DOA-3831 Piggybacking Request.docx

State of Wisconsin Department of Administration DOA-3831 (r06/2022) S. 16.71 Wis. Stats

State Bureau of Procurement 101 East Wilson Street, 6th Floor P. O. Box 7867 Madison, WI 53707-7867

STAR Piggybacking Request Instructions: Send the completed form via e-mail to:

Section 1: Agency Requesting Piggyback

|_| My agency has notified the Originating/Contracting Agency identified in Section 2 below that we intend to use their contract and they have agreed.

Section 2: Originating/Contracting Agency

Section 3: Contract Information

Is the purchase of software included in this request? If “yes”, complete Section 5 below. Yes |_| No |_| N/A |_|

Section 4: Eligibility Check

|_| My agency has validated the following, in compliance with the requirements of the State Procurement Manual, PRO-502.

|_| Supplier(s) is/are not on the Certification for Collection of Sales and Use Tax Ineligible Vendor Directory

|_| Supplier(s) is/are not on the Contract Compliance Ineligible Vendor Directory

Impact, if any, on any minority business enterprise, disabled veteran-owned business or work center:

N/A

|_| Contract scope matches my agency’s need.

Description of the scope of the original procurement and how it corresponds to the commodity/service to be purchased:

Conveyance Inspection Services for Elevators (Freight, Limited-use, limited-application, Part V, Passenger, Private residence, Rooftop, Sidewalk, Specialized purpose personnel elevator); Escalators; Lifts (Inclined platform, Orchestra pit, Type B material, Vertical platform); Moving walks; Dumbwaiters; Stairway chairlifts.

Section 5: Large, High-Risk IT Contract (Agencies Only; N/A for UW Campuses)

As required by §16.973(10) and (13), Wis. Stats, contracts involving a large, high-risk IT project as defined by the Division of Enterprise Technology must include certain contractual terms and controls. Further, contracts (including participating addendums, engagement agreements, statements of work or purchase orders) agencies enter into solely for the purpose of supporting or servicing a large, high-risk IT project are subject to review and approval by DOA.

|_| My agency has reviewed PRO-508, Information Technology (IT) and Telecommunications Procurements and PIM 22-001 Large, High-Risk Contract Review and Approval Process and will adhere to all required policies and procedures contained therein.

Section 6: Software Purchase Impact on STAR System

State agency software purchases must be compliant with the STAR Software Purchasing Policy (see PIM 17-001 and additional reference material attached therein). Please complete Section 6 for software purchases and include a technical contact that can be reached for questions related to your agency’s request.

Agency Technical Contact Name:

Phone Number:

E-Mail Address:

|_| My agency has reviewed the in-scope modules of the STAR System and we do not consider the requested software to overlap or conflict with system functionality.

|_| My agency has reviewed the in-scope modules of the STAR System and the requested software does appear to overlap or conflict, in whole or in part, with system functionality. We hereby request that approval be granted to make the purchase.

Provide a rationale for approval of the request where there appears to be a conflict or overlap with the STAR System:

State Bureau of Procurement Use Only

Request Approved:

|_| Yes |_| No Date:

Approved By (Initial):

If UW, STAR Contract Number Assigned:

This document can be made available in alternate formats to individuals with disabilities upon request.

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