Brenda's Single Source Document
GOODS AND/OR SERVICES
SINGLE SOURCE JUSTIFICATION FORM
This form is to be used when an agency believes an acquisition is a single source and the acquisition dollar amount is above $5,000. ALP Certified Buyers can approve only up to their delegated authority, but not to exceed $50,000. The Agency Head or Agency Head Delegate must sign if the acquisition is over $50,000. If the request is over the ALP authority of the certified buyer or over $50,000, the form must be submitted for approval to: procurement.user@state.mn.us. The signed form must be retained in the purchasing file.
[Note: Double click on check boxes to access pop-up box for completion.]
|DEPARTMENT NAME |DIVISION NAME |
|PROPOSED CONTRACT VENDOR |NEED IDENTIFIED (date) |
|Company: | |
|Address: | |
| | |
|Telephone: | |
|Web Address: | |
|Contact: | |
|E-mail: | |
| |REQUESTED DELIVERY DATE |
| |QUOTED PRICE |
| | |
| |$ |
|DESCRIPTION OF GOODS AND/OR SERVICE REQUIRED: |
| |
| |
| |
| |
|If services are included, complete the following: |
|If services are listed above, I have completed and attached a Service Contract Certification form. |
|I have consulted with Risk Management and have attached their response regarding insurance requirements. |
|SINGLE SOURCE CATEGORY (Check applicable box and attach documentation or provide explanation below.) |
| Legislation or appropriation mandates use of contract vendor (Legislation | Software license renewals, additions, or upgrades available from only |
|attached) |one source |
|Warranty voided if service provided by other contract vendor |Brand compatibility available from only one source (no other _[type |
|Other |product here] distributors) |
| |Other proprietary situation |
|THIS PROCUREMENT IS A SINGLE SOURCE BECAUSE (attach additional page if needed): |
|NOTE: The following are unlikely to be sufficient single source justifications: |
|Personal or agency preference for a product or vendor |
|Agency perception that the vendor is the best qualified (this should be determined through a competitive process) |
|Lack of agency planning resulting in limited time to conduct a competitive procurement |
|Past or existing relationship with the vendor |
|Special incentive or deal offered (can be assessed in open and competitive solicitation) |
|Agency convenience |
|SEARCH |
|Minnesota Statute § 16C.02 subdivision 18 states: "Single source" means an acquisition where, after a search, only one supplier is determined to be |
|reasonably available for the required product, service, or construction item. |
|A search was conducted consisting of: (check all that apply) |RESULTS |
|Internet search |AFTER THE SEARCH… |
|Market research / other vendors contacted |no alternatives were identified |
|Public notice given on OSP website |no alternatives were deemed acceptable because (explain |
|Other |below): |
|Describe the search from above in detail: |
|PRICE |
|Minnesota Statute § 16C.10 subdivision 1 states: The solicitation process described in this chapter is not required when there is clearly and |
|legitimately only a single source for the goods and services and the commissioner has determined that the price has been fairly and reasonably |
|established. |
|Price has been fairly and reasonably established by: | |
|Comparison to previous comparable purchase |Comparison to public sector contract pricing |
|Independent estimate |Discount off published catalog pricing |
|Market survey |Other, explain: |
|Describe methodology and results (attach any written supporting data, e.g., survey or market analysis): |
|APPROVALS NEEDED: |
| |
|Agency ALP Certified Buyer must review all requests. They can approve requests up to their delegated authority without further routing. |
|All requests above the ALP Certified Buyer’s delegated authority must be routed to OSP. |
|All requests above $50,000 must be routed to the Agency Head or Agency Head Delegate for approval, then routed to OSP for consideration of the |
|appropriate OSP staff. |
| |
|ALP Certified Buyer shall select which of the following approvals are necessary and send this form to the appropriate people for approval. |
|CERTIFICATIONS: Each signer must certify the following: |
|I recognize that State law requires the use of competitive solicitations unless exempted by law. I have reviewed the information and materials |
|relevant to this procurement of goods and services, and am requesting approval of an exception to the competitive process for the reasons described;|
|the price to be paid to the proposed single source vendor is fair, reasonable, and provides the best value to the State of Minnesota; and |
|this request for an exception to the competitive solicitation process is not the result of inadequate advance planning or for purposes of securing |
|the services of a preferred vendor. |
| |
|SIGNATURES |
|Person Requesting the Single Source Status. By signing this document, I certify that the statements in the Certifications section above are true. |
|Signature: |Date |
|Printed Name |Phone No. |
|Title |Fax No. |
|E-mail | |
|ALP Certified Buyer (Required signature). ALP Certified Buyers can approve only up to their delegated authority, but not to exceed $50,000. If over|
|$10,000, a solicitation document containing the State's terms and conditions must be created and advertised on the OSP website (unless there is |
|written approval from OSP). |
|By signing this document, I certify that the statements in the Certifications section above are true. |
|Signature: |Date |
|Printed Name |Phone No. |
|Title |Fax No. |
|E-mail | |
|Agency Head or Agency Head Delegate Approval (Required signature when over $50,000). By signing this document, I certify that the statements in the |
|Certifications section above are true. |
|Signature: |Date |
|Printed Name |Phone No. |
|Title |Fax No. |
|E-mail | |
| |
|Approved: |
|The ALP Certified Buyer is given a one-time special delegation to process this Single Source acquisition. (Any terms and conditions proposed by |
|vendor must be approved in writing by your agency's attorney general or OSP and retained in file, before issuing order.) |
|The ALP Certified Buyer is given a one-time special delegation to process this Single Source acquisition. A solicitation document containing the |
|State's terms and conditions for the vendor to sign when providing the firm price quote must be created; then issue a purchase order. |
|A solicitation document containing the State's terms and conditions must be created and advertised on the OSP website. |
|Please send an Open Market Requisition (OMR) to OSP to process. |
|________________________________________________________________________________ |
| |
|Not Approved. Reason:_________________________________________________________________ |
|Dept. of Admin, Office of State Procurement (Required signature when over $50,000 or over ALP Buyer’s authority). |
|Signature: |Date |
|Printed Name |Phone No. |
|Title |Fax No. |
|E-mail | |
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SSJ For OSP Use
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