Instructions:



Instructions:All fields must be completed to process the form.A separate form must be submitted for each agency whose payments resulted in disputed pleted forms should be submitted to feeprocessing@.If you have questions, please contact the MyFloridaMarketPlace (MFMP) Customer Service Desk at 1-866-352-3776 or feeprocessing@.Dispute Request Information:Date:Click here to enter text.Federal Tax ID #*:Click here to enter pany Name:Click here to enter text.Contact Name:Click here to enter text.Title:Click here to enter text.Phone Number:Click here to enter text.Contact Email: Click here to enter text.State Agency:Click here to enter text.Consolidated Billing Invoice (CBI) NumberCBI DatePurchase Order (PO), Contract or Invoice NumberTotal Payments from the stateDisputed Fee Amount (value of the transaction fees)Reason for DisputeFor example: 9003492For example: 6/1/2013For example: AZ12345For example:$70,000For example:$490For example:Exempt service, constructionClick here to enter text.Click here to enter a date.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter a date.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter a date.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Total Amount Disputed$ Click here to enter text.$ Click here to enter text.For Agency Transaction Fee Dispute LiaisonReviewer Name:Click here to enter text.Approved: ?Yes ? No Date Reviewed:Click here to enter a date.Exemption Reason Code: Choose an item.See listing of reason code descriptions on following ments:Click here to enter text.Approval of this form does not exempt any remaining PO, contract or invoice balance associated to this order. To prevent further assessment of fees, process a change order, check the ‘Transaction Fee Exempt?’ box, and select the appropriate exemption reason in the Accounting Details. Customers must have the ‘Transaction Fee Exempt’ permission to mark a transaction fee exempt. If you are unable to edit this field, contact your agency’s MFMP System Administrator.Transaction Fee Exemption Codes and DefinitionsExemption CodeExemption ReasonNotes3AProcurement under Section 337.11 Florida StatutesConstruction3BProcurement under Section 287.055 Florida StatutesProfessional architectural, engineering, landscape architectural, or surveying and mapping services3CProcurement under Chapter 255 Florida StatutesPublic Property And Publicly Owned Buildings3DTransaction with Non-Profit Entity3ETransaction with another Governmental Agency3FTransaction with required Sole Provider or price paid and payee established by federal or private grant3GPayment to Unregistered Vendor under Rule 60A-1.033(3) 3HPayment to vendor in exchange for providing health care services at or below Medicaid rates3IDisbursement to Recipient or Sub-Recipient; payment to satisfy Maintenance of Efforts requirement; or payment to match federal award4The transaction is critical to Agency's mission or necessary for public health, safety, or welfare; and imposition of the fee would prevent the consummation of the transaction5AEmergency Transaction per Rule 60A-1.031(5)(a)When the governor suspends purchasing regulations due to an emergency5BEmergency Transaction per Rule 60A-1.031(5)(b)When the agency head declares an emergency ................
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