Fillable SoleSource-Sep18 - Sole Source Justification Worksheet

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SoleSource-Sep18 - Sole Source Justification Worksheet

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1
Revised 09/11/18 AH
SOLE SOURCE JUSTIFICATION FORM
DATE: ___________________________
TO: Purchasing Department MS3280
Email: purchasing@semo.edu
Phone: 573-651-2202
FROM: Department: ___________________________________
Contact Name: _________________________________
Email: ________________________________________
Phone: ________________________________________
RE: Sole Source Procurement
DESCRIPTION OF REQUIRED ITEM
Specify
t
h
e exact product/service your department needs include brand, model, part number, etc.
_____________________________________________________________________________________
_____________________________________________________________________________________
Estimated Annual Cost: $__________________________ Index: __________________________
If the estimated annual cost is $25,000 or more, please indicate the Index to be charged for Advertising cost.
SUPPLIER INFORMATION
Comp
any Name: _____________________________________________________
Contact Name: _______________________________________________________
Telephone: __________________________________________________________
Email Address: _______________________________________________________
Banner ID Number: ___________________________________________________
Submit a W-9 to Purchasing@semo.edu for any new vendor.
Is the recommended supplier the manufacturer of the item(s)? ☐
Yes ☐ No
Does the manufacturer sell the items(s) through distributors?
☐ Yes ☐ No
2
Revised 09/11/18 AH
JUSTIFICATION
As defined by University Purchasing policies, a single feasible source procurement exists when one
or more of the following justifications apply. Please select the item(s) that applies to this purchase.
☐ Supplies are proprietary and only available from the manufacturer or a single distributor.
The parts are required to maintain validity of a warranty;
Additions to a system must be compatible with original equipment;
Only one (1) type of computer software exists for a specific application; or
Factory authorized maintenance must be utilized in order to maintain validity of a warranty;
The materials are copyrighted and are only available from the publisher or a single distributor; and
The services of a particular provider are unique, e.g. entertainers, authors, etc.;
☐ Based on past procurement experience, it is determined that only one distributor services the region in which
the supplies are needed.
☐ Supplies are available at a discount from a single distributor for a limited period of time.
The discounted price must be compared to a price established through a reasonable market analysis;
and
The discounted price should normally be at least ten percent (10%) less than the current contract or
other comparable price.
SOLE SOURCE RATIONALE
As
required by University Purchasing policies, the file must be documented to explain 1) how the
procurement meets the legal definition of a single feasible source, 2) the functionality of the supply that
makes it a single feasible source, and 3) why the functionality is the only one that will meet the needs of the
University. Documentation from both the department and the supplier is required, each specifically
addressing the requirements aforementioned.
DEPARTMENT Rationale
m
a
y be provided on the lines below or by an attached memo.
VENDOR Please attach th
e sole source justification memo from the vendor.
----------------
----------------
----------------
-------------------------------------------------------------------------------------------
3
Revised 09/11/18 AH
CHECKLIST FOR DEPARTMENT
☐ Sole S
our
ce Justification Form
Completed
☐ Department Documentation/Memo
☐ Vendor Memo
☐ W-9 (required for new vendors)
☐ Index number provided for Advertising cost
(required only for purchases $25,000 or more)
☐ All documentation sent to Purchasing
Department for review
--------------------------------
-----------------------------------------------------------------------------------------------------------
For Purchasing Department’s Use Only
CHECKLIST FOR PURCHASING
Purchase Requisition Number: __________________________
Date Received: ___________________
Documentation
☐ Departme
nt Docum
e
ntation/Memo Received
☐ Vendor Memo Received
Suspended/Debarred Vendors
If a company is listed as a Suspended/Debarred Vendor, we cannot proceed with this sole source procurement.
If the vendor is not listed, print screens for the file.
☐ Federal: www.sam.gov Date Checked: ___________________
☐ Missouri: http://oa.mo.gov/purchasing-materials-management Date Checked: ___________________
Advertising
The University must advertise sole source procurements in at least two (2) daily newspapers when the
estimated expenditure is $25,000 or more within a 12-month period.
☐ Posted on Purchasing Website ($
10,000 or more) Date Posted: _________________________
☐ Newspaper Advertisements Required ($25,000 or more) Date Ads Published: ___________________
Date Purchase Orde
r can be Processed:
Five (5) days after posted/pu
blished date
_________________________________
Inquiries
☐ No Inquiries Received
☐ Inquiry(s) Received
Date Received: _______________
Name and Contact Information of Requestor(s):
____
_________________________________________________
_____________________________________________________
____
_________________________________________________
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SoleSource-Sep18 - Sole Source Justification Worksheet

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Completed 10 February 2020

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