Capital Outlay Request Application

The Aging and Long Term Services Department will consider applications to fund capital projects statewide in support of the agency programs and services designed to meet the needs of older adults and adults with disabilities as authorized under the Older Americans Act. Applications will be accepted for code compliance, renovations, meals equipment/other equipment, vehicles, new constructions/major additions, and plan and design projects.

Applicant Contact Information

Information of person to contact regarding content of the application.

First Name

Last Name

Title

Facility

(aka)

Address

City

State

Zip

Phone

Fax

Email Address

Check here if the local government does not wish to submit a 2021 Capital Outlay Request Application for the facility, obtain the appropriate signature in Certification section below and submit to ALTSD.

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)].

Applicant's annual audit current and filed with the state auditor's office.

Yes

If yes, for FY:

Applicant's current fiscal operating budget has been approved by the DFA Budget and Finance Bureau of the Local Government Division.

Yes

If yes, Date:

Applicant has submitted financial quarterly/monthly reports to the DFA Budget and Finance Bureau of the Local Government Division.

Yes

If yes, Date:

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?

The current 2021-2025 ICIP Plan is attached.

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.

Name

Title

Electronic Signature. Signatures sent by electronic means (facsimile, scanned and sent via e-mail, or signed by electronic signature service where legally permitted) shall be deemed original signatures. Application is deemed received upon submission.

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A-1 Code Compliance Project Request Form

Facility

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Project Title

Contact First Name

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Contact Last Name

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Phone

Code Compliance Project - Complying with regulations regarding land use, zoning ordinances, health and housing codes, uniform building and fire codes, Americans with Disabilities Act (ADA).

Project Summary

The project summary should be at least 50 words and must include the amount of funding being requested. Please give a general description of how the funds will be used.

Total Project Cost $

Funds Committed $

Amount of Request $

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?

Yes; explain.

No; explain.

Explain:

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?

Yes; Date. Project Evaluation may be requested.

No; explain.

If yes, date:
If no, explain:

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)

16. Project Budget - Using your Project Description narrative, provide a budget breakdown that outlines projected expenses. Note: SBOF requires that the project must meet the bond obligation spend down requirement.

Expenditure Category	GOB Funds Requested	Funds from Other Sources	Total
Architectural & Engineering*
Construction
Equipment
Delivery/Install
Totals

*A&E Fees should not exceed 10-15% of the total construction budget.

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)

18. Project Timeline – insert activities specific to the proposed project. Also include information about when the requested funds will be spent to support each activity.

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)

*Adjust verbiage as needed.

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A-2 Renovation Project Request Form

Facility

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Project Title

Contact First Name

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Contact Last Name

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Phone

Renovation Project – restoring a current facility to an earlier condition by repairing or remodeling for health and safety issues.

Project Summary

The project summary should be at least 50 words and must include the amount of funding being requested. Please give a general description of how the funds will be used.

Total Project Cost $

Funds Committed $

Amount of Request $

10. Has the applicant implemented an action plan based on your priorities for energy efficiency?

Yes; explain.

No; explain.

Explain:

11. Has an evaluation for the proposed project been documented by a subject matter expert to clearly establish the criticality of need for the project?

Yes; Date. Project Evaluation may be requested.

No; explain.

If yes, date:
If no, explain:

12. During the evaluation, what findings and issues were identified by the subject matter expert?

13. 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)

14. Project Budget - Using your Project Description narrative, provide a budget breakdown that outlines projected expenses.

Expenditure Category	GOB Funds Requested	Funds from Other Sources	Total
Architectural & Engineering*
Construction
Equipment Purchase
Delivery/Install
Totals

*A&E Fees should not exceed 10-15% of the total construction budget.

15. 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)

16. Project Timeline – insert activities specific to the proposed project. Also include information about when the requested funds will be spent to support each activity.

Project Timeline (Insert milestones/activities specific to the proposed project.)	Upon full execution of the Grant Agreement the following tasks will commence to meet the timeline/milestones. (i.e. Months 1-2)	Oversight/Responsible Staff (i.e. Name, Title)

*Adjust verbiage as needed.

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A-3 Meals Equipment/Other Equipment Request Form

Facility

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Project Title

Contact First Name

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Contact Last Name

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Phone

NOTE: Each equipment item requested in this category must be valued at $10,000 or more.

Check all that apply:

Meals Equipment - machinery, apparatus, components and other tools necessary in preparing, cooking, and serving food.

Other Equipment - machinery, apparatus, components and other tools to make an action, operation, or activity easier to serve program objectives.

