Attachment_-_Request_for_Substitution_-_Exemption.pdf
PDF 102 KB Posted
- Attached to
- HVAC Filter Maintenance and Repair
- Solicitation number
- 27-FMD-007
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Request for Substitution/Exemption form issued by the City of Phoenix Public Transit Department Compliance Section for use by prime contractors participating in Disadvantaged Business Enterprise (DBE) utilization programs. The form enables contractors to request approval for modifications to their proposed DBE participation, including the release of proposed DBE subcontractors, substitution of DBE subcontractors, changes to the scope of work assigned to DBE subcontractors, or reductions to amounts originally proposed for DBE subcontractors. All requests must be submitted to the Compliance Section at ptdcompliance@phoenix.gov prior to implementing any changes. The form requires the duly authorized representative of the prime contractor to document the requested exemption type, summarize the contractor's justification, and provide evidence of good faith efforts undertaken to secure additional DBE participation. The form includes sections for the prime contractor name, contract number, project number and description, identification of affected DBE subcontractors, and detailed description of the scope of work to be performed.
Upon receipt, the City's Contract Compliance Section reviews the submission and completes designated approval sections, including authorization of the request, documentation of any revised DBE goals and utilization percentages, identification of the reviewing compliance specialist, and attachment of supporting exhibits such as the initial Small Business Participation Plan, DBE Annual Plan, and DBE Certification of Final Payment. No DBE subcontractor shall be substituted, terminated, or have their scope of work reduced or proposed amount changed without written approval from the Compliance Section. This form operates in conjunction with the City's broader DBE compliance requirements under 49 C.F.R. Part 26, which mandate that successful contractors maintain comprehensive participation plans, document good faith engagement efforts, and provide monthly reporting of all DBE and small business expenditures through the City's Certification and Compliance System portal.
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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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