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 Compliance Section for use in the HVAC Filter Maintenance and Repair contract. The form provides a mechanism for prime contractors to request approval for modifications to Disadvantaged Business Enterprise (DBE) utilization commitments prior to implementing changes. Contractors may use this form to request exemptions for releasing proposed DBE subcontractors, substituting DBE subcontractors, changing the scope of work performed by DBE subcontractors, or reducing the dollar amount originally proposed for DBE subcontractors. The form requires the authorized representative of the prime contractor to provide detailed justification and documentation of good faith efforts undertaken to identify alternative DBE participation. All requests must be submitted to ptdcompliance@phoenix.gov for approval by the City's Contract Compliance Section before any modifications to the DBE utilization statement or contractor's monthly DBE statement are implemented. No substitution, termination, or scope reduction may occur without written approval from the Compliance Section.
The form serves as a compliance and documentation tool under the City of Phoenix's DBE participation plan requirements, which are mandated by 49 C.F.R. Part 26. Upon receipt and review, the Contract Compliance Specialist will approve or deny the request and document any revised DBE goals and utilization percentages. The form requires supporting documentation of good faith efforts and must be completed with specificity regarding the affected DBE subcontractors, their assigned scope of work, and the rationale for the requested exemption or substitution.
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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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