Project Summary

The narrative should be at least 50 words and should include the amount of funding requested. Please give a general description of how the funds will be used.

Total Project Cost $

Funds Committed $

Amount of Request $

Background

The background narrative section must provide the reviewer with an explanation of the problem that has created the need for the capital outlay funds that are being requested in this application. It should provide evidence that the problem exists as well as information on how the proposed project will contribute to a solution to the problem. Provide justification through local government documents or media publications discussing that the problem is a high priority and that the proposed solution is one that decision-makers support. It is important that the reader who reviews this application understands why your project should be funded over others.

1. Are additional funds committed for this project (match, leverage, prior year funding)?

Yes

If Yes; provide the following:

Source

Grant # (if applicable)

Amount $

Date Available

If No; explain:

2. What equipment will be purchased if funding is received? (Each equipment item requested must cost more than $10,000 and have a life expectancy of 7-10 years).

Add Additional Row

Item

3. Does the project address a health, safety, risk or hazard to the public that immediately endangers occupants of the facility?

ADA compliance issue, explain.

Equipment damage, explain.

Sanitary issue, explain.

Other, explain.

Explain:

4. How will the proposed project alleviate a risk/health and safety issue?

5. Is corrective action urgent and unavoidable?

Yes; explain.

No; explain.

Explain:

6. Is the project ready to proceed (Has the equipment been identified? Is the space sufficient in size for the equipment? Verify size, dimension, and weight.)

Yes; describe.

No; explain.

Are the requested funds sufficient to complete the purchase and installation?

Plan/design completed by (name of contractor & date): __

Construction plan and specs completed by (name of contractor & date): __

Vendor selected (name of vendor & date): __

Cost estimates/quotes are provided.

The project can be completed within __ months?

Other, describe.

7. After completion of the project will operating cost increase, decrease, or remain the same? Explain.

8. Has the applicant conducted an energy audit?

Yes; date. Audit may be requested.

No; explain.

If yes, date:
If no, explain:

9. Will the project incorporate energy sustainability upgrades as per 2009 International Energy Conservation Code and Executive Order 2019-003 signed by Governor Michelle Lujan-Grisham on January 29, 2019.

Yes; explain. By definition- Energy Star kitchen equipment – uses 15% or less energy to operate

a. Energy Star solid-door refrigerators and freezers.

b. A high-efficiency air-cooled commercial ice maker.

c. Convection ovens and ranges.

d. Energy Star Dishwasher – uses 4.25 gallons of water or less per cycle.

e. Other – explain.

10. This purchase will:

Provide critically needed equipment

Replace non-working equipment

Replace end of life equipment as determined in the Asset Management Plan

Upgrade equipment

If yes to any of the above, what items?
If no to any of the above, explain:

11. Why is this funding necessary? Describe the outcome of not receiving this funding. (Include the number of clients that will not get served or type of service that cannot be provided).

12. Have mandatory quotes been obtained?

Yes, a copy of the quote is provided.

No; explain.

Explain:

13. Project Budget - Using your Project Description narrative, provide a budget breakdown that outlines projected expenses.

Expenditure Category	GOB Funds Requested	Funds from Other Sources	Total
Equipment - Specify
Delivery/Install
Totals

*A&E Fees should not exceed 10-15% of the total construction budget.

14. 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, 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)

15. Project Timeline – insert activities specific to the proposed project. Also include information about when the requested funds will be spent to support each activity.

Project Timeline (Insert milestones/activities specific to the proposed project.)	Upon full execution of the Grant Agreement the following tasks will commence to meet the timeline (i.e. Months 1-2)	Oversight/Responsible Staff (i.e. Name, Title)

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A-4 Vehicle Request Form

Facility

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Project Title

Contact First Name

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Contact Last Name

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Phone

Vehicles - for transporting people or goods (such as home-delivered meals). Note: At least 50% of vehicles in a fleet must be accessible for persons with disabilities.

Project Summary

The Project Summary narrative should be at least 50 words and should include the amount of funding requested. Please give a general description of how the funds will be used.

Total Project Cost $

Funds Committed $

Amount of Request $

Background

1. Are additional funds committed for this project (match, leverage, prior year funding)?

Yes

If Yes; provide the following:

Source

Grant # (if applicable)

Amount $

Date Available

If No; explain:

2. List the type and number of vehicle(s) that will be purchased if funding is received. (Include cost estimates from supplier or state pricing agreement.)

