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VEHICLE REQUEST FORM (ADMV-109) INSTRUCTIONS FOR VEHICLE REQUEST (NJ Department of Treasury)

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STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF ADMINISTRATION - TRANSPORTATION SERVICES
VEHICLE REQUEST FORM (ADMV-109)
INSTRUCTIONS FOR VEHICLE REQUEST FORM
(A separate Vehicle Request Form must be submitted for each TYPE of vehicle being requested)
Request must be signed by the department’s Chief of Staff, Assistant Commissioner or Commissioner, and
e-mailed to:
Supervisor, Vehicle Procurement
vehiclerequests@treas.nj.gov
If you answer ‘yes’ to any of the following questions an explanation is required in the justification section.
10) If an individual assignment, is the driver considered essential personnel in the event of bad weather or
official closure?
11) If the vehicle is to be used as an emergency response vehicle, please provide details on how the vehicle
will be utilized.
12) If the vehicle is to be used to tow, please provide specifics including what would be towed, approximate
weight, and frequency of towing needs.
13) If the vehicle is to be used to carry passengers, please indicate if the passengers will be State employees or
others. Also indicate how many passengers, the frequency of transportation, and any special accommodations
required for passengers.
14) If the vehicle will be used to carry supplies or cargo, please provide a description of what will be
transported and the frequency of transportation.
15) If the vehicle is to be used out-of-state, explain why and where and also provide the estimated percentage
of time the vehicle will be out of state.
16) If Line of Credit financing is requested, please provide an explanation why it is necessary.
JUSTIFICATION (One detailed statement for each request is acceptable. If multiple vehicles, please
address in one comprehensive justification statement.)
Please provide a detailed explanation supporting this request. The justification must address why
reimbursement for personal use is not considered as an option. If this is an addition to the fleet, explain how
program needs are currently being met; if this is a replacement request, what will be the impact of not
replacing the vehicle, and explain if the vehicle will be used differently than the vehicle it replaces.
The justification must also include the steps you have taken to promote fuel efficiency. Specifically, explain
what your department has done to reduce fuel consumption, downsize to more fuel efficient vehicles, and how
you promote the use of alternative fuel consumption in those vehicles that can accept an alternative fuel and
are utilized in a region where the alternative fuel is available.
If the request is not for a compact, please explain why your department is unable to comply with C.L. 12-11-
ADM.III.A.8 (a), whereby compact sedans are required unless unsuitable for the agency’s needs.
If a 4 wheel drive is being requested, please provide details on why it is being requested, including how often
you expect the 4 wheel drive capability will be utilized.
Provide any other information deemed critical to support this request.
ADMV-109 rev 6/2015 Instruction Page
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF ADMINISTRATION - TRANSPORTATION SERVICES
VEHICLE REQUEST FORM (ADMV-109)
FOR ANY VEHICLE UNDER GVW 16,000 POUNDS
TO: Supervisor, Vehicle Administration:
Department of the Treasury, Division of Administration
FROM: ____________________________________________
(Department)
_________________________________________________
(Print Name)
_________________________________________________
(Signature)
1. Is this an individual or pool assignment? INDIVIDUAL POOL
2. If an individual assignment, will the individual’s official work station be home or office? HOME OFFICE
3. In what county or region will the vehicle be used? ___________________
4. Where will the vehicle be parked when not in service? _____________________________
5. Estimated monthly mileage: # of Business Miles _____________ # of Commuting Miles_______________
6. How many days a week will the vehicle be used? __________________
7. What hours will the vehicle be used? ___________________________
8. Allocate usage by percent, as follows:
Highway ____________________ Off-road________________________
Inner City/urban ________________ Institution grounds (paved roads) _______________
Rural roadways __________________ State Parks (paved roads) _____________________
Other (explain) ___________________
9. Type of Acquisition: Contract Purchase Bid Waiver Lease
If you answer ‘yes’ to any of the following questions please provide details in the justification section
10. Is the employee considered essential personnel in the event of official closure? YES NO
11. Will the vehicle be used as an emergency response vehicle? YES NO
12. Will the vehicle be required to tow? YES NO
13. Will the vehicle be used to carry passengers? YES NO
14. Will the vehicle be used to carry supplies or cargo? YES NO
15. Will the vehicle be used out-of-state? YES NO
16. Will line of credit funding be requested? YES NO
ADMV-109 rev 6/2015 PAGE 1
ADM#______
A. VEHICLE INFORMATION (must be provided for each vehicle requested – see instructions)
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF ADMINISTRATION - TRANSPORTATION SERVICES
VEHICLE REQUEST FORM (ADMV-109)
FOR ANY VEHICLE UNDER GVW 16,000 POUNDS
(Include Additional Pages if Necessary)
ADMV-109 rev 6/2015 PAGE 2
B. JUSTIFICATION FOR RE
Q
UEST:
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF ADMINISTRATION - TRANSPORTATION SERVICES
VEHICLE REQUEST FORM (ADMV-109)
DEPARTMENT: _______________________ Manufacturer’s Cut-off date ___________________________
DIVISION: _____________________________ CONTRACTOR’S NAME: ____________________________
DATE Submitted to Treasury Administration: ________________ CONTRACT #:___________________
T #:___________________
QUANTITY LINE # VEHICLE DESCRIPTION COLOR TRADE IN
SG PLATE #
OPTION LIST
PRICE
UNIT COST
(Less Discount)
TOTAL COST
Total Amount $__________________
NOTE: A contract vehicle request must be received at least 2 weeks prior to the manufacturer’s cut-off date. Master Notification-Cut-Off Date is available at
http://www.nj.gov/treasury/purchase/mnmaster.pdf
A non-contract vehicle request must be received at least 1 week prior to the Purchase Bureau’s FY cut-off date
http://www.nj.gov/treasury/purchase/agency.shtml
Agency Contact: _____________________________________________ Contact Person for Tech Support Regarding Specifications:
Division: ____________________________________________________ Agency Contact: ____________________________________
Address: ____________________________________________________ Phone: ____________________________________________
Phone: ______________________________________________________ Email: _____________________________________________
Fax: ________________________________________________________
E-Mail: _____________________________________________________
Agency Ref. #:________________________________________________
_________________________________________________________________________________________________________________________________
TO BE COMPLETED BY TRANSPORTATION SERVICES: Treasury Vehicle Administration ADM#______________________
Approved by Treasury Administration on _____________ Sent back to agency for modification on ______________
ADMV-109 rev 6/2015 PAGE 3
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Completed 13 August 2020

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