"Exemption Request Form" - Mississippi

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

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Download "Exemption Request Form" - Mississippi

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3771 Eastwood Drive
Jackson, Mississippi 39211
Phone 601-432-8000 Fax 601-713-6380
Exemption Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Institution:
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
ITS Acquisition Approval (CP-1) should be effective through this date:
(Please allow time for all vendor invoices to be paid)
Cost Estimates
Time Constraints
Fiscal Year
Initial Costs
Ongoing Costs
Item Needed by:
Funds Expire:
Total
Discuss Funding (e.g. how much of needed funding is definite; total project budget; any matching or other non state funds; fund number)
Anticipated Lifecycle of Products/System (i.e. estimate years effective use)
Acquisition Details
Items Requested:
Name
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)?
Vendors Contacted: (Note: attach written estimates or other information received from vendors)
Critical Factor(s): (in the selection of a vendor/brand/solution for this acquisition)
Planned Acquisition Method
Describe the manner in which this procurement will be conducted in fulfillment of state law
By my signature, I acknowledge: (1) this agency/institution will follow all applicable laws for public purchasing in the acquisition, including developing open specifications,
advertising according to public law, ensuring a thorough and equitable evaluation of all responses, and responding in a timely manner to all public records and post
procurement review requests; (2) this agency/institution will negotiate any and all applicable contracts and contract amendments arising from this procurement, with
signature authority for the State being delegated by the ITS Executive Director to the executive of this agency/institution; and (3) any protests resulting from this
procurement will be heard by the ITS Executive Director and/or ITS Board, in accordance with the ITS Protest Procedure and Policy. Authority of ITS Executive Director
to negotiate limitation of liability per MS Code Section 25-53-21(e) cannot be delegated and does NOT apply to this exemption. 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
Exemption Request
Project Title:
Stimulus (ARRA) Funds? Yes__ No __
Customer Contact Information
Agency/Institution:
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
ITS Acquisition Approval (CP-1) should be effective through this date:
(Please allow time for all vendor invoices to be paid)
Cost Estimates
Time Constraints
Fiscal Year
Initial Costs
Ongoing Costs
Item Needed by:
Funds Expire:
Total
Discuss Funding (e.g. how much of needed funding is definite; total project budget; any matching or other non state funds; fund number)
Anticipated Lifecycle of Products/System (i.e. estimate years effective use)
Acquisition Details
Items Requested:
Name
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)?
Vendors Contacted: (Note: attach written estimates or other information received from vendors)
Critical Factor(s): (in the selection of a vendor/brand/solution for this acquisition)
Planned Acquisition Method
Describe the manner in which this procurement will be conducted in fulfillment of state law
By my signature, I acknowledge: (1) this agency/institution will follow all applicable laws for public purchasing in the acquisition, including developing open specifications,
advertising according to public law, ensuring a thorough and equitable evaluation of all responses, and responding in a timely manner to all public records and post
procurement review requests; (2) this agency/institution will negotiate any and all applicable contracts and contract amendments arising from this procurement, with
signature authority for the State being delegated by the ITS Executive Director to the executive of this agency/institution; and (3) any protests resulting from this
procurement will be heard by the ITS Executive Director and/or ITS Board, in accordance with the ITS Protest Procedure and Policy. Authority of ITS Executive Director
to negotiate limitation of liability per MS Code Section 25-53-21(e) cannot be delegated and does NOT apply to this exemption. 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