SPACE PLANNING REQUEST
SPR PART 1
OMB PREAPPROVAL FORM
Department:
Space Planning Request
Department of Treasury, DPM&C Office of Planning, Programming & Budgeting
Certifications & Approvals
DPMC USE ONLY
SPR No.:
Municipal Code:
OMB Tracking No. ________________
OMB USE ONLY
_
REQUESTING AGENCY
I hereby certify that all information contained within this document is true and accurate, that the space requested
represents the minimum square footage necessary for this agency to carry out its functions and that this agency will
comply with DPMC’s Policy for Hazardous Materials/Waste Remediation for State-Leased Facilities. I am aware
that if any of the above statement made by me is false I am subject to punishment. (See NJSA52:18A-191.8 and
NJAC 17:11-32)
Organization/Unit:
Signature
_________________________________________
Division:
Signature
_________________________________________
Date ___________________
________________________________________
_________________________________________
Chief Fiscal Officer:
Signature
Date ___________________
________________________________________
Department:
Signature
_________________________________________
Date ___________________
__________________________________________
_________________________________________
Date ___________________
OMB
I hereby certify that I have reviewed the current and projected employee position data and funding
associated with this request:
Budget Analyst:
________________________________________
___________________
Signature
Date
________________________________________
___________________
Signature
Date
Deputy Director of Budget & Accounting:
DPM&C DIRECTOR
Approved
Disapproved
Revised 7/01/05
________________________________________
___________________
Signature
Date
Page 1 of 5
SPACE PLANNING REQUEST
SPR PART 1
OMB PREAPPROVAL FORM
Date: ______________________________
ORGANIZATION
Department: ____________________________
CURRENT LOCATION
Address: ____________________________
Division:
____________________________
____________________________
Unit:
____________________________
Approximate Sq. Ft. ___________________
Type of Operation (Please Check One)
Administrative
Client Service
Special Use
Check Box if Request for
Renewal Option
FUNDING SOURCE (attach additional sheets if necessary)
ACCOUNT #
C/D %
Check appropriate box
State Owned
or
Lease # _________
If leased, check appropriate box
Month to Month
or
Term
STAFFING LEVELS
Existing SPR:
_________________
SPR#
____________________
Current FTE:
_________________
Approved Additional FTE:
______________
(Documented approval by governor’s office)
Total FTE (Current + Additional)
_____________________
AGENCY CONTACT
Proposed Lease Term:
Desired Catchment Area:
Name:
______________________________
Phone #:
______________________________
Email:
______________________________
Check if Smart Growth Form Submitted
Is this Space Planning Request an upgrade from DPMC’s Standard Space Allocation for
Administrative/Client Service Offices?
NO
YES
If yes, justify below and attach completed SPR PART 3 of Space Planning Request Form. Fill in all columns
in Part 3 except Special Use columns.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(Attach additional sheets if necessary)
Revised 7/01/05
Page 2 of 5
SPACE PLANNING REQUEST
SPR PART 1
OMB PREAPPROVAL FORM
Will this Space Planning Request result in the vacancy of currently occupied space?
NO
YES
If yes, provide explanation as to why space is being vacated and any agency plans to backfill space.
__________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
(Attach additional sheets if necessary)
Indicate All Attachments
Space Planning Request PART 3
Additional Justification/Upgrade from Standard Space Allocation
for Administrative/Client Service Offices
Additional Explanation of Vacating of Premises and Backfill
Other (explain) _____________________________________
For Use by OMB
Approved for Standard Space Allocation
Manager ____________________ Analyst__________________
Date
Disapproval/Approved as Qualified Below
____________________
Date
__________________
Manager ____________________ Analyst__________________
Date
____________________
Date
__________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
Revised 7/01/05
Page 3 of 5
SPACE PLANNING REQUEST
SPR PART 1
OMB PREAPPROVAL FORM
Employee Status Report – Current FTE
Duplicate form as necessary to include all positions
Code*
&
Shift
Job Title
Field/
Office
(F/O)
NAME or ALLOWABLE HIRE
Position No.
BLDG. Code
*Enter Position Space Type Code shown in SPR Part 3, Section A
Revised 7/01/05
Page 4 of 5
SPACE PLANNING REQUEST
SPR PART 1
OMB PREAPPROVAL FORM
Vacant Position Status Report – Additional Approved FTE & Other
Duplicate form as necessary to include all positions, including part-time/consultants/interns, etc
Code*
&
Shift
Job Title
Field/
Office
(F/O)
Info on proposed funding source
Position No.
BLDG. Code
*Enter Position SpaceType Code shown in SPR Part 3, Section A.
Revised 7/01/05
Page 5 of 5