SEND TO:	OIT Procurement Coordinator oitprocurement@oit.nj.gov Phone: (609) 777-3773	Program Management Office 300 River View Plaza, 1st Floor PO Box 212, Trenton, NJ 08625-0212

TODAY’S DATE	PHONE:
FROM
AGENCY
DIVISION
ADDRESS

Submit all related purchases as one package, whenever possible, and list all items below:
Procurement # (PO, Waiver, Requisition #)	Amount	Contract #	Vendor
Total Amount	$ 0.00
Is this a resubmission of a previous procurement request? Yes No Provide previous procurement # and explain resubmission:
Questions	Who to Contact	Phone / FAX
Who may OIT contact for purchasing issues / questions?	Phone: FAX:
Who may OIT contact for technical issues / questions?	Phone: FAX:
Funding Sources: Federal Match % Federal Grant % State %	Dedicated Fund or State Grant Fees Other (Explain)
Funding Deadline Date: (If this box is checked you must provide an explanation as to why)

Note: All procurements of Records Management/Storage Systems/Services require approval with this package. If this is not included, your procurement package will be returned without approval.

See Circular Letter 10-02-OMB for additional information.

Every question on this form must be answered or request will be returned to sender

PROCUREMENT INFORMATION
Select what is being purchased: HARDWARE (HW) SOFTWARE (SW) SERVICES HW Maintenance Renewal SW Maintenance Renewal Professional Services: New Extension HW Upgrade SW Upgrade HW Replacement SW Replacement Training New Hardware SW Services Other: HW Services New/Additional Software License SaaS / Hosted Subscription: New Renewal Describe in detail what is being purchased (spell out acronyms). Describe the business need that is being addressed and include the consequences of not approving this request. Describe any alternatives and/or options that were available instead of the item being purchased. (Include an explanation for not choosing them) If this procurement supports State, Affinity Group, or Departmental goals of integration, consolidation, or standardization, check which one(s) and explain how: State Affinity Group Department Explain how: Are there any Technical Information & Requirements (System Platform/App/Database): No Yes, identify:

DATA CENTER IMPACT
Some purchases may have an impact at an OIT or Agency Site Computer Room.
7a. Does this purchase involve hardware / equipment that will be installed at an OIT site? No Yes, select the proposed OIT location(s) below. HUB River Road Data Center (Building 15) OARS @ Hamilton - OIT Availability and Recovery Site (OARS) 7b. Does this purchase involve hardware/equipment that will be installed at an Agency Site? No Yes, identify the proposed location(s) (including central computer room, remote location, etc.):
OTHER
Executive Order #125 requires purchases using funds from the Federal Disaster Relief Appropriations Act, 2013, P.L.113-2 (Federal Hurricane Sandy Funds) to be in compliance with the directives found here http://nj.gov/infobank/circular/eocc125.pdf. Does this purchase use Hurricane Sandy funding? No Yes

ALIGN PROCUREMENT TO IT TACTICAL PLANS
Tactical Plan Tracking #:
Tactical Plan Project Name:
Select only one of the four main categories (a, b, c or d) and any applicable sub categories that further explains how this procurement aligns to the tactical plan noted above. Maintenance – Check maintenance type Renewal of maintenance licenses for hardware and/or software Equipment for new staff Hardware and/or software upgrades to maintain current operations (not replacement) New office or office relocation IT Training necessary to maintain existing systems Compliance with licensing agreements (license true-up) Other services (i.e., consulting) to maintain existing systems Other, explain: Refresh – Check refresh alignment type Replacement of equipment (hardware/server) that has reached end of life & no longer supported (only hardware not software) Reached the Agency’s scheduled Refresh cycle – Equipment in the Refresh cycle includes: computers, printers, servers, projectors, scanners, network and infrastructure equipment, telephony equipment, etc. (only hardware not software) Provide a statement if any additional Refresh plans: Existing Project - If purchase is for an existing project explain how it aligns to the existing Tactical Plan project noted in #10. New Project - If purchase is for a new project, provide a revised Tactical Planning Part 1 (spreadsheet) and Project Status Worksheet to OIT.workrequest@oit.nj.gov and answer questions under Project Information below.
PROJECT INFORMATION
Is this procurement being made in support of a NEW project? Yes No If Yes, describe: What is the estimated start date of this project? Has this project been scheduled for or been through a Business Case Review meeting? Yes, what is the date of the BCR meeting: No, if no why not?

ALLOWABLE PROCUREMENT JUSTIFICATIONS CIRCULAR 16-05 OMB/DPP/OIT
Executive Order #42 implemented a Moratorium on Procurements of Information Technology (IT) hardware, software and related services and Circular 16-05-OMB/DPP/OIT, developed by OIT, DPP and OMB, provides allowable procurement justifications. Completion of the following is required. Be as accurate and detailed as possible in describing the nature of the procurement. This information may be shared with OMB. ALLOWABLE PROCUREMENT JUSTIFICATIONS: Please check below which of the provisions of Circular 16-05-OMB/DPP/OIT apply and provide an explanation. Use of dedicated or non-State funding Identify the funding source: Can this funding source be used to reduce State costs in some way? Yes No Discontinuance of ongoing project resulting in a loss of investment or increase in future cost Federal Mandate or State Law or Court Order Equipment, software or network failures affecting critical business functions The hardware, software and/or services being sought is (are) mission critical Request is for continuation maintenance on critical hardware or software Other (explain): Further clarifying information: NOTE: Purchases utilizing exclusively federal funds must include a federal certification form as part of the review package.
AGENCY AUTHORIZATION
I certify that this purchase is compliant with the requirements set forth in this form and conforms to current State contract and purchasing rules and regulations. Agency IT Director or Designee Print Name: Agency IT Director or Designee Signature: Date: