19
Attachment 5 CIP Submission Tables & Forms • Tables P, Q, & R • Form CIPOp • Form CIP Op B • Form PAB • Form S • Form DMC
Attachment 5
CIP Submission Tables & Forms
• Tables P, Q, & R • Form CIPOp • Form CIP Op B • Form PAB • Form S • Form DMC
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FORM CIPOp
INSTRUCTIONS FOR FORM CIPOp: FB 2017-19 ESTIMATED OPERATING COSTS RELATED TO CIP REQUESTS
Form CIPOp is to be completed for each new CIP request listed in FB 2017-19 Department Summary of Proposed CIP Lapses and New CIP Requests (Form S).
Sufficient details to support the cost estimate must be provided. Narrative explanation (Part III) should be as precise as possible with quantitative workload and/or other supporting data.
Form CIPOp: Item Description and Preparation Instructions ■
Program ID and Program Title:
Fill in with the Program ID and the Program Title.
Department Contact/Phone:
Enter the name and phone number of the person responsible for the Form CIPOp.
Date Prepared/Revised
Underscore "Prepared" or "Revised" as applicable and enter date.
Request Category
Indicate type of request, as allowed in the Budget guidelines.
• Major R&M of Existing Facilities
• Completion of Ongoing CIP
• Health, Safety, Court Mandates
• Energy Efficiency
• Public Infrastructure Improvements
• Other
I. CIP Project Number
Fill in with CIP Project Number as entered on Table P.
-2-
Project Title
Fill in with the facility or project name and brief descriptive statement of the project (e.g., Kahuku High School - repave parking lot) from Table P.
Description of Request
Fill in with the description of the CIP project from Table P. Explanation is in Part III.
II. Operating Cost Summary
Summarize the total estimated costs by cost elements, position counts (permanent and temporary), and $ amount. Provide a breakdown by all MOF.
III. Explanation of Cost Estimate
As applicable, provide narrative for the following:
1. Explain how the operating costs related to the CIP request was derived.
2. Discuss impact on program performance measures (current approved measures): measures of effectiveness, target group size, activity indicators.
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FORM CIPOpB
INSTRUCTIONS FOR FORM CIPOpB: FB 17-19 BIENNIUM BUDGET DEPARTMENT SUMMARY OF ESTIMATED
OPERATING COSTS RELATED TO CIP REQUESTS
Form CIPOpB is a summary listing of each department's Form CIPOp, FB 17-19 budget estimated operating costs related to CIP requests. The listing should be in departmental priority order.
Form CIPOpB: Rem Description and Preparation Instructions
Date Prepared/Revised
Underscore "Prepared" or "Revised" as applicable and enter date.
Department Priority
Enter the department priority number as entered on Form CIPOp. Requests with multiple MOF should be listed using the same priority number, with separate entries for each MOF.
Program ID
Enter the program ID of the request as entered on Form CIPOp.
Project No.
Enter the CIP project number as entered on Form CIPOp.
Project Title
Enter the facility or project name and brief descriptive statement of the project (e.g., McKinley High School - repave parking lot) as entered on Form CIPOp.
Description of Cost
Enter a brief description of the cost as entered on Form CIPOp.
MOF and $ Amounts (FYs 18-19 and FYs 20-23)
Enter the total estimated operating costs by MOF for each project as entered on the respective Form CIPOp. (Note: Amounts for FYs 20-23 by MOF are in thousands, as entered on Form CIPOp)
Total by MOF
Totals, including breakdown by MOF, will be automatically computed and auto populated. Formulas have been entered on these lines to compute the MOF totals automatically.
FORM PAB
Department of Budget
and Finance (rev. 9/13)
Questionnaire - General Obligation Bond Fund Appropriations
PART 1 Department and Project . 1 Department
2 Project Name 3 Project CIP No.
4 Session Law (act no. and year) 5 Program Area Function 6 Item No.
7 Project Description and Estimated Useful Life
PART 2 'Project Cost and Funding Sources 8 Does this request for funding require general obligation bond fund appropriations?
If "no" box is checked, no further information other than signature and date is required.
■ Yes ■ No
9 Has any appropriations been made for any portion of project prior to this request? ■ Yes ■ No
10 Funding sources for costs of project made by this request
a Direct Federal payment for construction and related capital costs
b General obligation bond fund appropriations
c General fund appropriations
d Other State of Hawaii and county funds
e Section 501(c)(3) funds
f Private funds
9 Total capital costs made by this request
PART 3 'Use of general obligation bond fund appropriations and use of project 11 Total amount made by this request for each purpose to which general obligation bond fund appropriations will be applied
a Total construction and related capital costs
b Total nonconstruction and noncapital State of Hawaii costs
c Total grants to counties
d Total grants to Section 501(c)(3) corporations
e Total grants to private persons and organizations and Federal government
f Private funds
9 Total loans to Section 501(c)(3) corporations
h Total loans to private persons and organizations and Federal government
i Total use of general obligation bond fund appropriations
12 Total square footage and percentage of use of project for each purpose
to which general obligation bond fund appropriations will be applied Square Footage Percentage of Total
a Total common area
b Total area used by State of Hawaii and counties
c Total area used by Section 501(c)(3) corporations
Total area used by private persons and organizations and Federal government in d trade or business
e Total area
PART 4 'Payment of operating and debt service costs and management o project 13 Will any lease or contract with a concessionaire or vendor be entered into in respect of
any portion of the project? If yes, attach schedule and copy of each contract.
