187_Aging Sole Source Request_CSFP Signed.pdf

Request for Sole Source Authorization_updated 7/2015 Page 1

Request for Sole Source Authorization (SSA) Division of Purchasing (DOP)

Email Completed Request Form to DOP at purchasing@adm.idaho.gov

New Request (Answer Questions 1-5)

Request to Renew SSA# (Answer Questions 6-8)

(Check this box to request an additional term for the same goods/services)

Request to Amend SSA# (Answer Questions 9-10) (Check this box to request a change to the goods/services, term, or other conditions of the SSA)

Agency Purchasing Representative (Name):

E-mail/Phone:

Name of Agency:

Request for the Purchase of:

Requested Supplier (vendor name):

Cost Estimate (attach quote):

Desired Term: Start Date: to End Date:

(For one-time purchases, please enter a one-year term from the date on which you wish to place the order)

Do you anticipate the need for renewals? Yes No

Sole Source History (renewals and amendments):

Provide a history of the sole source including: SSA number, date issued, term, cost, and brief description for original SSA and each renewal/amendment; and total value to date. See SSA Instructions for examples.

IDAPA 38.05.01.045 provides that sole source purchase shall be used only if a requirement is reasonably available from a single supplier.

NEW REQUESTS (complete #1-5)

1. Describe the Product or Service.

2. Describe your Agency’s Business Need for the requested product or service.

DOP use only:

SSA#

mailto:purchasing@adm.idaho.gov

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3. Justification: Check each box that applies and attach required documentation.

Sole source provider of a licensed or patented good or service (attach provider’s letter) Sole manufacturer AND distributor (attach manufacturer’s letter) Sole provider of factory-authorized/warranty service (attach provider’s letter) Sole provider of items that are compatible with existing equipment, systems, programs, etc.

Other (attach description and justification)

4. Describe what makes this Product or Service unique.

5. Provide a list of other suppliers contacted and describe the method for determining that there are no other possible suppliers.

REQUEST TO RENEW (complete #6-8) Note: each agency seeking authorization to renew a current SSA must conduct a business/financial analysis every 5 years, at a minimum, documenting estimated costs (as well as other factors) related to maintaining the current provider versus switching/migrating to a new provider/alternative solution, if one is available.

6. Confirm your Agency’s continuing Business Needs.

7. Justification: Check each box that applies and attach required documentation.

Sole source provider of a licensed or patented good or service (attach provider’s letter) Sole manufacturer AND distributor (attach manufacturer’s letter) Sole provider of factory-authorized/warranty service (attach provider’s letter) Sole provider of items that are compatible with existing equipment, systems, programs, etc.

Other (attach description and justification)

8. Describe the steps taken to confirm that the product/service continues to qualify as a sole source; include a list of suppliers contacted.

REQUEST TO AMEND (complete #9-10)

9. Describe (with specificity) the requested modifications to the scope of work, product requirements, cost or other proposed changes to your current SSA.

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10. Describe your Agency’s business need for the requested modifications.

Agency Certifications:

I certify that the Agency has sufficient appropriation balances for payment of the requested product/service.

(Checking this box takes the place of a DA-1 or IPRO request.)

I am aware that Idaho Code and IDAPA require procurements to be competitively bid unless specifically exempt;

that the statements contained in this Request are complete and accurate, based on my professional judgment and independent investigation; that no personal advantage will accrue to me or any member of my immediate family as a result of this direct procurement; and that based on my analysis of my agency’s business need and research into available products or services, no other vendor can provide the same or similar product or service to meet my agency’s need.

End-User/Program Agency Requestor:

Signature Date

Printed Name Title

Agency Purchasing Representative:

Printed Name Title

Upon approval by the Administrator, the Agency may proceed with the purchase and issue its own purchase order or contract document for this acquisition. The Division of Purchasing’s SSA number noted above (with Administrator approval, below) is the only authorization needed for the Agency to proceed with this purchase. Agency purchases from this sole source authorization shall not exceed the dollar amount listed above unless approved in writing by the Division of Purchasing.

APPROVED REJECTED

DOP ADMINISTRATOR:

Printed Name

Additional Conditions which apply to this approval:

The Agency must consult with its legal counsel regarding terms and conditions prior to entering into a contract with the approved supplier.

The Agency must complete a business/financial analysis prior to any additional renewals of this SSA.

Other (specify):