Date:	Click or tap to enter a date.

To:	Darren Hobbs

Deputy Commissioner, Department of Administrative Services

DAS/Construction Services

450 Columbus Blvd., Ste. 1303 N.

Hartford, CT 06103

Darren.hobbs@ct.gov

Cc:	Craig Russell

Director, Construction Support Services

craig.russell@ct.gov

Re:	Enter Project Name

Enter Project Location Name

Enter Project Location

In accordance with C.G.S. Sec. 4b-52(c), the Enter Client Agency is filing a Request for Declaration of Emergency Status for an emergency condition that exists at Enter Project Location Name located at Enter Project Location. Enter Project Location Name is Enter description of government operations at facility location.

Describe condition leading up to the emergency. Describe why the condition is an emergency.

The scope of work for the emergency condition is as follows: Enter Project Scope.

Estimated Total Project Costs: $ Enter Estimated Project Cost

Funding Sources for this project are as follows:

Funding Source Description	Amount
Click here to enter text.	$	Click here to enter text.

The agency understands that in order for a condition to be declared an emergency, the condition shall adversely affect either public safety or the proper conduct of essential government operations or both. The condition described above adversely impacts public safety in that:

(Provide a detailed description, with specific examples, of the adverse impact on public safety. You may refer to, and attach, any supporting documentation, if available).

And/or

The condition interferes with the conduct of essential state government operations in that:

(Provide a detailed description, with specific examples, of the adverse impact on essential state government operations. You may refer to, and attach, any supporting documentation, if available).

The Project Manager assigned to oversee this project on behalf of Enter Client Agency is Enter Project Manager Name, who can be reached by phone at Enter PM Phone Number or by email at Enter PM email

This project shall be performed in accordance with the DAS 0500 Agency Administered Projects Procedures Manual, and all other applicable State statutes, regulations and Life Safety codes.

The Enter Client Agency requests that this project be administered by: ☐ CT DASS or ☐ User Agency.

Sincerely,

Enter Authorized Agency Representative

Enter Title