Attachment_-_Request_for_Substitution_-_Exemption.pdf
PDF 102 KB Posted
- Attached to
- Traffic Signal Cabinet Art Wrap
- Solicitation number
- RFQu-26-0114
- 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. The form is designed to be submitted to the department's Compliance Section for approval prior to making changes to a Disadvantaged Business Enterprise (DBE) utilization statement. Contractors must seek approval before substituting, terminating, reducing the scope of work, or changing the proposed amount for a DBE subcontractor.
The form allows prime contractors to request exemptions in four key areas: releasing a proposed DBE subcontractor, substituting a DBE subcontractor, changing the scope of work to be performed by a DBE subcontractor, or reducing the amount originally proposed for a DBE subcontractor. The prime contractor must provide a summary of their exemption request and demonstrate good faith efforts in finding additional DBE participation. The final approval of such requests is reserved for the Contract Compliance Specialist, who can modify the DBE goal and utilization percentage as deemed appropriate.
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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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