Form Wia-1011a - Wioa Pre-Approval Questionnaire
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
WIA-1011AFORFF (11-17)
Workforce Development Administration (WDA)
Workforce Innovation and Opportunity Act (WIOA) Title I-B
WIOA PRE-APPROVAL QUESTIONNAIRE
for Equipment and Vehicles Over $5,000
Complete this form for equipment or vehicles purchased in part or in full with WIOA grant funds when the single unit
cost exceeds $5,000 or total purchase cost exceeds $10,000.
EQUIPMENT OR VEHICLE DESCRIPTION (Make, model, model year, etc.)
PROPOSED PURCHASE PRICE
PROVIDER/AGENCY NAME
AGENCY ADDRESS (No., Street, City, State, ZIP Code)
REQUESTOR’S NAME
TITLE
PHONE NUMBER (Include area code)
1. The following price per outcome or unit benchmarks were considered (List at least two price benchmarks. Attach documentation
if available):
2. The price benchmarks were compared to:
Other potential providers (List number of other providers):
The provider’s past price (List year[s] considered):
Other (Describe methodology):
3. Based on this comparison:
Price(s) are reasonable and justified because they are at or below going rates.
Price(s) are otherwise justified because (explain):
4. Was a competitive price analysis performed in accordance with 2 CFR 200.323 dated 12/26/14?
Yes (Attach a copy of documentation)
No (Explain):
5. Were Arizona state procurement guidelines followed in compliance with state policy?
Yes (Attach documentation)
No (Explain):
6. Use the table to show the breakdown of WIOA funds used for the equipment or vehicle.
FUNDING STREAM
PY
FY
PROG
ADMIN
PROG
ADMIN
AMOUNT
AMOUNT
(20
)
(20
)
YT
AD
DW
TOTALS
7. How will the equipment/vehicles be utilized? (Explain in detail)
8. Who will utilize the equipment/vehicle(s)? Are there designated or primary operators?
9. Will programs other than WIOA utilize the equipment or vehicle(s)?
Yes
No (If yes, explain in detail):
10. How will the equipment be secured after normal business hours? If a vehicle, where is it parked overnight and weekends?
11. Are maintenance and other costs allocated to the appropriate cost allocation?
Yes
No (If no, explain in detail):
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