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Date Contractor Phone Address City/State/Zip Consumer Phone Address City/State/Zip 1. Permits Contractor must report the amount of any permits or check none Assistive Technology Partnership-Standard Quote Form-Ceiling Track Lift System August 2017 2. Project Costs Itemize any items over $100 0 Billed to Medicaid Demolition/debris removal $ Lift/motor/charger/hand control $ $ Slings $ $ Track/supports/supplies $ Lumber (for construction) $ Electrical supplies $ $ Travel $ Equipment rental $ Miscellaneous $ $ b. Total $ c. Total $ Itemize additional costs $ $ $ d. Total $ 3. Labor e. Total $ Total Cost of project a,b,c,d,e Quote $ Signature Federal ID/SS# Quote good for 60 days unless otherwise noted Estimated date: Start Completion Weight capacity of ceiling track lift: # of pounds Consumer Weight: # of pounds Building $ None Electrical $ None Misc. $ None a. Total $

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Page 1: Contractor report the amount of any permits check none Contractor Phone Address City/State/Zip Consumer Phone Address City/State/Zip 1. Permits Contractor must report the amount of

DateDateContractor Phone

Address City/State/Zip

Consumer Phone

Address City/State/Zip

1. Permits Contractor must report the amount of any permitsor check none

Assistive Technology Partnership-Standard Quote Form-Ceiling Track Lift System

August 2017

2. Project CostsItemize any items over $1002. Project CostsItemize any items over $1002. Project CostsItemize any items over $100

Billed to MedicaidDemolition/debris removal $Lift/motor/charger/hand control

$ $

Slings $ $Track/supports/supplies $Lumber (for construction) $Electrical supplies $ $Travel $Equipment rental $Miscellaneous $ $ b. Total $ c. Total $ Itemize additional costs Itemize additional costs

$ $

$ d. Total $3. Labor e. Total $ Total Cost of project a,b,c,d,e Quote $

Signature

Federal ID/SS#

Quote good for 60 days unless otherwise noted

Estimated date: Start Completion

Weight capacity of ceiling track lift: # of pounds

Consumer Weight: # of pounds

Building $ NoneElectrical $ NoneMisc. $ None

a. Total $

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