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2. Note this form is intended for submission by Department Heads only.

   If you are a resident and have an item that you would like to see as a potential capital expenditure explored by a town department, please submit a brief description to the Chair of the Capital Planning Committee and you will receive a response and update on potential next steps.

4. Department Name*
6. Department Head Name*
8. Department Head Title*
10. Fiscal Year Requested*

    1. FY24 (use for in year requests)
    2. FY25
    3. FY26
12. Item Description*

    Please provide as many details as possible that describe the vehicle you are looking to acquire, the purpose that the vehicle serves in your department, and the services that it allows you to provide to residents.

14. Select how your project fits into one or more of the following conditions from the town's Capital Plan*

    1. Imminent threat to the health and safety of citizens / property
    2. Preservation of operations
    3. Legal requirement of Federal or State agencies
    4. Improvement to infrastructure
    5. Improvement in the efficiency and effectiveness of service delivery
    6. Alleviation of an overtaxing or burdened situation
    7. Supports community plan (i.e. Master Plan, Open Space and Recreation Plan)
    8. Results in lower energy consumption
    9. Results in lower operations and maintenance costs
    10. Continues the phased funding for a project included in a prior year’s budget
    11. Scheduled replacement (i.e. motor vehicles, roofs, computers)

    Select all that potentially apply

16. Why is the project being requested?*

    Elaborate on how your project fits into one or more of the following conditions from the town's Capital Plan selected above. Specifically address if you believe there are energy efficiencies or reduction to carbon footprint coming out of this project.

18. Picture of Vehicle Requested

    Files must be less than 5 MB.

    Allowed file types: gif jpg jpeg png pdf ppt pptx xls xlsx.

19. New Or Used*

    1. New
    2. Used
21. Estimated Useful Life (in years)*
22. Amount Requested*

    This amount should be the total cost including any equipment that may be installed in the vehicle.

24. Expected Funding Source*

    1. General Fund
    2. Ambulance Fund
    3. Recreation Revolving Fund
    4. Water Enterprise
    5. Donation
    6. Community Preservation Funds (requires separate approval process from CPC)
    7. ARPA
    8. Other (please include details in section below)
    9. Combination (please include details in section below)
26. What alternate funding sources have you pursued to offset any portion of the amount requested?*

    Include any and all details related to potential grant funding in this section, as well.

28. Describe whether this vehicle meets or is exempt from the provisions of the Town's Green Community Status*

    Consultation is recommended with John Parent on a response to this question

30. Describe and quantify any revenue that this vehicle creates for the town (if applicable)*
32. Estimated Annual Maintenance Cost of Project *
34. Description of Item Being Replaced (if applicable)
36. Provide details of the expected timeline for implementation of this project, upon funding*
38. Estimated Trade In Value of Item Being Replaced (if applicable)
39. Estimated Mileage of Item Being Replaced (if applicable)
40. Estimated Annual Maintenance Cost of Vehicle Being Replaced (if applicable)
42. Provide details of the timeline for purchase and delivery of the vehicle, upon funding *
44. Please provide any supporting documentation that supports the amount requested including any available vendor quotes.*

    Files must be less than 5 MB.

    Allowed file types: gif jpg jpeg png pdf doc docx ppt pptx xls xlsx.

46. Please provide any additional files that you believe may be helpful with our review of this request

    Files must be less than 5 MB.

    Allowed file types: gif jpg jpeg png pdf doc docx xls xlsx.

48. Date Submitted *
    Date Submitted
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

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