Single/Sole-Source Justification Form - DFA

Cornell Procurement ServicesSingle/Sole-Source Justification FormComplete this form for general equipment and service requisitions with a value greater than $10,000 (for all funds) where competition may berestricted. Completing this form does not guarantee that the proposed vendor will be selected. Procurement Services may require additionalinformation. It is the requisitioner’s responsibility to provide all the required information and documentation indicated on this form.Submit this form to your financial transaction or business service center to be attached to the requisition. This completed form mustbe attached to the requisition with any additional backup, if available.DefinitionsSole Source: The only known supplier for unique products and services, with no other options available.Single Source: Circumstances dictate the use of this vendor despite other potential options, i.e., availability, timeliness, location, etc.Part I: Ordering Department/Supplier InformationAccount CodeDepartment NameRequisition or e-doc NumberVendor NamePart II. A.: Explanation for Single/Sole SourceSelect one or more of the following statements to support why the requisition noted above should be a single/sole-source purchase.Any selection requires explanation in the additional space provided, which follows. Select all that apply.Sourcing Reason1. Competitive assessment, significant evaluation process performed, which included demonstrations. (Attach your evaluation ofthe demonstrations for each vendor.)2. Unique specifications or program and/or approved by senior leader of unit/organization (provide name below).Name3. Impacts Cornell research from a regional perspective and/or affects multiple Cornell research groups.4. Future or current research collaborative relationship.5. Items sold through manufacturer only; no other comparable unit available. Used ordemonstration equipment available at a lower-than-new cost.6. Must match existing piece of equipment. Available only from the same source of original equipment. Upgrade toexisting software. Available only from the producer of this software, who sells on a direct basis only.7. Repair/maintenance service requires expertise in operations on unit. Necessary parts are not available from any source exceptoriginal equipment manufacturer or their designated servicing dealer.8. Good(s)/service(s) provided by the vendor are unique and, therefore, competitive bids are not applicable (single source).9. Other reason. Please explain.Questions? Contact Procurement Services at procurement@cornell.edu.Submit this form to your financial transaction or business service center to be attached to the requisition.1 of 3Division of Financial AffairsLast updated: 2013-03-20 09:07:40

Single/Sole-Source Justification Form, continuedExplain Selected Reason(s)An explanation is required for any statement selected in Part II.A. above. Information provided in the explanation might include researchperformed or subject matter expertise detailed to justify the use of a particular vendor and their product. You must clearly indicate why theproposed vendor is the only vendor that will meet your requirements. Please attach documents if additional space is required.End-User Explanation (align response with sourcing reason(s) selected in items 1-8 above)Procurement Agent AttestationI agree with the explanation provided above for the following reason(s):Part II. B.: Establishment of the Reasonableness of the PriceSelect one or more of the following statements to indicate why you feel the accepted non-competitive price was fair and reasonable.Any selection requires explanation in the additional space provided, which follows. Select all that apply.Fair Price1. The price was obtained from a catalog or standard price list for items sold to the general public. (Catalog or price list must beprovided or be on file.)2. The quoted price minus the vendor's donation and/or discount is lower than the price available to the general public and reflectssubstantial savings.Must state the dollar amount or percentage here:(Explain the dollar calculation below.)3. The quoted prices compare favorably to market prices or to previous prices that were obtained previously and were found to befair and reasonable, and which were paid for the same or similar items on the following purchase:Date PO# Bid4. The vendor has certified that the prices offered are equal to or lower than those offered to any government agency or privateinstitution for both like items/services and quantities (includes published educational discounts).5. Independent sources indicate that this price is reasonable (i.e., public contracts, Purchasing Organization, Kelly Blue Book,Edmunds, consortium).6. Other reason(s), e.g., volume discount.Questions? Contact Procurement Services at procurement@cornell.edu.Submit this form to your financial transaction or business service center to be attached to the requisition.2 of 3Division of Financial AffairsLast updated: 2013-03-20 09:07:40

Single/Sole-Source Justification Form, continuedExplain Selected Reason(s)An explanation is required for any statement selected for Part II.B. above. Information provided in the explanation might include a catalogprice page, pricing for similar products or other price comparison information gathered to justify price reasonableness. Please attach anyjustification information that would support this explanation.Part III: CertificationI certify that, to the best of my knowledge, I have investigated and found that the above reasons and explanations justify this requisition as asingle/sole-source purchase, and that price reasonableness is adequately confirmed. I am the individual who has gathered and provided thisdetailed information, and any further questions regarding these details can be directed to my attention.SignatureDatePrint NameTitleE-mailPhoneProcurement Services' Attestation (For Office Use Only)Justification appears appropriate.Justification appears inappropriate. The agent has contactedthe department representative and advised them of thestatus of the order. An explanation is attached.Agent SignatureDateQuestions? Contact Procurement Services at procurement@cornell.edu.Submit this form to your financial transaction or business service center to be attached to the requisition.3 of 3Division of Financial AffairsLast updated: 2013-03-20 09:07:40