OST F 2770.4 iSupplier Waiver Request Form

U.S. Department of Transportation
Delphi eInvoicing Payment Request System
Waiver Request Form - Instructions

General Instructions
Purpose of Form
The DOT and its Operating Administrations (OA's) are modernizing its
financial management systems, and as a result there will be changes to the
way grant recipients submit payment requests to the Department.
Recipients will be required to have electronic internet access to register in
DOT's electronic payment system, Delphi eInvoicing.
Under limited conditions, DOT Financial Management officials may allow
exceptions to the requirement that grantees register in and submit
payment requests through the Delphi eInvoicing system. The enclosed
form is used to request a waiver from using the Delphi eInvoicing system.
Applicability
All recipients of grants or cooperative agreements submitting payment
requests to the Department of Transportation must be registered in and
submit payment requests through DOT's Delphi eInvoicing system.
Note: This process is not applicable to grant recipients currently requesting
payment electronically through the National Highway Traffic Safety
Administration's Grant Tracking System (GTS), the Federal Highway
Administration's Rapid Approval State Payment System (RASPS), or the
Federal Transit Administration grant recipients currently requesting
payment through the Electronic Clearing House Operating System (ECHO),
Waiver Process
If you are unable to access the internet, or are otherwise unable to use the
DOT's Delphi eInvoicing system, your organization must submit and be
granted a waiver of compliance. Refer to DOT Form 2770.4 and related
instructions for information regarding the waiver process. Recipients may
apply for an exemption or waiver by submitting a written waiver request to
DOT Office Financial Management. This request must contain the following
information:
1.Name, address, grantee institution or entity name, phone number
and email address.
2.Recipients must provide specific reasons as to why they are unable to
use or access the internet to register and enter payment requests using
the online payment system.
All requests should be sent to Director of the Office of Financial
Management, US Department of Transportation, B-30, room W93-322, 1200
New Jersey Avenue SE, Washington DC 20590-0001,
[email protected]. DOT Financial Management
representatives will not consider requests that are incomplete.

OMB Control Number: 2105-xxxx
Expiration Date: mm/dd/yyy

Once complete and validated by DOT, the Director of the Office of
Financial Management will review the request and provide a response
approving or denying the request via mail or e-mail to the recipient
point of contact. The review process should take approximately thirty
(30) days from the time the request is received by the Office of
Financial Management.
Mailing Instructions
Mail via certified USPS, UPS, Fedex, etc. to:
US Department of Transportation
Office of Financial Management,
1200 New Jersey Avenue SE, Room W93-322
Washington DC 20590-0001
Paperwork Reduction Act (44 U.S.C. 3501) Burden Statement: A
federal agency may not conduct or sponsor, and a person is not
required to respond to the requirements of the Paperwork Reduction
Act unless that collection of information displays a currently valid OMB
Control Number. The OMB Control Number for this information
collection is 2105-XXXX. Public reporting for this collection of
information is estimated to be approximately 30 minutes per response,
including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, completing and
reviewing the collection of information. All responses to this collection
of information are required to request grant related payments from the
DOT. Send comments regarding this burden estimate or any other
aspect of this collection, including suggestions for reducing this
burden to: Information Collection Clearance Officer, Department of
Transportation, 1200 New Jersey Avenue SW, Washington, DC 20590,
S-83.

Privacy Act Statement: Privacy Act Statement (5 U.S.C. §
552a, as amended): AUTHORITY: 31 USC 3512, authorizes DOT
to collect this information. PURPOSE(S): DOT will use the
information provided to establish your identify prior to your
receiving an account within our system, and is intended solely
to establish a unique identity and proof thereof. ROUTINE
USE(S): In accordance with DOT's system of records notice,
DOT/ALL 7 Departmental Accounting and Financial Information
System, DAFIS, the information provided may be disclosed to
“consumer reporting agencies” as defined in the Fair Credit
Reporting Act (15 U.S.C. 1681a(f)) or the Federal Claims
Collection Act of 1982 (31 U.S.C. 3701(a)(3)). DISCLOSURE:
Provision of the requested information is voluntary; however
failure to furnish the requested information may result in an
inability of the Department to grant you access to our system.

Note: Concerns over system security are not valid reasons and will not be
granted a waiver from DOT Financial Management because the Delphi
eInvoicing system is fully secure and meets the latest technical security
requirements as proscribed by the Office of Management and Budget and
the National Institute of Standards and Technology (NIST).

DOT F 2770.4

OPI: Office of Financial Management, B-30

OMB Control Number: 2105-xxxx
Expiration Date: mm/dd/yyyy

U.S. Department of Transportation
Delphi eInvoicing system
Waiver Request Form

Contact Information:
Recipient Legal Name:
Doing Buisness As (DBA) Name:
Point of Contact (POC) Name:
Phone Number:
Recipient DUNS Number:
Recipient Address Line 1:
Recipient Address Line 2:
Recipient City/State/Zip Code:

Waiver Justification:
Provide a detailed justification providing specific reasons as to why the grantee organization is unable to use or access the internet to
register and enter payment requests using the online payment system.

Waiver
Justification

Grantee POC Signature

OST F 2770.4

Date

OPI: Office of Financial Management, B-30

OMB Control Number: 2105-xxxx
Expiration Date: mm/dd/yyyy

DOT Response Required for Non-concur:

DOT Response

DOT Financial Management Representative Signature

Date

Mail via certified USPS, UPS, Fedex, etc. to:
DOT Enterprise Services Center
FAA Accounts Payable, AMZ-100
PO Box 25710
Oklahoma City, OK 73125

OST F 2770.4

OPI: Office of Financial Management, B-30