NASD Department: Name/Title:

CAPITOL IMPROVEMENTS REQUEST FORM

School

Date: Phone #:

1. Project Title: i.e. Elementary School Renovation

Click here to enter a date. 2. Category: 3. Priority: Medium Education 5. Purpose of Project Request: Add a new item to the CIP

4. Location: 6. Link to District Strategic plan (NOTE: NASD does not currently have a strategic plan) :

7. Project History (Previous CIP Year or connection to other projects):

8. Description:

9. Justification & Useful Life:

10. Cost (Years 2 – 6 use an inflationary factor of 4%) BUDGET FY TOTAL Program year FY 2019 Program year FY 2020 Program year FY 2021 Program year FY 2022 Program year FY 2023 Program year FY 2024 TOTAL SIX YEARS After Sixth Year

$0 $0 $0 $0 $0 $0 $0 $0

COST ELEMENT Construction Engineering Construction Engineering Construction Engineering Construction Engineering Construction Engineering Construction Engineering

10A. Recommended Sources of Financing PRINCIPAL SECONDARY Debt Financing Debt Financing Debt Financing Debt Financing Debt Financing Debt Financing

10B. Source of Cost Estimate: TBD

11. If Equipment, Number of units requested:

11A. Number of similar units in operation:

12. Net Effects on Operating Expenditures (±) Direct Costs

13. Equipment Cost Purchase Price

personnel:

Plus: Installation Less: Trade In/Credit Net Cost

purchase of service

number $ amount

Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item.

Per Unit

materials & supplies equipment purchases utilities other Subtotal

14. Estimated Use of Requested Equipment

Indirect Operating Costs

Estimated useful life in years:

fringe benefits General Admin Costs other Subtotal Total Operating Costs Debt Service (P&I) Total Costs

15. Net Effect on District Revenue (±)

Total

Weeks per year (months if seasonal): For the weeks used, estimate: Average days per week: Average hours per day used:

General Fund other income Subtotal gain from sale of replaced assets Total

This form should be completed for each project whether it is for a new project, project modification, or cancellation of a previously approved project. The form uses drop down boxes, to minimize data entry and maximize space. Use additional sheets as necessary.

1. Project Title: Insert title of proposed project. 2. Category: Pick, from the pull down menu, which category the project will be listed under. 3. Priority Pick, from the pull down menu, the priority of the project. A project listed in an outer year should not have a high priority. Likewise, those projects in the current year should not rank low. Emergency projects are ones which normally would begin in year 5 or 6 but are earlier for a life safety reason. 4. Location: Indicate the location or boundary limits of the proposed project. If a site is required but has not been selected, this should be indicated; or, if a site is tentative, provide as much accuracy as possible. A map may be attached. 5. Purpose of Project Request Form: Pick, from the pull down menu, if the project is new, a modification, cancellation or emergency. For equipment pick an option that indicates the need to purchase the equipment. 6. Strategic Plan Link: Pick, from the pull down menu, the chapter of the Strategic Plan where the item is recommended; type in the section and page number (NOTE: NASD does not currently have a strategic plan). 7. Project History: If the project is currently in the CIP, indicate the previous year of project. Additionally, describe the expected relationships of this project to existing or planned facilities and services. 8. Description: Explain the nature of the project and indicate whether the project is to replace existing facilities, equipment or land, or is an addition involving an increase in service delivery. Also, summarize the probable impact of the project on the environment or the surrounding community, if applicable. The description of land acquisition and construction projects should include dimensions, overall characteristics, unusual conditions, and any other pertinent information. Include references to any supporting studies or other relevant background information regarding the project. 9. Justification and Useful Life: Indicate the need for the project and what it is expected to accomplish and its anticipated useful life. Describe its relationship to local, regional, state and federal policies and plans, as well as the requesting department's multi-year plans and program. Explain the selection of the time period proposed. 10 and 10A. Cost and Recommended Sources of Financing: Insert the appropriate fiscal year for the budget (1st Year) and each program year (2nd through 6th), based upon an inflationary factor of two percent (2%). Then, indicate the proposed project expenditures for each fiscal year in the six-year budget and program; and any expenditure beyond the sixth year (After Sixth Year). Next, use the pull down menu and identify the cost element for each year (Engineering, Acquisition etc). Next, use the pull down menus to select the recommended sources of financing. If more than one source is anticipated list both sources. Finally, indicate the source of a cost estimate. 11 and 11A. Number of Units Requested/in Operation: Indicate the total number of units to be purchased, as well as the number of units of similar equipment items in the inventory of the requesting department. 12. Net Effects on Operating Expenditures: Indicate the effect of the project on the operating expenditures for each category shown. Estimate the budgetary impact of each change, in dollars, if possible, otherwise indicate the change with a ± in the project's first year. Changes in operating costs in subsequent years should also be noted if different from firstyear changes. For personnel, show the estimated increase or decrease in the number of employees, and in salary or wage expenses. For purchase of services, show costs related to services received from suppliers, such as contract labor. Identify any entries for “other”. Debt service costs will be computed later by the School Business Department as an annual debt service cost (principal and interest) over the project's life. 13. Cost: Provide cost data requested. 14. Estimated Use of Requested Item(s): Indicate the number of weeks per year the item is expected to be used and estimate the average usage for the specified period. Also show estimated useful life of the item based on planned usage. 15. Net Effects on District Revenue: Indicate the effect of the project on District revenue in each category shown in terms of an increase or decrease (±) over the first year of the project's life. If possible, estimate the amount of change in income in subsequent years if substantially different from the first year if applicable.

3 - CIP Submission Form.pdf

... for a new project, project modification, or cancellation of a previously approved ... Program year FY 2019 $0 Construction Engineering Debt Financing Choose ...

384KB Sizes 1 Downloads 257 Views

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