Minivan

12-Passenger Van

15-Passenger Van

Hot Meal Delivery Vehicle

Medical Transport Vehicle

Number

Amount per vehicle $

3. Is special equipment required for the vehicle(s)?

Yes

If yes,

Handicap modifications

Ramps or lifts

Grab bars

Other

Number

4. Does the project address a health, safety, risk or hazard to the public that immediately endangers the occupants? Check all that apply.

ADA compliance issue, explain.

Equipment damage, explain.

Sanitary issue, explain.

Other, explain.

Explain:

5. How will the proposed project alleviate the risk/health and safety issue?

6. Is corrective action urgent and unavoidable?

Yes; explain.

No; explain.

Explain:

7. Is the project ready to proceed (need verified; equipment identified)? Check all that apply.

Yes; describe.

No; explain.

Are the requested funds sufficient to purchase and equip the vehicle?

Replace non-working vehicle(s) from the Vehicle Inventory List (specify the number(s) of vehicle(s) being replaced):

Add new vehicle(s) to the inventory.

The vehicle(s) can be ordered and delivered within a __ month period?

Other, describe.

8. Has an evaluation for the proposed project been documented by a subject matter expert to clearly establish the criticality of need for the project?

Yes; date. Project Evaluation may be requested.

No; explain.

If yes, date:
If no, explain:

Yes; explain. By definition- Efficiency vehicle – fuel efficiency is a form of thermal efficiency, meaning the ratio of effort to result of a process that converts chemical potential energy contained in a carrier into kinetic energy or work.

a. Fuel efficient.

b. Hybrid Vehicle or Electric Vehicle.

10. Why is this funding necessary? Describe the outcome of not receiving this funding. (Include the number of clients that will not get served or type of service that cannot be provided).

11. What types of vehicles are utilized and are any of the vehicle(s) in this inventory to be replaced by this purchase? (For vehicle type, indicate “ A” for Client Transportation; “B” for Meal Delivery; “C” for Handicap Accessible; “D” for Other; “F” for 4x4.)

Add Additional Row

Vehicle Type	ID #	Year	Make	Model	Mileage	Condition	Is this vehicle being replaced?

No; explain:

12. If this purchase will replace a vehicle(s) with less than 100,000 miles or the vehicle is less than 7 to 10 years old, provide justification for the request and include copies of maintenance records (provide inventory ID#).

13. Have mandatory quotes been obtained?

Yes, a copy of the quote is provided.

No; explain.

Explain:

14. Project Budget -- Using your Project Description narrative, provide a budget breakdown that outlines projected expenses.

Expenditure Category	GOB Funds Requested	Funds from Other Sources	Total
Vehicles-Specify
Equip-Specify
Totals

15. 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, 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)

16. Project Timeline – insert activities specific to the proposed project. Also include information about when the requested funds will be spent to support each activity.

Project Timeline (Insert milestones/activities specific to the proposed project.)	Upon full execution of the Grant Agreement the following tasks will commence to meet the timeline/milestones. (i.e. Months 1-2)	Oversight/Responsible Staff (i.e. Name, Title)

*Adjust verbiage as needed.

17. After completion of the project will you incur additional operating and maintenance costs? If yes, how will this be provided for in the budget? (i.e. fuel efficiency, maintenance cost, insurance premiums).

Yes; describe.

No; explain.

Describe:
Explain:

18. Will there be a cost savings?

Yes; describe.

No; explain.

Describe:
Explain:

19. Can any of the old vehicles be sold or transferred to another entity?

Yes; describe.

No; explain.

Describe:
Explain:

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A-5 New Construction/Major Addition Request Form

Facility

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Project Title

Contact First Name

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Contact Last Name

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Phone

New Construction/Major Addition: building a new structure, increasing the size of a structure by more than 35 percent of its footprint, demolishing or reconstructing more than 35 percent of the exterior walls or structural members of a building.

New construction or major addition requests must include estimated costs for equipment and furnishings. Equipment and furnishings cannot be separated and requested on other forms.
Projects for enlarging a facility or completing construction of a center, estimated at $200,000 or more, must be documented as “new construction/major addition”.
Parking lots and landscaping must be included in the plans for new construction/major addition.
and design for new construction/major addition.

Project Summary

The Project Summary narrative should be at least 50 words and should include the amount of funding requested. Please give a general description of how the funds will be used.

Total Project Cost $

Funds Committed $

Amount of Request $

12. Has the applicant implemented an action plan based on your priorities for energy efficiency?

Yes; explain.

No; explain.

Explain:

13. If this request is for a new facility, has the applicant met with the Area Agency on Aging (AAA) or the Senior Services Bureau to confirm availability of program support funds?

Yes; explain.

No; explain.

