SOLE SOURCE FORM-HUMAN SERVICES CAMPUS APPROVED.PDF

Office of Procurement Services
GOODS AND SERVICES
SOLESOURCEFORM
This form is to be used when an agency believes an acquisition is a sole source and the acquisition dollar amount is above 
$
,000. The Chief Procurement Officer can approve purchases up to $100,000. Board of Supervisors approval is required
. This form must be submitted for approval to: Office of Procurement Services | 160 S 4th Ave | 
Phoenix, AZ 85003. Fax number: 602.506.6766. The signed form must be retained in the purchasing file. Unless approved by 
the Board of Supervisors in a formal agenda item or the Chief Procurement Officer in a formal Contract a SS form is valid from 
July 1 thru June 30th of each Fiscal Year. 
DEPARTMENT NAME
DEPARTMENT RX#
Department Contact
ContactPhoneNumber
PROPOSED CONTRACT VENDOR
NEED IDENTIFIED Date:
REQUESTED DELIVERY
Date:
QUOTED PRICE:
Accounting String:
Company:
Address:
City, State:
Zip/Postal Code:
Phone:
Fax:
Contact Name:
Material / Service Information
Is this a Technology Procurement?
Yes
No
Needs Statement:
Describe in detail the material or service to be procured and
how only it meets your needs.
Features/Requirements:
Identify the major features/capabilities that are required. What
unique design/performance feature(s) make this material or 
vendor the only one that can meet your requirements? Provide
a brief explanation as to why only these features or this vendor
can meet your requirements. Identify the manufacturer/model
or your existing equipment, service or system if applicable.
Competing Brands/Vendors Investigated:
Did you consider other materials or vendors with similar
capabilities? Indicate specific competitor's brands/models or 
vendors that were investigated and describe why they do not
meet your requirements. You need to state that - to the best of
your knowledge - these are the only companies making this
material, equipment or providing this service. List sales
representatives and their phone numbers so the Procurement
Officer can contact them to verify that other materials,
equipment or services do not meet your requirements.

SEARCH
MC1-349-A states: Any request by a Using Agency that a Procurement be restricted to one potential Contractor shall be accompanied by
an explanation as to why no other would be suitable or acceptable to meet the need. The Using Agency requesting sole source 
Procurement shall provide written evidence to support a sole source determination. A requirement for a particular proprietary item does
not alone justify a sole source Procurement if there is more than one potential Respondent for that item.
Asearch was conductedconsistingof: (checkall that apply)
Market research 
Public notice given, list 
Other vendors contacted 
Other 
RESULTS
no alternatives were identified 
no alternatives were deemed acceptable
because (explain below): 
Describe the search from above in detail:
PRICE
The estimated cost of this Procurement is: 
$100k 
> $100k 
MC1-347 States: The Chief Procurement Officer may make the determination that the sole source method set forth in
MC1-349 shall be used if a Commodity or Service is available from only one vendor, and the purchase is estimated to Cost
no more than $100,000. 
Price has been fairly and reasonably established by: 
Comparison to previous comparable purchases 
from a different vendor 
Independent estimate 
Comparison to public sector contract pricing 
Discount off published catalog pricing 
Market survey 
Other, explain: 
Describe methodology and results (attach any written supporting data, e.g., survey or market analysis): 
THISPROCURMENTISASOLESOURCEBECAUSE (attachadditionalpage ifneeded):

Office of Procurement Services
Approved. Please send a Requisition to OPS to process.
Not Approved.
Reasoning:
CERTIFICATIONS
I certify:
1) I recognize that the Maricopa County Procurement Code 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;
2) the price to be paid to the proposed sole source vendor is fair, reasonable, and provides the best value to Maricopa
County; and
3) 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.
Agency Head orAppointingAuthoritySignature(Required)
Printed Name
Signature
Date
Save
Email
Printed Name
Signature
Date
CONFLICTOFINTERESTSTATEMENT
The submitting department agrees that there is no real or potential conflict of interest in recommending this material or 
service as a sole source procurement.
NOTE: If a real or potential conflict exists, contact the Procurement Officer listed on your Requisition.