HomeMy WebLinkAboutC07-275 CDPHEJ C T 2 9 2007
-ni !J 7° HUMAN29SERVICES STATE OF COLORADO
Sip Flitter, Jr., Governor
Jams S. Martin, Exemtive ®'trector
Dedicated to protecfing and anpromg the health and environment of the people of Colorado W1 -
4300 Cherry Creek Dr. S. Laboratory Services Division * t
Denver, Colarado 80246-1530 8100 Lowry Blvd. * 1e�s
Phone (303) 692-2WO Denver, Colorado 802+30-
TDD Line (303) 691-7700 (303) 692-3090
Located in Glendale, Colorado
tft://Www.cdphe.slate.co.us
October 25, 2007
Jill Hunsaker
Eagle County Health & Human Services
551 Broadway
Eagle, Colorado 81631
Dear Ms. Hunsaker:
Colorado Department
oaf PnblicHe"
and Emkonment
Enclosed is the fully executed WIC Contract for the period October 1, 2007 — September 30, 2008.
If you have questions, please call me (303) 692-2457 or email Robert.robinson(kstate.co.us.
Sincerely,
Robert Robinson
WIC Fiscal Officer
db
Enclosure
J:\WICCommon\Rob\WIC Contract 10.01.07 9.30.08.doc
DEPARTMENT OP PUBLIC MALTHAND ENVIRON DENT
ROUTING NO. 08 FLA WHI
APPROVED T'ASH ORDER CON'PRACT - WAIVER N 1%
TUsTask Osderanaattisinuedpursuant toM"UrConuaetmademOVnl2007 with
srATE Mud°B nMdWr0IFAAW0u
State of Colorado for the use & benefit of the
Depaz=ent of Public Ffealth and
Environment
PSD
WIC
4300 CberryCreekDrive South
Deaver, Colorado 80127
TASK CRDERMADE DATE:
August 20, 2007
PUSC EbXXSABRAI XZ NUMBER:
POFI AVI0800442
TERM
This Task Order shall be effective upon
approval by the State Controller, or designee,
or on 10/01/2007 whichever is later. The
Task Order shall end on 09/30/2008.
PRICE S UMURE:
Cost
PR0aMzMENr uEnioD
Exempt
BM/RPP/I]STMCI AGREE1APTNUMBER:
Not Applicable
LAWSPEaMD VENDMSTAWM:
Not Applicable
CONIRACDOR
Board of County Commissioners of Eagle County
500 Broadway
Eagle, Colorado 81631,
for the use and benefit of the
Eagle County Healtb & Human Services
551 Broadway
Eagle, Colorado 91631
0MCMUCRENTITYTYPE:
Colorado Political Subdivision
CMIMAarCR FEIN Cut soaAL SEaMTY NUMBER:
846000762 L
ERUM STATEMENTS RECEIVED
Monthly Contract Reimbursement Statement
sTATtRORYA1J1mown.
N/A
aw ACrPRtCENOTToExEm.
$147,748.00
FEDEML IUMINo` $147,748.00
STATEFtrc=DCU_M : $
MAXMAMAUDUNrAVAn ME PER PTSCALYEAR:
FY08: $110,811
FY 09: $ 36,937
FY 10: $
FY 11: $
FY 12: $
STATE REPRESENTATIVE: 00Nnv.0 RRMMESENTAMVE:
Robert Robinson j>7l i htnsalner
of Public Health and Enviroamem
PSD
WIC
4300 Cherry Qeek Drive South
Denver, CO 80127
SCOPE CP WCKL-
Administration of a component of the WIC Program within an approved service area Service
includes, but is not limited to, nutrition education and the provision of certain attritional foods to
falls below W�� wow' and cluldren under five (5) years of age, whose iurcome
specified levels and have an ideatiifiable attrition risk factor as described in 7 CFR, Part
246, and the Stare's Wrr.. P..,o..,.,, D�,...e.t..— -LR ---, '
Page 1 of 4
CC`) - G9,7 S -�u
EXHIBITS:
The following exhibits are hereby incorporated:
Exhibit A - Additional Provisions (and its attachments if any — e.g., A-1, A-2, etc.)
Exhibit B - Statement of Work and Budget (and its attachments if any — e.g., B-1, B-2, etc.)
