Artificial Division Exception Form Executive Order KBB 04-30 states: "The Louisiana Procurement Code, in R.S. 39:1596, authorizes the governor to establish procedures for the procurement of small purchases with the caveat that procurement requirements shall not be artificially divided so as to constitute a small purchase under this Section". State Requisition Numbers and Names of Suppliers to be Considered Excepted: Requisition No. _____________   Supplier: ________________________________ Requisition No. _____________   Supplier: ________________________________ Requisition No. _____________   Supplier: ________________________________ Requisition No. _____________   Supplier: ________________________________ Check all that qualify (all must be checked to qualify for consideration): [____] No items requested from suppliers listed are the same [____] No items requested from suppliers listed are similar by commodity classification [____] No items requested from suppliers listed are available from other suppliers listed [____] No items requested shall constitute a division violation under Executive Order State any further reasons to justify autonomy of above requisitions: I hereby certify that all information herein is true and accurate to the best of my knowledge. I further certify purchases made at this time are not artificially divided so as to constitute a violation of the Small Purchases Executive Order. I assume all responsibility for any violations and penalties as per Louisiana Revised Statute 39:1679. Name ____________________ Signature ____________________ Date ___________ For Purchasing Use Only: ____________________________ Date Reviewed ___________