■ Yes ■ No
14 Will any lease, incentive payment contract or management contract be entered into in respect of
any portion of the project? If yes, attach schedule and copy of each contract.
■ Yes ■ No
15 Will any payment be made (directly or indirectly) by the Federal government or any private person or organization pursuant to contract or other arrangement in respect to any portion of the project?
If yes, attach schedule and copy of each contract.
■ Yes ■ No
16 Please list the Department staff member(s) assigned to cooperate with the Department of Budget and Finance in its Project monitoring responsibilities, including (i) facilitating prior Department of Budget and Finance review and approval for any contracts with third parties relating to the Project or any transfer or sale of the Project and (ii) assisting with an annual review of the use of the Project. (Attach a separate sheet providing name(s), phone number(s), and email address(es).)
Name of Signer Signature Date Telephone Number
Instructions for Form PAB
Who must file this Form PAB. Anyone requesting any appropriation of general obligation bond funds must file this Form PAB.
Whereto file. This Form PAB must be filed with the Budget, Program Planning and Management Division of the Department of Budget and Finance.
Purpose. The purpose of this Form PAB is to elicit information that will enable the State of Hawaii to allocate general obligation bond fund appropriations in a manner that will comply with applicable requirements of Federal income tax law and regulations.
Line 1. Enter the name of the Department making the request for general obligation bond fund appropriations.
Line 2. Enter the name of the project for which general obligation bond fund appropriations are being requested.
Line 3. Enter the CIP number for the project.
Line 4. Enter the act no. and year of Session Law act under which appropriations have been made or are to be made for the project.
Line 5. Enter the program area function (e.g., economic development).
Line 6. Enter the item number of the project.
Line 7. Enter the description of the project and its estimated useful life (e.g., Waianae Rental Housing, 30 years).
Line 8. Check the 'yes' box if any portion of the project is to be funded with general obligation bond fund appropriations. Otherwise, check the 'no' box, if the 'no' box is checked, no other information on Form PAB, other than the signature line, is required. Please sign, date and return this Form PAB.
Line 9. Check the 'yes' box if any appropriation has been made for any portion of the project prior to this request, and attach the prior Form PAB or schedule containing all relevant details including the date, amount, and Session Law act and year.
Line 10. With respect to the appropriations (regardless of the source of such appropriations) made by this request for funding of any portion of the project: a. Enter the amount made or expected to be made by the Federal
government including reimbursements, for construction and related construction and acquisition costs in respect of the project.
b. Enter the amount funded or expected to be funded from general obligation bond fund appropriations.
c. Enter the amount funded or expected to be funded from general fund appropriations.
d. Enter the amount funded or expected to be funded by other State • of Hawaii funds or county funds.
e. Enter the amount funded or expected to be funded by payments from corporations which are classified as section 501(CX3) corporations under the Internal Revenue Code.
f. Enter the amount funded or expected to be funded by private persons and organizations. Enter the total of the amounts in a, b, c, d, e, and f of Line 10. Attach a schedule containing all details, including amounts and name and address of each person contributing to the funding of the project. Funding as used in this Line 10 means funding for capital and related acquisition items, including land, but does not include funding of operational and maintenance expenses or debt service payments after the in-service date of the project.
Line 11. With respect to the general obligation bond fund appropriations made by this request for funding of any portion of the project: a. Enter the total amount made or expected to be made for
construction and related construction and acquisition costs of the project.
b. Enter the total amount made or expected to be made to pay other State of Hawaii costs (e.g., a judgment claim, a contract settlement payment).
c. Enter the total amount of grants made or expected to be made to counties in the State of Hawaii.
d. Enter the total amount of grants made or expected to be made to section 501(CX3) corporations.
e. Enter the total amount of grants made or expected to be made to private persons and organizations and the federal government.
f. Enter the total amount of loans made or expected to be made to counties in the State of Hawaii.
9. Enter the total amount of loans made or expected to be made to section 501(CX3) corporations. Enter the total amount of loans made or expected to be made to private persons and organizations and the federal government.
L Enter the total of the amounts in a, b, c, d, e, f, g and h of Line 11.
Attach a schedule containing all details, including amounts and name and address of recipients of bond fund appropriations.
