Repair or Replacement Request

Repair or Replacement Request
ICDVVA funds may be used for repair or replacement of items that contribute to maintaining a healthy and safe environment for crime victims, such as a furnace in a shelter. Any repair or replacement in an amount over $499 must be preapproved by ICDVVA in writing. Without preapproval, reimbursement will be denied. Please allow 30 days for review and approval of this request, unless the repair/replacement is an emergency. In an emergency situation, please consult your grant manager.

The following conditions must apply to every repair/replacement request:
- The building is owned, not rented or leased, by the subrecipient
- The subrecipient has no other source of support for the expense
- The cost is reasonable
- The expense is prorated among all sources of income
Please include bids or estimates for all expenses requested.
Program Name*
Requester Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Please choose one of the following statements about this expense:*

This expense was anticipated in our budget narrative for this grant year.This expense was not anticipated in our budget narrative for this grant year.
If the expense was not anticipated, please explain why it has become necessary:
Type of Repair or Replacement (itemize all related expenses, i.e., purchase of item,labor, installation):*
Total Estimated Cost and date of installation/work*
Who will supply the item/perform the work? Do you have multiple bids for the work needed?*
Please attach the invoice for the repair/replacement, plus any competing bids you have collected.

Browse Files

Cancelof
If you are not submitting competing bids, please explain why.
Please address the following 4 requirements: The building is owned, not rented or leased, by the subrecipient; the subrecipient has no other source of support for the expense; the cost is reasonable; the expense is prorated among all sources of income.*
Requesting Program Executive Director's Name:*
Requesting Program Executive Director's Signature:*

Clear
ICDVVA Action:

ApprovedDenied
Reason for denial:
ICDVVA Approval Signature
Date:

MonthDayYear
Should be Empty: