(for use of University Counsel)
Contract Number:
Revised 8/31/06
FINANCIAL IMPACT STATEMENT
Section I. INFORMATION ABOUT THE VENDOR OR SERVICE PROVIDER AND THE CONTRACT
I-A Name of company
Contact person
Address
Phone, fax, email
Federal tax ID number
I-B Project name / description
Is this a renewal of or modification to a previously approved contract? YES
NO
If “YES” to the above, provide the contract number
Is the attached contract an unmodified Temple University form? YES
NO
I-C Temple University contact:
Name
Department
Phone, email
Section II. FINANCIAL AND COMMITMENT INFORMATION
II-A The term of the contract is from (DATE)
to (DATE) .
II-B Does the contract require a capital expenditure greater than $50,000 YES
NO
(or $10,000 for architecture, engineering or other design services)?
If “YES” to the above, ATTACH a signed Capital Expenditure Request (CER) ATTACHED
(Available on the Facilities Management website at www.temple.edu/facilities/)
II-C The total amount of payments by Temple University pursuant to this contract is: $
This amount will be paid (CHECK ONE):
Entirely in the
fiscal year:
In multiple fiscal years as detailed below:
FY Account Number Center Number Amount
FY Account Number Center Number Amount
FY Account Number Center Number Amount
Other (describe in detail)
Revised 8/31/06
Section III. PROCUREMENT INFORMATION
III-A The purchasing process was conducted by
Purchasing
Other
(Name of School/Department)
If “Purchasing”, skip to Section IV. Otherwise, complete this Section III
.
III-B Is this a sole source request (did you solicit a price YES
NO
for the goods or services from only one vendor)?
If “YES”, ATTACH justification for sole source and skip to Section IV. Otherwise, complete this Section III
.
How many firms were solicited
Names of vendors / suppliers solicited and response received
Name
Response (yes/no)
Name
Response (yes/no)
Name
Response (yes/no)
Are any of the solicited firms certified as a MBE (Minority Business Enterprise), WBE (Woman Business Enterprise), or DBE
(Disadvantaged Business Enterprise)?
YES
NO DON’T KNOW
If “YES”, list the name of the applicable vendor / supplier and its certification (state/city/other)
.
Name
Certification
Name
Certification
Are any of the solicited firms local businesses? (see instructions)
YES
NO DON’T KNOW
If “YES”, list the name of the applicable vendor / supplier and its zip code
.
Name
Zip Code
Name
Zip Code
Section IV. APPROVALS
IV-A Budget Unit Manager or Authorized Signatory
Signed
Date
Printed
IV-B Vice President or Provost
Signed
Date
Printed
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