (who is familiar with the project?)
   Name:
   Phone:
   Email:
   
29.	Lobbyist/government affairs representative for the organization
   Name:
   Firm:
   Phone:
   Email:

Additional Material
30.	Please attach at least three letters of support for the project from community leaders, local elected 
officials, or community organizations.

31.	If this is a defense request, please attach the FY10 HASC and HAC-D forms.

32.	If this is a military construction request, please attach DoD Form 1391.

33.	If this is an EPA water and wastewater infrastructure project (also called STAG), does the 
community have a financing plan certified by an authorized local official demonstrating how it will 
cover the 45% matching funds? Yes____/No____

34.	If this is a National Park Service Save America's Treasures historic preservation program 
request, does the grantee have the required 50% non-federal matching funds? Yes____/No____

35.	If this is a transportation request, please include the following:

a.	What is the State/local share of the project cost? ____% or $________ (Most projects 
require a match of at least 20% of the projects total cost.)

b.	How much of the request will be spent by September 30, 2010?

c.	Is the project on the State's Transportation Improvement Plan? Yes____/No____

d.	Is the project considered by the State and/or regional transportation officials as critical to their 
needs? Yes____/No____


1