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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. FY23 (use for in year requests or items for Fall 2022 Town Meeting)
    2. FY24
    3. FY25
12. Project Description*

    Please provide a general overview of the project and the proposed benefit to the town.

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. Estimated Useful Life (in years)*
19. Amount Requested*

    This amount should be the total cost of any project, including contingencies. If the project is expected to be bonded, the Finance Team will determine the term and interest cost associated.

21. 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)
23. 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.

25. Describe and quantify any revenue that this project may create for the town or alternatively operating costs that may be reduced (if applicable)*
27. Estimated Annual Maintenance Cost of Project *
29. Provide details of any accessibility considerations for this project. *
31. Provide details of the expected timeline for implementation of this project, upon funding*
33. 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.

35. 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.

37. Date Submitted *
    Date Submitted
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39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

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