Exhibit C - Limited Amendment Template for Task Orders
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide more specificity than these general clauses, the more specific provision shall control.
This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including, but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including
any renewals or extensions, may not exceed five (5) years. The parties intend and agree that all work shall
be performed according to the standards, terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(1), C.R.S., as amended, this Task Order Contract is not valid until it
has been approved by the State Controller, or an authorized delegee thereof. The Contractor is not
authorized to, and shall not; commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegee. The State shall have no financial obligation
to the Contractor whatsoever for any work or services or, any costs or expenses, incurred by the Contractor
prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order
Contract on or before its proposed effective date, then the Contractor shall commence performance under
this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order
Contract after its proposed effective date, then the Contractor shall only commence performance under this
Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through
and including the date specified on page one of this Task Order Contract, unless sooner terminated by the
parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract.
Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made
a part hereof as if fully set forth herein. Unless otherwise stated, all exhibits and/or attachments to this Task
Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated,
the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event
of conflicts or inconsistencies between the Master Contract and this Task Order Contract (including its exhibits
and/or attachments), or between this Task Order Contract and its exhibits and/or attachments, such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: 1) the
Special Provisions of the Master Contract; 2) the Master Contract (other than the Special Provisions) and its
exhibits and attachments in the order specified in the Master Contract; 3) this Task Order Contract; 5) the
Page 2 of 4
Additional Provisions -_Exhibit A. and its attachments if included, to this Task order Contract; 4) the
SeopeJStatement of Work - Exhibit B, and its attachments if included, to this Task order Contract; 6) other
exlubits/attachnmts to this Task order Contract in their order of appearance,
The Contractor, in accordance with the terms and conditions of the Master Contract and this Task order
Contract, shall perform and complete, in a timely and satisfactory warmer, all work item described in the
Statement of Work and Budget, which are incorporated herein by this refereree, made a part hereof and
attached hereto as "Exhibit B".
The State, with the concurrence of the Contractor, may, among other things, Prospectively renew or extend
the term of this Task order Contract, subject to the limitations set forth in the Master Contract, increase
, delete or
decrease the amount payable under this Task order Contract, or add tote from, and/or modify this
Task order Contract's Statement of Work through a "Limited Amendment for Task orders" that is
substantially similar to the sample form Limited Amendment that is incorporated herein by this reference
and identified as Exhibb C. To be effective, this Limited Amendment must be signed by the State and the
Contractor, and be approved by the State Controller or an authorized delegate thereof. Upon proper
execution and approval, this Limited Amendment shall become a formal amendment to this Task order
Contract. This contract is subject to such modifications as may be required by changes in Federal or State
law, or their implementing regulations. Any such required modification shall automatically be incorporated
into and be Part of this Task order Contract on the effective date of such change as if fully set forth herein.
The conditions, Provisions, and terms of any RFP attached hereto, if applicable, establish the minimum
standards of performance that the Contractor must meet under this Task order Contract. If the Contractor's
Proposal, if attached hereto, or any alluhnents or exhibits thereto, or the ScoPe/Statement of Wk -
ose set forth in the RFP, ththe
or
Exhibit B, establishes or creates standards of performance greater than thoseContractor shall also meet those standards of performance under this Task order Contract.
Page 3 of 4
IN WITNESS WMREOP, the State las executed this Task Older Contract as of the dayfirst rst above
written.
Contractor:
Board of County Commissioners of Eagle County
for the use and benefit of the
Eagle County Health & Human Services
Name ofCautrectngEatity
�, - (0000 17 4o
Social Security Number or FEIN
Prim Nano & TYde ofAutborized ca
GOVEIMMENTAL ENTITIES:
STATE OF COLORADQ;
B R, �- OR
B9
For Fxecudve Dha*w
DePartment of Pubtic Haim and Envh mnrew
MENNEN
MIMI
(An attestatbn and seal are required)
Attest (Seal) -
(TovvNClty/County Cleric or Egrdv ) govaoment seal hero)
ALL CONTRACTS MUST BE APPROVED BY TBE STATE CONTROLLE
CRS 2430-202 requires that the State Controller appmve all state conhacts. This cont act is not valid until the Stabs
Controller, or such assidun as he may delegate, has signed it The contractor is not authorized to begin pafomraoce unto
the contract is signed and dated below if perfomww begins prior to the date below, the State of Colorado may not be
obligated to pay Eor the goods "or services provided,
ATE CONTROLLER:
Leslie AL Sh elt
BS'
Date
Page 4 of 4
EJMIT A
ADDITIONAL PROVISIONS
To Contract Dated 08/27/2007 - Contract Routing Number 08 FLA 00442
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
1. This contract contains federal fiends (see Catalog of Federal Domestic Assistance (CFDA) number
10.5570)
2. The United State Department of Agriculture ("USDA-), through its Food and Nutrition Service ("FNS')
has awarded federal finds to the Colorado Department of Public Health and Environment to operate the
Special Supplemental Nutrition Program for Women, Infants and Children, officially known as the "WIC"
Program„
If the Agreement Award authorizes the State to pay all allowable and allocable expenses of a contractor as
of the effective date of that agreement, then the State shall reimburse the Contractor for any allowable and
allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective
date of this Contract. If the underlying agreement does not authorize the State to pay all allowable and
allocable expenses of a contractor as of the effective date of that agreement, then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by
the Contractor on or after the effective date of this Contract, with such effective date being the later of the
date specified in this contract or the date the contract is signed by the State Controller or delegee.
To receive compensation under this Contract, the Contractor shall submit a signed monthly, itemized
Contract Reimbursement Statement (CRS) for administrative costs in accordance with the Fiscal Section of
the State WIC Procedure Manual which has been made available to the contractor as of the effective date of
this contract Administrative costs include allowable operational and administrative costs as specified in
the 7 C.F.R., Part 246, as amended, which can be found at www. fns.usda aov/w ic/lawsandregul_ations and
OMB Circular A-122, which can be found at www.whiWhouse-RO—V/Ojndb/ChrWars/al22/al22 2004 htmL as
well as applicable rules and regulations of the State of Colorado. A sample CRS is attached hereto as
Attachment A-1 and incorporated herein by this reference. The CRS must be submitted by the 20 day of
the month following the end of the billing period for which services were rendered. Expenditures shall be
in accordance with the Statement of Work attached hereto as Exhibit Band incorporated herein.
The CRS shall: 1) reference this Contract by its contract routing number, which number is located on page
one of this Contract; 2) state the applicable performance dates; 3) state the name, title and hours worked by
payee; 4) describe the incurred expenditures if reimbursement is allowed and requested; and, 5) show the
total requested payment. Payment during the initial, and any renewal or extension, term of this Contract
shall be conditioned upon affirmation by the State that all services were rendered by the Contractor in
accordance with the terms of this Contract. Invoice/Cost Reimbursement Statements shall be sent to:
Robert Robinson
Division of Prevention Services
WIC Program
Colorado Department of Public Health and Environment
PSD -NS -A4
4300 Cherry Creek Drive South
Denver, CO 80246
To be considered for payment, final billings under this Contract must be received by the State within a
reasonable time after the expiration or termination of this Contract; but in no event no later than sixty (60)
calendar days from the effective expiration or termination date of this Contract.
Pagel of 2 Revised: 4/1/04
EXHIBIT A
Unless otherwise provided for in this Contract, "Local Match" shall be included on all billing statements, in
the column provided therefore, as required by the funding source.
The Contractor shall not use federal funds to satisfy federal cost sharing and matching requirements unless
approved in writing by the appropriate federal agency.
3. If this Contract is terminated prior to its expiration date, then the final payment to the Contractor may be
withheld, at the discretion of the State, until a final audit has been completed.
4. Incorrect payments to the Contractor due to omission, error, fraud, defalcation, or for any other reason,
shall be recovered from the Contractor by the State: by deduction from subsequent payments under this
Contract or other contracts between the State and the Contractor, or, by the State as a debt due to the State.
The State and the Federal government reserve the right to audit the Contractor's books and records for a
period of six (6) years after this Contract expires or terminates in order to validate the allowableness of
costs paid under this Contract. Any costs not allowable under the State of Colorado Procurement Code and
Rules or, the State's WIC Program regulations shall be reimbursed by the Contractor, or offset against
current obligations of the State to the Contractor, at the State's election.
5. Continued State financial reimbursement under this Contract is contingent upon the continued operation of
the WIC Program as described in this Contract, and the Contractor's timely submission of all reports, data,
or other documentation required under this Contract.
