Attachment_-_Request_for_Substitution_-_Exemption.pdf
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- Attached to
- Employee Health Clinic Services
- Solicitation number
- RFP PS-26-0095
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Request for Substitution/Exemption form utilized by the City of Phoenix Public Transit Department Compliance Section for managing Disadvantaged Business Enterprise (DBE) subcontractor changes on city contracts. The form allows prime contractors to request approval for modifications to their proposed DBE utilization, including releasing proposed DBE subcontractors, substituting DBE subcontractors, changing the scope of work assigned to DBE subcontractors, or reducing the dollar amount originally proposed for DBE subcontractor participation. All requests must be submitted to the City of Phoenix Public Transit Department Compliance Section at ptdcompliance@phoenix.gov prior to implementing any changes. The form requires the prime contractor's authorized representative to document the exemption request, summarize the good faith efforts undertaken to find additional DBE participation, and provide supporting documentation as necessary. The Contract Compliance Section reviews submissions and indicates approval status, revised DBE goals, and revised DBE utilization percentages on the form.
This form serves as a critical compliance document ensuring adherence to federal DBE participation requirements under 49 CFR Part 26 for federally-funded transit projects. No DBE subcontractor may be substituted, terminated, have their scope of work reduced, or have their proposed amount changed without explicit written approval from the City's Compliance Section. The submission process requires authorization signatures from both the prime contractor and the contract compliance specialist, with documentation of all good faith efforts to maintain or exceed DBE participation goals. The form references related exhibits including Initial SBPP Plans, Annual SBPP Plans, Certifications of Final Payment, and other compliance documentation required throughout the contract term.
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Text version
City of Phoenix
PUBLIC TRANSIT DEPARTMENT
REQUEST FOR SUBSTITUTION/EXEMPTION
This form must be submitted to the City of Phoenix, Public Transit Department Compliance Section (ptdcompliance@phoenix.gov), for approval prior to making any changes to the proposed statement of DBE utilization or Contractor’s monthly statement of DBE utilization form. No DBE shall be substituted or terminated, nor shall their scope of work be reduced or proposed amount changed without the approval of the Compliance Section.
Prime Contractor: Contract Number:
Project Number and Description:
Affected DBE Subcontractor(s):
Scope of Work to be Performed by Affected DBE Subcontractors(s):
1. I am the duly authorized representative of the above listed Prime Contractor and am authorized to request this exemption on behalf of the Prime Contractor.
2. I hereby request that an exemption be granted to the above-mentioned Prime Contractor to (check those that apply):
Release proposed DBE subcontractor Substitute DBE subcontractor
Change scope of work to be performed by DBE subcontractor
Reduce amount originally proposed for DBE subcontractor
3. I have summarized the Prime Contractor's request for an exemption and the good faith efforts required in finding additional DBE participation on the above-mentioned contract as follows: (Attach additional pages and supporting documentation as necessary.)
Date:
Phone:
Yes No %
Date:
Authorized Signature:
Signature of Authorized Agent for Contractor
Name and Title:
FOR CONTRACT COMPLIANCE USE ONLY
Request Approved: Revised DBE Goal:
Revised DBE Utilization:
Contract Compliance Specialist:
| Exhibit - Initial SBPP Plan |
| Exhibit - DBE Annual SBPP Plan |
| Exhibit - DBE Request for Substitution or Exemption |
| Exhibit - DBE Certification of Final Payment |
| Phone: |
| Prime Contractor: |
| Contract Number: |
| Project Number and Description: |
| Affected DBE Subcontractors: |
| Scope of Work to be Performed by Affected DBE Subcontractorss: |
| to check those that apply: |
| Substitute DBE subcontractor: |
| undefined: |
| proposed for DBE: |
| follows Attach additional pages and supporting documentation as necessary: |
| Name and Title: |
| FOR CONTRACT COMPLIANCE USE ONLY: |
| No: |
| Date_2: |
| Text39: |
| Text40: |
| Text41: |
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