Fillable EXCLUSIVE ACQUISITION JUSTIFICATION FORM (University of Texas at Dallas)

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EXCLUSIVE ACQUISITION JUSTIFICATION FORM (University of Texas at Dallas)

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Page 1 of 5 Updated: Apr 2018
EXCLUSIVE ACQUISITION JUSTIFICATION FORM
(For Noncompetitive Purchases Over $15,000)
The competitive bidding process is the foundation of government purchasing. In rare situations though, due to
the unique nature of some goods and services, competition may not be possible. It is the responsibility of the
Purchasing Office to verify that competition is not required and that the acquisition will result in “best value” for
the institution in compliance with Texas Education Code §51.9335(b).
In order to make this determination, the Purchasing buyer must understand the unique characteristic(s) of the
good or service. This form is designed to assist faculty and staff in communicating the required information to
Purchasing.
Answer the questions below as completely as possible. Submit the completed form to Purchasing at
purchasing@utdallas.edu
. If more space is needed, attach additional page(s). Requests must be typed.
GENERAL INFORMATION
Today’s Date: Estimated Dollar Amount:
S
elect anticipated contract type:
☐ Business Contract ☐ Purchase Order (PO) Document ID #:____________________
CONTACT INFORMATION
DEPARTMENT INFORMATION SUPPLIER INFORMATION
Contact Name: Supplier Name:
Department: Contact Name:
Campus Phone: Phone:
Email Address: Email Address:
TYPE OF JUSTIFICATION
Proprietary and Best Value: (as defined in Texas Government Code 2155.067, Education Code Section 74.008, Section b)
☐ Only known supplier that meets your “definition of scope.” (Complete sections A and B.)
Emergency: (as defined in Texas Government Code 2155.086, Section c)
☐ A purchase for which delay would create a hazard to life, health, safety, welfare or property. (Complete sections A
and C.)
Professional Services: (as defined in Texas Government Code 2254.002, e.a. Architects, Engineers, RNs, CPAs, Physicians, Land
Surveyors, etc.)
☐ Designated professional for which competitive bidding is not permitted. Note: To be used only when professional
service providers have not been pre-qualified. (Complete sections A and D.)
Page 2 of 5 Updated: Apr 2018
SECTION A - GOODS/SERVICES INFORMATION
PRODUCT MAKE/MODEL
OR SERVICE
DESCRIPTION OF REQUEST
Describe the good or service to be
procured and how it meets your
needs.
SECTION B – PROPRIETARY AND BEST VALUE JUSTIFICATION
SPECIAL USE REQUIREMENTS
(equipment only)
To be compatible with existing
equipment:
F
or the repair, maintenance, or
modification of existing equipment:
F
or use as spare or replacement
equipment:
_____Y
ES _____NO
_____Y
ES _____NO
_____Y
ES _____NO
REQUIRED FEATURES
List the specific feature(s) or
characteristic(s) that are required,
which are unique to the good or
service provided by this supplier.
Describe the importance of the
unique feature(s) as it applies to the
intended use and project goals.
Describe how the selected supplier
meets these requirements.
EVALUATION OF OTHER
SOURCES
Identify other sources that were
evaluated (including the names,
manufacturers, model numbers, etc.)
and the reason they were found to be
unsatisfactory for the intended use or
in meeting project goals. (Attach
copies of any quotes collected from
other suppliers, if applicable.)
RISK ELEMENTS
D
escribe any substantial risks that
could not be overcome if the product
or service was procured from another
supplier.
Page 3 of 5 Updated: Apr 2018
SECTION C – EMERGENCY JUSTIFICATION
RISK ELEMENTS
State the financial or operational
damage/risk that will occur if needs
are not satisfied immediately. (You
must provide specifics when
explaining any loss or damage.)
SPECIAL CIRCUMSTANCES
State why the needs were not or
could not be anticipated so that
goods/services cannot be purchased
following standard procedures.
SUPPLIER SELECTION
State the reason and process used
for selecting the supplier. (Attach
quotes/proposals received from other
sources, if applicable.)
In order to provide the required goods/services, the supplier (check one):
☐Requires a physical PO
• The department must create a requisition document and submit an Exclusive Acquisition Justification Form to
the Purchasing Office
.
• T
he department contacts Purchasing buyer to expedite requisition processing.
•
P
urchasing buyer issues the PO to the supplier.
•
P
ayment is made on a payment voucher.
☐Requires a verbal PO
• The department must submit an Exclusive Acquisition Justification Form to the Purchasing Office.
