TSC_Jacobs_North_-_Justification_form.pdf

Rev: 09/05/2023

BREVARD COUNTY BOARD OF COUNTY COMMISSIONERS

SINGLE/SOLE SOURCE JUSTIFICATION AND APPROVAL FORM

Sole Source: The ONLY known supplier for unique products and services where no other options are available.

Single Source: Though there may be alternate sources for the product or service requested, circumstances dictate the use of the proposed vendor. (i.e., availability, timeliness, location, etc.)

PART I – GENERAL REQUESTOR INFORMATION

Date Submitted: __________ Requesting Department: ____________________________________

Contact Person/Phone #: ____________________________________

// Annual Purchase

Requisition #:

One-time Purchase

Amount of Purchase: (One time) // (Estimated annual amount)

PART II – RECOMMENDED VENDOR INFORMATION

Vendor/Contractor Name:

Vendor/Contractor Contact Name:

Vendor/Contractor Phone:

Vendor/Contractor Email:

PART III – SINGLE/SOLE SOURCE VALIDATION

1. Provide a detailed description of service/commodity to be provided by the vendor.

2. State why the recommended vendor is the only one capable of providing the required supplies and/or commodities. Include any back-up information or documentation that supports your recommendation. (Acceptable responses to this question will include strong pragmatic/technological information that supports the claim that there is only one vendor that can provide the services and/or commodities). Attach vendor letter and additional sheet if necessary.

3. List any other sources that have been contacted and explain in detail why they cannot fulfill the County's requirements. (Responses to this section should include information pertaining to any research that was conducted to establish that the vendor is a sole source.

Responses should include information pertaining to discussions with other potential suppliers, and why they were no longer being considered by the County).

PLEASE FORWARD ALL REQUESTS TO: SingleSource@brevardfl.gov

Angel.Boss Underline

Angel.Boss Highlight

Check all entries below that apply to the proposed purchase which exempt formal competition. Attach a memorandum containing complete justification and support documentation as directed in the selected entry. (More than one entry will apply to most sole source products/services requested).

1. SOLE SOURCE REQUEST IS FOR THE ORIGINAL MANUFACTURER OR PROVIDER.

THERE ARE NO REGIONAL DISTRIBUTORS. (Attach the manufacturer’s written communication that no regional distributors exist. Item no. 4 must also be completed.)

2. SOLE SOURCE REQUEST IS FOR THE ONLY STATE OF FLORIDA DISTRIBUTOR OF

THE ORIGINAL MANUFACTURER OR PROVIDER. (Attach the manufacturer’s - not the distributor’s – written certification that identifies all regional distributors. Item no. 4 must also be completed.)

3. THE PARTS/EQUIPMENT ARE NOT INTERCHANGEABLE WITH SIMILAR PARTS OF

ANOTHER MANUFACTURER. PARTS ARE “DIRECT REPLACEMENTS”

PARTS/COMPONENTS FOR EXISTING EQUIPMENT. (Explain in a separate memorandum.)

4. THIS IS THE ONLY KNOWN ITEM OR SERVICE THAT WILL MEET THE SPECIALIZED

NEEDS OF THIS DEPARTMENT OR PERFORM THE INTENDED FUNCTION. (Attach separate memorandum with details of specialized function or application.)

5. THE PARTS/EQUIPMENT REQUIRED FROM THIS SOURCE ARE TO PERMIT

STANDARDIZATION. (Attach separate memorandum describing the basis for standardization request.)

6. NONE OF THE ABOVE APPLIES. A DETAILED EXPLANATION AND JUSTIFICATION FOR

THIS SOLE SOURCE REQUEST IS CONTAINED IN AN ATTACHED MEMORANDUM.

PART IV – CERTIFICATION AND APPROVALS

I have reviewed the following Single/Sole Source justification and concur with the request, fully understanding the implications of Section 838.22 of the Florida Statutes:

(2) “It is unlawful for a public servant or a public contractor who has contracted with a governmental entity to assist in a competitive procurement to knowingly and intentionally obtain a benefit for any person or to cause unlawful harm to another by circumventing a competitive solicitation process required by law or rule through the use of a sole-source contract for commodities or services.”

(3) ”It is unlawful for any person to knowingly agree, conspire, combine, or confederate, directly or indirectly, with a public servant or a public contractor who has contracted with a governmental entity to assist in a competitive procurement to violate subsection (1) or subsection (2).”

(5) ”Any person who violates this section commits a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.”

Each undersigned individual hereby attests that he/she took part in the non-competitive procurement identified above, and has reviewed Florida Statutes, Chapter 838 as it relates to sole source contracts, and that he/she is independent of, and has no conflict of interest in, the entity evaluated and selected.

Requisitioner Signature: _______________________________________________ Date: ___________

Requesting Department Director Signature: ________________________________ Date: ___________

Central Services Office Director or Purchasing Manager’s approval: ________________________________________ Date: ___________

Assistant County Manager/County Manager Approval (as applicable–ACM $50K-$100K//County Manager $100K-$200K// BoCC $200K<):

_________________________________________ Date: ___________

Sole Source Approval ID #: ___________

Contact Person_Phone: X54294