6. The participant level shall be negotiated between the State and Contractor based on the availability of food
dollars and the average food package costs and shall be approved and documented in writing, and amended
as needed.
7. Health Insurance Portability and Accountability Act (HIPAA) Business Associate Determination. The
State has determined that this contract does not constitute a Business Associate relationship under HIPAA.
8. Time Limit For Acceptance Of Deliverables.
a. Evaluation Period The State shall have 60 calendar days from the date a deliverable is delivered
to the State by the Contractor to evaluate that deliverable, except for those deliverables that have a
different time negotiated by the State and the Contractor.
b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design
specifications for that particular deliverable, or is otherwise deficient, then the State shall notify
the Contractor of the failure or deficiencies, in writing, within 30 calendar days of: 1) the date the
deliverable is delivered to the State by the Contractor if the State is aware of the failure or
deficiency at the time of delivery; or 2) the date the State becomes aware of the failure or
deficiency. The above time frame shall apply to all deliverables except for those deliverables that
have a different time negotiated by the State and the Contractor in writing pursuant to the State's
fiscal rules.
Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed
deliverable, the Contractor shall have a reasonable period of time, not to exceed 30 calendar days,
to correct the noted deficiencies. If the Contractor fails to correct such deficiencies within 30
calendar days, the Contractor shall be in default of its obligations under this Task Order Contract
and the State, at its option, may elect to terminate this Task Order Contract or the Master Contract
and all Task Order Contracts entered into pursuant to the Master Contract.
Page 2 oft Revised: 4/1/04
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EXHIBIT B
STATEMENT OF WORK
To Contract Dated 08/27/2007 - Contract Routing Number 08 FLA 00442
These provisions are to be read and interpreted in conjunction with the provisions of the contract specified above.
1. The Contractor shall conduct and administer a component of the Special Supplemental Nutrition Program for
Women, Infants and Children. Applicable regulations are contained at 7 C.F.R., Part 246, which can be found
at www.fns.usda.go-v/wic/lawsandrem&tions.
2. The Contractor fully understands that the WIC Program is a project to supply specified nutritious foods and
nutrition education to pregnant, lactating, and postpartum women and children under five (5) years of age who
fall below those levels of income established by the United States Department of Health and Human Services
(USDHHS) income poverty guidelines, which can be found at www.cdRhe.state.co.uWg&MclwicolqU&V,
and, who have an identifiable nutrition risk factor as described in the applicable regulations and the State WIC
Procedure Manual, which has been made available to the Contractor as of the effective date of this Contract.
3. The Contractor shall utilize the State's food delivery system, which system has been approved by the USDA
Food and Nutrition Service ("FNS'l.
4. The Contractor shall insure the availability of those health services identified in the applicable Federal
Regulations to participants up to the income level specified for the WIC Program: by providing those services
in on-site clinics; or, by referring participants to State of Colorado licensed physicians or public or nonprofit
agencies which will provide those services.
5. The Contractor shall protect the confidentiality of a recipient's identity by limiting access to the recipient's
records to: the USDA, the General Accounting Office (GAO), State WIC officials, local WIC employees, the
recipient's health care provider, programs with a formal information sharing agreement with the State's WIC
Office and listed on the Participant's Rights and Obligations form, agencies with overlapping service areas,
counties with Commodity Supplemental Food Programs to prevent dual participation, and auditors representing
a federal, state, or local government. Access to records by other third parties must be accompanied by a release
of information signed by the recipient.
6. The Contractor shall not discriminate on the basis of race, color, national origin, sex, age, or disability in
rendering services to Program applicants or recipients as described at 7 C.F.R., Part 246.8, and the State WIC
Procedure Manual.
7. The Contractor shall operate its WIC Program in accordance with FNS Instruction 113-2, "Title VI Civil Rights
Compliance and Enforcement in the Special Supplemental Food Program for Women, Infants and Children and
the Commodity Supplemental Food Program" issued March 14, 1980, which has been made available to the
Contractor as of the effective date of this Contract.
8. The Contractor shall train and monitor those local retailers assigned by the State's WIC Program, and document
in local agency files its activities with those local retailers as specified in the State WIC Procedure Manual.
