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 for managing Disadvantaged Business Enterprise (DBE) subcontractor changes on state and local contracts. The form serves as the official mechanism for prime contractors to request approval for releasing proposed DBE subcontractors, substituting DBE subcontractors, changing the scope of work assigned to DBE subcontractors, or reducing the amount originally proposed for DBE subcontractor participation. Contractors must submit the completed form to the City of Phoenix Public Transit Department Compliance Section at ptdcompliance@phoenix.gov prior to implementing any modifications to their proposed DBE utilization statement or monthly DBE utilization reports. The form requires the authorized representative of the prime contractor to document the good faith efforts undertaken to identify additional DBE participation and must include supporting documentation as necessary. The form also requires that no DBE shall be substituted, terminated, have their scope of work reduced, or have their proposed amount changed without explicit written approval from the Compliance Section.
The form designates specific fields for the prime contractor, contract number, project number and description, affected DBE subcontractor information, and scope of work details. Upon submission, the Contract Compliance Section reviews the request and indicates approval status, revised DBE goals, revised DBE utilization percentages, and the responsible Contract Compliance Specialist's contact information. This document directly supports the City of Phoenix's DBE participation requirements under 49 C.F.R. Part 26, which mandate that successful contractors maintain comprehensive DBE participation plans and documentation of good faith efforts to engage DBE-certified suppliers 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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