Purchase Request Form

Work email address of the person completing this request *:

Agency Name:

Name of Contact Person:

Phone Number:

Fiscal Year:

Non-mission critical agency expenses are defined as items or services not required to achieve the agency’s core mission or functions.

Method of Purchase:

Brief Description (Please reference Section a. of Executive Order 2019-13):

Cost (Please reference Section a. of Executive Order 2019-13)

Program costs should include the Account Code and Account Name to indicate the category of expense in which the exception is being requested. Please select the account code (s) for entire request. Example: 537190 – Laboratory & Medical Supplies and 531110 – Shipping Account Codes for personnel are excluded from the non-emergency purchase process. (Salary Expenses 511000; Insurance Premiums (Health, Life, etc.) 512000; FICA & Retirement Contributions 513000; Benefit Payments 514000. If you have more than 3 account codes to reference for this purchase, please list remaining account codes/amounts on the last sheet of this form.

Please list the purchase amount per funding source:

State:

Revolving/Fees:

Federal:

Other:

Total Funding:

Necessity for Purchase (Please reference Section a. of Executive Order 2019-13)

Please provide reason for necessity of purchase:

Please list any costs that could attach to the State if the request is denied:

Deadline Date: