Fillable Single/Sole Source Justification Form

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Single/Sole Source Justification Form

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The Single/Sole Source Justification Form form is 4 pages long and contains:

  • 3 signatures
  • 12 check-boxes
  • 28 other fields

Country of origin: OTHERS
File type: PDF

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Single/Sole Source 1 Updated 2/6/19 – Strategic Sourcing
Buyer’s Initials_______
Date Approved_______
Single/Sole Source Justification Form
Requester Information (Full Name and Title):
Requesting Location (School or Department):
School or Department Budget Approver Signature (Principal, Department Head):
Requisition number or Independent Contractor Agreement number:
Vendor Information
Vendor Name:
Vendor Contact (representative who provided quote/website where quote was obtained):
Name-
Email-
Phone Number-
Does the vendor accept P-Card/VISA as a form of payment (check one): ☐ Yes or ☐ No
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Single/Sole Source 2 Updated 2/6/19 – Strategic Sourcing
Buyer’s Initials_______
Date Approved_______
Check ONLY ONE of the following:
☐ Sole Source - Good or service is only available from one particular source/vendor, due to
lack of competition, proprietary technology, copyright or the supplier's unique capability.
☐ Single Source - Good or service is directed to one source/vendor because of
standardization, warranty, location, or other factors, even though other competitive sources may
be available.
☐ Emergency Purchase- A purchase made due to an unexpected and urgent request where
health and safety or the conservation of public services is at risk.
Check AT LEAST ONE of the below non-competitive justifications:
☐ No Substitute Item - Engineering drawings, specifications or standardized products require
that equivalent products will not be accepted.
☐ Only Qualified Supplier - The reliability, maintainability, warranty or life of a system/product
may be compromised unless a specific, qualified and reliable source/vendor is selected.
☐ Product Incompatibility - Attachments, spare/replacement parts, etc. from other vendors are
not compatible with the original product.
☐ Professional/Consulting Services - Services are unique to the vendor/contractor or are
required by a governmental agency/program/the District (ex. Grants, Architects, etc.).
☐ Proprietary Good/Service - Good or service is protected by a patent or copyright, etc. that
prevents soliciting alternate sources. Patent or Copyright #: Requires justification letter from
vendor, see below.
☐ Time Restraints - Timely delivery of product or service will affect the success of project
outcome. Only one source/vendor can meet the specified time line.
☐ Emergency Purchase - Explain:
Explain why the procurement process cannot be followed for this product or service:
Single/Sole Source 3 Updated 2/6/19 – Strategic Sourcing
Buyer’s Initials_______
Date Approved_______
Anticipated total cost of product/service (please email the required documents to Buyer with this
document)
**Request a quote from the vendor and obtain the vendor/manufacture sole source letter. If
the vendor has any term and conditions related to the product or service please retain this
information and ensure that the information is attached to your request form**
Detailed Justification:
Why is this uniquely specified product/service required? (Describe in significant detail and
include manufacturer name, model number(s), item number(s), grant number(s), etc...)
Single/Sole Source 4 Updated 2/6/19 – Strategic Sourcing
Buyer’s Initials_______
Date Approved_______
COMPLETION OF THIS FORM DOES NOT GUARANTEE THE APPROVAL OF THE
PROCUREMENT REQUEST. PROCUREMENT SERVICES RESERVES THE RIGHT TO
COMPETITIVELY BID, NEGOTIATE OR TO SOLICIT ADDITIONAL INFORMATION AND
REMAIN THE FINAL AUTHORITY ON ALL PROCUREMENT ISSUES. ATTACH THIS
APPROVED FORM TO YOUR REQUISITION REQUEST AND EMAIL TO THE BUYER.
By submitting this Sole Source Justification Certification, I the undersigned, certify that:
● The above justification is accurate and complete to the best of my knowledge and belief.
● I am complying with the policies and guidelines of Denver Public Schools.
● I understand a protest could significantly prolong the time of the procurement.
● I understand this Sole Source Justification will be a public document available for public
inspection.
Requester Signature: _______________________________________________
Printed Name: ____________________________________________________
Date:____________________________________________________________
Reviewed and approved (Strategic Sourcing only):
NAME: ___________________________ SIGNATURE: ____________________________
TITLE:______________________________________ DATE:_______________
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SingleSole Source Justification Form

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Completed 16 December 2020

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