<ORGANIZATION’S LETTERHEAD WITH ADDRESS>

<DATE>

Oregon Department of Transportation
Program & Funding Services
Oregon Department of Transportation
355 Capitol Street NE, MS 21
Salem, OR 97301

To Whom it May Concern:

Pursuant to its Grant Agreement no. <IGA#> with ODOT, <CITY/COUNTY> requests its allocation of federal Surface Transportation Block Grant (STBG) funds to finance the following transportation project(s) eligible under Oregon Constitution Article IX, Section 3a (the “Project”):
<DESCRIPTION OF GAS TAX ELIGIBLE ACTIVITIES WITH SPECIFIC LOCATION (must be in the City/County requesting funds) INCLUDING THE JURISDICTION OF THE ROADWAYS.  STATE IF THE ROADWAY(S) CROSS, ABUT, OR IN ANY WAY INTERSECT A STATE HIGHWAY.>

<CITY/COUNTY> hereby exchanges $<FEDERAL AMOUNT> in STBG funds for state funds at a ratio of 90 cents state funds for each dollar of STBG funds exchanged.  Accordingly, we request ODOT to disburse to <CITY/COUNTY> a total of $<.90 x FEDERAL AMOUNT> in state funds that <CITY/COUNTY> will use to finance the Project.

By signing below, I certify that I am authorized to sign on behalf of the <CITY/COUNTY> and that the <CITY/COUNTY> will use the funds received in accordance with the limitations of Oregon Constitution Article IX, Section 3a.

Please contact <NAME> at <PHONE NUMBER>, <EMAIL> if you have any questions or concerns regarding this request.

Sincerely,

<SIGNATURE>

<NAME>
<TITLE>
<EMAIL>
Template