Rev.9/09
SOLE SOURCE FACT SHEET AND CHECKLIST FOR SERVICES
This form must be completed and submitted to the Purchasing Department. when making sole source requests for
services. If a question is not applicable, please indicate N/A. Use layman's terms and avoid jargon and the use
of acronyms.
Department:
Contract No.:
Estimated Total Dollar Amount of Order/Contract:
Contractor's Name:
Contractor's Address:
Contractor's Vendor Number:
Contractor's Contact Person:
Contractor's Contact Person Telephone No.:
Location Where Service is to be Performed:
1.
Please check the reason(s) for this request:
a.
Only Single contractor is capable of providing the services.
Only known source - similar services not available from another contractor.
Services must be provided by contractor to ensure compatibility.
Original Procurement from Office of Administration ITQ for Information Technology Services.
b.
A federal or state statute or federal regulation exempts the services from the competitive
procedure.
c.
It is clearly not feasible to award the contract for services on a competitive basis. For example:
Software maintenance agreements, including upgrades and software support, exceeding
$10,000.00.
d.
The services involve the repair, modification, or calibration of equipment and are to be performed
by the manufacturer of the equipment or by the manufacturer's authorized dealer, provided the
contracting officer determines that bidding is not appropriate under the circumstances.
e.
The contract for services is in the best interest of the Commonwealth.
2.
Briefly describe the services you are requesting and their function. Please attach a draft of the “Statement
of Work”.
3.
Describe the unique features/compatibility of the services that precludes competitive procurement.
4.
What research has been done to verify the contractor as the only known source?
5.
Does the contractor have any distributors, dealers, resellers, etc., that can perform the services?
Yes. Please attach a list of known sources.
No.
6.
Must this service be in compliance with the manufacturer's warranty or existing service agreement? If yes,
please explain.
7.
What are the future consequences of the procurement? That is, once this procurement is approved and
processed, what additional upgrades, additions, supplies, services, etc., are anticipated/projected over the useful
life of this item?
8.
If this is an upgrade, addition, alteration, etc., to an existing service how was the original item procured
(sole source or competitive)? What additional, related, sole source procurements have occurred since the initial
procurement? Please identify the previous purchase order or contract number(s).
9.
How has this service been procured in the past? (Competitive sealed bidding, competitive sealed
proposals, sole source, ITQ, other). Please provide document numbers.
If procured through the Office of Administration ITQ for Information Technology Services, complete the
following:
Original amount of Order.
Contract period for Order.
Is this the final phase for this project? (Yes or No)
If no, explain what additional time and dollar amount may be required.
10.
What are the consequences of not procuring this specific service?
11.
If timing is a factor, who established the time frame and why?
12.
List any other information relevant to the acquisition of this service (attach additional 8-1/2" x 11 sheets, if
necessary).
13.
For sole source requests in excess of $100,000 include the contractor-signed cost or pricing data
certification with this form when this form is submitted to the approving authority.
Signature of person completing form:
Title:
(Print Name of person completing form)
Date:
Phone No.:
Signature of Approving Authority:
________________________________
Barbara Reitz
Purchasing Manager
Agency Head or Designee
Date:__________
____________________________________Date:___________
University Legal Counsel Approval
Fax No.: