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HomeMy WebLinkAboutC07-306 Colorado Department of Public Health and Environment_TBIDEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ROUTING NO. 08 FLA 00343 APPROVED TASK ORDER CONTRACT - WAIVER # 154 This Task Order Contract is issued pursuant to Master Contract made on 01/23/2007, with routing number 08 FAA 00016 STATE: State of Colorado for the use & benefit of the Department of Public Health and Environment Prevention Services Division, HCP 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 TASK ORDER MADE DATE: August 10, 2007 PO/SCENCUMBRANCE NUMBER PO FLA HCP0800343 ftaff7i- 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 STRUCTURE: Fixed Price PROCUREMENT METHOD: Exempt BID/RFP/LIST PRICE AGREEMENT NUMBER Not Applicable LAW SPECIFIED VENDOR STATUTE: Not Applicable STATE REPRESENTATIVE: Kathy Watters Department of Public Health and Environment Prevention Services Division, HCP 4300 Cherry Creek Drive South Denver, CO 80246-1530 CONTRACTOR: Board of County Commissioners of Eagle County (a political subdivision of the State of Colorado), for the use and benefit of the Eagle County Health and Human Services 551 Broadway Eagle, Colorado 81631 CONTRACTOR ENTITY TYPE: Colorado Political Subdivision CONTRACTOR FEIN OR SOCIAL SECURITY NUMBER 846000762 BILLING STATEMENTS RECEIVED: Not Applicable STATUTORY AUTHORITY: CRS 26-1-304 CONTRACT PRICE NOT TO EXCEED: $13,622.00 FEDERAL FUNDING DOLLARS: $6,130.00 STATE FUNDING DOLLARS: $7,492.00 MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR:- FY EARFY 08: $10,218.00 FY 09: $ 3,404.00 CONTRACTOR REPRESENTATIVE: Kathleen Forinash Eagle County Health and Human Services 551 Broadway Eagle, CO 81631 SCOPE OF WORK: Working in partnership with the State and other local agencies to provide care coordination for families who have children with Traumatic Brain Injury (TBI) and are enrolled in the TBI Trust Fund Program. Page 1 of 4 Cod- 30c -Q ErrsrM, 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. 1. 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.1Z.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 teens and conditions of this Task Order Contract. ' 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 Additional Provisions - Exhibit A, and its attachments if included, to this Task Order Contract; 4) the Scope/Statement of Work - Exhibit B, and its attachments if included, to this Task Order Contract; 6) other exhibits/attachments to this Task Order Contract in their order of appearance. Page 2 of 4 - 4. 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 manner, all work items described in the Statement of Work and Budget, which are incorporated herein by this reference, made a part hereof and attached hereto as "Exhibit B." 5. 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 or decrease the amount payable under this Task Order Contract, or add to, delete 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 Exhibit 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. 6. 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 attachments or exhibits thereto, or the Scope/Statement of Work - Exhibit B, establishes or creates standards of performance greater than those set forth in the RFP, then the Contractor shall also meet those standards of performance under this Task Order Contract. Page 3 of 4 IN WITNESS WHEREOF, the State has executed this Task Order Contract as of the day first above written. CONTRACTOR Board of County Commissioners of Eagle County (a political subdivision of the State of Colorado), for the use and benefit of the Eagle County Health and Human Services Legal Name of Contracting Fatuity D11 t..6 - it ,. Picot Name & Title ofAuthofized Officer GOVERNMENTAL ENTITIES: STATE OF COLORADO: BILL RITTM JR. GOVERNOR By For Executive Director Department of Public Health and Environment (Place government seal here) ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This contract is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin perforrnance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for the goods and/or services provided n STATE CONTROLLER Page 4 of 4 G. -r EXIIIBIT A ADDITIONAL PROVISIONS To Task Order Dated 08/10/07 - Contract Routing Number 08 FLA 00343 These provisions are to be read and interpreted in conjunction with the provisions of the Task Order specified above. 1. 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. 2. The United State Department of Health and Human Services (USHHS), through the Maternal and Child Health Services Block Grant (MCH") has awarded the State Title V federal funds under Notice of Grant Award (NGA) number B04MC04248, (see Catalog of Federal Domestic Assistance (CFDA) number 93.994). The State's Prevention Services Division (PSD) is charged with the administration of funds from the Title V MCH Block Grant to improve the health and well being of the maternal and child/adolescent populations through assessing population needs, influencing health policy, engaging in strategic planning and coordinating/implementing best practices and evidenced -based programs. The authority for the administration of the Title V MCH Block Grant, including the maternal, child and children with special health care needs resides in Title V of the Social Security Act, §§ 501-509. The State has formulated a comprehensive statewide plan to carry out a Maternal and Child Health Program, funded by Title V MCH dollars. As part of the comprehensive plan, it is the express