Line 12. Enter, to the extent applicable (e.g., an office building), the total square footage and percentage of total square footage of the project used by various persons or organizations. All use, including indirect and incidental use, is to be included. a. The total common area (e.g., hallways, parking
structure) used by all persons and organizations. b. The total area (excluding the common area) used
exclusively by the State of Hawaii and counties in Hawaii.
c. The total area (excluding the common area) used exclusively by section 501(CX3) corporations.
d. The total area (excluding the common area) used exclusively by private persons and organizations (including concessionaires and vendors) and the Federal government in their trade or business.
e. Enter the total of the amounts in a, b, c and d of Line 12.
Attach a schedule containing all details, including a breakdown by area used, and name and address of each user.
Line 13. Check the 'yes' box if any lease or contract with a concessionaire or vendor is expected to be entered into in respect of any portion of the project (e.g., vending machines, newsstand, store, pharmacy, pay telephones, onsite laundry services, cafeteria or other food services). Attach a separate schedule containing all relevant details, including the date, the name and address of each concessionaire or vendor, the terms and provisions of the lease or contract, and a copy of the contract.
Line 14. Check the 'yes' box if any lease, incentive payment contract or management contract is to be entered into in respect of any portion of the project. Attach a separate schedule containing all relevant details, including the date, the name and address of each party to such lease or contract, the terms and provisions of the lease or contract, and a copy of the lease or contract.
Line 15. Check the 'yes' box if any payment is expected to be made (directly or indirectly) by any private person or entity or the Federal government pursuant to contract or other arrangement in respect of any portion of the project. Attach a separate schedule containing all relevant details, including the date, the name and address of each party to such contractor arrangement, the terms and provisions of the contract or arrangement, and a copy of the contractor a description of the arrangement.
Line 16. Identify on a separate sheet the contact information for department staff member(s) assigned to cooperate with the Department of Budget and Finance in its project monitoring responsibilities.
(rev. 9/2013)
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FORM S
INSTRUCTIONS FOR FORM S: FB 2017-19 DEPARTMENT SUMMARY OF PROPOSED CIP LAPSES AND NEW CIP REQUESTS
Form S is a summary listing of all FB 2017-19 CIP requests to be proposed in departmental priority order. Form S (Biennium) files can be downloaded in Excel format with Part B prefilled with Table P information from eCIP. A blank Form S (Biennium) Excel file can also be downloaded if necessary.
Form S: Item Description and Preparation Instructions
Date Prepared/Revised
Underscore as applicable and enter date.
Part A - Proposed Lapses
Act/Year
Enter the Act number and year enacted of the project that is being proposed for lapsing.
Item Number
Enter the item number of the project from Part IV of the Appropriations Act (e.g., G-12).
Capital Project Number
Enter the capital project number as shown in the Appropriations Act.
Proiect Title and Reason for Lapsing
Enter the project title as shown in the Appropriations Act and the reason why the appropriation should be lapsed (e.g., project completed, project cancelled, etc.). Additionally, include the appropriation symbol and amount being lapsed.
Means of Financing (MOF) and Amount
Enter the MOF and the amount of funds proposed for lapsing.
Total by MOF
Totals, including breakdown by MOF, will be automatically computed. Formulas have been entered on these lines to compute the MOF totals automatically.
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Part B — New CIP Requests
Request Category
Indicate the type of request, as allowed in the Budget guidelines. Request Category must be completed on Form S (Biennium) manually after downloaded from eCIP. See Attachment 2 for guidelines.
• Major Repair and. Maintenance of Existing Facilities
• Completion of Ongoing CIP
• Health, Safety, Court Mandates
• Energy Efficiency
• Public Infrastructure Improvements
• Other
Priority
Enter unique priority number for the project for this section; projects with multiple MOF should be listed by MOF with the same priority number.
Program ID and Project Number
Enter the program ID and project number of the project as entered on Table P.
Project Title
Enter the facility or project name and brief descriptive statement of the project (e.g., Kahuku High School - repave parking lot) as entered on Table P.
MOF and FB 2017-19
Enter the requested amounts by MOF for each project as entered on Table P.
Total by MOF
Totals, including breakdown by MOF, will be automatically computed and auto populated. Formulas have been entered on these lines to compute the MOF totals automatically.
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FORM DMC
INSTRUCTIONS FOR FORM DMC: FB 17-19 BUDGET ESTIMATED DEFERRED MAINTENANCE COSTS
Form DMC is to be completed for the FB 17-19 Department Summary of Estimated Deferred Maintenance Costs.
Item Description and Preparation Instructions for Form DMC
Department
Fill in with appropriate department title.
Program ID/Org
Fill in the Program ID and the Organization Code of the program that would be responsible for the cost.
Island
Fill in the island location of the deferred maintenance cost (i.e., Kauai, Oahu, Molokai, Maui, Lanai, Hawaii).
State Owned Bldg/Facility/Other
Fill in the name of the building, facility, or other improvement to which the deferred maintenance cost is related.
Description of Deferred Maintenance
Provide a brief descriptive statement of what the deferred maintenance cost includes.
Means of Financing (MOF) and Amount
Fill in the estimated amount by MOF for each deferred maintenance cost.
Comments
Provide any additional comments, if necessary.