Explain:

14. Has an evaluation for the proposed project been documented by a subject matter expert to clearly establish the criticality of need for the project?

Yes; Date. Project Evaluation may be requested.

No; explain.

Date:
If no, explain:

15. During the evaluation, what findings and issues were identified by the maintenance expert?

16. Why is this funding necessary? Describe the outcome of not receiving this funding. (Include the number of clients that will not get served or type of service that cannot be provided).

17. Project Budget - Using your Project Description narrative, provide a budget breakdown that outlines projected expenses

Expenditure Category	GOB Funds Requested	Funds from Other Sources	Total
Architectural & Engineering*
Construction
Equipment
Delivery/Install
Totals

*A&E Fees should not exceed 10-15% of the total construction budget.

18. 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, 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)

19. Project Timeline – insert activities specific to the proposed project. Also include information about when the requested funds will be spent to support each activity.

Project Timeline (Insert milestones/activities specific to the proposed project.)	Upon full execution of the Grant Agreement the following tasks will commence to meet the timeline/milestones. (i.e. Months 1-2)	Oversight/Responsible Staff (i.e. Name, Title)

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A-6 Plan-Design Request Form

Facility

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Project Title

Contact First Name

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Contact Last Name

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Phone

Plan & Design – planning process including location studies, architectural drawings and plans, engineering, archaeological and environmental surveys or clearances, zoning, design activities necessary if seeking LEED certification, and all other steps incident to creating a plan for a final product.

Project Summary

The Project Summary narrative should be at least 50 words and should include the amount of funding requested. Please give a general description of how the funds will be used.

Total Project Cost $

Funds Committed $

Amount of Request $

Background

1. Are additional funds committed for this project as match, or leverage or received prior year funding (i.e. CDBG, NMDOT 5310 Program, NMFA, or TIF)?

Yes

If Yes; provide the following:

Source

Grant # (if applicable)

Amount $

Date Available

If No; explain:

2. Will the plan and design project be for a new facility?

Yes; describe.

No; explain.

If yes, describe:
If no, explain:

3. Will the design provide for a more cost efficient facility?

Yes; explain.

No; explain.

Explain:

4. How will the proposed project alleviate a risk or a health and safety issue?

Project Description

The Project Description narrative should give the reader a detailed description of the project that will be funded by the requested grant. This description should explain the duration of time during which the funds will support the project, the goals of the project, how they will be achieved, how success or failure will be measured, what services you promise to deliver to what population and what results you expect to bring about.

5. Is the project ready to proceed (the site is prepared, infrastructure in place, property or land secured): Do requested funds complete a fully functional phase?

Yes

Property secured

ROW secured

RFP in process

Cost estimates

Other, describe.

6. What is the timeline for completion of the plan?

7. Is the plan feasible and realistic for the number of clients served?

Yes; describe.

No; explain.

If yes, describe:
If no, explain:

8. Has an evaluation for the proposed project been documented by a subject matter expert to clearly establish the criticality of need for the project and has it been provided with the application?

Yes; Date. Copy of Evaluation may be requested.

No; explain.

Date:
If no, explain:

9. During the evaluation, what findings and issues were identified?

10. From what sources will applicant seek funding for construction costs?

11. Why is this funding necessary? Describe the outcome of not receiving this funding. (Include the number of clients that will not get served or type of service that cannot be provided).

12. Project Budget - Using your Project Description narrative, provide a budget breakdown that outlines projected expenses. Also include information about when the requested funds will be spent to support each activity.

Expenditure Category	GOB Funds Requested	Funds from Other Sources	Total
Architectural & Engineering*
Soils Testing, fees; licenses; permits; sales taxes; contingencies, etc.
Totals

*A&E Fees should not exceed 10-15% of the total construction budget.

13. 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, 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)

14. Project Timeline – Project Timeline – insert activities specific to the proposed project.

Project Timeline (Insert milestones/activities specific to the proposed project.)	Upon full execution of the Grant Agreement the following tasks will commence to meet the timeline/milestones. (i.e. Months 1-2)	Oversight/Responsible Staff (i.e. Name, Title)

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Attachments

Asset Management Facility/Fixture Inventory Listing

Asset Management Meals Equipment/Other Equipment Inventory Listing

Asset Management Form for Vehicle Inventory Listing

Infrastructure Capital Improvement Plan (ICIP 2020-2024)

Quotes and/or Cost Estimates for the Proposed Project(s)

Operating and Use Agreements

Applicable to non-profit providers

Additional Documents

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Terms & Conditions

I agree to the terms & conditions

Terms & Conditions

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