intent of the state to support local public health agencies in contributing to a coordinated, efficient statewide program which focuses on specific MCH performance measures set by the MCH state and Federal agencies. Local public health agencies, working in partnership with other community organizations, facilitate the development and enhancement of community-based systems of care for the maternal, and child population. The goal of these systems is to ensure that all families have access to direct care services, as well as, enabling and population -based services that address the issues and health problems delineated in the MCH performance measures. If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, 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 Task Order Contract. If the underlying Award does not authorize the State to pay all allowable and allocable expenses of a contractor as of the effective date of that Award, 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 Task Order Contract, with such effective date being the later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the State Controller or delegee. Monthly reimbursements under this Task Order for the period of October 1, 2007 through September 30, 2008 shall be paid to the Contractor by the State based upon one -twelfth (1/12) of the total financial obligation or ONE THOUSAND ONE HUNDRED THIRTY-FIVR DOLLARS, ($1,135.00) each month for the first eleven (11) months and ONE THOUSAND ONE HUNDRED THIRTY-SEVEN DOLLARS, ($1,137.00) for the twelfth (final) month of the initial term of this Task Order. The total cumulative reimbursements may not exceed the total financial obligation of the State. 4. Expenditures shall be in accordance with the Statement of Work attached hereto as Exhibit B and incorporated herein. Page 1 of 3 EXHIBIT A 5. Submission of Actual Budget Allocations for Federal Fiscal Year 2006-2007. On or before December 1, 2007, the Contractor shall submit to the State a "Core Public Health Actual Expenditures Report" form, included in the MCH Guidelines, found on the HCP website: www.hci)colorado.org, showing the Contractor's actual expenditures for children with special health care needs (CSHCN), for the federal fiscal year 2006-2007 (October 1, 2006, through September 30, 2007). The completed report shall be submitted via electronic mail to: cdt)he.asmchreuorts(i�state.co.us 6. Contractor shall cooperate with the State and provide all requested records regarding recipients for whom services were provided under this Task Order. 7. The State is responsible to ensure that the program planning, evaluation, and monitoring requirements as described in this Task Order and the Attachments are met by the Contractor. To fulfill these responsibilities, the State has the right to make site visits and schedule any other meetings at the Contractor's location. 8. The State HCP Office shall assure the HCP Regional Office provides technical assistance and that the technical assistance is coordinated with the Public Health Nursing Consultant in the State's Office of Local Liaison. 9. Title V, Section 504 (b) (6). Title V funds may not be used to pay for any item or service (other than an emergency item or service) furnished by an individual or entity convicted of a criminal offense under the Medicare or any State health care program (i.e., Medicaid, Maternal and Child Health, or Social Services Block Grant Programs). 10. The Contractor agrees to provide services to all 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", (Act). Public Law 103-227 requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, day care, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable Federal funds is Medicare or Medicaid; or facilities where WIC coupons are redeemed. Failure to comply with the provision of Public Law 103-227 may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this Task Order, the Contractor certifies that the Contractor will comply with the requirements of the Act and will not allow smoking within any portion of any indoor facility used for the provision of services for children as defined by the Act. The Contractor agrees that it will require that the language of the Act be included in any subcontracts which contain provisions for children's services and that all contractors shall sign and agree accordingly. 11. The Contractor certifies, to the best of its knowledge and belief, that no federally appropriated funds have been paid or will be paid by or on behalf of the Contractor, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of this Task Order, and the extension, continuation, renewal, amendment, or modification of this Task Order, or any grant, loan, or other cooperative agreement that utilizes Federal funds. If any funds other than federally Page 2 of 3 EXHIBIT A appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, Member of Congress, an officer or employee of Congress in connection with this Task Order, or any other grant, loan, or other cooperative agreement, then the Contractor shall complete and submit Standard Form - LLL, "Disclosure Form to Report Lobbying" in accordance with its instructions. The Contractor shall require that the language of this certification be included in the award documents for sub awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans, and cooperative agreements) and that all sub recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. This certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 12. The Contractor