Attachment_-_Request_for_Substitution_-_Exemption.pdf
PDF 102 KB Posted
- Attached to
- Employee Health Clinic Services
- Solicitation number
- RFP PS-26-0095
- 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 to manage changes to Disadvantaged Business Enterprise (DBE) utilization on public transit contracts. The form is submitted to the Public Transit Department Compliance Section (ptdcompliance@phoenix.gov) and must receive approval prior to implementing any modifications to a contractor's proposed DBE utilization statement. The form permits prime contractors to request exemptions for four specific scenarios: releasing a proposed DBE subcontractor, substituting a DBE subcontractor, changing the scope of work for a DBE subcontractor, or reducing the amount originally proposed for a DBE subcontractor. Contractors must provide good faith efforts documentation and supporting materials when requesting exemptions, and the form requires authorization signatures from duly authorized representatives of the prime contractor.
The form includes sections designated for contract compliance use only, where compliance specialists document approval decisions, revised DBE goals, revised DBE utilization percentages, and reference associated exhibits including the Initial SBPP Plan, DBE Annual SBPP Plan, and DBE Certification of Final Payment. 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 emphasizes the City of Phoenix's commitment to DBE participation requirements and establishes a formal process for requesting modifications to originally proposed DBE subcontracting arrangements on contracts related to employee health clinic services and other city initiatives.
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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: |
File details come from the government source that posted it. Updated .