Please complete as much of this form as possible before submitting the application. Items in bold are required. Agency Name: Issuing Office: Address: City: State: Zip Code: Disbursing Office: Address: City: State: Zip Code: Contracting Officer: Phone: Fax: Email Address: Address: City: State: Zip Code: Installation Address: City: State: Zip Code: Expected Ship Date: Expected Installation Date: Vendor Sales Contact: Phone: Fax: Email Address: Contact for this transaction: Phone: Fax: Email Address: Type of Lease: LTOP (Lease To Own Plan) LWOP (Lease With Option to Purchase) Periodic Payment: $ Term (months): 12   24   36   48   60 Other (please specify) Contract Number: Purchase/Delivery Order Number: Product Description: Product Breakdown Hardware: $ Software: $ Support: $ Installation: $ Prepaid Maintenance: $ Other Costs (please itemize below): 1. $ 2. $ 3. $ TOTAL: $ ESSENTIAL USE INFORMATION What essential government use does this department perform? What essential function do the users of this product perform? How does this product help the users perform this function? Do the users plan to use this equipment for the full term of the lease? Yes   No What is the cost impact on the user? Does this product generate cost savings for the user? Yes   No Why is this product being acquired? Please be specific in the description of the project. If this is a replacement product, what is it replacing? (Make and Model) If this is a replacement product, how long has the current product been in service? Have funds been obligated for the leasing of this product? Yes   No Is multi-year financing available? Yes   No What, if any, are the performance responsibilities of the manufactuer/vendor after acceptance? BACKGROUND INFORMATION OF THE USER AGENCY Is there any threat of the Agency downsizing or cutting funding during the proposed lease term? Yes   No Is there any threat of the installation location downsizing or closing during the proposed lease term? Yes   No Is there any possibility of the Agency itself being eliminated? Yes   No Does the Agency receive any non-appropriated funding? Yes   No Does the Agency plan on moving this installation location? Yes   No If yes, where and when? Is the facility in which the equipment/software is to be located government owned or leased? Owned   Leased If the facility in which the equipment/software will be located is leased, what is the duration of the facility lease? If the facility is leased, what is the commencement date & expiration date of the lease? Commencement date of facility lease:    Expiration date of facility lease:   Submitted by:

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