Laserfiche WebLink
STATE OF CALIFORNIA — — AGREEMENT NUMBER AMENDMENT NUMBER AGREEMENT SUMMARY 9 S-HEAP-00007 <br />STD 215 (Rev. 08/2017) <br />12, AGREEMENT <br />AGREEMENT <br />TERM <br />FROM <br />TERM <br />THROUGH <br />TOTALCOSTBID, <br />THIS TRANSACTION <br />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)ustlficatton If secondary method is used) Q Use of Master Service Agreement <br />© Invitation for Bid (IFB) ❑ Exempt from Bidding (Give authodty for exempt status) ❑ Safe Source Contract (Attach STD, 821) <br />0 other (Explain) Authorizing legislation provides a predetermined allocation of funds. <br />Note._ Proof of advertisement In the State Contracts Register oren approved form STD. 821, Contract Advertising Examptlon Requaat must be attached <br />14. SUMMARY OF BIDS (List ofbidders, bid amount and smelt buslne&a status) (If an amendment, sole source, or exempt leave blank) <br />N/A <br />15. IF AWARD OF AGREEMENT IS TO OTHER THAN THE LOWER BIDDER, EXPLAIN REASON(S) titan amendment, sole source, arexampt, leave blank) <br />N/A <br />16. WHAT IS THE BASIS FOR DETERMINING THAT THE PRICE OR RATE IS REASONABLE? <br />N/A <br />17a. 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 State Personnel Board has been so notified. ❑ is checked, a Completed JUSTIFICATION - CALIFORNIA CODE OF <br />REGULATIONS, TITLE 2, SECTION 547.60 must be attached t0 this document. <br />Q Not Applicable(Interagency/ Public Works l Other ) <br />17b. EMPLOYEE BARGAINING UNIT NOTIFICATION <br />❑ By checking this box, I hereby certify compliance with Government Code section 19132(b)(1). <br />AUTHORIZED SIGNATURE SIGNER'S NAME (Pdnt or Type) DATE SIGNED <br />N/A NIA NIA <br />FOR AUREEMENTS IN EXCESS OF $5,000. Has the loll <br />been reported to the Department of Fair Employment and <br />[:]No ❑ Yes ❑✓ WA <br />19. HAVE CONFLICT OF INTEREST ISSUES BEEN IDENTIFIED AND RESOLVED L , ❑ No Yes ❑ NIA <br />IS <br />AS REQUIRED BY THE STATE CONTRACT MANUAL SECTION 7.10? Np ❑Yes N/A 23. S THIS A SMALL BUSINESS NI ANDIS <br />20, FOR CONSULTING AGREEMENTS: Did you review any 1 DISABLED VETERAN BUSINESS <br />contractor evaluations on file with the DOS Legal Once? ❑ None on file ❑ No ❑ Yes Q NIA CERTIFIED BY rER <br />21. IS A SIGNED COPY OF THE FOLLOWING ON FILEAT YOUR AGENCY FOR THIS CONTRACTOR? ❑ No ❑ Yes <br />A, Contractor Cemdieation Clauses B. STD 204 Vendor Data Record <br />ElNo ❑ Yes Q WA. ❑ No ❑ Yes ❑ N/A SBIbVBE CentflcN/A Number: <br />N/A <br />24. ARE DISABLED VETERANS BUSINESS ENTERPRISE GOALS <br />REQUIREQ? (If an amendment, explain changes If any) ❑ No (Explain below) ❑ Yes _% of Agreement <br />N/A <br />25. IS THIS AGREEMENT (WITH AMENDMENTS) FORA PERIOD OF TIME <br />LONGER THAN THREE YEARS? No ❑ Yes tlf Yes, provide justification below) <br />N/A <br />1 certify that all copies of the referenced Agreement wilt conform to the original agreement sent to the Department of General Services. <br />SIGN RE NAMEfrITLE (Print or Type) JDATESIGNED/ g <br />jAnna POCIZyn, Starf Services Manager 1I <br />l r <br />