Attachment_-_Request_for_Substitution_-_Exemption.pdf
PDF 102 KB Posted
- Attached to
- Data Analytics Services State and local contract opportunity
- Solicitation number
- RFQu 2021-WAD-472-06
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Request for Substitution/Exemption form from the City of Phoenix Public Transit Department used to request approval for changes to Disadvantaged Business Enterprise (DBE) utilization on contracts. The form must be submitted to the Public Transit Department Compliance Section prior to implementing any modifications to proposed DBE utilization or contractor monthly statements. The form permits prime contractors to request exemptions for releasing proposed DBE subcontractors, substituting DBE subcontractors, changing the scope of work for DBE subcontractors, or reducing amounts originally proposed for DBE subcontractors. The duly authorized representative of the prime contractor must complete the form, provide a summary of the exemption request and good faith efforts to secure additional DBE participation, and submit supporting documentation as necessary.
The form requires the prime contractor to identify the contract number, project number and description, affected DBE subcontractors, and the scope of work to be performed. Upon submission, the City's Contract Compliance Section reviews the request and determines approval status, revised DBE goals, and revised DBE utilization percentages. The compliance specialist completes the approval section of the form and may reference supporting exhibits including the Initial SBPP Plan, DBE Annual SBPP Plan, DBE Request for Substitution or Exemption, and DBE Certification of Final Payment. This form is directly related to the City of Phoenix Water Services Department's Data Analytics Services solicitation, which requires contractors to demonstrate good faith efforts to promote Small Business and DBE firm participation on FTA-assisted projects through documented engagement and compliance reporting.
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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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