Application to Finance Conservation Measures Per Section 287.064(10)(A) F.S

CONSOLIDATEDEQUIPMENTFINANCINGPROGRAMfor

CONSERVATIONMEASURES

Department of FinancialServices

Application to Finance Conservation Measures Per Section 287.064(10)(a) F.S.

Note:Thisapplicationformmustbesubmitted,withallrequiredsubstantiating

documentation,atleast21daysbeforeawardingthecontractforsuchequipment.

1.a)Name ofAgency:

b)Address ofAgency:

c)AgencyContact:Phone: EmailAddress: Fax:

d)Agency Address and Contact Person (if different fromabove)

e)Reviewed by Purchasing Office(signature):

f)HeadoftheAgencyorhisorherDesignee(signature):

2.a)CM Number &Description

b)Proposed Location ofEquipment:

c)Equipment Vendor Name,Address:Equipment Vendor FEIDNo.

d)Financing Vendor Name,Address:

Name: Address:

e)Financing Vendor FEIDNo.

3.Attachwrittenjustificationbasedonpublicpurposeservedbyacquisition,need,sizeofpurchase,andfinancialbenefittotheStatefordeferredpaymentpurchase.Attachdocumentation supporting recurring funds requirement in Sections 287.063(5)and

287.064 (11) (i.e. Budget OfficerLetter)

4.FLAIRAccountfromwhichpayments willbemade: ______

______

5.VendorSelectionMethod—StateTermContract#-

Other SelectionMethod

* Attach bid tabulation sheet or other appropriatedocument.

6.Were funds specifically appropriated to purchase or replace existing equipmentwiththisequipment? No Yes

Appropriation line itemnumberAppropriation amount for currentFY $

7.IfacquisitionisforInformationTechnologyResourcesthathaveapurchasepricemorethanthresholdamountforCat.THREEin§287.017,F.S.,attachChiefInformationOfficerorDelegateApprovalifrequiredbyyouragencyoruniversity.

8.Ensurethat:

a)An equipment schedule is prepared indetail.

b)The equipment meets the definition of commodity, pursuant to Section287.012(5),F.S.,andtheownershipprovisionsoftheagreementwillbesatisfied.

c)Insuranceselectiononequipmenthasbeenmade (checkoneofthefollowing):

Self-insuranceCommercial insurancepolicy

9.Acquisition for all Conservation Measures should be in compliance withprovisionsofSection489.145,F.S.

10.a)Requested financingtermQuarters

b)Equipment usefullifeQuarters

c)Anticipated periodtheequipmentwillbeusedbeforemajorupgrade,modification orreplacement Quarters

d)Anticipated completiondate

11.Equipment—TotalPurchasePrice

Less Discounts, Credits,Rebates

LessTrade-in

Less Freight andInstallation

LessMaintenanceTotalCashSalePrice—Amounttobecapitalized LessDownPayment(ifany)

12.Amount to befinanced:

Firstpaymentisduewithinten(10)daysoffunding.Subsequent payments are due quarterlythereafter.

Sendto:

Department of FinancialServices

Bureau of Accounting, Finance and Federal ReportingSection200E.GainesStreet,464LFletcherBuilding

Tallahassee, Florida32399-0364

Phone: (850) 413-5511

E-mail Address:

APPROVED

DEPARTMENTOFFINANCIALSERVICESDIVISION OF ACCOUNTING ANDAUDITINGBY: DATE: APPROVALNO: