Disadvantaged Business Enterprise - Neutral (DBE-N) Program AGENCY: Public Transit Department

02_26-IFR - PTD

REQUEST FOR SUBSTITUTION/EXEMPTION

THIS FORM MUST BE SUBMITTED TO THE CITY OF PHOENIX, PUBLIC TRANSIT DEPARTMENT COMPLIANCE SECTION, FOR APPROVAL PRIOR TO MAKING ANY CHANGES TO THE PROPOSED STATEMENT OF SMALL BUSINESS (SB) UTILIZATION OR CONTRACTOR’S MONTHLY STATEMENT OF SMALL BUSINESS UTILIZATION FORM. NO SMALL BUSINESS SHALL BE SUBSTITUTED OR TERMINATED, NOR SHALL THEIR SCOPE OF WORK

BE REDUCED OR PROPOSED AMOUNT CHANGED WITHOUT THE APPROVAL OF THE CONTRACT

COMPLIANCE SECTION.

Prime Contractor: Contract Number:

Project Number and Description:

Affected Small Business Subcontractor(s):

Scope of Work to be Performed by Affected Small Business Subcontractors(s):

1. I am the duly authorized representative of the above-listed Prime Contractor and am authorized to request this exemption on behalf of the Prime Contractor.

2. I hereby request that an exemption be granted to the above-mentioned Prime Contractor to (circle those that apply);

A. Release a proposed SB subcontractor C. Substitute a SB subcontractor B. Change the scope of work to be performed by an SB subcontractor D. Reduce the amount originally proposed for a

SB subcontractor

3. I have summarized the Prime Contractor's request for an exemption and the good faith efforts required in finding additional Small Business participation on the above-mentioned contract as follows: (Attach additional pages and supporting documentation as necessary.)

Authorized Signature: ________________________________________________ Date: ___________________ Prime Contractor's Representative

Name and Title: _____________________________________________________ Phone: __________________

FOR CONTRACT COMPLIANCE USE ONLY

Request Approved: YES NO Revised Small Business Commitment: $

REVISED SMALL BUSINESS UTILIZATION

Contract Compliance Specialist: Date: