"Sole Source Certification Request Form" - Mississippi

Sole Source Certification Request Form is a legal document that was released by the Mississippi Department of Information Technology Services - a government authority operating within Mississippi.

Form Details:

  • The latest edition currently provided by the Mississippi Department of Information Technology Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Information Technology Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Sole Source Certification Request Form" - Mississippi

1422 times
Rate (4.4 / 5) 85 votes
3771 Eastwood Drive
Jackson, Mississippi 39211
Phone 601-432-8000 Fax 601-713-6380
Sole Source Certification Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Public University:
Contact Person:
Address:
Phone:
Fax:
Email Address:
MAGIC Customer Number (only required from state agencies):
Division/Dept:
Handmail:
Yes
No
Project Summary
Narrative Description of Project (include details of original acquisition if applicable):
ITS Acquisition Approval (CP-1) should be effective through this date (Please allow time for all vendor invoices to be paid):
Time Constraints
Anticipated Lifecycle of
Cost Estimates
Item Needed by:
Products/System (i.e. estimated
Fiscal Year
Initial Costs
Ongoing Costs
Funds Expire:
years of effective use):
Discuss Funding (e.g. how much of needed funding is definite; total project
budget; any matching or other non state funds)
Total
Acquisition Details
Items Requested
Quantity
Description
Building Location(s)
Describe platform & infrastructure (connectivity; software/hardware platforms; utilization of State Data Center resources: mainframe, eGovernment
portal, payment engine, document management, hosting). For equipment or hosting outside the State Data Center, attach justification:
Progress to Date: What has been done related to this project, including any communication with ITS staff (data/voice/procurement/other)?
Sole Source Certification
Note: Certification must be renewed for each revision or continuation of previous Sole Source Approvals.
Specific business requirements to be met by the requested products or services:
Explain why these products or services are the only ones that can meet your needs (include unique features/special functionality):
Explain why the source is the only entity that can provide the products or services (Include other products/vendors researched or evaluated):
Explain why the amount to be expended for the services is reasonable:
Explain what your agency did to obtain the best possible price for the services:
Vendor’s Certification of Sole Source attached:
Yes
No
Vendor’s proposal attached:
Yes
No
MAGIC Vendor Code(s) Vendor must be in MAGIC before a CP-1 can be issued.
Place Order To
Remit To
Vendor Name:
Vendor Name:
Vendor Address:
Vendor Address:
By my signature, I certify that, to the best of my professional knowledge: the requested product or services are a sole source as outlined in the ITS
Procurement Handbook, Rule 207.2:013-030 Procurement Types: Sole Source, and as outlined in Mississippi Code annotated Section 31-7-13. In
addition, I acknowledge that there is a charge for ITS procurement services associated with this request which will be billed to the requestor by ITS and
that my agency/public university is responsible for these charges/costs.
_______________________________________
___________________________________
Name (Agency Head or Public University CIO)/Title
Signature
Date
3771 Eastwood Drive
Jackson, Mississippi 39211
Phone 601-432-8000 Fax 601-713-6380
Sole Source Certification Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Public University:
Contact Person:
Address:
Phone:
Fax:
Email Address:
MAGIC Customer Number (only required from state agencies):
Division/Dept:
Handmail:
Yes
No
Project Summary
Narrative Description of Project (include details of original acquisition if applicable):
ITS Acquisition Approval (CP-1) should be effective through this date (Please allow time for all vendor invoices to be paid):
Time Constraints
Anticipated Lifecycle of
Cost Estimates
Item Needed by:
Products/System (i.e. estimated
Fiscal Year
Initial Costs
Ongoing Costs
Funds Expire:
years of effective use):
Discuss Funding (e.g. how much of needed funding is definite; total project
budget; any matching or other non state funds)
Total
Acquisition Details
Items Requested
Quantity
Description
Building Location(s)
Describe platform & infrastructure (connectivity; software/hardware platforms; utilization of State Data Center resources: mainframe, eGovernment
portal, payment engine, document management, hosting). For equipment or hosting outside the State Data Center, attach justification:
Progress to Date: What has been done related to this project, including any communication with ITS staff (data/voice/procurement/other)?
Sole Source Certification
Note: Certification must be renewed for each revision or continuation of previous Sole Source Approvals.
Specific business requirements to be met by the requested products or services:
Explain why these products or services are the only ones that can meet your needs (include unique features/special functionality):
Explain why the source is the only entity that can provide the products or services (Include other products/vendors researched or evaluated):
Explain why the amount to be expended for the services is reasonable:
Explain what your agency did to obtain the best possible price for the services:
Vendor’s Certification of Sole Source attached:
Yes
No
Vendor’s proposal attached:
Yes
No
MAGIC Vendor Code(s) Vendor must be in MAGIC before a CP-1 can be issued.
Place Order To
Remit To
Vendor Name:
Vendor Name:
Vendor Address:
Vendor Address:
By my signature, I certify that, to the best of my professional knowledge: the requested product or services are a sole source as outlined in the ITS
Procurement Handbook, Rule 207.2:013-030 Procurement Types: Sole Source, and as outlined in Mississippi Code annotated Section 31-7-13. In
addition, I acknowledge that there is a charge for ITS procurement services associated with this request which will be billed to the requestor by ITS and
that my agency/public university is responsible for these charges/costs.
_______________________________________
___________________________________
Name (Agency Head or Public University CIO)/Title
Signature
Date