Fillable Ocfs-4631 - Local Assistance Mwbe Waiver Request Form (Page 2 of 2) in pdf

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:

A statement setting forth your reason(s) for requesting a partial or total waiver.

A copy of the RFP used to solicit subcontractors

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.

A list identifying the date(s) that all solicitations for certified MWBE participation were published in any of the above publications.

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.

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.

Provide copies of responses made by certified MWBEs to your solicitations when possible, describe specific reasons that responding certified MWBEs were not

selected.

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.

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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