DOA-3831STARPiggybackingRequest Concrete.doc
DOC document 703 KB Posted
- Attached to
- Concrete Services
- Contract number
- 435500-O20-CONCRTSVC-03
- Issued by
- Wisconsin
About this file
This is a STAR Piggybacking Request form (DOA-3831) from the Wisconsin Department of Administration's State Bureau of Procurement, allowing state agencies to utilize existing contracts established by other agencies. The form involves the Wisconsin Department of Health Services (Business Unit Number 43500) as the originating/contracting agency with contact Monica Mooberry, and references contract number 435500-O20-CONCRTSVC-03 with Fox Services (Supplier ID 0000003905). The document serves as a mechanism for agencies to leverage existing competitively bid contracts under Wisconsin Statute Section 16.71.
The contract covers concrete services under commodity/service codes including 15012, 15015, 15035, 74514, 75033, 91051, 91347, 9136, and 91430. The original contract was competitively bid through Request for Bid S-0743 DCTS-18 and runs from September 1, 2019 through August 30, 2020, with two additional one-year renewal options available. The form confirms the contract meets eligibility requirements including being open for piggybacking, competitively procured, and that the supplier is not listed on ineligible vendor directories. The document indicates no impact on minority business enterprises, disabled veteran-owned businesses, or work centers, and includes provisions for software purchase compliance review under the STAR System policy.
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Other files
| File | Type | Posted |
|---|---|---|
| 435500-O20-CONCRTSVC-03 Exhibit 1 - SWC.pdf | ||
| 435500-O20-CONCRTSVC-03.pdf |
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Text version
State of Wisconsin
Department of Administration
DOA-3831 (r04/2018)
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
| Agency Requesting Piggyback: |
| Agency Business Unit Number: |
| Agency Contact Name: |
| Phone Number: |
| E-Mail Address: |
FORMCHECKBOX
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
| Originating/Contracting Agency: |
| Agency Business Unit Number: |
| Department of Health Services |
| 43500 |
| Originating/Contracting Agency Contact Name: |
| Phone Number: |
| E-Mail Address: |
| Monica Mooberry |
| 608-261-6846 |
| monicaa.mooberry@dhs.wisconsin.gov |
Section 3: Contract Information
| Contract Number |
| Supplier Name |
| Supplier ID Number |
| 435500-O20-CONCRTSVC-03 |
| Fox Services |
| 0000003905 |
| Commodity/Service Codes: |
| 15012, 15015, 15035, 74514, 75033, 91051, 91347, 9136, 91430 |
| Estimated Annual Spend: |
| $ |
Is the purchase of software included in this request? If “yes”, complete Section 5 below. Yes FORMCHECKBOX No FORMCHECKBOX
N/A FORMCHECKBOX
Section 4: Eligibility Check
FORMCHECKBOX
My agency has validated the following, in compliance with the requirements of the State Procurement Manual, PRO-D-29.
FORMCHECKBOX
Contract is Open
| Contract Effective Dates: |
| 9/1/19-8/30/20 |
| Renewal Options: |
| two (2) one year |
FORMCHECKBOX
Competitively Bid
| Request for Bid/Proposal Number: |
| RFB S-0743 DCTS-18 |
FORMCHECKBOX
Supplier(s) is/are not on the Certification for Collection of Sales and Use Tax Ineligible Vendor Directory
FORMCHECKBOX
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
FORMCHECKBOX
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:
State Bureau of Procurement Use Only
Request Approved:
FORMCHECKBOX
Yes FORMCHECKBOX No Date:
Approved By (Initial):
If UW, STAR Contract Number Assigned:
Section 5: 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 5 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:
FORMCHECKBOX
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.
FORMCHECKBOX
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:
This document can be made available in alternate formats to individuals with disabilities upon request.
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