If equipment/vehicle, will it be used full-time or part-time?
Reason & Purpose for purchase (Attach additional sheets if necessary):
Will other programs use capital asset/equipment/vehicle? Yes No
If yes, shared purchase, use, maintenance, or rental fee? List other programs and percent of time used. (A rental fee or proportionate time use is required if a program does not share in the purchase.) Briefly describe how procurement will be done and confirm that all Agency, State, and Federal
procurement guidelines will be met. (WPN 09-1B, 3/12/09).
Provide statement that lowest bid will be selected or sufficient justification of “best value selection” if low bid not recommended for awarding agency approval: (WPN 09-1B, 3/12/09)
Was a lease alternative explored? Yes No
If yes provide: Terms, Condition, & Purchase Option: (WPN 09-1B, 3/12/09) List all funding sources used for this purchase:
Local agency certifies that procurement records will be on file and available for review. Local agency further certifies that this purchase will be in accordance will all applicable rules, procedures, and guidelines per contract referenced above. ** Authorized person must sign request**
Attach additional sheets for further items or explanation if necessary. Will non-weatherization programs use this equipment? Yes No
If yes, indicate shared purchase, use, maintenance, or rental fee. List other programs and percent of time used. Note: A rental fee for proportionate time use is required if a program does not share in the purchase. Submit this form to your agency’s field representative.
Link toActive Form: Exhibit 6.7, Budget Revision Request Form