NYC-WTC_000152549

NYC 9/11 Public Portal Document

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Agency Agency ORC ID#_______ -________ * Date Received__ /—/— ‘Agency 3/4 letter abbreviation + 4 digit sequential (ORC Use ONLY) (□ Re-Submission)_______ Agency tracking » Agency Contact Name ____________ Title Location _____ Phone ( .)L Fax ( ) e-Mail

Request for Approval by the OTPS Review Committee (ORC) to Commit Agency OTPS Funds in Excess of $50,000

• Type of Proposed Action □ Procurement - Contract (PIN .) (Contract # .) __ New Award(s) ___Renewal Award ___ Amendment/Change Order ___ Encumbrance □ Procurement - Purchase Order (PO# .) IT Small Purchase __ Requirements Contract (__ DCAS__ NYS) __ Other (Specify. .) □ Voucher for Miscellaneous Expenditure (VME# .) □ Real Property Lease or License □ Utilities or Phone Service □ Other (Specify_____________________________ .)

• Description of Proposed Action (Include purpose, scope, parties and the term of the contract or other agreement; if an Emergency Procurement pursuant to Charter Section 315, so indicate.)

□_ additional page(s) attached • Justification for Proposed Action (Check all that apply) □ Directly related to public health or safety □ Necessary to enhance or maintain the City's revenue base, or to prevent additional City expenditures □ Required by law □ Necessary for continuation of critical agency functions □ Funded by state, federal, other non-City or capital funds

• Explain the basis of each justification cited above. (Include any adverse consequences of not implementing the proposed action.)

□ _ additional page(s) attached • Dollar Amount of Proposed Action $ Unit(s) of Appropriation: Budget Code(s): Object Code(s): Cost (Amounts in 000s) _________ Funding Source FY'Ol FY'O2 FY'03 FY'O4 FY '05 - Total Capital_________________ $ $ 1 $ $ $ (-%L Expense________________ ^City__________________ 1 £ 1____ 1 £ £ - State (Spedfy____________ ____L I £ 1____ 1 £ £ C-%1 - Federal (Spedfy__________ ____L 1 £ 1____ 1 £ £ C-%1 Other (Spedfy ____ L 1 £ 4____ 1 £ £ (_%1 Total $ $ $ $ $ $ (100%)

• How Proposed Action Will be Funded □ Uncommitted OTPS Funds □ De-encumbrance of (Spedfy J This is to certify that this proposed action complies with the criteria set forth in Executive Order No. 52 (October 9, 2001) and that I approve this proposed action. Agency Head Signature _ Date__ /__ /_______ I ORC Disposition □ Approved □ Disapproved Initials Pate//— J

NYC-WTC_000152555