CAPITAL BUDGET REQUEST

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					                     CAPITAL BUDGET REQUEST
                              FY 2013
            CAPITAL IMPROVEMENT PROJECT DESCRIPTION
                    (New Buildings, Additions or Major Renovations)

AGENCY:                               AGENCY PROJECT PRIORITY:


PROJECT DESCRIPTION/LOCATION:


CONTACT PERSON:                             TELEPHONE:


PROJECT JUSTIFICATION:

  (A) Concisely describe what the project is.



  (B) What is the existing program and how will it be improved?




  (C) What will be the impact on your operating budget?



  (D) What are the consequences if this project is not funded?




ESTIMATED BUDGET:                               FUNDING:
Land            $                               PBF               $
A/E fees                                        General Account
Construction                                    Agency Funds
5% Contingency                                  Federal Funds
FF&E                                            Other
Other
Total          $                                Total             $



                               Agency Head Signature: ______________________________

                                                   Date: ______________________________




DPW   1.0    4/11
                       CAPITAL BUDGET REQUEST
                                FY 2013
                   ALTERATION AND REPAIR PROJECTS

AGENCY:


PROJECT DESCRIPTION/LOCATION                            COST       PRIORITY




                         Agency Head Signature: ______________________________

                                         Date: ______________________________




DPW   2.0   4/11
                      CAPITAL BUDGET REQUEST
                               FY 2013
                   ASBESTOS ABATEMENT PROJECTS

AGENCY:


PROJECT DESCRIPTION/LOCATION                           COST       PRIORITY




                        Agency Head Signature: ______________________________

                                        Date: ______________________________




DPW   3.0   4/11
                   CAPITAL BUDGET REQUEST
                            FY 2013
                       "ADA" PROJECTS

AGENCY:


PROJECT DESCRIPTION/LOCATION                          COST       PRIORITY




                       Agency Head Signature: ______________________________

                                        Date: _____________________________




DPW   4.0   4/11
                                 CAPITAL BUDGET REQUEST
                          SIX-YEAR PLAN FY 2013 THROUGH FY 2018
                                  CAPITAL IMPROVEMENTS

AGENCY:



 PROJECT DESCRIPTION/LOCATION     FY 2013   FY 2014    FY 2015      FY 2016     FY 2017      FY 2018
                                     $         $          $            $           $            $




      TOTAL

                                                  Agency Head Signature: ______________________________

                                                                  Date: ______________________________




DPW    5.0    4/11

				
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