SEP_Form_2024_-_Pipeline_repair_jason_right_V2_.pdf

Rev. 04-02-24

STATE OF EMERGENCY PROCUREMENT FORM

Name of Person Procuring Goods/Services: Phone:

Department:

Estimated Expenditure: No NTE (only appropriate if over 100K)

Cost or Price Analysis Attached (if $250,00 or more)

Fixed Asset: No Yes* (Serial # )

Vendor Name (if known):

Payment Method: Purchase Order Purchasing Card

Cardholder Name (Please Sign Page 2):

JUSTIFICATION

1. Identify which circumstance listed in § 200.320(f) applies.

(1) Micro-purchase ($10,000 or less)

(2) The item is available only from a single source.

(3) The public exigency or emergency for the requirement will not permit a delay resulting from competitive solicitation.

Emergency: a threat to life, public health or safety, or improved property requires immediate action to alleviate the threat

Exigency: there is a need to avoid, prevent, or alleviate serious harm or injury, financial or otherwise, to the non-state entity, and use of competitive procurement proposals would prevent the urgent action required to address the situation.

(4) The Federal awarding agency or pass-through entity expressly authorizes non-competitive proposals in response to a written request from the non-Federal entity (Rarely occurs).

(5) After solicitation of a number of sources, competition is determined inadequate.

2. Provide a brief description of the product or service being procured:

3. Explain why a non-competitive procurement is necessary, including the nature of the public exigency or emergency and illustrating why a competitive procurement would cause an unacceptable delay. IMPORTANT: Non-competitive procurements cannot be used for permanent repairs.

4. State how long will you need to use the non-competitive procurement and the impact it will have on the community if you are not able to use the non-competitive procurement for that amount of time.

Hannah Brechue Inserted Text

Rev. 04-02-24

5. Describe steps taken to determine full and open competition could not have been used or was not used (e.g. research conducted to determine that there were limited qualified resources available that could meet requirements). N/A If Micro-purchase.

6. Describe any known conflicts of interest and any efforts that were made to identify possible conflicts of interest before the procurement occurred. If a conflict is unavoidable, explain how it was unavoidable and any steps taken to address the impact of the conflict.

7. Include any other information justifying the use of non-competitive procurement in this instance.

8. What funds do you expect to use for this purchase (FEMA, FTA, General Fund, etc.)?

9. Is the vendor on the debarment and suspension list on the SAM.gov website? (if yes, DO NOT proceed with vendor)

Yes No

APPROVALS

$10,000 or less – N/A

$10,001 to $50,000 requires EOC Unit Leader, Branch Director, DOC Manager or Director on Duty approval

$50,001 to $100,000 requires EOC Section Chief on Duty approval

Over $100,000 requires EOC Incident Manager on Duty approval

Name of Approver: Date of Approval:

P-Cardholder Signature (if Applicable):

DISTRIBUTION

Purchase Order:

Include a copy of quote and this form with the Purchase Requisition.

P-Card:

One copy with receipt to P-Card Account Coordinator One copy with receipt attached to Disaster Daily Log *One copy with receipt to Fixed Assets if applicable