9. The Contractor shall conduct and document nutrition education services as described in the applicable WIC
Regulations, the State WIC Procedure Manual, and shall cooperate with the State's WIC Nutrition Consultant
relative to the delivery of these services. The Contractor shall abide by the State's nutrition education plan or
submit an annual nutrition education plan to the State's WIC Program which shall outline its objectives,
activities, and methods of evaluation
10. The Contractor shall maintain appropriate staff, as defined in the "Local Staffing" section of the State WIC
Procedure Manual to administer its WIC Program
Pagel of3 Revised. 4/1/04
EXHIBIT B
11. The Contractor shall insure that the qualifications of personnel assigned by the Contractor to perform the
services covered by this Contract shallbe available for review and approval by the State's WIC Program.
12. The Contractor shall insure that all of its WIC staff will complete: all required training by attending new
employee training; and the WIC Certification Program within the time lines specified in the "Local Staffing"
section of the State WIC Procedure Manual.
13. Subject to available finding from the State, the Contractor shall insure that all appropriate. personnel involved in
its WIC Program attend regularly scheduled workshops sponsored by the State's WIC Program on
administrative policies, procedures, and nutrition.
14. The Contractor shall operate its WIC Program in the manner described by the current version of the State WIC
Procedure Manual, as amended, including but not limited to the Clinic Users Procedures, which manual has
been made available to the Contractor as of the effective date of this Contract.
15. The Contractor shall be responsible for the security and accountability of negotiable food instruments and shall
reimburse the State for any WIC Program funds which are misused or otherwise diverted due to negligence,
fraud, theft, embezzlement, or any other loss caused by the Contractor, its employees, or agents.
16. The Contractor shall retain all financial records, supporting documents, statistical records, and all other records
documenting the services provided by the Contractor under this Contract for a period of three and one half (3 %z)
years after the expiration or termination of this Contract. The records described herein shall be available to the
State at all reasonable times at the Contractor's general offices. If any litigation, claim, or audit is started before
the expiration of the three and one half (3 %:) year period, then the records shall be retained until all litigation,
claims, or audit findings involving the records have been resolved.
17. The Contractor shall obtain the prior written approval of the State before, and as a condition of, purchasing any
equipment with WIC funds which costs One Hundred Dollars ($100.00) or more. If such approval is given by
the State, and the equipment is purchased by the Contractor, then that equipment shall be the property of the
State's WIC Program. A copy of the invoice for any equipment purchased under this Contract which costs One
Hundred Dollars ($100.00) or more shall be submitted to the State by the Contractor with a request for
reimbursement. No equipment purchased with WIC funds may be disposed of by the Contractor without the
prior written approval of the State and the USDA. If requested by the State, the Contractor shall deliver all
equipment purchased through this Contract to the State. The Contractor shall maintain an inventory of all
equipment purchased under this Contract and shall verify that inventory on an annual basis.
18. The Contractor's claims for the reimbursement of all administrative costs shall be made in accordance with all
applicable requirements imposed by the USDA, including but not limited to 7 C.F.R., Part 246, as amended, all
applicable Office of Management and Budget (OMB) circulars, and the State's WIC policies, as amended
19. The Contractor shall keep on file and have available for review, audit, and evaluation:
a. a copy of this Contract;
b. information on the service area and financial eligibility standards used by the Contractor;
c. complete and accurate participant records documenting nutrition risk, certification information of
applicants, foods prescribed, nutrition care, counseling, and referrals provided under its WIC
Program;
d. a complete, accurate, and current accounting which documents all funds received and expended
pursuant to this Contract;
e. detailed inventory records including purchase date, acquisition cost, location, inventory number,
and disposition information;
f. complete and accurate retail records documenting training, monitoring, and those problems, if any,
with each retailer,
g. racial/edmic participation data;
h. fair hearing information; and
Page 2 of 3 Revised 4/1/04
EXMIT B
i. participant abuse records.
20. The Contractor shall insure that no claim is submitted to the State for the reimbursement of those services which
are already funded by other state or federal programs, or for costs which are not allowable.
21. The Contractor shall provide services to all WIC Program participants and employees in a smoke-free
environment. In accordance with Public Law 103-227, also known as the Pro -Children Act of 1994, "smoke-
free" shall mean that smoking is not permitted in any portion of any indoor facility owned, leased, or otherwise
contracted for by the Contractor if that facility is routinely or regularly used for the provision of child care or
health services to any child under the age of eighteen (18) when those services are fimded in whole or in part
with Federal fiends.
