BPM006728_Exhibit_D_-_RSA_HM_Request_for_Project_Pricing.pdf
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- Attached to
- Master Agreement AZ|CTR077220
- Contract number
- CTR077220
- Issued by
- Arizona
About this file
This document is a Home Modification Request for Project Pricing form from the Arizona Department of Economic Security (ADES), specifically from the Rehabilitation Services Administration (RSA). The form is designed to solicit pricing proposals from contractors for home modification projects for clients with specific accessibility needs.
The document provides a two-section template for contractors to complete, including client and RSA staff information in Section I, and a detailed project pricing proposal in Section II. Contractors are required to break down their proposed work by service/task, including material and labor costs, with space for up to 6 specific tasks plus administrative costs. The form emphasizes confidentiality of client data and stipulates that approved projects must be completed within 30 calendar days of receiving the RSA Purchase Authorization. Contractors are instructed to email their completed pricing proposal to the RSA Home Modification Coordinator, with space provided for contractor details, estimated timeframe, and additional notes.
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Text version
Exhibit D
V1_RSA Request for Project Pricing
Arizona Department of Economic Security (ADES) Rehabilitation Services Administration (RSA)
HOME MODIFICATION
REQUEST FOR PROJECT PRICING
SECTION I: PROJECT INFORMATION
ADES/RSA is issuing this request for pricing for a client’s home modification. Information included in this document contains CONFIDENTIAL client data which must be always protected.
Complete and submit Section II: Project Pricing Proposal in accordance with the service specification recommendations attached to this document.
If approved, the project must be completed in 30 calendar days from the receipt of RSA Purchase Authorization unless otherwise specified.
Email your Project Pricing Proposal to: pferry@azdes.gov
Paul Ferry, RSA Home Modification Coordinator Phone: (602) 309-7682
Project Number:
CLIENT INFORMATION:
Client Name: ________________ Phone Number: ______________ Email: ____________________
Family Contact: ______________ Phone Number: ______________ Email: ____________________
Adress: __________________________________________________________________________
Major Cross Streets: ________________________________________________________________
RSA INFORMATION:
VR Counselor: ______________ Phone Number: _______________ Email: ____________________
Evaluator: _________________ Phone Number: ________________ Email: ___________________ mailto:pferry@azdes.gov
Exhibit D
V1_RSA Request for Project Pricing
Arizona Department of Economic Security (ADES) Rehabilitation Services Administration (RSA)
HOME MODIFICATION
REQUEST FOR PROJECT PRICING
SECTION II: PROJECT PRICING PROPOSAL
Service/Task Description of service/task including make/model/materials to be used.
See before photos below.
Material Cost
Labor Cost
Total ($)
1.
2.
3.
4.
5.
6.
7. Administrative
Total(s) Total Project Pricing:
Contractor Signature: _________________________________ Date: _______________________
Printed Name: ______________________________
CONTRACTOR INFORMATION:
Name: _________________________________________________
Address: _______________________________________________
Phone Number: ____________________________ Email: ________________________________
Project Number: ____________________________
Contractor Estimated Timeframe: ____________________________________________________
Additional Contractor Notes:
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