"Local Assistance Mwbe Waiver Request Form" - New York

Local Assistance Mwbe Waiver Request Form is a legal document that was released by the New York State Division of Homeland Security & Emergency Services - a government authority operating within New York.

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Download "Local Assistance Mwbe Waiver Request Form" - New York

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New York State Division of Homeland Security and Emergency Services
LOCAL ASSISTANCE MWBE WAIVER REQUEST FORM
IMPORTANT: Separate attachments must be included with this form, detailing the basis for a partial or total waiver request. By submitting this document, the grantee
(contractor) certifies that the grantee has made a good faith effort to promote MWBE participation pursuant to the MWBE requirements set forth in the grant contract.
2. NYS SFS Number :
1. Grantee (Contractor) Name:
3. Federal Identification Number:
1a. Preparer Name/Title:
4. Contract Number:
5. Contract Amount:
1b. Street Address:
6. Approved MWBE Goals:
1c. City, State, Zip Code:
MBE
%
Amount $
WBE
%
Amount $
7.
Type of MWBE Waiver Requested:
Full
Partial
a.
MBE Waiver
If partial waiver, please enter the requested revised MBE percentage and amount
% / $
b.
WBE Waiver
If partial waiver, please enter the requested revised WBE percentage and amount
% / $
8. Signature:
Date:
Email Address:
Telephone Number:
By signing and submitting this form, the grantee (contractor) certifies that a good faith effort has been made to promote MWBE participation pursuant to the MWBE
requirements set forth under the contract. Failure to submit complete and accurate information may result in a finding of noncompliance, non-responsibility, and a
suspension or termination of the contract.
FOR DHSES USE ONLY
Submit to:
New York State Division of Homeland Security and /Emergency Services
REVIEWED BY:
Grant Program Administration (GPA)
DATE:
1220 Washington Avenue
Waiver Granted: YES:__ MBE:__ WBE:__
th
Building 7A,6
Floor
Waiver Denied:__
Albany, NY 12242
__ Total Waiver
__ Partial Waiver
__ Conditional (Specific conditions in Comments Section)
__ Notice of Deficiency (NOD) Issued NOD Date __________
Reviewer Comments:
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New York State Division of Homeland Security and Emergency Services
LOCAL ASSISTANCE MWBE WAIVER REQUEST FORM
IMPORTANT: Separate attachments must be included with this form, detailing the basis for a partial or total waiver request. By submitting this document, the grantee
(contractor) certifies that the grantee has made a good faith effort to promote MWBE participation pursuant to the MWBE requirements set forth in the grant contract.
2. NYS SFS Number :
1. Grantee (Contractor) Name:
3. Federal Identification Number:
1a. Preparer Name/Title:
4. Contract Number:
5. Contract Amount:
1b. Street Address:
6. Approved MWBE Goals:
1c. City, State, Zip Code:
MBE
%
Amount $
WBE
%
Amount $
7.
Type of MWBE Waiver Requested:
Full
Partial
a.
MBE Waiver
If partial waiver, please enter the requested revised MBE percentage and amount
% / $
b.
WBE Waiver
If partial waiver, please enter the requested revised WBE percentage and amount
% / $
8. Signature:
Date:
Email Address:
Telephone Number:
By signing and submitting this form, the grantee (contractor) certifies that a good faith effort has been made to promote MWBE participation pursuant to the MWBE
requirements set forth under the contract. Failure to submit complete and accurate information may result in a finding of noncompliance, non-responsibility, and a
suspension or termination of the contract.
FOR DHSES USE ONLY
Submit to:
New York State Division of Homeland Security and /Emergency Services
REVIEWED BY:
Grant Program Administration (GPA)
DATE:
1220 Washington Avenue
Waiver Granted: YES:__ MBE:__ WBE:__
th
Building 7A,6
Floor
Waiver Denied:__
Albany, NY 12242
__ Total Waiver
__ Partial Waiver
__ Conditional (Specific conditions in Comments Section)
__ Notice of Deficiency (NOD) Issued NOD Date __________
Reviewer Comments:
Page 1 of 2
New York State Division of Homeland Security and Emergency Services
LOCAL ASSISTANCE MWBE WAIVER REQUEST FORM
Instructions for Completion of Form and Supporting Documentation Requirements
IMPORTANT: Separate attachments must be included with this form, detailing the basis for a partial or total waiver request. By submitting this document, the grantee (contractor)
certifies that a “Good Faith Effort” has occurred to promote MWBE participation pursuant to the MWBE requirements set forth in the grant contract.
1. Name and Address
Provide the grantee (contractor) name and address, and include the name and title of the form preparer.
2. NYS SFS Number
Provide the grantee NYS SFS Number (an eleven digit number assigned via the NYS Financial System).
3. Federal Identification Number
Provide your Federal Identification Number.
4. Contract Number
Input the applicable DHSES contract number in relation to this MWBE Request for Waiver Form.
5. Contract Amount
Enter the Amount of your Contract (Grant Award)
Enter the total MWBE percentage and dollar amount currently approved by the NYS Division of Homeland Security and Emergency
6. Approved MWBE Goals
Services (DHSES).
Specify the type of MWBE Waiver requested, indicating if the request is for a partial or total waiver. Include the individual percentage
7. Waiver Request
and dollar goals for MBE or WBE. Select a. if only a MBE goal revision is requested, b. if only a WBE goal revision is requested, and
a. and b. if both MBE and WBE goal revisions are requested.
8. Preparer Information
Preparer must sign and date the MWBE Request for Waiver Form. Include the preparer’s telephone number and e-mail address.
ALL MWBE WAIVER REQUESTS FORMS MUST INCLUDE SUPPORTING DOCUMENTATION ATTACHMENTS. MWBE WAIVER REQUESTS WILL NOT BE CONSIDERED
WITHOUT THE FOLLOWING:
1.
A statement setting forth your reason(s) for requesting a partial or total waiver.
2.
A copy of the RFP used to solicit subcontractors
3.
A list of the general circulation, trade association, and MWBE-oriented publications in which you solicited certified MWBEs for the purposes of complying with
your participation goals.
4.
A list identifying the date(s) that all solicitations for certified MWBE participation were published in any of the above publications.
5.
A list of all certified MWBEs appearing in the NYS Directory of Certified Firms that were solicited for purposes of complying with your certified MWBE participation
levels.
6.
Copies of notices, dates of contact, letters, and other correspondence as proof that the solicitations were made in writing and copies of such solicitations;
could
be the same as #2.
7.
Provide copies of responses made by certified MWBEs to your solicitations when possible, describe specific reasons that responding certified MWBEs were not
selected.
8.
Provide a description of any contract documents, plans, or specifications made available to certified MWBEs by the grantee (contractor) for purposes of soliciting
their participation and steps taken to structure the scope of work for the purpose of subcontracting with or obtaining supplies from MWBEs.
9.
Provide documentation of any negotiations between you, the grantee (contractor), and the MWBEs undertaken for purposes of complying with the certified MWBE
participation goals.
10. Provide any other information you deem relevant which may help us in evaluating your request for a waiver.
11. Provide the name, title, address, telephone number, and email address of the grantee’s (contractor’s) representative authorized to discuss and negotiate this
waiver request.
Note: Unless a Total Waiver has been granted, the grantee (contractor) will be required to submit all reports and documents pursuant to the provisions
set forth in the contract, as deemed appropriate by the DHSES, to determine MWBE compliance.
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