Attachment_-_Request_for_Substitution_-_Exemption.pdf

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: