Fillable SoleSource3 - Sole Source Justification Worksheet

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SoleSource3 - Sole Source Justification Worksheet

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1 Revised 06/20/18 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 the 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
Company 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 06/20/18 AH
JUSTIFICATION
As defined by section 34.044, RSMo, 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 section 34.044, RSMo, 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 may be provided on the lines below or by an attached memo.
VENDOR Please attach the sole source justification memo from the vendor.
-------------------------------------------------------------------------------------------------------------------------------------------
3 Revised 06/20/18 AH
CHECKLIST FOR DEPARTMENT
☐ Sole Source 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
☐ Department Documentation/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
In accordance with RSMo Chapter 34.040, 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 ($5,000 or more) Date Posted: _________________________
☐ Newspaper Advertisements Required ($25,000 or more) Date Ads Published: ___________________
Tax Compliance
Proof of tax compliance by the vendor must be on file. Date Purchase Order can be Processed:
Five (5) days after posted/published date
☐ Match on Sam II
OR __________________________________
☐ Vendor No Tax Due Certificate
Inquiries Name and Contact Information of Requestor(s):
☐ No Inquiries Received _____________________________________________________
☐ Inquiry(s) Received _____________________________________________________
Date Received: _______________
_____________________________________________________
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SoleSource3 - Sole Source Justification Worksheet

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Completed 10 February 2020

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