shall protect the confidentiality of all applicant or recipient records and other materials that are maintained in accordance with this Task Order. Except for purposes directly connected with the administration of this Task Order, no information about or obtained from, any applicant or recipient shall be disclosed in a form identifiable with the applicant or recipient without the prior written consent of the applicant or recipient, or the parent or legal guardian of a minor applicant or recipient with the exception of information protected by Colorado statute as it applies to confidentiality for adolescent services in which case the adolescent minor and not the parent or legal guardian must provide consent or, as otherwise properly ordered by a court of competent jurisdiction. The Contractor shall have written policies governing the access to, and duplication and dissemination of, all such information. The Contractor shall advise its employees, agents, servants, and subcontractors, if any, that they are subject to these confidentiality requirements. 13. Contractor shall ensure that the provisions of Section 601 of Title VI of the Civil Rights Act of 1964 are carried out. That Act states that "no person in the United States shall on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." The Office of Civil Rights has concluded that it is the responsibility of any program which is a recipient of funds from the Department of Health and Human Services to ensure that clients who do not speak or understand English well, be provided interpretation services to ensure that the service provider and the client can communicate effectively. The Contractor shall have policies and procedures to ensure that interpretation services are available for clients with Limited English Proficiency and will advise such clients that an interpreter will be provided for them If a client has their own interpreter, they shall be advised that the Contractor will provide an interpreter if the client so chooses. 14. The services or activities under this Task Order may be carried out by the Contractor itself, or through subcontracts with other providers or, through collaborative partnerships with other community partners. The State authorizes the Contractor to subcontract some, or all, of the services that are to be performed under this Task Order. However, a subcontractor is subject to all of the terms and conditions of this Task Order. Additionally, the Contractor remains ultimately responsible for the timely and satisfactory completion of all work performed by any subcontractor(s) under this Task Order. If the Contractor desires to subcontract some, or all, of the services that are to be performed under this Task Order, the Contractor shall obtain the prior, express, written consent of the State before entering into any subcontract. 15. Survival of Certain Contract Terms. Notwithstanding anything in this contract to the contrary, the parties understand and agree that all terms and conditions of this contract which may require continued performance, compliance, or effect beyond the termination date of the contract and shall survive such termination date and shall be enforceable by the State as provided herein in the event of failure to perform or comply by the Contractor. Page 3 of 3 EXHIBIT B STATEMENT OF WORK Board of County Commissioners of Eagle County To Task Order Dated 08/10/07- Contract Routing Number 08F L A 00343 Under this Contract the Contractor shall provide the core public health services of assessment, policy development, and assurance on behalf of the CSHCN population as described and defined in the "Core Public Health Services Delivered by MCH Agencies" a component of the Maternal and Child Health Services (MCH) Guidelines. These services may include direct, enabling, population -based, or infrastructure building activities. The MCH Guidelines are available on the MCH website: www.cdphe.state.co.us/ps/mch/plan/forms.html and the Health Care Program for Children with Special Needs (HCP) website: www.hcpcolorado.org and are periodically updated The Contractor will be notified by email when updates/revisions are made. The Contractor is responsible for complying with any updatestrevisions. The MCH Guidelines are incorporated and made part hereof by reference. 2. The Contractor shall perform and complete, in a timely and satisfactory manner, all activities and services related to this Task Order in accordance with the MCH Guidelines. 3. The Contractor shall contribute to the Western Slope HCP Regional Office's Plan for CSHCN, which shall be carried out in federal fiscal year 08. The Western Slope HCP Regional Office Plan is designed to: contribute to the accomplishment of the National Core Outcomes and Performance Measures for CSHCN, identified in the MCH Guidelines. Contributions shall consist of, but are not limited to, completing requests from the HCP Regional Office to provide county specific data related to resources and needs of the population of CSHCN and participation in trainings or other learning activities sponsored by HCP in order to support families and local providers in understanding and accessing recommended follow up. 4. The Contractor shall work with the State's delegated HCP Regional Office (RO) staff for: orientation and training of new staff, as needed; consultation on HCP policies and procedures; consultation and technical assistance on community systems building efforts and community needs assessment activities, as needed; ensuring adequate and timely communication with the HCP Regional Office multidisciplinary team; and meeting at least once annually with delegated HCP RO staff for a multi - county HCP meeting. 