Attachment_-_Request_for_Substitution_-_Exemption.pdf
PDF 102 KB Posted
- Attached to
- Cancer Screening Services State and local contract opportunity
- Solicitation number
- RFP PS-26-0132
- 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 for use in conjunction with Disadvantaged Business Enterprise (DBE) utilization requirements. The form serves as the formal mechanism through which prime contractors may request approval to release a proposed DBE subcontractor, substitute an existing DBE subcontractor, modify the scope of work assigned to a DBE subcontractor, or reduce the dollar amount originally proposed for DBE participation. All requests for substitution or exemption must be submitted to the City of Phoenix Public Transit Department Compliance Section at ptdcompliance@phoenix.gov prior to implementing any changes to the initial DBE utilization statement or the contractor's monthly DBE utilization form. No modifications to DBE participation—including subcontractor substitution, termination, scope reduction, or amount changes—may occur without explicit written approval from the Compliance Section.
The form requires the prime contractor's authorized representative to document the specific DBE subcontractor(s) affected, the scope of work to be performed, and the rationale for the requested exemption, along with evidence of good faith efforts undertaken to secure alternative DBE participation. The Compliance Section retains final authority to approve or deny all requests and will record the decision, the revised DBE goal percentage, the revised DBE utilization percentage, and the assigned Contract Compliance Specialist. The form includes designated sections for supporting documentation and exhibits, including the Initial Small Business Participation Plan, DBE Annual Small Business Participation Plan, and certification of final payment. This document directly supports the City of Phoenix's Cancer Screening Services contract, which includes a maximum annual value of $3,500,000 and mandates substantial DBE and small business participation requirements.
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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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