New York State Department of Transportation



MWBE Waiver Request FormDate: Contract No. Proposed Letting Date: Post Award Submission Date:Project Description: Estimated Cost: Requestor: Program Area: Region: Local Sponsor: Annual Goal Plan Goal: MBE WBE Agency Contact InformationName: Sondra Little, Director, Office of Civil RightsEmail: Sondra.Little@dot.Phone number: (518) 457-1129Description of Work: Identify the Reason for Request [Choose all that apply]: Availability – List the number of MBEs and WBEs available in the Directory of Certified Businesses for the subcontract work items identified. Attach search results documentation from the directory.Limited sub-contracting opportunities – List the work items and/or the specialty items not available for sub-contracting (e.g. field change payments, fuel and asphalt adjustment, etc.) Please include the dollar value of the items.Sole Source or Single Operation – Explain why there is only one provider of the good or service being procured. Identify the single operation.Pre-Letting Goal (Original) _____Post-Award Attainment (Recommended) _____Comments: The Office of Civil Rights (OCR) has reviewed and accepted the attached MWBE utilization plan (UP), good faith effort documentation and waiver request from the contractor/service provider. Attachments include:Utilization plan & Waiver Review Good Faith Effort Documentation Notice of Deficiency- if applicable Any other documents that may be helpful in the review of this waiver OCR does/does not concur with the recommendation. MBE: % WBE: % ________________________________________________________Director, Office of Civil RightsDateRequests for M/WBE goal(s) waivers require prior approval from the Office of Civil Rights, submission of an in-depth justification for the request and a contract goal assessment. The contract goal assessment should include the following:A review of the standard goals established in the Goal Details table in the Annual Minority and Women Owned Business Program Goal Plan. contract and subcontract scope(s) of work. This should include a consideration of work items, quantity, contract terms, and materials.The potential subcontract opportunities available in the prime contract. This should include a consideration of primary and secondary work operations.The relevant availability data contained within the disparity study with respect to the scope of the contract and potential subcontracting opportunities.The number and types of certified minority- and women-owned business enterprises found in the directory of certified minority- and women-owned businesses available to perform the State contract work.The geographic location of the contract performance.The extent to which geography is material to the performance of the contract.The ability and willingness of certified minority- and women-owned enterprises located outside of the geographic location of contract performance, notwithstanding the regional location of the certified enterprise, to perform on the State contract.The total dollar value of the work required by the State contract in relation to the dollar value of the subcontracting opportunities.The relationship of the monetary size and term of the State contract to the monetary size and term of the project for which the State contract is awarded. DATE \@ "MMM-yy" Mar-20 - Rev ................
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