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STATE OF CALIFORNIA e =AGREIMENT NUMBER AMENDMENTNUMBER <br />AGREEMENT SUMMARY <br />STD 215 (Rey.08/2017) EAP-00007 <br />12. AGREEMENT <br />AGREEMENT <br />TERM <br />FROM <br />TERM <br />THROUGH <br />TOTAL COST OF <br />THIS TRANSACTION <br />BID, SOLE SOURCE, EXEMPT <br />Original <br />8/31/2021 <br />EXEMPT <br />Amendment 1 <br />Amendment 2 <br />TOTAL <br />❑ Request for Proposal (RFP) (Attach justification 1f secondsty method is used) ❑ Use of Master Service Agreement <br />❑ Invitation for Bid (IFB) ❑ Exempt from Bldding (Give authority for exempt status) ❑ Sole Source Contract (Attach STD. 821) <br />❑✓ other (EkplaM) Authorizing Iegisladoh provides a predetermined allocation of funds. <br />% SUMMARY OF BIDS (Ust ofbldders, bid amount and small business status) (If an amendment, sole source <br />N/A , or exempt leave blank) <br />15, IF AWARD OF AGREEMENT IS TO OTHER THAN THE LOWER BIDDER, EXPLAIN REASON(S) (Ifan amendment, sole source, or exempt leave blank) <br />N/A <br />16. WHAT IS THE BASIS FOR DETERMINING THAT THE PRICE OR RATE IS REASONABLE? <br />N/A <br />178. JUSTIFICATION FOR CONTRACTING OUT (Check one) - <br />Contracting out is based on cost savings per Government Code Contracting out Is justified based on Government Code 19130(b). When this box <br />❑ 19130(a). The Slate Personnel Board has been so notified. ❑ Is checked, a completed JUSTIFICATION _ CALIFORNIA CODE OF <br />REGULATIONS, TITLE 2, SECTION 647.60 must be attached to this document <br />✓❑ Not Appltcable (Interagency f Public Works / Other ) <br />17b. EMPLOYEE BARGAINING UNIT NOTIFICATION <br />❑ By checking this box, ! hereby certify compliance with Goverment Code section 19132(b)(1). <br />AUTHORIZED SIGNATURE SIGNER'S NAME (Print or type) DATESIGNED <br />N/A N/A N/A <br />,n ... ,....,,v,,,.,...,.,. cc. n WW1MMUMMVLU1[U Z5AI <br />boen reported to the Department of Fair Employment and Housing? No Ye ❑✓ WA ATTACHED <br />HAVE CONFLICT OF INTEREST ISSUES BEEN IDENTIFIED AND RESOLVED L+ I No Yea N/ No ❑ Yes ❑ NiA <br />AS REQUIRED BY THE STATE CONTRACT MANUAL SECTION 7.10? El No ❑✓ A .,, m ,,,, . ...... .......... <br />zU. ma you review any A DISABLED VETERAN BUSINESS <br />contractor evaluations on file with the DGS Legal Office? ❑ None on file ❑ No ❑ Yes 0 N/A CERTIFIED BY DGS? <br />21. IS A SIGNED COPY OF THE FOLLOWING ON FILE A7YGUR AGENCY FOR THIS CONTRACTOR? ❑ No ❑ Yes <br />A, Contractor Certification Clauses B. STD 204 Vendor Data Record <br />❑ No ❑ Yes 0 NIA_ ❑ No ❑ Yes ❑ NIA SBIbVBE Certification Number: <br />_ N/A <br />24. ARE DISABLED VETERANS BUSINESS ENTERPRISE GOALS - Na (Explain below) Yes %oFAgreement <br />REQUIRE[)? Of an amendment, explain changes if any) ❑ ❑ <br />N/A <br />26, IS THIS AGREEMENT (WITH AMENDMENTS) FORA PERIOD OF TIME Na Yes !f Yes, provide LONGER THAN TI4REE YEARS? - ❑ ❑ ( p justification below) <br />N/A <br />I certify that aN copies of the referenced Agreement will conform to the original agreement sent to the Department of General Services. <br />SIGN RE NAMEITITLE(Pdntor Type) DATE SIGNED/ <br />Anna Podzyn, Staff Services Manager ll ( <br />G <br />