Request Form

 

Please Use One (1) Form for Each Item Requested

 

  1. Project Information

Project Name:

Contact Person:

Phone Number: (____)_________

Project Dates:_________

Start Date:_______

Completion Date:_________

Ongoing? ___Yes____ No

Project Status (Check one): New Project _____; Existing Project _____; Revised Project_____

(*Office Use Only) Project Number:___________

Brief Project Description:

 

 

 

 

Estimated Total Cost: $

Location Information:

911 Address:

Magisterial District:

 

Tax Parcel No(s). Parcel ID No(s).

Provide a Map of the location and a Preliminary Site Plan

 

 

 

 

 

 

 

II. Project Specifics

A. Project Description:

 

 

 

 

 

 

 

 

 

 

B. Statement of Need/Justification:

 

 

 

 

 

 

 

 

 

 

 

 

 

C. IMPACTS:

1. Fiscal Impacts:

 

 

 

2. Environmental Impacts:

 

 

 

3. Economic Impacts:

 

 

 

4. Community Impacts:

 

 

 

 

 

 

D. Project Schedule
 
Fiscal Year #1
Fiscal Year #2
Fiscal Year #3
Fiscal Year #4
Fiscal Year #5

Project Elements

 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Planning & Design

x

x

x

x

xxx

X

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Land Acquisition

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Construction

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Site Improvement &
Preparation

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Equipment &
Furnishings

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Procurement
Requirements

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Other:

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x
Other:

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

 

 

 

 

 

 

 

 

 

 

 

 

 

III. Project Costs

A. Cost Estimate Schedule

Project Element

FY #1

FY #2

FY #3

FY #4

FY #5

Total

Planning & Design

x

x

x

x

x

x

Land Acquisition/ Option

x

x

x

x

x

x

Site Improvement/ Preparation

x

x

x

x

x

x

Construction

x

x

x

x

x

x

Furnishings/Equipment

x

x

x

x

x

x

Other: ____________________

x

x

x

x

x

x

Other:

x

x

x

x

x

x

Other

x

x

x

x

x

x

Total Expenditures: (a)

x

x

x

x

x

x

Funds Available: (b)

x

x

x

x

x

x

Funds Required: (c)

x

x

x

x

x

x

PLEASE DETAIL ANY ANTICIPATED NON-COUNTY FUNDING SOURCES:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Operating Budget Impact

Item

FY #1

FY #2

FY #3

FY #4

FY #5

Total

Personnel Costs

x

x

x

x

x

x
Non-Personnel Costs

x

x

x

x

x

x
Capital Outlay

x

x

x

x

x

x
Add Anticipated Revenues

x

x

x

x

x

x
Total Net Costs

x

x

x

x

x

x
Assumptions:

 

 

 

 

©Montgomery County Department of Planning & Inspections
Last Updated: 12 August, 2002
Comments and suggestions should be sent to the Planning Department Webmaster