ADM-4 Contract or Equipment Lease Compliance Checklist

See ADM-4, Contracting for Service

Property

Name of Property

Date Prepared

Date

Name of contractor or lessor

Description of service or goods

Previous provider

N/A if new contract scope

Annual budgeted amount

Input $0 if not budgeted

Reason for change

Annual amount per agreement

Original commencement date

Date

Total amount over term

Termination date

Date

Prior annual amount

Input $0 if new contract

CONTRACTS AND LEASES (provide explanation in “Remarks” for any item that is NOT checked)

Check any of the following blocks that apply:

MUST BE CHECKED:

REMARKS: (must be provided is any of the above is NOT checked)

Preparer: Indicate “N/A” on signature lines of individuals who are not required to review or approve this agreement. See Table 1 – Approving Authorities in ADM-4 for guidelines.

Each signer below affirms that there are no factors related to this contract that would disqualify him or her, as described in “Disqualification for Conflict of Interest” in ADM-4, Contracting for Service. If a signature of any person in the chain is omitted because of a conflict, write “Excused for conflict of interest” in the signature element.

Preparer Name:

REQUIRED

Preparer Signature:

Property Manager Name:

REQUIRED

Property Manager Signature:

SPM/General Manager Name:

Signature Required up to $250,000

SPM/General Manager Signature:

PGM/Director of Operations Name:

Signature Required over $250,000

PGM/Director of Operations Signature:

Chief Engineer Name:

Engineering Contracts/Scope

Chief Engineer Signature:

Group Engineering Manager Name:

Engineering Related Scope

Group Engineering Manager Signature:

Contract or Equipment Lease Compliance Checklist

AGREEMENT DATE

SERVICE CONTRACTS ONLY

COORDINATION AND APPROVAL