Commonwealth of Pennsylvania

The objective of this form is to capture all relevant documentation an Agency may have to assist the Department of General Services/Office of Administration ("DGS/OA"), Bureau of Procurement/Office of Information Technology ("BOP/OIT"), in expediting the source justification review process. This form must be completed electronically, signed, and submitted with all relevant documentation to DGS/OA. If a question is neither mandatory nor applicable, please indicate "N/A". Please use standard terminology and define acronyms.

IT sole sources must first be reviewed and approved through the DCIO/CoP process.

* = Required.

  1. Agency Name:*  
  2. Procurement Description:*
This description will appear on the eMarketplace website for public viewing.
Shopping Cart #*
Estimated Cost: ($XXX.XX)*
Initial Contract Term: *
Renewals: *
SPR #*
Shopping Cart #*
SPR #*
  3. Supplier - Name:*  
Full Address:*  
Contact Name:*  
Telephone: *  
Format : ###-###-####
Format : ###-###-####
Confirm E-mail:*  
SRM Supplier #:*  
  4. Delivery or service location:*  

Check the appropriate reasons for this source justification:
Only known source - Not available from another supplier.
Material or service MUST be compatible with existing equipment. Documentation must be provided from the manufacturer.
Value set by 2 independent 3rd party appraisals.
Describe in detail in Section C.
A federal or state statute or regulation exempts the procurement from the competitive procedure. Any applicable information precluding the procurement from competitive procedures must be attached.
Clearly not feasible to award the contract on a competitive basis.

1. Describe the unique features of this procurement that prohibit a competitive environment. If applicable, attach a Statement of Work ("SOW"). *  
2. Document and attach the research that has been conducted to date to verify the supplier is the only known source. *  
3. Does the supplier utilize distributors, dealers, resellers, etc.? If "Yes," please identify. *  
4. Are there compatibility requirements or compliance requirements with a warranty or service agreement? If "Yes," please explain. *  
5. How has the material or service been procured in the past? Please provide previous source justifications, contracts, & PO's for this material or service. *  
6. If procured through the IT ITQ process, please provide original $ amount and contract period of order. Is this the final phase of the project? *  
7. If this is an upgrade, addition, alteration, etc., to an earlier procurement, please describe in detail. *  
8. What are the consequences of not approving this procurement? *  
9. If timing is a factor, what is the time factor and why? *  
10. List any other information relevant to the acquisition of this procurement here or as an attachment. *  
11. For requests > $100,000, has the supplier signed cost or pricing data certification and is the pricing breakdown attached? *  

IMPORTANT*: The printed names on this form shall constitute the signatures of these individuals. Agencies must insure that these individuals review the completed form and give their consent to apply their printed name on this form. No handwritten signatures shall be required in order for the form to be considered "signed" by those individuals whose names appear in the signature section of the form.
Shopping Cart Contact Person (Person whom DGS will contact regarding the Shopping Cart):
Name:*   Title:*   Date:*
E-mail:*   P-Group:*  
Agency Contact Person: Person in your agency that DGS can contact for additional information, etc.
Name:*   Title:*   Date:*
Approval Section: You must click "Add Contact" after each entry.
Name:*   Title:*   Date:*
Contact Type:*   E-mail:*  


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Approval Process:
By clicking this button, the form will be submitted to
DGS/OIT depending upon the category selected.