Attachment-4.5-Request-for-Waiver-Form.pdf

ATTACHMENT 4.5: REQUEST FOR WAIVER FORM

INSTRUCTIONS: SEE PAGE 2 OF THIS ATTACHMENT FOR REQUIREMENTS AND DOCUMENT SUBMISSION INSTRUCTIONS.

Contractor Name:

Federal Identification No.:

Address:

Procurement No.:

City, State, Zip Code:

MWBE Subcontract Goals: MBE: 15% WBE: 15%

By submitting this form and the required information, the company certifies that every Good Faith Effort has been taken to promote MWBE participation pursuant to the MWBE requirements set forth under this procurement.

Contractor is requesting a: Total Partial Certification Conditional

1. MBE Waiver – A waiver of the MBE Goal for this procurement is requested.

2. WBE Waiver – A waiver of the WBE Goal for this procurement is requested.

3. ESD Certification Waiver – A waiver of the requirement that the MBE/WBE be certified by Empire State Development (ESD).

(Check here if MBE/WBE is NOT ESD certified.)

4. Conditional Waiver – (Attach separate sheet outlining special conditions or extenuating circumstances.)

Prepared By (Signature)

Date

Printed or Typed Name and Title of Preparer

Telephone Number

Email Address

SUBMISSION OF THIS FORM CONSTITUTES THE CONTRACTOR’S

ACKNOWLEDGEMENT AND AGREEMENT TO COMPLY WITH THE

MWBE REQUIREMENTS SET FORTH UNDER NYS EXECUTIVE

LAW, ARTICLE 15-A. FAILURE TO SUBMIT COMPLETE AND

ACCURATE INFORMATION MAY RESULT IN NONCOMPLIANCE

AND/OR PROPOSAL DISQUALIFICATION.

************* FOR DEPARTMENT USE ONLY **************

REVIEWED BY: DATE:

MWBE Certified:

MWBE Not Certified:

Waiver Granted: YES NO

Total Waiver Partial Waiver ESD Certification Waiver *Conditional Notice of Deficiency

*Comments:

MWBE REQUIREMENTS AND WAIVER SUBMISSION

When completing the Request for Waiver Form please check all boxes that apply. To be considered, the Request for Waiver Form must be accompanied by documentation for items 1 – 10, as listed below. Copies of the following information and all relevant supporting documentation must be submitted along with the request:

1. A statement setting forth your basis for requesting a partial or total waiver.

2. The names of general circulation, trade association, and MWBE-oriented publications in which you solicited MWBEs for the purposes of complying with your participation goals.

3. A list identifying the date(s) that all solicitations for MWBE participation were published in any of the above publications.

4. A list of all MWBEs appearing in the NYS Directory of Certified Contractors that were solicited for purposes of complying with your MWBE participation levels.

5. Copies of notices, dates of contact, letters, and other correspondence as proof that solicitations were made in writing and copies of such solicitations, or a sample copy of the solicitation if an identical solicitation was made to all MWBEs.

6. Provide copies of responses made by MWBEs to your solicitations.

7. Provide a description of any contract documents, plans, or specifications made available to MWBEs for purposes of soliciting their bids and the date and manner in which these documents were made available.

8. Provide documentation of any negotiations between you, the Contractor, and the MWBEs undertaken for purposes of complying with your MWBE participation goals.

9. Provide any other information you deem relevant which may help us in evaluating your request for a waiver.

10. Provide the name, title, address, telephone number, and email address of contractor’s representative authorized to discuss this waiver request.

Note: Unless a Total Waiver has been granted, Contractors will be required to submit all reports and documents pursuant to the provisions set forth in the procurement and/or contract, as deemed appropriate by the Department, to determine MWBE compliance. In cases where the Department grants a full or partial waiver of MWBE participation goals, the waiver request will be posted to the Department’s website.