Attachment L-1 - MWBE Application for Waiver 3.1.15.docx

SECTION 1: BASIC INFORMATION

Contractor’s Name:

Federal ID Number:

SFS Vendor ID Number:

Street Address:

E-Mail Address:

City, State, Zip Code:

Telephone:

Contract Number: ENTER CONTRACT NUMBER

Contract Value: $

Description of Contract: Enter Solicitation Title

M/WBE Goals Assigned to the Contract:

SECTION 2: TYPE OF M/WBE WAIVER REQUESTED

Does a certified M/WBE exist anywhere in New York State that can provide at least 20% of the products and/or services needed to the contract? If so, please explain in detail the reason you are requesting a waiver. (Attach additional sheets if necessary).

SECTION 3: SUPPORTING DOCUMENTATION

Provide the following documentation as evidence of your good faith efforts to meet the M/WBE goals set forth in the contract and support of your waiver application: (Please check all that apply and include attachments).

|_| Attachment A. List of the general circulation, trade and M/WBE specific publications and dates of publications in which your firm solicited for certified M/WBE participation as a subcontractor/supplier and copies of such publications.

|_| Attachment B. List of the certified M/WBEs found in the New York State Contracting System M/WBE Directory (https://ny.newnycontracts.com/) that were solicited for this contract. Provide proof of the dates or copies of the solicitations and copies of the responses made by the certified M/WBEs. Describe specific reasons that responding certified M/WBEs were not selected.

|_| Attachment C. Descriptions of the contract documents/plans/specifications made available to certified M/WBEs by the contractor when soliciting their participation and steps taken to structure the scope of work for the purpose of subcontracting with or obtaining supplies from certified M/WBEs.

|_| Attachment D. Description of the negotiations between the contractor and certified M/WBEs for the purposes of complying with the M/WBE goals for this contract.

|_| Attachment E. Identify dates of pre-bid, pre-award or other meetings attended by the contractor and scheduled by OMH with certified M/WBEs whom OMH determined were capable of fulfilling the M/WBE goals set in the contract.

|_| Attachment F. Any other information deemed relevant to the request for waiver.

SECTION 4: SIGNATURE AND CONTACT INFORMATION

DECLARATION: The undersigned certifies that he or she is authorized by the Contractor identified above to make this declaration. The Contractor has made good faith efforts, as defined in NYS law, to meet the M/WBE goals contained in NYS law and under the applicable contract. The undersigned acknowledges that failure to submit complete and accurate information in connection with a waiver request may result in denial and/or a finding of non-compliance. Failure to establish good faith efforts may result in suspension or termination of a New York State contract.

Prepared By : (Signature)

Date:

Name and Title of Preparer:

ATTACHMENT L-1

APPLICATION FOR WAIVER OF M/WBE PARTICIPATION GOALS

This form must be submitted for review and approval by the NYS Office of Mental Health M/WBE liaison and the Governor’s staff. Waiver approval must be received prior to the completion of the contract and a prerequisite for full and final payment.

The Freedom of Information Law requires public disclosure of certain records held by NYS OMH. Based upon the foregoing, you are hereby notified that this document, and related documents, constitutes “records” that fall under the scope of the Freedom of Information Law. Therefore, such documents may be made available to the public.

Instructions for Completing and Submitting an Application for a Waiver of M/WBE Utilization Goals

Article 15-A of the New York State Executive Law and 5 NYCRR 140-145 require State Agencies to increase participation by Minority and Women-Owned Business Enterprises (M/WBEs) on State contracts. All solicitations are reviewed and have goals established for them for both MBE and WBE utilization. The goals are expressed as a percentage of the anticipated payments made under the contract. A state agency shall not grant any automatic waivers of goal requirements on a State contract. A State agency may grant a partial or total waiver of goal requirements upon submission and approval of a waiver application documenting a contractor’s good faith efforts. Governor’s Office Executive Chamber approval is also a requirement of a State Agency waiver approval. Failure to make good faith efforts may result in a State contract being awarded to another bidder, or, if the contract is already in progress, may result in financial penalties.

Section 1: Basic Information

Complete all sections including the contractor’s name, address federal identification number, State Financial System (SFS) vendor identification number and contract number. Please provide a current e-mail address and telephone number where the firms authorized representative may be reached. In the space provided, please provide a detailed description of the contract. Where requested, please state the original M/WBE utilization goals that were established for the contract.

Section 2: Type of Waiver Request

In this section please indicate the type of waiver being requested. If requesting a partial waiver, please provide the revised utilization goal percentage being proposed by the firm. In the space provided, explain in detail the need of a waiver of the M/WBE participation goals.

Section3: Supporting Documentation Demonstrating Good Faith Efforts requires extensive documentation in order to comply with the requirements of Article 15-A of the Executive Law. See the form for specific details on the documentation required and check all that apply.

Section 4: Signature and Contact Information The waiver application must be signed by an authorized official of the firm who will be responsible for the contract. By signing the waiver application, the authorized official is certifying that he or she is authorized to make the DECLARATION that has been set forth, and that the Contractor has made good faith efforts, as defined in NYS law, to meet the M/WBE goals contained in NYS law and under the applicable contract. The undersigned acknowledges that failure to submit complete and accurate information in connection with a waiver request may result in denial and/or a finding of noncompliance. Failure to establish good faith efforts may result in suspension or termination of a New York State contract. Please state the date that the Application for Waiver of M/WBE Participation Goals was signed by the authorized official who is responsible for the contract.

For NYS OMH USE ONLY:

Review By:

Title:

Date:

OMH Waiver Recommendation

|_| Full MBE Waiver be granted

|_| Partial MBE Waiver granted, revised MBE goal: %

|_| MBE Waiver denied |_| Full WBE Waiver be granted

|_| Partial WBE Waiver granted, revised WBE goal: %

|_| WBE Waiver denied

Executive Chamber Waiver Recommendation

Date Notice of Determination sent to Contractor:

Comments: