781_SOLE_SOURCE_STATEMENT_op4.pdf

NAVSUPINST 4200.85D, Encl (1) 1 of 2

JUSTIFICATION FOR SOLE SOURCE (Simplified Acquisitions <$250K)

The service or material listed on ______________ is sole source and competition is precluded for reasons indicated below. There are no substitutes available for this material or service.

Restricted to the following source. Provide original manufacturer’s name and contact information. (If manufacturer distributes via dealers, ALSO provide dealer information.)

Manufacturer:

Description of the item or service required, the estimated cost, and required delivery date.

___ Specific characteristics of the material or service that limit the availability to brand name mandatory (unique features, function of the item, etc.).

___ The requested material or service represents the minimum requirements of the government.

NAVSUPINST 4200.85D, Encl (1) 2 of 2

CHECK & FILL IN ALL APPLICABLE BLANKS BELOW

____ The material/service must be compatible in all aspects (form, fit and function) with existing systems presently installed/performing. Describe the equipment/function you have now and how the new item/service must coordinate, connect, or interface with the existing system.

____ A patent, copyright or proprietary data limits competition. The proprietary data is:

___ These are “direct replacements” parts/components for existing equipment.

___ Other information to support a sole source buy:

I CERTIFY THAT STATEMENTS CHECKED, AND INFORMATION PROVIDED ABOVE, ARE

COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THE

PROCESSING OF THIS SOLE SOURCE JUSTIFICATION PRECLUDES THE USE OF FULL AND

OPEN COMPETITION.

Signature _____________________________________

Title_________________________________________ Activity ________________

Date __________________

Contracting Officer Signature _______________________________ Date _________________

EST COST: $18,7500

6/16/2019