*Name of Organization

*Name of Requestor Submitting Form

*Date Request Submitted

*Date of Anticipated Need

*Amount REQUESTED for upcoming year

*Amount in CURRENT budget

If your organization received funds in previous fiscal years please explain how these funds were used and what was the impact or result.

*Describe the project, program or item(s) to be purchased: Include the following: Description of the need and how this benefits a public purpose. Please identify all entities/partners involved. Provide any other information you feel necessary.

*Future Cost & Maintenance: Are there additional future costs related to this project beyond the current fiscal year? If so, how will those costs be addressed? Is there future maintenance issues associated with this project? If so, how will they be handled?

*Impact of Partial Funding, Delay or Denial: Is partial purchase/implementation possible? Impact? What if the funding is denied or postponed until next budget cycle? Impact?

*Name and contact number of the person who will be present to speak to this budget request at the public hearing