STATE FINANCIAL MARKETPLACE

COMPLIANCE Certification FORM

 __________________________________   _______________________________

    Department Name                                                          Lead Analyst and Phone Number

__________________________________  ____________________________________

                      Project Title                                         Purchase Order Number and/or Projected Issue Date

 ________________________    _______________   ________________________

 Approximate Contract Dollar Amount              Current Interest Rate*        Approximate Finance or Lease Charges*

I hereby certify the following:

A.    I am the Department Director or designee and have a full understanding that once these assets or this project is financed, there is no termination for convenience of this financing contract;

B.     ¨This is a delegated procurement and is within this department's delegation, delegation #________; or, ¨ the Procurement Division of DGS has conducted this procurement;  

C.     The purchase described herein is either ¨ an information technology purchase
      which was conducted in compliance with the relevant delegations, statutes, policies
      and procedures for information technology (e.g. PCC Section 12100 et seq., SAM
      Section 5200, etc.); ¨ or a commodity purchase conducted in compliance with the
      relevant delegations, statutes, policies and procedures for commodities (e.g. PCC
      Section 10300 et seq, SAM Section 3500, etc.);

D.     Any new or enhanced information technology capabilities are consistent with
      project justification approved by the appropriate control agencies, which would
      include, but is not limited to, the Feasibility Study Report (FSR), a Budget Change
      Proposal (BCP) and any approval letter from an appropriate control agency;

E.      This is a procurement award based on one of the following.  Please identify by name the procurement vehicle, solicitation or NCB number, and attach supporting documentation: 

¨  CMAS Contract                  ¨ Master Agreement (e.g. MRA, MPA, WSCA,   

                                                                          Statewide Commodity Contract)

¨   Non-Competitive Bid (Non-Competitively Bid Contract Justification Form completed and attached)

¨  Competitive Bid                 ¨ CSSI Contract No. ______________________

¨ Other (please specify)   ________________________________

The matters described herein are in compliance with the criteria and procedures identified in Management Memo 03-10 and/or competitive bidding rules.  Supporting documentation, which includes but is not limited to the evaluation and selection document, the procurement summary, the ITPP, the purchase estimate, and any exemption request and approval is attached;

F.     This procurement used the model contract Terms and Conditions for the above referenced procurement vehicle, and the standard GS $Mart or Lease $Mart terms and conditions.  Any variations must be previously approved by DGS.  Supporting documentation, which identifies any changes to the standard language and DGS approval, is attached;

G.     This purchase order and/or agreement has been duly authorized, executed and delivered by the State acting through its duly qualified elected or appointed officers or agents in accordance with it's contract type; and

H.         The foregoing statements are true to the best of my knowledge and belief.

Certified by: _________________________________________ Date: __________                                                      Department Director

I understand and certify that this is a _____ year financing arrangement and that approximately $________________ per fiscal year will be required to be set aside out of this department's budget over the next ____ fiscal years to complete this financing obligation.

Fund Source __________________________        Budget Line Item: _______________

Certified by: ____________________________________________ Date: ___________

                                                                                                                                                                                                Department Budget Officer

Financing transactions less than $250,000 will be approved by the State Financial Marketplace Manger, between $250,000 and $499,999 will be approved by the Chief of the Office of Risk Management or the Deputy Director of the Management Services Division, and all financing transactions over $500,000 must be approved by the Director of the Department of General Services.

Department of General Services          Approved/Recommended                   Denied/Not Recommended

___________________________________________________

Patrick Mullen, Resource Management Branch, Department of General Services, Procurement Division

Department of General Services  Approved/Recommended  Denied/Not Recommended       

___________________________________________________  

Kim Hunt, Chief of the Office of Risk Management or                                                    Date

Jack Barr, Deputy Director of the Management Services Division

Director, Department of General Services         Approved       Denied           

___________________________________________________

Ron Joseph, Director, Department of General Services                                                                         Date