ITC49_LeaseQuote_Form_130417~2.doc

Commonwealth of Massachusetts – Statewide IT Asset Lease Services Contract ITC49

IT ASSET LEASE QUOTE FORM

IT ASSET TRANSACTION SUMMARY

Lessee: Click here to enter text.

Lessee Location: Click here to enter text.

Lessee Contact Name: Click here to enter text.

Telephone: Click here to enter text.

Fax: Click here to enter text.

Email: Click here to enter text.

The Lessee hereby requests financing under the Statewide IT Asset Lease Services Contract ITC49 for the following IT Asset(s). The table will expand to accommodate additional rows. Lessee should append a row at the bottom of the list of IT Assets for de-installation, packaging, and/or return of the IT Asset(s) upon lease termination, if appropriate.

Requested:

Useful Life in Years

(3 or more Years) (Term of TELP)

IT Asset Contractor Name (Entity being paid by IT Asset Lease Services Contractor): Click here to enter text.

Contractor Address: Click here to enter text.

Contractor Remittance Address if different:Click here to enter text.

Contact Name: Click here to enter text.

Telephone: Click here to enter text.

Fax: Click here to enter text.

Email: Click here to enter text.

Description of items being purchased from this IT Asset Contractor: Click here to enter text.

Anticipated Delivery Date for Acceptance of IT Asset by Lessee after Delivery: Click here to enter text.

Total Amount of IT Asset Cost to be paid to IT Asset Contractor: Click here to enter text.

Anticipated Date for funding to be made by Statewide IT Asset Lease Services Contractor/Lessor: Click here to enter text.

Anticipated Lease period (which may not exceed useful life): Click here to enter text.

Describe the essential use of the IT Asset and whether this IT Asset is replacing a current IT Asset or is a new essential use: Click here to enter text.

Statewide IT Asset Lease Services Contractor Name: Click here to enter text.

Vendor Code: Click here to enter text. (For state agency Lessee payments.)

Contact Name: Click here to enter text.

Telephone: Click here to enter text.

Fax: Click here to enter text.

Email: Click here to enter text.

QUOTE:

The Statewide IT Asset Lease Services Contractor must complete the following, execute this document and submit a proposed Payment Schedule for this Quote. If accepted, the Lessee will execute this document (below) then complete and submit the necessary IT Asset Listing, Essential Use Certification, Certificate of Appropriation, and IT Asset Acceptance Certificate to their Financial/Budget Authority for approval, and, after receipt and acceptance of the IT Asset, shall complete the IT Asset Acceptance Certificate, including the Final IT Asset Lease Payment Schedule.

Statewide IT Asset Lease Services Contractor Offer of Fixed Interest Rate Quote (Valid for 30 days): Click here to enter text. % Statewide IT Asset Lease Services Contractor Payment Schedule Number of payments: Click here to enter text.

Complete and attach the IT ASSET ACCEPTANCE CERTIFICATE AND LEASE PAYMENT SCHEDULE Lessee certifies that this document is being submitted to its funding authority to confirm availability of Lease funding. Contractor certifies that this quote will be held for 30 days and is being made in compliance with the Statewide IT Asset Lease Services Contract ITC49

AUTHORIZING SIGNATURE FOR THE IT ASSET LEASE SERVICES CONTRACTOR:

X: . Date: .

(Signature and Date Must Be Handwritten At Time of Signature)

Print Name: Click here to enter text.

Print Title: Click here to enter text.

AUTHORIZING SIGNATURE FOR THE LESSEE:

X: . Date: .

(Signature and Date Must Be Handwritten At Time of Signature)

Print Name: Click here to enter text.

Print Title: Click here to enter text. .

Revised: 4/17/2013