CTR079271_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-26-091 10/16/2025

ADES/DCAD/HML Teri Ponticello (520) 705-7318

Submitting Direct Contract for Keys to Change - Homeless Youth and Family Services (Emergency Shelter/RRH)

CI2008

TP 11.24.25

Homeless Youth and Family Services TBD

Keys to Change 46-3333160

Letticia Brown-Gambino, Associate Executive Director

LetticiaBG@hsc-az.org

06/30/2026

Arizona S.B.1735

Stacie Dearinure <sdearinure@azdes.gov>

Significant Procurement Notification Form 1 message

Google Forms <forms-receipts-noreply@google.com> Mon, Sep 22, 2025 at 3:31 PM To: frubio@azdes.gov

Thanks for filling out Significant Procurement Notification Form Here's what was received.

Edit response

Significant Procurement Notification Form The following information is required to be provided to the State Procurement Administrator by all state governmental units (SGU; agencies, boards, and commissions) as per Standard Procedure 003 - Significant Procurement Role (SP 003 link).

Notes about this Google Form to provide notification of a SPR:

• You will receive a copy of your response via email

• You may edit your response after it is submitted in two ways. To ensure there's no duplication of efforts, please do one of the following:

1) Once you submit the form, you may click on "Edit you response" in the same browser; or

2) If some time has passed and it's necessary to make edits, please check your email for the original submission as it will have an "Edit response" link. If you don’t remember when you originally submitted your SPR notification, you may check the date and time on the spreadsheet via https://spo.az.gov/contracts/significant-procurement-roles and match it to the email.

• If your entry needs to be deleted, email SPOCompliance@azdoa.gov to provide an explanation for the deletion. If accepted, SPO Compliance will delete the entry.

Please contact the State Procurement Office (SPO) at SPOCompliance@azdoa.gov for any questions.

Email *

10/17/25, 9:40 PM State of Arizona Mail - Significant Procurement Notification Form https://mail.google.com/mail/u/0/?ik=5bda0cdb29&view=pt&search=all&permthid=thread-f:1844005057106763975&simpl=msg-f:1844005057106763975 1/3 https://docs.google.com/forms/d/e/1FAIpQLSdxSzWnNvO30KUubljXrDSub3gfqJ1GX15weZF0kbYkDUx3Qw/viewform?usp=mail_form_link https://docs.google.com/forms/d/e/1FAIpQLSdxSzWnNvO30KUubljXrDSub3gfqJ1GX15weZF0kbYkDUx3Qw/viewform?edit2=2_ABaOnufqlFmMlVjQ9kGRhVM083DzC11ZNU0M9FGZ-pnObw8o5V8KnSBi4XoZa80d4vE0-Ds https://spointra.az.gov/resources/standard-procedures https://spo.az.gov/contracts/significant-procurement-roles https://spo.az.gov/contracts/significant-procurement-roles mailto:SPOCompliance@azdoa.gov mailto:SPOCompliance@azdoa.gov frubio@azdes.gov

What is the name of the person leading the procurement? *

Frances Rubio

Which agency is the procurement for? If it is a mandatory statewide contract, select your agency. *

Economic Security, Department of

What is the title of the procurement? *

Homeless Youth and Families Eviction Prevention, Emergency Shelter and Rapid Rehousing

What is the procurement type? *

RFQ - Request for Quotation

IFB - Invitation for Bid

RFP - Request for Proposal

✓ CI - Competition Impracticable (SPO Form 101)

Emergency Procurement (SPO Form 102)

SS - Sole Source (SPO Form 103)

NPTQ - Not Practicable to Quote (Determination Template D301(4))

Other:

10/17/25, 9:40 PM State of Arizona Mail - Significant Procurement Notification Form https://mail.google.com/mail/u/0/?ik=5bda0cdb29&view=pt&search=all&permthid=thread-f:1844005057106763975&simpl=msg-f:1844005057106763975 2/3 mailto:frubio@azdes.gov

What is the date when the first procurement disclosure statement (PDS) was signed (i.e. SPO Form 120 or SPO Form 130)? *

MM

09 /

DD

04 /

YYYY

What is the actual date or estimated date that the purchased materials will be delivered or the purchase of services or construction will begin, per A.R.S. § 41- 753(D)? *

MM

10 /

DD

15 /

YYYY

What is your name (if different from above)?

Stacie Dearinure

What is your e-mail address (if different from above)?

sdearinure@azdes.gov

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10/17/25, 9:40 PM State of Arizona Mail - Significant Procurement Notification Form https://mail.google.com/mail/u/0/?ik=5bda0cdb29&view=pt&search=all&permthid=thread-f:1844005057106763975&simpl=msg-f:1844005057106763975 3/3 mailto:sdearinure@azdes.gov https://docs.google.com/forms?usp=mail_form_link

CI2008