Attachment_-_Request_for_Substitution_-_Exemption.pdf
PDF 102 KB Posted
- Attached to
- Purchase of Motorcycles
- Solicitation number
- 26-FSD-022
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This document is a Request for Substitution/Exemption form from the City of Phoenix Public Transit Department, which requires prime contractors to obtain approval before making changes to Disadvantaged Business Enterprise (DBE) utilization. The form is designed to ensure compliance when a prime contractor wants to release, substitute, change the scope of work for, or reduce the amount allocated to a DBE subcontractor. The document must be submitted to the Public Transit Department Compliance Section at ptdcompliance@phoenix.gov for review and approval prior to implementing any modifications.
The form provides checkboxes for specific types of changes, such as releasing a proposed DBE subcontractor, substituting a DBE subcontractor, changing the scope of work, or reducing the originally proposed amount for a DBE subcontractor. The prime contractor must summarize their request and demonstrate good faith efforts in finding additional DBE participation. The form includes sections for the prime contractor to provide details about the project, affected DBE subcontractors, and the proposed changes. The final section is reserved for Contract Compliance use, where the request will be reviewed and either approved or denied, with potential adjustments to the DBE goal and utilization percentage.
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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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