Request_for_Substitution_or_Exemption_PTD_02_2026.pdf
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- Solicitation number
- RFP PS-27-0005
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Request for Substitution or Exemption form for the City of Phoenix Public Transit Department's Disadvantaged Business Enterprise - Neutral (DBE-N) Program, used in conjunction with a Worker's Compensation Third Party Administration Claims Management Services contract. The form serves as a formal request mechanism for prime contractors to seek approval from the City's Contract Compliance Section prior to making changes to small business (SB) subcontractor utilization commitments. Contractors may request exemptions to release proposed SB subcontractors, substitute SB subcontractors, change the scope of work performed by SB subcontractors, or reduce the dollar amounts originally proposed for SB subcontractors. The underlying Worker's Compensation TPA Claims Management Services contract is a five-year agreement with a commencement date of July 1, 2027, and contains no options to extend. The agreement will terminate upon the earliest occurrence of reaching the end of the five-year term or termination pursuant to contract provisions.
Any substitution or exemption request requires submission of the completed form to the Contract Compliance Section for advance approval, and no changes to SB participation may be made without authorization. Prime contractors must provide detailed justification for their exemption requests, including documentation of good faith efforts made to identify additional small business participation. The form requires signature by a duly authorized representative of the prime contractor, along with the contractor's name, title, and contact information. Upon review, the Contract Compliance Section documents its decision and specifies the revised small business utilization commitment amount, ensuring accountability and compliance with the city's small business participation requirements throughout contract performance.
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Text version
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:
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