Microsoft Word - SFM Form 6-77 20131231.doc



Date: FORMTEXT ?????Formerly Form 6-77From:Agency Name: FORMTEXT ?????Agency #: FORMTEXT ?????To:State Fleet ManagementDivision Name: FORMTEXT ?????Division #: FORMTEXT ?????1430 Senate Street, 3rd FloorAddress: FORMTEXT ?????Columbia, SC 29201-3710City, State, Zip: FORMTEXT ?????FAX: 803-737-1160Agency Contact: FORMTEXT ?????Phone: FORMTEXT ?????statefleet@admin.SECTION IRequest to PurchaseFleet Addition: FORMCHECKBOX Yes FORMCHECKBOX No(If Yes, provide justification below or attach letterhead. If No, complete Section II) FORMCHECKBOX New FORMCHECKBOX Used FORMCHECKBOX Bid OutBids must be approved by SFM prior to initiating Request For ProposalQTY: FORMTEXT ?????Provide USED VIN & Odometer if known:VIN/Serial Number: FORMTEXT ?????Odometer: FORMTEXT ?????Make: FORMTEXT ?????Model: FORMTEXT ?????Body Style: FORMTEXT ?????Year: FORMTEXT ????Annual Estimated Mileage Utilization: FORMTEXT ?????(i.e. Sedan, Van, Truck, Trailer…)Funds source: State: $ FORMTEXT ????? Federal: $ FORMTEXT ????? Other: $ FORMTEXT ????? Define Other: FORMTEXT ?????PO Purchase Amount:$ FORMTEXT ?????Purchase Order Number: FORMTEXT ?????(i.e. USDA Vehicle, Loan, Gift)Vendor Contract #: FORMTEXT ?????Check if you will request the following: FORMCHECKBOX SASS-007B Form: Exemption from State Motor Vehicle Identification Requirements (i.e. State Seal, Confidential tag). FORMCHECKBOX SASS-007C Form: Permanently assign vehicle to a driver.Vendor Name: FORMTEXT ?????Vendor Address: FORMTEXT ?????Vendor City, State, Zip: FORMTEXT ?????Fleet Additions require justification in accordance with § 1-11-310 and Fleet Management Policy Directives 1-5. Agency director must certify that no vehicle is available to reassign to fill this need. (Attach additional sheet, if necessary).The State standard fleet sedan or SUV is a compact model. Requests for special fleet sedans or SUV’s (Intermediate model) must be justified in writing. (Attach additional sheet, if necessary). FORMTEXT ?????SECTION IIRequest for Disposal/Retention (Attach separate sheet for multiple vehicles) FORMCHECKBOX Disposal FORMCHECKBOX Retention**VIN/Serial Number: FORMTEXT ?????Tag Number: FORMTEXT ?????Odometer: FORMTEXT ?????Estimated Value:$ FORMTEXT ?????Make: FORMTEXT ?????Model: FORMTEXT ?????Body Style: FORMTEXT ?????Year: FORMTEXT ????** Old vehicle must be disposed of within 90 days of placement in service of replacement vehicle, unless one-year retention is approved by SFM. Submit on separate page detailed justification why your agency needs to retain this vehicle.SECTION IIIAgency Head ApprovalSignature of Agency Director/Institution Head or designee:* Designee must be on file with SFM as Approved Authority FORMTEXT ?????Print Agency or Institution Head NameSignature of Agency or Institution HeadSECTION IVAction By State Fleet Management (To Be Completed By State Fleet Management)1153795-482600085725-4762500 Approved DisapprovedDateState Fleet Manager Signature ................
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