Justification for Items Peculiar to One Manufacturer

Requestor

All fields denoted with an asterisk (*) are required fields in order to submit a new item request. If any of these fields are not filled an automated message 

will remind you.

Requestor's Name: *

Do you have any relationship - business, financial, personal, or otherwise - with the supplier of this 

product or any of the supplier's representatives? *

Date of Submission:

Phone: *

Title: *

Department Name: *

Organization Name: *

Requestor's E-mail: *

Product Information

All fields to be completed by person requesting evaluation.

Type of Product: *

Mfr Web Site:

Product Manufacturer

Brand Name:

Sales Rep Phone:

Mfr/Sales Rep:

Name & Description*

Distributor Name-PV

Mfr/Sales Rep e-mail:

Distributor Part #:

Stock Number Currently Exists 

Place stock number in box to the right

Request For New Stock Number

Plant Name

Approved Source

For Seafood VETCOM

Manufacturer SKU#

Location Address

Establishment #

USDC

Country of Origin

Select One FRESH FROZEN REFRIGERATED SHELF STABLE CANNED OTHER

Description

Variety/Color/Flavor

NAMP/IMPS# For Meats Weight Range Grade

Processing Raw Precooked Fully Cooked Other (Please Specify)

Battered Breaded Marinated Seasoned

Cut Chopped Diced Shredded Sliced Ground

Pack Bulk Individually Wrapped Portions

Portion Size

Weight Count/LB Unit of Measure

Units Per Case Purchase Ratio Factor

Can/Container Size

Container Material
Manufacturer Shelf Life Data Code Breaker

Code Breaker Sheet Included

NAPA Allowance

Product Usage

1. State primary reason for initiating this new product request:

2. Is there a benefit to the war fighter not currently satisfied by the current products used?

3. If Yes, explain.

4. Is there currently a product in the Subsistence Prime Vendor catalog performing the same function?

5. If Yes, please list the name, manufacturer, and manufacturer code

6. Please check all applicable reasons for request

Current Item is Impracticable Health/Safety Requirement

Other (Please Specify)

7. If this new product is replacing an existing product, please list existing product name, manufacturer, manufacturer catalog codes

8. Please provide the following information for the proposed product:

Unit Price to be transmitted

As documented by attached invoice/price quote

Estimated Annual Usage

Estimated Annual Cost

10. If Yes, please list the manufacturer(s):

9. Are there similar products on the market?

Required by Law or Regulation

Shelf Life Requirements
Value Analysis

12. Do you have information validating the performance of this product?

13. Specify facts supporting justification, including documentation (e.g. market research, comparison cuttings, cost, yield, information):

Yes No 14. Similar product on contract: 

Number used last F/Y Projected use new product for this F/Y

Old Product Cost (each): New Product Cost (each):

Annualized Cost Impact: New Annualized Cost Impact:

15. Is this product available through a distributor?

18. The customer or technical personnel certify that the basis for the enclosed justification or documentation have been certified as 

complete and accurate. If affirmed by DSCP, I understand the requirements to use/consume all Prime Vendor's held inventory that 

this "new" item request will replace.

Customer or Tech Personnel Signature Date

11. Explanation of why a particular brand name, product or a feature of a product, peculiar to one manufacturer is essential to the 

Government's requirements and why other companies' similar products do not meet, or cannot be modified to meet, the agency's 

needs.

16. A statement of the actions, the agency may take to remove or overcome any barriers that limit the Government's requirements to 

a brand name item before any subsequent acquisition for similar products is made:

17. When will this decision be re-evaluated?

Thank you for your request. A DSCP representative will contact you shortly.
To be Completed by the Contracting Agency

 

To be completed by the Contracting Officer: 

1. Contracting Officer's determination that the anticipated cost to the Government will be fair and reasonable:

2. The Contracting Officer certifies that this justification or documentation is accurate and complete to the best of the Contracting 

Officer's knowledge and belief.

Contracting Officer's Signature Date

Item is hereby approved and authorized to be added to this Prime Vendor Catalog

Item is not approved Reason:

Customer

Coordination Between:

Account Manager

Acquisition Specialist

Name Date

Date

Date

Name

Name

All sole source item selections must be approved by your respective Service Headquarters. Once the request(s) are approved, please forward the sole 

source justification form to your appropriate DLA Troop Support, Tailored Vendor Logistics Specialist.