For more information on completing this form, refer to NDOT 530 I.

1. New Revised State of Nebraska Department of Transportation Local Public Agency (LPA) Project Programming Request For: City County Other	TO BE COMPLETED BY NDOT
Control No.:
Project No.:
Project Name:
2.	LPA Name (and County):	Project Coordinator:
3.	Responsible Charge/Project Liaison:	Target Letting Date:
4. PURPOSE AND NEED/PROJECT DESCRIPTION
Purpose and Need of Proposed Project (What is the problem to be resolved?):
Latitude:	° ’ ”	Longitude:	° ’ ”	New/Reconstruction Maintenance Other
Road, Street, Trail, Historical Renovation, Other	From	To	Length	National Functional Classification	National Highway System (Yes or No)
Detailed Project Description (Location of Proposed Project, Logical Termini Justification, Location Map, Typical Cross Sections, etc.; attach any additional sheets necessary):
5. FUNDING TYPE:	STP BR HSIP TA
6. ESTIMATED PROJECT FUNDING (Attach supporting documentation for estimates)
FFY of TIP/STIP	Federal	Local Match	Nonparticipating	Other	Total
7. PE Phase
a. PE	0.00
b. NEPA	0.00
c. Final Design	0.00
d. RC	0.00
e. NDOT	0.00
PE Subtotal	$0.00	$0.00	$0.00	$0.00	$0.00
8. ROW	0.00
9. Utilities	0.00
10. Construction	0.00
11. CE Phase
a. CE	0.00
b. RC	0.00
c. NDOT	0.00
CE Total	$0.00	$0.00	$0.00	$0.00	$0.00
12. TOTAL	$0.00	$0.00	$0.00	$0.00	$0.00
13. OTHER CONSIDERATIONS
a. Will special assessments district(s) be used to collect a portion of the required local funding match? Yes No
b. Project on One- & Six-Year Plan? Yes No Attach One- and Six-Year Plan Revision or New Plan Documentation.
c. Does your LPA have a signed ADA Policy and a signed Title VI Nondiscrimination Agreement? Yes No (Attach if not previously submitted.)
14. DESIGN DETAILS
Existing	Proposed	Remarks/Existing Condition
a. Surface Width
b. Surface Type
c. Shoulder Width
d. Shoulder Type
15. EXISTING STRUCTURES
Structure No.	Feature Crossed	Type of Structure	Length	Width	Sufficiency Rating	Proposed Treatment
16. SCHEDULE CONSIDERATIONS (Attach explanations and supporting documentation to this form)
Is there an expectation that the proposed project will involve any of the following: Yes No
a. ROW Acquisition (including Easements)	Estimated No. of Tracts:
b. Relocation of Residences or Businesses	Residences Businesses
c. Utility Relocation or Adjustment	Gas Water Power Phone Other
d. Railroad Involvement	Crossing Parallel Within 50’
e. New Horizontal Alignment
f. Design Relaxation or Exception
g. NDOT Permit to Occupy
h. Has ROW already been acquired?
i. PE Procurement RFP Locally Funded LPA In-House On-Call	17. TRAFFIC DATA
j. CE Procurement RFP NDOT On-Call LPA In-House N/A	Construction Year ADT
k. Anticipated NEPA level PA PCE CE EA EIS	Design Year ADT
l. Project Scheduling Template:	% Trucks
18. ADDITIONAL REMARKS OR COMMENTS BY LPA
(Attach as needed)
19. SIGNATURES
Requested by LPA Responsible Charge/Project Liaison:	Date:
Approved by MPO (if applicable):	Date:
Approved by NDOT Local Projects Unit Head:	Date:
Approved by NDOT Local Projects Engineer:	Date:
Approved by NDOT Local Assistance Division Manager:	Date:
Approved by NDOT Program Management Engineer:	Date:

This is not a contractual agreement.