Community Mitigation Reserve Fund Application with grayed boxes 12182014.docx

2015 COMMUNITY MITIGATION FUND APPLICATION

CHECK BOX IF REQUESTING THE CREATION OF A MITIGATION RESERVE FUND FOR A COMMUNITY

APPLICATIONS DUE NO LATER THAN FEBRUARY 2, 2015.

For anyone with specific impacts, please complete the gray boxes 1-4 beginning on page 2. If you are not applying for mitigation of specific impacts by February 2, 2015, you do not need to complete grayed boxes 1-4.

NAME OF MUNICIPALITY/GOVERNMENT ENTITY/DISTRICT

DEPARTMENT RECEIVING FUNDS

NAME AND TITLE OF INDIVIDUAL RESPONSIBLE FOR HANDLING OF FUNDS

ADDRESS OF INDIVIDUAL RESPONSIBLE FOR HANDLING OF FUNDS

PHONE # AND EMAIL ADDRESS OF INDIVIDUAL RESPONSIBLE FOR HANDLING OF FUNDS

NAME AND TITLE OF INDIVIDUAL AUTHORIZED TO COMMIT FUNDS ON BEHALF OF MUNICIPALITY/GOVERNMENTAL ENTITY

ADDRESS OF INDIVIDUAL AUTHORIZED TO COMMIT FUNDS ON BEHALF OF MUNICIPALITY/GOVERNMENTAL ENTITY

PHONE # AND EMAIL ADDRESS OF INDIVIDUAL AUTHORIZED TO COMMIT FUNDS ON BEHALF OF MUNICIPALITY/GOVERNMENTAL ENTITY

NAME OF GAMING LICENSEE

IMPACT DESCRIPTION

Please describe in detail the impact that is attributed to the construction of a gaming facility. Please provide support for the determination that the construction of the gaming facility caused or is causing the impact.

PROPOSED MITIGATION

Please identify below the manner in which the funds are proposed to be used. Please provide documentation (e.g. - invoices, proposals, estimates, etc.) adequate for the Commission to ensure that the funds will be used for the cost of mitigating the impact from the construction of a proposed gaming establishment. Please describe how the mitigation request will address the specific impact indicated. Please attach additional sheets/supplemental materials if necessary.

IMPACT CONTROLS/ADMINISTRATION OF IMPACT FUNDS

Please provide detail regarding the controls that will be used to ensure that funds will only be used to address the specific impact. If non-governmental entities will receive any funds, please describe what reporting will be required and how the applicant will remedy any misuse of funds.

RELEVANT EXCERPTS FROM HOST OR

SURROUNDING COMMUNITY AGREEMENTS

Please describe and include excerpts from any relevant sections of any Host or Surrounding Community Agreement. Please explain how this impact was either anticipated or not anticipated in that Agreement.

CERTIFICATION BY MUNICIPALITY/GOVERNMENTAL ENTITY

On behalf of the aforementioned municipality/governmental entity I hereby certify that the funds that are requested in this application will be used solely for the purposes articulated in this Application.

Signature of Responsible Municipal Official/Governmental Entity

Date

APPROVAL OF THE MASSACHUSETTS GAMING COMMISSION

On behalf of the Massachusetts Gaming Commission, the Commission hereby authorizes the payment from the Community Mitigation Fund in accordance with M.G.L. c. 23K as outlined in this Application.

Executive Director

Date

Ombudsman

Date

Massachusetts Gaming Commission 101 Federal Street, 23rd Floor Boston, MA 02110

INSTRUCTIONS FOR FILING FOR

If a Community is filing for a mitigation reserve fund only, please check the box on page 1 and fill out all the boxes in blue. Skip grayed boxes 1-4. Detail regarding the use of the reserve fund can be provided to the Commission on a rolling basis upon consultation with the Commission (See Guidelines on page 6).

If a Community or other Applicant has a specific impact, please fill out entire application form.

If a Community or other Applicant is requesting both a reserve fund and has a specific impact, please fill out the entire application form.

Any questions contact: John S. Ziemba, Ombudsman 101 Federal Street, 23rd Floor, Boston, MA 02110

(617) 979-8423 john.s.ziemba@state.ma.us

Applications must be sent electronically and via regular mail. An application received by the Commission either electronically or via regular mail by February 2, 2015 will meet the application deadline.

Applications should be sent to the:

And via e-mail to:

john.s.ziemba@state.ma.us image1.jpg