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Official Connecticut Capital Improvement Template in PDF

The Connecticut Capital Improvement form serves as a crucial tool for requesting enhancements to existing community living arrangements. This form is designed to outline the necessary improvements, provide a detailed description of the need, and estimate the total project cost. By utilizing this form, providers can ensure that their requests are formally recognized and processed by the Department of Developmental Services.

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Structure

The Connecticut Capital Improvement form serves as a crucial document for requesting enhancements to existing community living arrangements. This form facilitates the process of securing approval for necessary improvements aimed at ensuring the health and safety of residents. Key sections of the form include details such as the property address, a description of the requested improvement, and the rationale behind the need for the upgrade. Additionally, it outlines the scope of work and provides an estimated total project cost, ensuring transparency and accountability in funding. The form also requires information regarding the bidding process, including contractor details and bid amounts, to maintain competitive pricing and quality standards. By completing this form, providers demonstrate their commitment to improving living conditions for individuals with developmental disabilities, while adhering to the regulations set forth by the State of Connecticut. Ultimately, the form plays an essential role in the state's efforts to enhance community living environments, fostering a safer and more supportive atmosphere for all residents involved.

Connecticut Capital Improvement Example

	State of Connecticut
	Department of Developmental Services
Dannel P. Malloy	Jordan A. Scheff
Governor	Commissioner

DEPARTMENT OF DEVELOPMENTAL SERVICES

REQUEST FOR CAPITAL IMPROVEMENT TO EXISTING

COMMUNITY LIVING ARRANGEMENTS

DATE

(A)

APPROVAL IS REQUESTED FOR THE CAPITAL IMPROVEMENT DETAILED BELOW AT:

Property Address (B)

Improvement Requested (C):

Description of Need (D):

Scope of Work (E):

Estimated Total Project Cost (F): $

Expense Incurred by: (check one)

Explanation of Cost Estimate (G):

Provider

CIL

Phone: 860 418-6000  TDD 860 418-6079  Fax: 860 418-6001

460 Capitol Avenue  Hartford, Connecticut 06106

www.ct.gov/dds  e-mail: ddsct.co@ct.gov

An Affirmative Action/Equal Opportunity Employer

	BID SUMMARY FORM
Provider:		Date:
Address:
Project Location:		Number:
Description of Work:
Type of Contractor (General, Trade)
Contractors Requests to Submit Bids
		Date Received	Bid Amount

Contract Award To:

If exception to bidding process is requested, check reason:

Unable to solicit three bids	Urgency to complete work
Other:
If lowest bid is not selected, write justification for choice:
Remarks:
Prepared by:	Approved By:
Provider	Region

Property Address:

(H)

The undersigned acknowledge that this document does not constitute a contract for development of a property and further acknowledges that any payments by the State of Connecticut related to this property may only be made pursuant to Sections 17b-244 and 17a-228 of the General Statutes and the regulations promulgated thereunder.

PROPOSED BY:			PROPOSED BY:
Private Residential Provider			Development Staff/Property Developer
			(if Applicable)
________________________			_____________________
Signature (Name)	(I)	(Date)	Signature (Name) ( J)		(Date)
Print/Type Name			Print/Type Name
Tel No.:			Tel.No.
REVIEWED BY:			AFTER CONSULTATION WITH:
_______________________		________________	___________________		_________
Signature (Name) (L)		(Date)	(Signature) (Name)	(M)	(Date)
Regional Director for Region			Commissioner
Department of Developmental Services			Department of Social Services
(Or Authorized Designee)			(Or Authorized Designee)
Print/Type Name
Tel.No:
		APPROVED BY
		____________________________________		______________
		(Signature) (Name)	(N)		(Date)
		Commissioner
		Department of Developmental Services
		(Or Authorized Designee)

By signing below, I hereby certify that this capital improvement project is considered by the Department of Developmental Services to be a required project for the health or safety of the residents as detailed in CGS 17b-244.

____________________________________	______________
(Signature) (Name) (O)	(Date)
Commissioner
Department of Developmental Services
(Or Authorized Designee)

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Document Specifications

Fact Name	Description
Governing Law	This form is governed by Sections 17b-244 and 17a-228 of the Connecticut General Statutes.
Purpose	The form is used to request approval for capital improvements to existing community living arrangements.
Contact Information	For inquiries, contact the Department of Developmental Services at 860-418-6000.
Approval Process	Approval must be obtained from the Commissioner of the Department of Developmental Services.
Cost Estimate	The estimated total project cost must be clearly stated on the form.
Bid Summary Requirement	A bid summary form is required, detailing contractor information and bid amounts.

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