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.
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SECTION A
1. Agency Name:*	Administration Aging Agriculture All Using Agencies Attorney General Auditor General Banking Budget Capitol Preservation Committee Center for Juvenile Justice Civil Service Commission Commonwealth Court Community & Economic Development Conservation & Natural Resources Corrections Council for the Arts Courts Crime and Delinquency Commission Department of Drug and Alcohol Education Emergency Management Agency Environmental Hearing Board Environmental Protection Fish and Boat Commission Game Commission Gaming Control Board General Counsel General Services Governors Office Governors Office for Management & Productivity Health Historical and Museum Commission House of Representatives Human Relations Commission Independent Regulatory Review Committee Inspector General Insurance Judicial Conduct Board Labor & Industry Legislative Agency of General Assembly Legislative Budget & Finance Committee Legislative Service Agency Liquor Control Board Lt Governors Office Military and Veterans Affairs Milk Marketing Board Municipal Retirement System PA Higher Education Assistance Agency PENNVEST Philadelphia Regional Port Authority Probation and Parole Public School Building Authority Public School Employees Retirement System Public TV Network Public Utility Commission Public Welfare Revenue Securities Commission Senate State State Employees Retirement System State Ethics Commission State Police State System of Higher Education State Tax Equalization Board Supreme Court Transportation Treasury Turnpike Commission
2. Procurement Description:* This description will appear on the eMarketplace website for public viewing.
Materials Description:	Shopping Cart #*		Estimated Cost: ($XXX.XX)* $5K - $10K $10,001 - $50K $50,001 - $100K $100,001 - $250K $250,001 - $500K $500,001 - $1M $1,000,001 - $5M $5M + Initial Contract Term: * Renewals: *
Services Description:	SPR #*
IT-Materials Description:	Shopping Cart #*
IT-Services Description:	SPR #*
3. Supplier - Name:*
Full Address:*
Contact Name:*
Telephone: *	Format : ###-###-####	FAX:	Format : ###-###-####
E-mail:*
Confirm E-mail:*
SRM Supplier #:*
4. Delivery or service location:*

SECTION B

Check the appropriate reasons for this source justification:

1. Sole Source: Only known source - Not available from another supplier.

2. Single Source (Material/Repair/Maintenance): Material or service MUST be compatible with existing equipment. Documentation must be provided from the manufacturer.

3. Single Source (Used Equipment): Value set by 2 independant 3rd party appraisals.

4. Single Source (Professional Expert): Describe in detail in Section C.

5. Exempt (Law): 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.

6. Feasibility: Clearly not feasible to award the contract on a competitive basis.

SECTION C
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? *

SECTION D
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:* (mm/dd/yyyy)
E-mail:*		P-Group:*
Agency Contact Person: Person in your agency that DGS can contact for additional information, etc.
Name:*		Title:*		Date:* (mm/dd/yyyy)
E-mail:*
Approval Section: You must click "Add Contact" after each entry.
Name:*		Title:*		Date:* (mm/dd/yyyy)
Contact Type:*	Approving Authority Additional Approval	E-mail:*

Attachment:

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Approval Process:

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