RQS20221028000000000602 DEPARTMENT OF ADMINISTRATIVE AND FINANCIAL SERVICES 4 DIVISION OF eae S501 AA (0 SE RWW Wu} 01g EAD PROCUREMENT JUSTIFICATION FORM (PJF) This form must accompany ail contract requests and sole source requisitions (RQS) over $5.000 submitted to the Division of Procurement Services. INSTRUCTIONS: Please provide the requested information in the white spaces below. All responses (except Signatures) must be typed; no hand-written forms will be accepted. See the guidance document posted with this form on the Division of Procurement Services intranet site (Forms page) for additional instructions. PART I: OVERVIEW Department Office/Division/Program: | MDOT M & O Region 4 Department Contract Administrator or Grant Coordinator: (If applicable) Department Reference #: $ $54,71 Jeff Lary Amount: (Contract/Amendment/Grant) CONTRACT Proposed Start Date: Advantage CT / RQS # Proposed End Date: Effective Date: New End Date: Grant Start Date: Grant End Date: Original Start
Date: Previous End Date: Project Start Date: Project End Date: AMENDMENT C A Newcomb & Sons VC1000011794 P O Box 206 Vendor/Provider/Grantee Name, City, State: Carmel, Me 04419 Brief Description of Goods/Services/Grant: Guardrail Parts PART I: JUSTIFICATION FOR VENDOR SELECTION Check the box below for the justification(s) that applies to this request. (Check all that apply.) A. Competitive Process G. Grant B. Amendment H. State Statute/Agency Directed C. Single Source/Unique Vendor |. Federal Agency Directed D. Proprietary/Copyright/Patents J. Willing and Qualified E. Emergency K. Client Choice F. University Cooperative Project L. Other Authorization REV 11/18/2021 Page 1 of 2 NOI 1120221106 11/03/2022 - 11/09/2022 William J.E. Allen 11/2/2022 DocuSigned by: William ). Mew 2D5B6E39F57E44 MAINE JOBS & RECOVERY PLAN (MJRP) Does this request utilize ARPA/MJRP funds? Yes If Yes, please attach the approved Business Case(s). No If No, proceed to Part V. PART V: APPROVALS The signatures below indicate approval of this procurement request. Signature of requesting Departments Commissioner /, _ (or designee): Typed Name: | (4) Wane lver, C.08-_. Date: | /O-27-2ez7_ Signature of DAFS Procurement Offici Typed Name: Date: REV 11/48/2021 Page 2 of 2