22. The Contractor shall be responsible for the security of all WIC equipment in its control or possession and shall
immediately report any loss or damage to that equipment to the State's WIC Office. The Contractor shall be
liable for any loss or damage to that equipment which is caused by the negligence, abuse, or misuse of the
equipment by the Contractor.
23. The Contractor shall not make any changes, additions, or otherwise alter in any way, the WIC computer
software or its equipment without the prior written approval of the State's WIC Office. This clause also
prohibits the Contractor from adding any unapproved software or, attaching any WIC computer equipment to
any local area network system, or any Internet system
24. The Contractor shall abide by all security requirements which are specified in the State WIC Procedure Manual.
25. The Contractor certifies that it is in compliance with those regulations implementing Executive Order 12549,
Debarment and Suspension, 7 C.F.R., Part 3017, Section 3017.510. The Contractor hereby certifies, by
execution of this Contract, that neither it nor its principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal
department or agency.
26. No State or other public funds payable under this Contract shall be used for the acquisition, operation or
maintenance of computer software in violation of United States copyright laws or applicable licensing
restrictions. The Contractor hereby certifies that, for the term of this Contract and any extensions, the
Contractor has in place appropriate systems and controls to prevent such improper use of public funds. If the
State determines that the Contractor is in violation of this paragraph, the State may exercise any remedy
available at law or equity or under this Contract, including, without limitation, immediate termination of the
Contract and any remedy consistent with United States copyright laws or applicable licensing restrictions.
Page 3 of 3 Revised: 4/1/04
EDIT C
. DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
(ADD PROGRAM NAME HERE)
DEPARTMENT OR AGENCY NUMBER
***
CONTRACT ROUTING NUMBER
LIMITED AMENDMENT #*
This Limited Amendment is made this **** day of *********, 200*. by and between the State of Colorado, acting
by and through the DEPARTMENT OF PUBLIC HEALTH AND MIW ONMENT whose address or principal
place of business is 4300 Cherry Creek Drive South, Denver, Colorado 80246 hereinafter referred to as the
"State"; and, LEGAL NAME OF ENTITY (legal type of entity), whose address or principal place of business is
Street Address, City. State & Zip Code, hereinafter referred to as the "Contractor".
FACTUAL RECITALS
The parties entered into a contract dated ******** ** ****, with contract encumbrance number PO ***
and contract routing number ** *** *****. whereby the Contractor was to provide to the State the
following:
[briefly describe what the Contractor was to do under the original contract — indent this paragraphl
[Please choose one of the following four options and then delete this heading and the other three options not
selected:]
The State promises to [choose one and delete the otherlincrease/decrease the amount of funds to be paid to the
Contractor by ********** Dollars. ($*.**) during the current term of the Original Contract in exchange for the
promise of the Contractor to perform the [choose one and delete the otherlincreased/decreased work under the
Original Contract
The State promises to pay the Contractor the sum of ********** Dollars. *.** in exchange for the promise of
the Contractor to continue to perform the work identified in the Original Contract for the renewal term of ****
years/months, ending on ******** **, ****.
The State promises to [choose one and delete the otherlincrease/decrease the amount of funds to be paid to the
Contractor by ********** Dollars. ($*.**) for the renewal term of **** [choose one and delete the
otherlyears/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the
[choose one and delete the otherlinereased/decreased specifications to the Scope of Work described herein.
The State hereby exercises a "no cost" change to the [insert those that apply and delete those that don'tlbudget,
specifications within the Scope of Work, project managementtmanager identification, notice address or
notification personnel, or performance period within the [choose one and delete the otherleurrent term of the
Original Contract or renewal term of the Original Contract.
NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree
as follows:
Consideration for this Limited Amendment to the Original Contract consists of the payments and services
that shall be made pursuant to this Limited Amendment, and promises and agreements herein set forth.
2. It is expressly' agreed to by the parties that this Limited Amendment is supplemental to the original
Page 1 of 4
contract, contract routing number ** *** *****, [insert the following language here if previous
amendment(s), change order(s), renewal(s) have been processedlas amended by [include all previous
amendment(s), change order(s), renewal(s) and their routing numbers], ]insert the following word
here if previous amendment(s), change order(s), renewal(s) have been processed]collectively referred
to herein as the Original Contract, which is by this reference incorporated herein. All terms, conditions,
and provisions thereof, unless specifically modified herein, are to apply to this Limited Amendment as.
though they were expressly rewritten, incorporated, and included herein.
