HomeMy WebLinkAbout(0033) 21-0135 Approved MWBE Waiver WN (3).pdfFORT WORTH., CITY OF FORT WORTH
Purchasing Division
REQUEST FOR BUSINESS EQUITY CONTRACTING/SUPPLIER
AGREEMENT GOAL
When a Buyer submits this Request for Goal Form to the Business Equity Division for the requesting department, it is the Buyer's responsibility to provide
the Business Equity Division Staff with copies of all documentation and meeting notices relevant to this procurement.
Check type of Project: a ITB RFP F RFQ Sole Source Other
Bid/ProjectNumber: 21-0135 Bid/ProjectName: DUMP BED TRUCK BODIES
Agreement Estimated $ 315, 000.00 Advertisement Date: 5/19/2021 2nd Advertisement Date: 5/26/2021
Requesting Department Fleet Ext:2008 Buyer Name LaKita Slack Ext:8314 Date:5/12/2021
(Please ATTACH a line item cost breakdown of the requested Scope of Work)
If this is not the initial change order/amendment, submit copies of all previous change orders/amendments regardless of whether a M&C was required for funding.
Email to: DVIN BEDfce(a,,fortworthtexas.gov
FEDERALLY FUNDED? Yes �✓ No IF yes, explain funding source
Is this a Revision? ❑ Yes �✓ No IF yes, enter revision number? Amendment? ❑ Change Order? ❑ CO/A#
PORTION BELOW TO BE COMPLETED BY BUSINESS EQUITY DIVISION:
Project Goal Type: M/WBE GOAL DBE GOAL
Signature of DVIN-BE Authorized Personnel
NOTE: If a goal is set the Business Equity Division will participate in all meetings related to this procurement.
WAIVER OF COMMODITY OR SERVICES
Business Equity requirements may be waived upon written approval of the Department of Diversity and Inclusion -Business Equity Division
(DVIN-BE) Assistant Director. If one of the conditions listed below exists, the DVIN-BE Staff shall notify the DVIN-BE Assistant Director
via this form, stating the specific reason(s) for requesting approval.
Check appropriate reason below:
DVIN-BE: A waiver of the goal for Business Equity subcontracting requirements is approved by the DVIN-BE, in accordance with the Business
Equity Ordinance, because the public or administrative emergency exists which requires the goods or services to be provided with unusual immediacy;
or
WDVIN-BE: A waiver of the goal for Business Equity subcontracting requirement is approved by the DVIN-BE, in accordance with the Business
Equity Ordinance, because the purchase of goods or services is from sources where subcontracting or supplier opportunities are negligible; or
DVIN-BE: A waiver of the goal for Business Equity subcontracting requirements is approved by the DVIN-BE, in accordance with the Business
Equity Ordinance, because the application of the provisions of this ordinance will impose an economic risk on the City or unduly delay
acquisition of the goods or services; or
DVIN-BE: A waiver of the goal for Business Equity subcontracting requirements is approved by the DVIN-BE, in accordance with the Business
Equity Ordinance, because the Business Equity Waiver is based on the sole source information provided by the Purchasing Division Buyer.
E_'
her:
Compliance Specialist Justification for Waiver:
Compliance officer could not find any suitable vendors in the database for these services.
�✓ Waiver Approved Walter K. Newman Digitally signed by Walter K. Newman 05/20/2021 2675
Date: 2021.05.20 19:30:47-05'00'
Signature of Business Equity Authorized Personnel Date Ext.
Business Equity Division Revised: 01/01/2021
Email DVIN BEOffice(&fortworthtexas.Qov
Phone: (817) 392-2674