5. The Contractor shall work with the State's delegated HCP Regional Office (RO) staff for consultation, technical assistance, oversight and training on documentation in HCP/Clinical Health Information Record of Patients (HCP/CHIRP) data base and to ensure that all HCP/CHIRP database users follow the HCP/CHIRP database policies and procedures in the HCP Policy and Procedure Manual and CHIRP User Guide which are made available on the HCP web site. 6. The Contractor shall follow the HCP/CHIRP Security policy and procedures outlined in the CHIRP User Guide, HCP Policy and Procedure Manual, and Data Security Use and Confidentiality Agreement signed by each user. 7. The HCP/CHIRP database, as provided by HCP, shall be used to document the contractor's core public health services that support meeting the National Six Outcomes for Children with Special Health Care Needs. Page 1 of 2 1. . 8. The Contractor shall follow the policies and procedures in the "HCP Policies and Procedures Manual" which is made available on the MCH website: www&dphe.state.co.gsIRkm—ch/planLforms.huw and the HCP website: www.hcpcolorado= 9. The Contractor shall attend regional teleconferences, meetings, and/or videoconference meetings, as appropriate, that the state may organize to address priority HCP needs, promote learning groups, and increase skills as HCP practitioners. 10. The Contractor shall participate in activities in conjunction with the State to ensure that the program planning, evaluation and monitoring requirements as described in this Task Order and Exhibits and Attachments are met. Activities include, but are not limited to, participation in site visits and meetings as requested by the State at the Contractor's location. 11. The Contractor shall provide all requested records regarding recipients for whom services were provided under this Task Order. 12. The Contractor shall provide the county's population of CSHCN with information regarding the resources and gaps and barriers in support and health care systems for the population of CSHCN as reported to the Office of Local Liaison for the "Five -Year Community Health Assessment Report". 13. The Contractor shall submit, but not limited to, the following reports, incorporated by reference. These documents, including instructions for completion and submission are available in the MCH Guidelines located on the MCH website: www cdphe state co us/ps/mch/nlan/forms html and the HCP website: www.hcocolorado.gM • Monthly updated clinic schedule • Core Public Health Services Actual Expenditure Report Section II for federal FY 2006-2007 • Number of Individuals Served (Unduplicated) Under Title V Report for federal FY2006-2007 • Table I Number of Individuals Served (Unduplicated) Under Title V for federal FY 2006- 2007; Completion of "Children with Special Health Care Needs line item. Page 2 of 2 EXHIBIT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER ELINILIATE ALL INFORMATION APPEARING 1N IIED LIMITED AMENDMENT FOR TASK ORDERS #* 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 ENVIRONMENT, 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 tune of entity) whose address or principal place of business is Street Address, City, State & Zin Code, hereinafter referred to as the "Contractor". FACTUAL RECITALS The parties entered into a Master Contract, dated,******** ** ****, with contract routing number ** *** ***** "the Master Contract") Pursuant to the terms and conditions of the Master Contract, the parties entered into a Task Order Contract, dated ******** ** ****, with contract encumbrance number PO *** ********** and contract routing number ** *** *****., f insert the following if previous amenclment(s), change order(s), renewal(s) have been ,processed: as amended by] [include all previous ameadment(s), change order(s), renewal(s) and their routing numbers, (insert the following if previous antendment(s), change order(s). renewal(s) have been processed: collectively] referred to herein as the "Original Task Order Contract, whereby the Contractor was to provide to the State the following: I Briefly describe what the Contractor was to do under the Original Task Order Contract — indent this paragraph] [Please choose one of tre following four options and delete the other three options not selected] The State promises to (choose one and delete the other] increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars. ($*.**) during the current term of the Original Task Order Contract in exchange for the promise of the Contractor to perform the Ichoose one and delete the other] increased/decreased work under the Original Task Order Contract. Page 1 of 5 w• 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 Task Order Contract for the renewal term of **** years/months, ending on ******** **, ****. The State promises to (choose one anti delete the otherl increase/decrease the amount of funds to be paid to the Contractor by ********** Dollars. ($*.