• P
urchasing buyer provides an emergency PO number to the department.
•
T
he department provides the emergency PO to the supplier.
•
P
ayment is made on a payment voucher.
☐Requires verbal approval from requesting department (no PO)
• In the case where there is an immediate threat to The University of Texas at Dallas and a supplier is on hand or
can quickly mobilize to perform needed repairs (or the emergency occurs after normal business hours), the
requesting department can give the go ahead for the supplier to start work.
•
T
he department must submit an Exclusive Acquisition Justification Form to Purchasing for review as soon as
possible.
• Payment is made on a payment voucher.
SECTION D – PROFESSIONAL SERVICES JUSTIFICATION
SUPPLIER SELECTION
Criteria used to select the supplier for
these services.
REASON FOR SELECTION
Identify specific qualifications of
selected supplier.
Page 4 of 5 Updated: Apr 2018
CONFLICT OF INTEREST STATEMENT
I,
, the undersigned, hereby certify that the following statements are true and correct
and that I understand and agree to be bound by the commitments contained herein. I am acting on my own accord and am
not acting under duress. I am not currently employed by, nor am I receiving any compensation from, nor have I been the
recipient of any present or future economic opportunity, employment, gift, loan, gratuity, special discount, trip, favor, or
service in connection with this supplier in return for favorable consideration of this request.
S
ignature: _______________________________________________ Date: ___________________
(Primary User)
Title: ___________________________________________________
(
Note: Texas Government Code, Chapter 572, Subchapter C, Sec. 572.069 – CERTAIN EMPLOYMENT FOR FORMER STATE OFFICER OR
EMPLOYEE RESTRICTED. A former state officer or employee of a state agency who during the period of state service or employment participated on
behalf of a state agency in a procurement or contract negotiation involving a person may not accept employment from that person before the second
anniversary of the date the officer’s or employee’s service or employment with the state agency ceased.)
DEPARTMENT APPROVAL – Dean/Chair/Business Officer*
B
y signing below, the department certifies that the information submitted on this form has been reviewed and this purchase
has departmental approval. The final determination of approval shall be made by the Purchasing Office.
Signature: ______________________________________________ Date: _____________________
(Dean/Department Head/Business Officer)
P
rinted Name: ____________________________________________
(
Dean/Department Head/Business Officer)
T
itle: ____________________________________________________
*Depar
tmental approver must be senior to the primary user.
(Note: Texas Government Code Chapter 572, Subchapter C, Sec. 572.069 – CERTAIN EMPLOYMENT FOR FORMER STATE OFFICER OR
EMPLOYEE RESTRICTED. A former state officer or employee of a state agency who during the period of state service or employment participated on
behalf of a state agency in a procurement or contract negotiation involving a person may not accept employment from that person before the second
anniversary of the date the officer’s or employee’s service or employment with the state agency ceased.)
Page 5 of 5 Updated: Apr 2018
PROCUREMENT APPROVAL – TO BE COMPLETED BY PURCHASING
DETERM
INATION:
____ Approved
____ Not Approv
ed
JUSTIFIC
ATION FOR PROCUREMENT METHOD:
Propriet
ary
_____Proprietary (i.e., Pharmaceuticals, Chemical Reagents)
_____Original Equipment Manufacturer (OEM) Maintenance/Renewal
_____Meets Unique Specification
_____Direct Publication/OEM Software Renewal or Maintenance
Best Value
_____Compatibility with Existing Equipment
_____Continuity of Service/Research
_____Contractor/Grantor Requirement
_____Best Value
Emergency Purchase
_____Emergency Purchase Emergency PO Number: ______________________
Professional Services
_____Professional Services
Rationale for determination/comments:
Signature: ___________
_____________________________ Date: ______________
(Buyer or Senior Buyer up to $25,000)
Signature: ___________
_____________________________ Date: ______________
(Director of Purchasing – over $25,000)
Signature: ___________
_____________________________ Date: ______________
(VP of Budget and Finance - over $1,000,000)
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EXCLUSIVE ACQUISITION JUSTIFICATION FORM (University of Texas at Dallas)

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Completed 24 July 2020

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