Approval Request for Emergency and Sole Source Purchase

Contracting Entities (CEs) should use this form under the following circumstances:

Emergency Procurement

A public emergency or unexpected emergency situation forces a need for immediate purchases that cannot be delayed by the time required for a full competitive solicitation for products and/or services.

Sole Source Procurement

The required product and/or service is available only from a single (sole) source distributor, supplier, or manufacturer, and this specific product and/or service is the only suitable solution to fill this need (preference for a particular brand or vendor when a suitable alternative exists should not be the basis for a sole source request).

DIRECTIONS: The following information is required. TDA will evaluate the request and provide approval or denial via e-mail within 3 business days of submittal of a complete form. TDA cannot process incomplete requests and may reach out concerning missing information and if there are any questions.

Note that CEs are required to maintain documentation that supports statements made in this submission. If approved, CEs must also maintain documentation related to the emergency or sole source procurement.

1. Select affected Program *

NSLP/SBP CACFP SFSP SSO TEFAP CSFP

1A. Select the affected CACFP sub-Program

Adult Day Care At-Risk Child Care Center Day Care Home

2. Is this request required due to disruption in operations caused by COVID-19? *

Yes No

3. Is this an emergency procurement request or sole source request (refer to the definitions above)? *

Emergency Procurement Sole Source

3A-1. Please provide a detailed description of the circumstances that justify an emergency procurement.

3A-2. Please provide a detailed narrative explaining the circumstances that justify a sole source procurement.

4. Upload a contract, invoice, quote, purchase order or other documentation that clearly identifies the supplier, manufacturer, or distributor and that identifies the quantity and cost of the purchase. *

5. Upload supporting documentation that shows the cost is reasonable. *

6. Upload a detailed narrative that describes the circumstances that require the emergency or sole source procurement, and any other supporting documents for this request, which may include elements of timing, information on the item/service being procured, and information provided by the supplier, manufacturer, or distributor.

6A. Please provide written documented evidence that research was conducted to ensure that there is only one source for the product and/or service. Research activities may include questioning other vendors of similar products/services or Internet research to determine if those vendors can meet the precise needs of the CE. If not, written justification should be provided to F&N as to why a particular vendor would not qualify as source.

7. Upload any documents, if applicable, that support your research activities, including copies of the solicitation, advertising, and other relevant documentation.

8. Enter the specific period of time that the CE plans to use this procurement method. Timeframe entered cannot exceed one year.

8A-1. Anticipated Contract Start Date *

Start Date should not be more than 30 days before Today's Date.

8A-2. Anticipated Contract End Date *

End Date should not be more than one year from Start Date.

Contract Start Date may not be more than 30 days before Today's Date.

Please select another date.

Contract End Date may not be more than one year from the Contract Start Date.

Please select another date.

Time frame entered cannot exceed one year.

Note that while TDA may approve the request, it may stipulate a shorter timeframe than requested. TDA will only approve a reasonable, limited timeframe that will allow the CE to establish a competitive process for future procurements of these products/services.

8B. Is this procurement a less-than-arms-length transaction, in which one of the parties involved may be able to control or substantially influence the actions of the other (for example, procurement from a business owned by a family member)?

Yes No

Attestation Statement

Today's Date *

MM-DD-YYYY

Note: Only CE staff may submit this form. A food service managment company (FSMC) staff member cannot submit this form on behalf of the CE or attest to its accuracy.

Contracting Entity (CE) Name *

CE Name exactly as it appears in TX-UNPS

CE Identification Number (CE ID) *

5-digit number assigned by TDA in TX-UNPS

Check each of the following statements as true: *

I am an Authorized Representative (AR) of the Contracting Entity (CE) listed on the "FND-101, CERTIFICATE of AUTHORITY for EXTERNAL USERS" or "FND-135, USER ACCESS MANAGER FORM" that has been approved by TDA prior to submission of this request. I certify that the CE has retained documentation related to the information submitted in this request. I am not a Food Service Management Company employee

Name of person attesting to the information on this form: *

First Name Last Name

Position/Title

Each party acknowledges and agrees that this information in this form is attested by the name entered in the above field and shall be considered as an original signature for all purposed and shall have the same force and effect as an original signature.

Name of the CE Contact for Emergency Procurement *

First Name Last Name

Position/Title

Email address for the CE Contact for Emergency Procurement *

Confirmation Email example@example.com

Phone number for the CE Contact for Emergency Procurement *

Please enter a valid phone number.

TDA may contact you with addition questions.

By submitting this appliation, the Contracting Entity is confirming that this form is true and correct.

FOR TDA INTERNAL USE ONLY

Date form was reviewed

Date

Reviewer Name

TDA form reviewer

Approval Status

Approved Denied

Decision date

Date

Number of Days Contract Start Date Precedes "Today's Date" (submission date)

Duration of contract (calendar days)

TDA Seal, Commissioner Sid Miller Footer

Non-competitive Procurement (Emergency or Sole Source) Request Form