**) for the renewal term of **** ichoose one and delete the otherl years/months, ending on ******** **, ****, in exchange for the promise of the Contractor to perform the )choose one and delete the otherl increased/decreased work described herein. The State hereby exercises a "no cost" change to the [choose those that apply and delete those that don't apply] budget, specifications within the Statement of Work, project management/manager identification, notice address or notification personnel, or performance period within the [choose one and delete the other] current term of the Original Task Order Contract or renewal term of the Original Task Order Contract. NOW THEREFORE, in consideration of their mutual promises to each other, stated below, the parties hereto agree as follows: 1. Consideration for this Limited Amendment to the Original Task Order 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 Task Order Contract, contract routing number ** *** *****, [iusert the following language here if previous amendment(s), change order(s), renewal(s) have been processed) as amended by [include all previous amendment(s), change order(s), renewal(s) and their routing numbers), [insert the following word if previous antendment(s), change order(s), renewal(s) have been pra'ev;std, other• ise delete "collectively"')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 Task Order Contract is and shall be modified, altered, and changed in the following respects only: [Please choose one of the following three options and delete the rave, options not selected] A. [l. se this paragraph when changes to the funding level of the Original Task Order Contract occur during the current terin of the Original Task Order C:ontractl This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment is for the current term of ********* ** Page 2 of 5 • �- EXHIBIT C ****. 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 the following sentence if not applicable in your situation[ The revised Statement of Work is incorporated herein by this reference and identified as "Attachment*". I Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. [lyse this paragraph when the Original Task Order Contract will be renewed for another term] This Limited Amendment is issued pursuant to paragraph 5 of the Original Task Order 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. ($*.**). ['Delete the following sentence if not applicable in your situation] The revised Statement of Work is incorporated herein by this reference and identified as "Attachment *". [Delete the following sentence if not applicable in your situation] The revised Budget is incorporated herein by this reference and identified as "Attachment *". The Original Task Order Contract is modified accordingly. All other terms and conditions of the Original Task Order Contract are reaffirmed. A. (Use this paragraph when there are "no cost changes" to the Budget, the specifications within the original Statement of Work. allowable contract provisions as noted, or performance period.] This Limited Amendment is issugd pursuant to paragraph 5 of the Original Task Order Contract identified by contract routing number ** *** *****. This Limited Amendment [choose those that apply and delete those that don't[ modifies the Budget in [identify location in contractl, modifies the Statement of Work in lidentify 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 Task Order Contract. The revised Ichoose those that apply and delete those that don't] Budget, Statement of Work, project management/manager identification, notice address or notification personnel, or period of performance is incorporated by this reference and identified as. All other terms and conditions of the Original Task Order Contract are reaffirmed. 4. The effective date of this Limited Amendment is **/**�/****, or upon approval of the State Controller, or an authorized delegate thereof, whichever is later. Page 3 of 5 5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General Provisions of the Original Task Order Contract, in the event of any conflict, inconsistency, variance, or contradiction between the terms and provisions of this Limited Amendment and any of the terms and provisions of the Original Task Order Contract, the terms and provisions of this Limited Amendment shall in all respects supersede, govern, and control. The Special Provisions and other terms and conditions of the Master Contract shall always control over other provisions of the Original Task Order Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Master Contract concerning the absence of personal interest of state of Colorado employees and the certifications in the Special Provisions relating to illegal aliens are presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED, BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 4 of 5 EXIHBYr C S IN WITNESS WHEREOF, the parties hereto have executed this Limited Amendment on the day first above written. CONTRACTOR: [LEGAL NAME OF CONTRACTOR] (a political subdivision of the State of Colorado) By: Name: Title: HEALTH FEIN: ATTEST: Because the Contractor is a governmental entity, an attestation is required (Seal, required) STATE: By: STATE OF COLORADO Bill Ritter, Jr. Governor For the Executive Director DEPARTMENT OF PUBLIC AND ENVIRONMENT PROGRAM APPROVAL: By: City, City and County, County, Special District, or Town Clerk or Equivalent I Delete inapplicable lallgluklle I By: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 2430-202 requires that the State Controller approve all state contracts. This limited amendment is not valid until the State Controller, or such assistant as he may delegate, has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below, the State of Colorado may not be obligated to pay for goods and/or services provided. STATE CONTROLLER Leslie M. Shenefelt By: Date: Page 5 of 5 .. �. �. P` „�A �.