FRA F 6180.132 HSIPR Pre-Application Form

Federal Railroad Administration HSIPR Program Preapplication

P reapplication for HSIPR Program OMB No. 2130-XXXX

Preapplication instructions:

• Please complete this document electronically.

• For each question enter the appropriate information in the designated gray box.

• For a Multi-State project/program, States are encouraged to identify a lead applicant.

• Applicants should email the completed template (as an attachment) and direct questions to: HSIPR@dot.gov

1. Who Are You?

Select applicant type, as defined in Appendix 1.1 of the HSIPR Guidance (Check the appropriate box from the list): State Amtrak If one of the following, please append appropriate documentation as described in Section 4.3.1 of the HSIPR Guidance: Group of States Interstate Compacts Public Agency established by one or more States Amtrak in cooperation with a State or States
Name of lead State or organization applying:      
Name(s) of additional States and/or organizations applying in this group (if applicable):      
Application Point of Contact (POC):      			POC Title:      
Street Address:      	City:      	State:      		Zip Code:      	Telephone Number:      
Fax:      		Email:      

2. What Is Your Project?

Project/Program Name:	     
Project/Program Purpose Information : Describe the purpose(s) of and need(s) for the project/program (less than 500 characters):       Describe the high-speed and intercity passenger rail service(s) that will benefit from the project/program and expected outcome(s) (e.g., delay reduction, trip-time improvements, frequency increases, etc.) (less than 1,000 characters):      
Project/Program Type Information: Types of capital investments contemplated (Check all that apply): Structure (bridges, tunnels, etc.) Track-Rehabilitation Track-New Construction New Right-of-Way Major Interlocking Communications, Signaling, Control Electric Traction Rolling Stock Refurbishment Rolling Stock Acquisitions Stations, Terminals Support Facilities (Yards, Shops, etc.) Grade Crossing Improvements Other (Please describe):       (B) Describe the types of proposed improvements (e.g., new passing tracks, interlocking reconfigurations, station improvements, equipment acquisitions, etc.) (less than 1,000 characters):       (C) Service Attributes (Check all that apply): Additional Frequencies on Existing Route Improved Reliability/On-Time-Performance on Existing Route New Service Increased Average Speed/Shorten Trip Times Other (Please describe):      
Location Information Describe the location of the proposed project/program, including any use of existing railroad assets or rights-of-way and potential use of public lands and property (less than 1,000 characters):       State(s) in which the project/program investment is/are located:       State(s) in which the benefiting service(s) is/are located:      
Anticipated FRA Funding Track (Click on the appropriate option from the dropdown menu):
If unsure, please specify:      
Total Anticipated Project/Program Cost (in year-of-expenditure dollars (YOE)):      

3. Who Are Your Partners?

Will your project/program proposal include matching funds? Yes If yes, as what percentage of total costs?       No
Proposed source(s) of capital matching funds (Please check all that apply):
State	Local		Private	Other (Please Specify)      
If an in-kind match is expected, provide a brief description of the asset and a documented estimate of the monetary value of any such contribution, and its eligibility under 49 CFR §18.24 (less than 500 characters).      
Provide the status of negotiations with railroad owners that own or will own the right-of-way (Check the appropriate box. Space is provided for two railroad owners. If more than two railroads, please include additional information in question 18 below.
Railroad owner 1 (Name):		     
Status of railroad owner 1:
Railroad owner 2 (Name):		     
Status of railroad owner 2:
If applicable, provide the status of negotiations with partner that will operate the benefitting high-speed rail/ intercity passenger rail services (e.g., Amtrak) (Check the appropriate box).
Final executed agreement on project scope/outcomes/commitments					Preliminary executed agreement/MOU
Operating partner consulted, awaiting support commitment					Operating partner not yet consulted
No agreement, but operating partner supports project					No operating partner involved
Operations being competitively bid

4. What Preparation Work Have You Done?

15. The following is a list of components that will help identify project/program eligibility. Please indicate the project/program’s status by providing information on the documents and activities below. Although applicants are asked to respond to all components, please note that not all components are required for all tracks.

	Current Status
	No study exists	If no study exists, are you applying for HSIPR funds to complete study?	Study underway	Study completed? (year)	Unsure/Not Applicable
Service Development Plan Planning Studies/Documents
Purpose & Need/Rationale				     
Service/Operating Plan				     
Prioritized Capital Plan				     
Ridership/Revenue Forecast				     
Operating Cost Forecast				     
Tier 1 Programmatic (or “service”) NEPA (Identify Document)				     
Assessment of Benefits				     
Project Plan Components Studies/Documents
Preliminary Engineering (PE)				     
Tier 2 (project-level) NEPA (Identify Document)				     
Detailed Capital Cost Estimates				     
Assessment of Benefits				     
General Plan Components Studies/Documents
Project Management Plan				     
Financial Plan (capital & operating – sources/uses)				     

5. What Help Do You Need?

16. Describe any areas in which you could use technical assistance, best practices, advice or support from others (less than 1000 characters):      

17. Please provide any additional comments or complementary notes:      

FORM FRA F6180.132 Page 5

PRA  Public Protection Statement: Public reporting burden for this information collection is estimated to average XX hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  According to the Paperwork Reduction Act of 1995, a federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information unless it displays a currently valid OMB control number.  The valid OMB control number for this information collection is 2130-XXXX.  All responses to this collection of information are voluntary.  Burden times for RDV workbook forms to be added into above statement: (1) Track 1 = 100 hours, (2) Track 2 = 200 hours, (3) Track 3 = 50 hours, (4) Track 4 = 50 hours