Single Source Justification
Date:
/ Revision: 0
To:
Michael Berezowski, COO
Regarding:
Stream RFQ Number ________________________________________________
Stream RFQ Name /
Initiator:
Name __________________________________
Telephone Number _____________________________
Procurement: Stream RFQ Contact Name _________________________
Stream Contact Telephone Number _____________
Stream Contact e-mail Address _________________________
Business Unit Manager:
Name __________________________________
Telephone Number ______________________________
e-mail Address _____________________________
1. Describe supplies or services required to meet the minimum need:
2. Stream RFQ attached?
YES
NO
3. Is this purchase restricted to a single source?
YES
NO
4. If yes, identify the source by the name and address (include telephone and point of contact if
known.)
Company Name _________________________________________
Address _________________
Contact Name ___________________________________________
Contact Telephone Number ________________________________________
Contact e-mail Address ______________________________
5. Why are these items/services restricted to the proposed contractor/supplier?
6. In general, what is there about the equipment/supplies/services which require that it be
procured only from a single source?
7. Why is the manufacturer or source cited uniquely qualified to provide the required items or
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Single Source Justification
Date:
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services?
8. Describe any effort to identify other sources to furnish the required items or services. If no
efforts were undertaken, state the reasons for not doing so.
9. If other sources were contacted, state by whom and briefly, results.
Company Name ________________________________________________________
Address __________________________________________________________________
Contact Name ______________________________________________________________
Contact Telephone Number ____________________________________________________
Contact e-mail Address _______________________________________________________
Stream RFQ Contact Name ___________________________________________________
Results:
Company Name ____________________________________________________________
Address __________________________________________________________________
Contact Name ______________________________________________________________
Contact Telephone Number ____________________________________________________
Contact e-mail Address _______________________________________________________
Stream RFQ Contact Name ___________________________________________________
Results:
10. Are the specifications for the item or equipment proprietary to the single source? If so, how
was this determined?
11. When are the supplies/services actually required?
12. What will be the impact if the supplies are not received or the services not furnished by the
stated date, if any?
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Single Source Justification
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13. What costs will be incurred for the project if the required equipment or supplies is not
provided or furnished on an urgent basis or delayed pending development of adequate
specifications or work statements? (e.g. Delay in commencing or continuing project,
estimated cost of delay, if possible, or impacts on other programs on which this project
depends.)
14. Can generic specifications which set forth the minimum requirements for the needed
equipment or the services be developed?
15. Is this requirement a result of an unsolicited proposal to furnish the supplies or provide the
service by the intended contractor/supplier?
YES
NO
16. What advance planning was undertaken to identify the need for the stated services or
supplies?
17. If none, state why the absence of such planning has not resulted in the restriction of the
purchase to the single source identified above.
18. What steps are being taken to insure that future acquisitions of these services or supplies are
made competitively? If the requirement is a one-time purchase only with no future buys
anticipated, the Preparer must so state.)
Certifications
The undersigned states that he/she has prepared the above documentation and that the facts and data
set forth are complete and accurate to the best of the undersigneds knowledge and belief.
Name _________________________________________________________________
Signature _______________________________________
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Date _____
Single Source Justification
Date:
/ Revision: 0
The undersigned states that he/she reviewed the above justification and based on the facts and data set
forth determines that the information is sufficient and adequate to justify procurement from a single
source or on a non-competitive basis.
Name __________________________________________________________________________
Signature _______________________________________
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Date ____________________
