OHCS Equipment Purchase Request Form

OHCS Equipment Purchase Request Form

If purchasing more than a single piece of equipment, a separate form submission is required for each piece, unless this is a bulk purchase of multiple pieces of the exact same equipment. No equipment purchase exceeding $5,000 may be made without prior approval from OHCS. If purchase is made prior to the approval by OHCS, the cost will be disallowed in monitoring and grantee will be required to repay OHCS for the expense.

All purchase requests must include copy of the bid solicitation, non-collusive bidding forms signed by the bidder and the actual bid documents.

Agency must comply with standards contained in 2 CFR Part 200, the Fixed Assets and Purchasing section of your OHCS Contract and any program requirement identified in the program's guidance.

Agency Name*

An agency's acronym is acceptable

Agency Contact Name*

Agency Contact Email Address*

Agency Contact Phone Number*

Phone

Purchased by Subrecipient*

Subrecipients may be allowed to purchase equipment (see your specific program guidance for allowability). If this purchase will be made by a subrecipient, check the box below and identify the subrecipient. Any subrecipient identified must have been prior approved as a subrecipient by OHCS.

Select

Subrecipient Name*

Information of Equipment Being Purchased

Please enter the general description of the equipment being purchased*

Please enter the make (or brand) of the equipment being purchased*

Please enter the model of the equipment being purchased*

How will purchasing this equipment support ongoing Program Services offered within your service area? How will the equipment be used?*

Should the OHCS Program used for this purchase ends, how will this equipment continue to be used?*

Location*

Identify where this equipment will be located (provide physical address/location - if this will be purchased and maintained by a subrecipient, enter the location in which the subrecipient will hold the equipment).

Sole Source Used*

Did you use use a sole source for the purchase of this equipment?

Select

Sole Source Justification*

Provide details as to why a sole source purchase is justified.

Identify who received the Bid Notice:*

Identify the Bid Specifications*

Please detemine if the lowest bid was selected*

Select

If the lowest bid was not selected please provide sufficient justification of the best value selection*

Total purchase price including any adjustments of the selected bid/quote*

This is the amount that you are requesting for approval.

Quote/Bid Price #1*

Enter the total of the quote/bid price from the first quote/bid

Quote/Bid Price #2*

Enter the total of the quote/bid price from the second quote/bid

Quote/Bid Price #3*

Enter the total of the quote/bid price from the third quote/bid

Additional Purchase Information

You may use this space to add any information you would like OHCS to know about the purchase of this equipment.

Please provide what grant source(s) and amounts will be utilized for the purchase of this equipment.

Grant #1*

Note: There is space in this request form to identify 4 separate grant sources; however, if more than 4 OHCS sources will be used, you will need to submit an additional budget document identifying each source and the funds that are proposed to be used for each source.

Select

Amount*

Would you like to add an additional grant source?*

Select

Grant #2*

Select

Amount*

Would you like to add an additional grant source?*

Select

Grant #3*

Select

Amount*

Would you like to add an additional grant source?*

Select

Grant #4*

Select

Amount*

I have fully reviewed the OHCS Requirements for the purchase of fixed assets/equipment.*

I certify that the above informatoin is true and correct. By signing, I certify that we are following 2 CFR 200, our Contract requirements, program guidelines and our own agency's purchasing policies and procedures.

Select

Authorized Grantee Signature*

Date of Signature*

Document Upload*

Please upload the following documents for 3 Bids/Quotes:

Request for Bids/Quotes
Responses to Bids/Quotes
If more than 4 grant sources will be used, please include a document that includes a budget detail of each grant and the funds to be used from each grant for this purchase.
All other documents you wish to be considered for this purchase request

Drag and drop files here or

SUBMISSIONS AFTER APPROVAL

a. Provide the following items to OHCS (depending on funding source)

For Homeless Services grants, submit to hsd.homelessservices@hcs.oregon.gov
For Housing Retention grants, submit to hsd.housingretention@hcs.oregon.gov
For Weatherization grant, submit to hsd.energyservices@hcs.oregon.gov.

b. Copy of invoice/delivery receipt.

c. Copy of approved Purchase Request form.

Send me a copy of my responses

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