3. It is expressly agreed to by the parties that the Original Contract is and shall be modified, altered, and
changed in the following respects only:
A. [Use this paragraph when changes to the funding level of the Original Contract occur
during the current term of the Original Contract]This Limited Amendment is issued pursuant
to paragraph *_*. of the Original Contract identified by contract routing number ** *** *****
This Limited Amendment is for the current term of ********* ** ****, through and including
The maximum amount payable by the State for the work to be performed by
the Contractor during this current term is [choose one and delete the
other]increased/decreased by ********** Dollars ($*.**) for an amended total financial
obligation of the State of ********** DOLLARS. *.** . [delete any portion of this sentence
that is not applicable]The revised specifications to the original Scope of Work and the revised
Budget, if any, are incorporated herein by this reference and identified as "Attachment *" and
"Attachment *". The first sentence in paragraph *_**. of the Original Contract is modified
accordingly. All other terms and conditions of the Original Contract are reaffirmed
A. [Use this paragraph when the Original Contract will be renewed for another term]This
Limited Amendment is issued pursuant to paragraph *_**. of the Original Contract identified by
contract routing number ** *** *****. This Limited Amendment is for the renewal term of
***'***** •* ****. through and including ********* ** ****. The maximum amount payable
by the State for the work to be performed by the Contractor during this renewal term is
********** Dollars. ($*.**) for an amended total financial obligation of the State of **********
DOLLARS. ($*.**). This is an [choose one and delete the otherlincrease/decrease of
********** Dollars. ($*.**) of the amount payable from the previous term. [delete any portion
of this sentence that is not applicable]The revised specifications to the original Scope of Work
and revised Budget, if any, for this renewal term are incorporated herein by this reference and
identified as "Attachment *" and "Attachment *". The first sentence in paragraph *_**. of the
Original Contract is modified accordingly. All other terms and conditions of the Original Contract
are reaffirmed.
A. [Use this paragraph when there are "no cost changes" to the Budget. the specifications
within the original Scope of Work. allowable contract provisions as noted. or performance
period.]Tbis Limited Amendment is issued pursuant to paragraph *_**. of the Original Contract
identified by contract routing number ** *** *****. This Limited Amendment [choose those
that apply and delete those that don'tlmodifies the Budget in [identify location in contract],
modifies the specifications to the Scope of Work in [identify location in contract], modifies
the project management/manager identification in [identify location in contract], modifies
the notice address or notification personnel in [identify location in contract], modifies the
period of performance in (identify location in contract] of the Original Contract. The revised
[choose those that apply and delete those that don't]Budget, specifications to the original
Scope of Work, project management/manager identification, notice address or notification
personnel, or period of performance is incorporated herein by this reference and identified as
"Attachment *". All other terms and conditions of the Original Contract are reaffirmed.
4. The effective date of this Amendment is date. or upon approval of the State Controller, or an authorized
delegate thereof, whichever is later.
5. Except for the General Provisions and Special Provisions of the Original Contract, in the event of any
Page 2 of 4
IN WITNESS WHEREOF, the parties hereto have executed this Form Amendment on the day first above written.
CONTRACTOR:
[LEGAL NAME OF CONTRACTOR]
(legal type of entity)
By:
Name:
Title:
FEIN:
ATTEST:
If the Contractor is a corporation
or governmental entity, then an attestation
is required.
(Seal, if available.)
By: City, City, City and County,
Special District, or Town Clerk or Equivalent
Corporate Secretary or Equivalent
[Delete inapplicable laisguage.]
STATE:
STATE OF COLORADO
Bill Owens, Governor
By:
For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT
PROGRAM APPROVAL:
By:
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS 2430-202 requires that the State Controller approve all
sta contracts.
This ed ti The limied amendmtractors not ent Is not
l
valid until the State Controller, or such assistant as he may delegate, below. if P prior to
authorized to begin performance until the contract is signed and dated
f roods and/or service pe begins
P
the date below, the State of Colorado may not be obligated to pay g
By:
Date:
Form: LAT 7-1-04GN
STATE CONTROLLER
Leslie M. Shenefelt
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