FULL AGENDA PACKET_2021-04-06 - Laserfiche WebLink

Home Browse Search

/ EXHIBIT 1 STAT[ OF CALIFORNIA A AGREEMENT NUMBER AMHNDMENT NUMBER AGREEMENT SUMMARY STO 215 (Rev.08/2017) 18-HEAP-00007 12, AGREEMENT ' ..................... r.._._.__. _._ ....... _. ...... AGREEMENT TERM TERM 70TAL COST OF BID, SOLE SOURCE, EXEMPT FROM THROUGH THIS TRANSACTION Original 8/31/2021 EXEMPT Amendment 1 Amendment 2 TOTAL 13. BIDDING METHOD USED ❑ Request for Proposal (RFP) (Attach justification If secondary method is used) ❑ Use of Master Service Agreement ❑ invitation for Bid (IFB) ❑ Exempt from Bidding (Give authority for exempt status) ❑ Sole Source Contract (Attach STD. 621) ❑J Other (Explain) Authorizing legislation provides a predetermined allocation of funds. . ..._.................... ...... Note: Proof of adverdaament in the State Contracts Register or an approved form STD. 821, Contract Advertising Exemption Request, must he attached 14. SUMMARY OF BIDS (List orbidders, bid amount and small business status) (If an amendment. sole source, or exemp( leave blank) N/A IS- IF AWARD OF AGREEMENT IS TO OTHER THAN THE LOWER BIDDER, EXPLAIN REASON(S) {lf en amendment, sole source, or exempt, leave blank) N/A 16. WHAT IS THE BASIS FOR DETERMINING THAT THE PRICE OR RATE IS REASONABLE? N/A 17a. JUSTIFICATION FOR CONTRACTING OUT (Check one) Contracting out is Justified based on ❑ GoverrvnCAent Code 19130(b). When this box Contracting out is based on cost savings per Government Code 19130(a). The State Personnel Board has been so notified. ❑ checked, a completed JUSTIFICATION - REGULATIONS, TITLE 2, SECTION 547.60 mustust be be CODE OF a tta attached to this document. ❑J Net Applicable (Interagency / Public Works I Other ) 17b. EMPLOYEC BARGAINING UNIT NOTIFICATION ❑ By checking this box,/ hereby certify compliance with Government Code section 19132(b)(1). AUTHORIZED SIGNATURE ISIGNERS NAME (Print or Type) DATE SIGNED N/A N/A N/A 18 been reported to the.Departme t of AGREEMENTS IN EXCESS F it Employmen and $5.000. Has the [citing of the agreement ❑ ❑ O WA 22. REQUIRED RESOWTIONS ARE No Yes ATTACHED 19. HAVE AS REQUNFLICT IRED E BYOF INTEREST ISSUES BEEN IDENTFIED THE STATE CONTRACT MANUAL SIECTIOND ROE? OLVED ❑ No ❑ Yes © N/A ®No ❑Yes [� N/A 23. IS THIS A SMALL BUSINESS AND/OR 20, FOR CONSULTING AGREEMENTS: Did you review any None on file ©No ❑Yes ❑J N/A A DISABLED VETERAN BUSINESS contractor evaluations on file with the DGS Legal OfOee? CERTIFIED BY DO$? .. _.... _.................. ...................... 21. IS A SIGNED COPY OF THE FOLLOWING ON FILE AT YOUR AGL-'NCY FOR THIS CONTRACTOR? ❑ No ❑ Yea A, Contractor Certification Clauses R STD 204 Vendor Data Record ❑ No ❑ Yes El] NIA El No ❑ Yea C J N/A SB OVBE CertificationNNumber. 24. ARE DISABLED VETERANS BUSINESS ENTERPRISE GOALS ❑ No {Explain detnwJ ❑Yes 9'0 of Agreement REQUIRED? (If an amendment, explain changes if any) N/A 26. IS THIS AGREEMENT' (WITH AMENDMENT`S) FOR A PERIOD OF TIME No Yes (If Yea, provide LONGER THAN THREE YEARS? ❑ ❑ p justification below) N/A I c ertify that all copies of the referenced Agreement wilt conform to the original agfeement sent to the Deparhnent of Genoral Services. SIGN RE NAMEI HTLE (Print or Type) DATE SIGNED g/� Anna Podxyn, Staff Services Manager II23 y ....... �o I..... �.�.....................__. _ ._... r