Sole Source Justification Form

• File Number: 8561.650
• Description: Finance ‎(Billing, Suspense Docs, Ectr)‎
• State: CO
• Basin: South Platte
• Water Division: 1
• Date: 1/1/3000
• Author: State of Colorado
• Title: Sole Source Justification Form
• Water Supply Pro - Doc Type: Contract/Agreement

State of Colorado - Sole Source Justification
Section 24-103-205, C.R.S., as amended
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TYPE or CLEARLY PRINT ALL INFORMATION
(Continue on reverse side, when needed)
You MUST complete this form before beginning any procurement where the basis for vendor selection is:
? There is only one product or service that can reasonably meet your need, AND
? There is only one vendor who can reasonably provide that product or service.
(You MUST meet BOTH criteria to have a sole source procurement. Procurement Rule R-24-103-205-01)
Department:
Address:
Contact Name:
Phone:
Department Approving Official Name:
Division:
RX, PO or Contract #:
FAX:
Department Approving Official Signature:
Describe in detail the products and /or services to be procured and how they meet your needs.
Vendor Name:
Vendor Address:
FEIN #:
Phone:
Have you procured products and/or services from this vendor in the past 2 years? If Yes explain = No = Yes
Start Date:
End Date:
Estimated Total Dollars for this Procurement: $
Provide estimated cost breakdown of supplies and/or services covered by this procurement:
? Supplies $ Services $
Attach a detailed explanation of Vendor's Sole Source Status - what is the basis for your identifying this ar as a sole source?
? Do you have an actual or potential conflict of interest in this purchase request? =No 0 Yes
? If yes, please explain on an attached sheet.
State Purchasing Use Only:
Comments: *** Approvedfor one timepurchase as described on this request ***.
Approved:
State Purchasing Director or Authorized Representative Date
DP-45-0996