CTR075490_Pre-Contract_Documents.pdf

Page 1 of 2PUR-1031A FORFF (5-24) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Division of Financial Operations

Office of Procurement

PROCUREMENT ASSISTANCE (PA) REQUEST

1. PROCUREMENT UNIT NAME: 2. PA NUMBER/SUB-NUMBER: 3. REQUEST DATE:

4. DIVISION/ADMINISTRATION/PROGRAM: 5. DIVISION CONTACT PERSON: 6. TELEPHONE NUMBER:

7. TYPE OF REQUEST/AGREEMENT (check all that apply):

Scope of Work Review

Solicitation

CI /SS /NPTQ Review

Amendment

Extension Yrs/Mos

Corrective Action

Assignment

Contract (Competitive Award)

Direct Contract

Intergovernmental Agreement (IGA)

Interagency Service Agreement (ISA)

Memorandum of Understanding (MOU)

Task Order

IT Agreement/EULA

Set-Aside

COOP

Grant Agreement

If Exempt by Statute A.R.S. No.:

Other

8. DETAILED DESCRIPTION OF REQUEST OR NEED:

9. OTHER DOCUMENTS AND INFORMATION:

Certificate of Insurance (COI) Compliant and Included If CI /SS /NPTQ, No.:

Business Associate Agreement/Data Sharing Agreement Central Registry Check/Fingerprinting Sign and Date when Checked

10. FUNDING SOURCE & AMOUNT (check the appropriate boxes):

Federal State Grant Other Estimated aggregate spend $499K or less

Estimated aggregate spend $500K or more

11. DESCRIPTION OF SERVICES OR CONTRACT TITLE: 12. CONTRACT NUMBER:

13. CONTRACTOR NAME/DBA: 14. FEIN NUMBER:

15. CONTRACTOR CONTACT PERSON’S NAME AND TITLE:

16. E-MAIL ADDRESS/TELEPHONE NO.:

17. CONTRACT ORIGINAL START DATE: 18. MAXIMUM END DATE:

19. CONTRACT CURRENT END DATE: 20. AMENDED END DATE:

21. SINGLE AUDIT STATUS:

Contractor/Vendor

Subrecipient N/A

22. LEGAL AD AUTHORIZATION:

FUNCTION CODE: OBJECT CODE: DEPARTMENT OBJECT CODE:

BA SIGNATURE FOR APPROVAL (Legal Ads):

23. AUTHORIZATIONS (Signatures, NO Initials) & DATES:

24. AUTHORIZED DIVISION REQUESTOR: 25. FINANCIAL SERVICES ADMINISTRATION:

26. ATTORNEY GENERAL (IGA, 3rd Party, etc.): 27. PROCUREMENT OFFICER:

28. PROCUREMENT OFFICER COMMENTS:

Team Stacie DCAD 25-268 12/19/2024

DCAD/CAPS Teri Ponticello (520) 705-7318

Submitting SOW for review for the new SFY26 Direct Contract with Southeastern Arizona Community Action Program (Community Action Services Program)

Community Action Services TBD

Southeastern Arizona Community Action Program 86-0425910

Yvette Ramirez, Executive Director seacapyr@qwestoffice.net /928-428-4653

Combination of funing sources

ARS §1-501-1- 502

Page 2 of 2PUR-1031A FORFF (5-24) INSTRUCTIONS

1. PROCUREMENT UNIT NAME – enter name of the assigned procurement team.

2. PA NUMBER / SUB-NUMBER – enter the Program-assigned Procurement Assistance (PA) number, and Sub-number number, if applicable.

Examples: After the SOW is finalized, if there are multiple contracts / agreements awarded for the same service; or a solicitation results in multiple awards, the procurement officer adds /1, /2, /3, etc.

3. REQUEST DATE – enter date program contracts officer begins processing.

4. DIVISION / ADMINISTRATION / PROGRAM – enter abbreviations for the division, administration and program submitting the request to OP.

5. DIVISION CONTACT PERSON – enter the name of the program contracts officer associated with this request.

6. TELEPHONE NUMBER – enter the telephone number of the of the contact person.

7. TYPE OF REQUEST / AGREEMENT – Check ALL applicable boxes considering there should be one PA per procurement action from the moment a need has been identified, until the action is completed i.e. solicitation awarded, contract fully executed, assignment completed.

Examples:

a) For a new solicitation, under section seven (7), the following boxes should be checked:

Scope of Work Review Solicitation

b) For new direct contract, under section seven (7), the following boxes should be checked:

Cl /SS /NPTQ Review Scope of Work Review Direct Contract

c) For new task order, under section seven (7), the following boxes should be checked:

Scope of Work Review Task Order

d) For a direct contract amendment which requires SOW revision, under section seven (7), the following boxes should be checked:

Cl /SS /NPTQ Review Scope of Work Review Amendment Direct Contract

e) For an IGA extension, under section seven (7), the following boxes should be checked:

Extension Yrs/Mos Intergovernmental Agreement (IGA)

f) For a contract action against competitively awarded contract, under section seven (7), the following boxes should be checked:

Contract Action Contract (competitive award)

g) For a competitively awarded contract amendment, under section seven (7), the following boxes should be checked:

Amendment Contract (competitive award)

8. DETAILED DESCRIPTION OF REQUEST OR NEED – provide details of the request. Use memo to expand if necessary.

9. OTHER DOCUMENTS & INFORMATION:

Certificate of Insurance (COI) Compliant and Included – Mark that the certificate of insurance is included and compliant, if applicable.

Business Associate Agreement / Data Sharing Agreement – Check if BAA / DSA is required for the request.

If CI / SS / NPTQ, No – If there is an existing limited competition determination, specify the number and provide electronic copy.

Central Registry Check / Fingerprinting – Division’s contracts officer shall sign and date when check has been completed, if applicable.

10. FUNDING SOURCE & AMOUNT – check the appropriate funding source(s) for the request & check if the total value of the Agreement/Contract. Is estimated aggregate spend $499K or less OR $500K or more?

11. DESCRIPTION OF SERVICES OR CONTRACT TITLE – provide service description or title of contract, as defined in the SOW.

12. CONTRACT NUMBER – enter the contract number, if applicable. If multiple contracts, create separate PAs for each contract.

13. CONTRACTOR NAME / DBA – enter the Contractor name and the doing business as (DBA) name, if applicable.

14. FEIN NUMBER – enter the Federal Employer Identification Number of the contractor, if applicable.

15. CONTRACTOR CONTACT PERSON’S NAME AND TITLE – enter the name and title of the contractor’s designated contact person.

16. E-MAIL ADDRESS / TELEPHONE NUMBER – enter the e-mail address and telephone number of the contractor’s designated contact person.

17. CONTRACT ORIGINAL START DATE – enter the first date when services can be rendered against the contract, if applicable.

18. MAXIMUM END DATE – enter the last possible date that service can be rendered against the contract, if applicable.

19. CONTRACT CURRENT END DATE – enter the last date of the current contract term, if applicable.

20. AMENDED END DATE – enter the amended term end date, if applicable.

21. SINGLE AUDIT STATUS – division staff check the appropriate box. Required only for service/taxonomy contracts

22. LEGAL AD AUTHORIZATION – function code, object code, and department object code provide from the Business Administrator (BA) and BA’s signature for funding approval

23. AUTHORIZATIONS & DATES – signatures of authorized individuals from the respective areas & dates of authorized individuals from the respective areas.

24. AUTHORIZED DIVISION REQUESTOR – signatures and dates of authorized individuals from the respective areas.

25. FINANCIAL SERVICES ADMINISTRATOR (IGA, ISA, IT Projects (including agreements, software, hardware, contractors (Non- FTE)), and non IT procurements with an aggregated spend of $500K and more) - signatures and dates of authorized individuals from the respective areas.

26. ATTORNEY GENRAL (IGA, 3rd PARTY, ETC) – signatures and dates of authorized individuals from the respective areas.

27. PROCUREMENT OFFICER – signatures and dates of authorized individuals from the respective areas.

28. PROCUREMENT OFFICER COMMENTS – Complete as needed.

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