120-26 LEAP - Challenge Application - Supplemental Forms.pdf

LEAP PARTICIPANT IDENTIFICATION SUPPLEMENTAL FORM Participating Local Unit: Entity Name: City of East Orange County: Essex Address: 44 City Hall Plaza, East Orange, NJ, 07018 Program Contact Information Program Administrator: Jean-Guy, Lauture, Business Administrator Contact Person & Title: Elizabeth Collins, Director of DPW Voice Phone/Extension #: 973-266-5000 Voice Phone/Extension #: Fax: F-ax: E-mail: jean-guy.lauture@eastorange- nj.gov E-mail: elizabeth.collins@eastorange-nj.gov Participating Local Unit: Entity Name: Township of West Orange County: Essex Address: 66 Main Street, West Orange, NJ, 07052 Program Contact Information Program Administrator: Peter Smeraldo Jr. Contact Person & Title: James Latore, DPW Superintendent Voice Phone/Extension: 973-325-4050 Voice Phone/Extension: 973-325-4153 Fax: Fax: E-mail: psmeraldo@westorange.org E-mail: jlatore@westorange.org PLANNED EXPENDITURES FORM – CONSULTANT SERVICES - LEAP 5 Submit this form or a separate consultant proposal detailing the following information. Applicant: City of East Orange Project Name: East Orange–West Orange DPW Shared Services Feasibility Study

Identify the consultant and describe the service(s) to be provided. (Continue on the back of this form if additional space is needed) Activity/Task Consultant Staff Level Assigned Rate Per Hour/Per Day Est. Time for Completion (hours/days) (A) Cost Per Activity/Task 1. $ $ 2. 3. 4. 5. 6. TOTAL $ OTHER EXPENSES (Itemize) (B) COST $ TOTAL Column (B) Costs $ TOTAL Columns (A) and (B) Costs (Also enter this amount on Form LEAP-4 next to “Consulting”) $

Participating Local Unit Acknowledgement By signing this application form, each participating local unit signatory attests to the express authority to sign on behalf of the local government he or she represents and to the accuracy of the information contained in the application. Date: Signature (Print) Name and Title: (Print) Applicant (Lead) Entity: City of East Orange Date: Signature (Print) Name and Title: (Print) Participating Local Entity: Township of West Orange Date: Signature (Print) Name and Title: (Print) Participating Local Entity: Date: Signature (Print) Name and Title: (Print) Participating Local Entity: