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STATE OF CALIFORNIA <br />AGREEMENT SUMMARY <br />STD 215 (Rev. 08/2017) <br />12, AGREEMENT <br />1 S-HEAP-00007 <br />NUMBER <br />AGREEMENT <br />TERM <br />FROM <br />TERM <br />THROUGH <br />TOTAL COST OF <br />THIS TRANSACTION <br />BID, BOLE SOURCE, EXEMPT <br />Original <br />8/31/2021 <br />EXEMPT <br />Amendment 1 <br />Amendment 2 <br />TOTAL <br />3. BIDDING me THOD USED <br />❑ Request for Proposal (RFP) (Aftach justification If secondarymethod Is used) ❑ Use of Master Service Agreement <br />❑ (nAtaffon for Bid (IFB) ❑ Exempt torn Bidding (Give authority for exempt status) ❑ Sole Source Contract (Attach STO. 821) <br />© Olhsr (Explain) Authorizing legislatiob provides a predetermined allocation of funds. <br />I* SUMMARY OF BIDS (fist ofbldders, bid amount and small business status) (if an amendment, sole Source, or axampt leave blank) <br />N/A <br />15. IF AWARD OF AGREEMENT IS TO OTHER THAN THE LOWER BIDDER, EXPLAIN REASON($) (!fan amendment sole source, eraxempt leave blank) <br />N/A <br />16. WHAT IS THE BASIS FOR DETERMINING THATTHE PRICE OR RATE IS REASONABLE? <br />N/A <br />17n, JUSTIFICATION FOR CONTRACTING OUT (Check one) Contracting out is justified based on Government Code 19130(b), When this box <br />❑ 19130Contracting).T out le based on cast savingsrhas <br />per Government Code ❑ Is checked, a completed JUSTIFICATION-CALIFORNIA CODE OF <br />Not Applicable <br />The State Personnel Board has been Other <br />notified, REGULATIONS, TITLE 2, SECTION 547.60 must be attached to this document. <br />Q Not Applicable(Interagency/Publla WorkslOther ) . <br />17b. EMPLOYEE BARGAINING UNIT NOTIFICATION <br />❑ By checking this box, I hereby certify compliance with Govemment Code section 19132(b)(1). <br />AUTHORIZED <br />N/A <br />(Print or Type) <br />SIGNED <br />— ...1--- ....... ..... i...a.,e .a wa wa, vamm , a. MUUMUU K4 ULU I IUNS ARE <br />been reported to the Departmeni of Fair Employment and Housing? ❑ No ❑ Yes Q WA ATTACHED <br />78. HAVE NIA <br />AS REQUIRED BY THE STATEICT OF INTERSTCONTRACT MANUAL SECTION DRES7.10? OLVED ❑ No ❑ Yes O WA 0 No ❑Yes ❑ 23. THIS A SMALL BUSINESS BUSINESS <br />20. FOR CONSULTING AGREEMENTS: Did you review any A A DISABLED VETERAN BUSINESS <br />contractor evaluations on file with the OGS Legal Oglos? ❑ None on file ❑ No ❑ Yes 0 WA CERTIFIED BY DOS? <br />21. IS A SIGNED COPY OF THE FOLLOWING ON FILE AT YOUR AGENCY FOR THIS CONTRACTOR? No ❑Yes <br />A, Contractor Certification Clauses B. STD 204 Vendor Data Record- <br />❑ No ❑ Yea 0 NIA_ ❑ No ❑ Yea ❑ WA $B/DVBE CeNticN/pion Number: <br />24. ARE DISABLED VETERANS BUSINESS ENTERPRISE GOALS N/A No (Explain below) ❑Yes °h afAgreemenF <br />REQUIREQ? (If an amendment, explain changes If any) <br />26. IS THIS AGREEMENT (WITH AMENDMENTS) FORA PERIOD OF TIME <br />LONGER THAN THREE YEARS? ❑ No ❑ Yes (If Yes, provide justiNcatfon below) <br />NIA <br />I oertify that all copies of the referenced Agreement will conform to the original agreement sent to the Department of General Services. <br />slUry (IL <br />NAMEfTITLE(Print orType) DATE SIGNED 6n <br />GAnna Podzyn,StaffServices Manager 11 rfJq��'lYS <br />