2. FY2016 Capital Planning Request Form
   All fields with a red asterisk are required. Please be as descriptive as possible, and attach any quotes at the end of the form.
4. Date Submitted*
   Date Submitted
   Enter Date Submitted
5. Department*
   -- Select One --Information TechnologyAccountingDPWAssessorsCouncil On AgingRecreationELCATBuilding InspectorClerk/Treasurer/CollectorPlanningPoliceFireSchool DepartmentBoard of Health

   Please Select Your Department
7. Contact Phone Number*
8. Your Email Address:*
12. Project Name:*
14. Amount:*
    Total amount requested for project, including all contingencies
15. Estimated Start / Completion Date:
    Estimated Start / Completion Date: Start Date

    —

    Estimated Start / Completion Date: End Date
17. Description of Project:*
    Please be as descriptive as possible when describing your proposed project.
19. How did you obtain above pricing?*

    1. State Contract
    2. Vendor Quote
    3. Vendor Estimate

    1. Internal Estimate
    2. Other (Enter in Comment Section)
20. Date Pricing was Obtained:*
    Date Pricing was Obtained:
22. Comments on Quotation (Optional):
24. How many projects are you requesting for this fiscal year?*
25. Of the total projects requested, this project ranks as number: *
27. Why is this project being considered?*

    1. Essential
    2. Required by Law
    3. Highly Necessary

    1. Economically Justified
    2. Other
28. Comments (Optional):
30. Alternatives to Project:
32. Consequences of no action:
34. Project Categorization:

    Please select which categories you believe your project falls into. You will need to justify any selections. Check all that apply.

    1. Public Safety
    2. Government Mandate
    3. Capital Infrastructure Maintenance

    1. Improved Operations
    2. Energy Efficiency

    1. Resident Quality of Life
    2. New Operations
36. Other comments or Information that may assist the Committee:
38. Attach scanned vendor quotes or other related materials here.
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field