Single/Sole Source Justification Form

Single/Sole SourceJustification FormComplete this form for general equipment and service requisitions with a value greater than $10,000 (for all funds) wherecompetition may be restricted. Completing this form does not guarantee that the proposed vendor will be selected. ProcurementServices may require additional information. It is the requisitioner’s responsibility to provide all the required information anddocumentation indicated on this form.Definitions:Sole Source - The ONLY known supplier for unique products & services with no other options availableSingle Source - Circumstances dictate use of this vendor despite other potential options. (i.e., availability, timeliness, location, etc.)This completed form must be attached to the requisition, including any additional back-up.Part IOrdering Department/Supplier InformationOrdering Department Code: ________________Requisition Number: _______________Department Name: _______________________________Vendor Name: ___________________________________Part II A.Explanation for Single/Sole SourceSelect one or more of the following statements (check the box) to support why the requisition noted above should be a single/solesource purchase. ANY selection requires explanation in the additional space provided. Check all that apply.Sourcing Reason:1. Items sold through manufacturer only; no other comparable unit available.2. Used or demonstration equipment available at a lower-than-new cost.3. Must match existing piece of equipment. Available only from the same source of original equipment.4. Upgrade to existing software. Available only from the producer of this software who sells on a direct basis only.5. Repair/Maintenance service requires expertise in operations on unit. Necessary parts unavailable from anysource except original equipment manufacturer or their designated servicing dealer.6. Service(s) provided by the vendor are unique and therefore competitive bids are not applicable.7. Preferred Suppliers available, but do not meet end user requirements as clearly detailed below.8. Competitive bidding is possible but will not yield value for reasons clearly defined below.9. Other reason.Return to: Procurement Services, 395 Pine Tree Road, Suite 330, Ithaca, NY 14850-28202Fax: (607)255-9450 Email: procurement@cornell.edu Revised: 09/17/2011Page 1 of 3

Single/Sole SourceJustification FormExplain Selected Reason(s):Explanation for Part II A is required for ANY selected statement. Information provided might include research performed or subjectmatter expertise detailed to justify the use of this particular vendor and their product. This must clearly indicate why the proposedvendor is the ONLY vendor that will meet your requirements. (Please attach documents if additional space is required)End User Explanation:Procurement Agent Attestation: I agree with the explanation provided for the following reason(s):Part II B:Establishment of the Reasonableness of the PriceSelect one or more of the following statements (check the box) to indicate why you feel the accepted non-competitive price was fairand reasonable. ANY selection requires explanation in the additional space provided. Check all that apply.Fair Price:1. The price was obtained from a catalog or standard price list for items sold to the general public inReason:substantial quantities. (Catalog or price list must be provided or be on file.)2. The quoted prices minus the vendor’s donations and/or discounts are lower than prices available to the generalpublic and reflect substantial savings. Must state dollars or percentage here: ______________ (Explain the dollarcalculation below.)3. The quoted prices compare favorably to market prices, or to previous prices obtained and found to be fair andreasonable, which were paid for the same or similar items on:Date: ______________ PO#: _____________ Bid: _____________4. The vendor has certified that the prices offered are equal to or lower than those offered to any governmentagency or private institution for both like items/services and quantities. (Includes published educational discounts)5. Independent sources indicate that this price is reasonable (i.e., Public Contracts, Group PurchasingOrganization, Blue Book)Return to: Procurement Services, 395 Pine Tree Road, Suite 330, Ithaca, NY 14850-28202Fax: (607)255-9450 Email: procurement@cornell.edu Revised: 09/17/2011Page 2 of 3

Single/Sole SourceJustification Form6. Other reason.Explain Selected Reason:Explanation for Part II B is required for ANY selected statement. Information provided might include a catalog price page, pricing forsimilar products or other price comparison information gathered to justify price reasonableness.Please attach any additional justification information that would support the above explanations.Part III CertificationI certify that to the best of my knowledge I have investigated and found that the above reasons and explanations justify thisrequisition as a single/sole source purchase and that price reasonableness is adequately confirmed. I am the individual who hasgathered and provided this detailed information and any further questions regarding these details can be directed to my attention.Signature _______________________________________Print Name ______________________________________E-mail address ___________________________________Date _______________________________Title _______________________________Phone # ____________________________Part IV Procurement Services’ Attestation (for Procurement Use Only)Justification appears appropriate.Justification appears inappropriate. Agent has contacted the departmentrepresentative and advised the status of the order. Explanation is attached.Agent Signature: ________________________________Date: ______________________Return to: Procurement Services, 395 Pine Tree Road, Suite 330, Ithaca, NY 14850-28202Fax: (607)255-9450 Email: procurement@cornell.edu Revised: 09/17/2011Page 3 of 3