ESi Acquisition SS.pdf

Page 1 of 4 Revised 11/2021

Sole Source Request § 24-103-205, C.R.S.

Instructions:

1. Complete all fields below. Failure to provide all information may delay the processing of your request.

2. Include any documentation to support your request as attachments with the form.

3. Submit the complete form, with attachments to tammy.lichvar@state.co.us

SECTION A – Agency Information

1. Division / Office:

2. Name of Requester:

3. Name of Program Manager:

SECTION B – Vendor Information

1. Vendor Name:

2. Vendor Contact:

3. Vendor Phone Number:

4. Vendor Email:

5.

• If yes, please explain:

A sole source procurement is justified when there is only one good or service that can reasonably meet the need and there is only one vendor who can provide the good or service. A requirement for a particular proprietary item (i.e., a brand name specification) does not justify a sole source procurement if there is more than one potential bidder or offeror for that item. Note: If this sole source is for services greater than $100,000, posting on an electronic procurement system may be required in accordance with §24-106-103(5) C.R.S.

Have you procured goods and/or services from this vendor in the past 2 years?

Choose: Yes No

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SECTION C – Description of Goods/Services

1. Describe in detail the goods and/or services to be procured and how they meet your needs. Explain WHY we MUST buy this particular good and/or service (special features, compatibility, etc.):

2. Are there other goods or services that can meet the state’s needs? Choose

• If yes, please explain:

SECTION D – Approval Period and Estimated Dollar Amount

1. Is this purchase a one-time purchase:

• If no, identify approval period being requested:

State Date (MM/DD/YY):

End Date (MM/DD/YY):

2.

TOTAL DOLLARS for this procurement:

Provide estimated cost breakdown of goods and/or services covered by this procurement:

Goods:

Services:

SECTION E – Price Reasonableness

1.

2.

3. Was a cost or price analysis conducted:

4. If you answered ‘no’ to 1-3 above, describe how the agency determined the prices were fair and reasonable, as required by §24-103-403 C.R.S. and §24-30- 202 C.R.S. for this sole source:

Yes No

Yes No

NoWere the prices or rates compared to established catalog or market prices? Yes

Were the prices or rates compared to historical prices or rates for similar goods or services procured by in the past? Yes No

Yes No

3.

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SECTION F – Conflict of Interest

1. Do you have an actual or potential conflict of interest in this purchase request?

If yes, please explain:

Section G – Sole Source Justification

1. Provide a detailed explanation of vendor’s Sole Source Status. What is the basis for identifying this as a sole source?

2. Is there any additional information that you’d like to provide in order for this request to be considered?

Yes No

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By signing below, you are certifying that the information submitted on this form is accurate.

The EDO Purchasing Director will make the final determination of Sole Source.

Signature __________________________________________ Date ___________

Printed Name and Title _________________________________________

FOR PROCUREMENT USE ONLY:

POSTED ON VSS? Yes No

Related Comments (responses received, quantity, etc):

DETERMINATION:

Sole Source approved – purchase as requested.

Sole Source not approved – issue bid using performance specifications.

RESULTING COMMITMENT DOCUMENT NUMBER:

Director of Purchasing (or delegate) Signature ____________________________________

This approval is valid until: _______________

DHSEM uses WebEOC and the Colorado Resource Rate Form (CRRF) to remain in compliance with this state statute.

With the Colorado Resource Rate Form (CRRF) database moving from WebEOC to the Gold System database the required CRRF information will no longer be available in or connected to WebEOC without this service from ESi Acquisition, Inc.

ESi Acquisition, Inc. is the exclusive entity possessing the necessary proprietary expertise and, critically, full source code access for the core software components to connect the CRRF information from Gold Systems Inc to WebEOC.

This exclusive access is mandatory for performing deep-level maintenance, sophisticated troubleshooting, and ensuring system stability and continuity.