Northampton County Schools P.O.Box 158, Jackson, NC 27845
Phone: (252) 534-1371 Fax: (252) 534-1371
SOLE SOURCE JUSTIFICATION FORM

Must be completed for all non-competitive purchases* costing $5,000.00 or more

VENDOR:	 		DATE:	 	
 		SCHOOL/DEPARTMENT:	 	
REQUESTER:	 	
 		P. O. NUMBER:

Describe the item(s) and its function:  	

SECTION I: Check the appropriate box below and provide documentation (or complete Section II, as required)

Proprietary:	Item	under	patent,	license,	copyright,	or	proprietary	design.	(attach documentation)

Replacement Parts:	The procurement is for replacement parts or components in support of equipment designed by the manufacturer; items that are compatible with existing equipment, inventory, systems, programs or services and not available from any other source.

Warranty Services:	Sole provider of factory-authorized warranty service. Use of alternate service provider will void existing warranty. (attach documentation)

Used Equipment:	The vendor is a holder of a used item that would represent good value and is advantageous to Northampton County Schools (attach information showing market price survey, availability, etc.)

Emergency Requirement:	Requirements must be met at once. An explanation of urgency, including a description of why procurement is critical and why only the proposed vendor can meet it. A lack of advance planning is not acceptable (Complete Section II.)

Exclusive Capability:	Only one supplier qualified. No other potential suppliers known. (Complete Section II.)

SECTION II: Narrative Justification:
This section must be completed if either explanation of Emergency Requirement or Exclusive Capability is identified as justification for sole source procurement. Explain why the identified vendor is recommended. The justification must be completely explained and documented. It is important to be very precise when completing this section.

SECTION III: What steps were taken to verify that the item(s) are not available elsewhere?

Other brands/manufacturers were examined (attach documentation and explain why these were not suitable)

Other vendors were contacted (attach contact information and explain why these were not suitable)

Other (please explain)

AUTHORIZATION AND APPROVALS:

Department’s recommendation for sole source is based upon an objective review of the good/service being required and appears to be in the best interest of Northampton County Schools. I am not aware of any conflict of interest on my part or personal involvement in any way with this request. No gratuities, favors, or compromising actions have taken place. Nor has my personal familiarity with particular brands, types of equipment, materials or firms been a deciding influence on my request for this sole source purchase. Efforts have been made to verify no other supplier(s) exist.

Signature of Requestor	Date

Signature of Department Head or Designee	Date

Approval by Purchasing/Finance	Date

”purchases” refers to an individual item or a group of items having an aggregate value of $2,500 or more.