684386141DF01 SOLE SOURCE redacted signed.pdf

Ref: TRIREFFACINST 4491.1

TRIREFFAC 4491/3 (Rev. 11-2020)

The Service or material listed on __________________________ is the sole source and competition must be restricted to one Document Number source, or only one brand name for reasons indicated below. There are no substitutes available for this material.

Restricted to the following source or brand name. Provide the original manufacturer’s name.

NOTE: If a sole source manufacturer distributes via dealers, also provide dealer information.

Manufacturer: _________________________________________ Cage: _____________________________________

Manufacturer POC Name & Phone Number: _____________________________________________________________

MFR Address: _____________________________________________________________________________________

Manufacturer’s Dealer/Rep: ______________________________ Cage: _____________________________________

Dealer/Rep Address, Phone Number: ___________________________________________________________________

Specific characteristics of the material or service that limit the availability to a soul source or particular brand name (unique features, function, of the item, etc.). Describe in detail why only this suggested source can furnish the requirements to the exclusion or other sources:

_______ _______ The requested material or service represents the minimum requirements of the Government.

Yes No

CHECK & FILL IN ALL APPLICABLE BLANKS BELOW

_______ _______ The material/service must be compatible in all aspects (form, fit, and function) with the

Yes No existing systems presently installed. Describe the equipment you have now and how the new item/service must coordinate, connect, or interfere with the existing system:

_______ _______ A patent, copyright, or proprietary data limits competition. The proprietary data is:

Yes No

_______ _______ These are “direct replacements” parts/components for existing brand name equipment.

Yes No

_______ _______ Other information to support a sole-source buy:

Yes No

I certify that statements checked, and information provided about, are complete and correct to the best of my knowledge and do not contain classified information. I understand the processing of this sole-source justification precludes the use of full and open competition.

Signature Title Date

Contracting Officer:

Signature Date

DLA Maritime Puget Sound Justification for Sole-Source

JUSTIFICATION FOR SOLE SOURCE

($10K TO $250K)

(1) Description of item or service required:

(2) Estimated cost:

(3) Required delivery date:

DBS9349

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