Capital Outlay Request Application
Applicant Contact Information
Information of person to contact regarding content of the application.
Executive Order 13-006 Requirement: State agencies must determine whether a grantee has
adequate accounting methods and procedures to expend state grant funds
in accordance with applicable law and account for and safeguard grant funds and assets
acquired by grant funds [EO¶2(A)(3)(a)].
Infrastructure Capital Improvement Plan - Local infrastructure capital improvement plan (ICIP) is a plan that establishes priorities for anticipated capital projects. The state-coordinated ICIP process encourages entities to plan for the development of capital improvements at a pace that sustains their activities. Is the proposed project a documented priority (1 through 5) on the most recently submitted Senior Facility ICIP?
Certification
I, the undersigned chief official of the local government (municipality, county, tribal), certify that the attached application is supported by the governing body of the applicant and I have been authorized to file this application for assistance from the State of New Mexico. I further certify that the information contained herein is true and complete to the best of my knowledge and belief.
I, the undersigned chief official of the local government (municipality, county, tribal), certify that the attached application is supported by the governing body of the applicant and I have been authorized to file this application for assistance from the State of New Mexico. I further certify that the information contained herein is true and complete to the best of my knowledge and belief.
Facility Information
Part 1: Facility Data
4. What sources of funding were used to construct or improve the
facility within the past five
(5) years?
5. Current Condition - as described in the Asset Management:
Facility/Fixture Inventory Listing.
Part II: Uses
Part III: Cost Benefit
Part IV: Operation and Maintenance
Is this section complete?
A-1 Code Compliance Project Request
Form
Populate with Facility name from Contact Information tab.
Populate with first name from Contact Information tab.
Populate with last name from Contact Information tab.
Project Summary
Background
If Yes; provide the following:
2. Will plan and design be required for the proposed code compliance project?
3. Provide copy of code compliance citation(s) or other documentation in support of the request.
4. Does the project address a health, safety, risk or hazard to the public that immediately
endangers occupants of the facility?
5. Describe how the proposed project will alleviate a risk or a health and safety issue?
Project Description
8. After the completion of the project will you incur additional operating and maintenance
costs?
9. Will there be cost savings?
10. Has the applicant conducted an energy audit?
The plan should have a set of actions or targets, resources needed (i.e. cost, time), dates
(include milestones) and responsibilities. The plan will assist to structure your project and
break down the process into small achievable goals. The plan will assist in attracting interest
from funders or sponsors to help pay for improvements
12. Has the applicant implemented an action plan based on your priorities for energy efficiency?
13. Has an evaluation for the proposed project been documented by a subject matter expert to
clearly establish the criticality of need for the project?
14. During the evaluation, what findings and issues were identified by the subject matter
expert?
15. Describe the outcome of not receiving this funding. Why is this funding necessary?
(Include the number of clients that will not get served or type of service that cannot be provided)
(Include the number of clients that will not get served or type of service that cannot be provided)
| Expenditure Category | GOB Funds Requested | Funds from Other Sources | Total |
|---|---|---|---|
| Architectural & Engineering* | |||
| Construction | |||
| Equipment | |||
| Delivery/Install | |||
| Totals |
17. Describe the oversight process that would ensure timely construction and completion of
the project. Provide information about the local government or other staff who will work on the
project, include their experience and qualifications to perform the activities that will be
funded.
(i.e. John Doe – Engineer - 12 years of experience; John Doe – Public Works Director – 12
years of experience)
| Project Timeline (Insert milestones/activities specific to the proposed project.) | Upon full execution of the Grant Agreement the following tasks will commence. (i.e. Months 1-2) | Oversight/Responsible Staff (i.e. Name, Title) |
|---|---|---|
Is this section complete?
Attachments
Applicable to construction related projects
Applicable to non-profit providers
Is this section complete?