435252-O19-786DLDOOR-02 R3.pdf

Revision: 12/2/2020 (previous versions obsolete)

Wisconsin Department of Health Services

Contract Centralization Legal Review

Agreement Number:

Bureau of Procurement and Contracting (BPC) Review:

This agreement uses a BPC template with Office of Legal Counsel (OLC) approved language.

This agreement uses intergovernmental cooperative purchasing.

OLC Review Required:

This agreement does not use a BPC template with Office of Legal Counsel (OLC) approved language or uses a BPC template with requested language changes.

Description:

Office of Legal Counsel (OLC) Review and Approval:

This agreement has been reviewed and approved by the Wisconsin Department of Health

Services Office of Legal Counsel.

Name: Date Signed

Title:

DocuSign Envelope ID: 1257A773-03C8-488C-B141-9177101C2F68

435252-O19-786DLDOOR-02 R3

Office of Legal Counsel

X

Please indicate any information that will help the OLC reviewer recall the result of the review of this document.

X

6/15/2022

Cody Wagner

Revision: 7/27/2020 (previous versions obsolete)

CONTRACT FOR GOODS

between

State of Wisconsin Department of Health Services (DHS) and

Sentry Security Fasteners for

Detention Lock

This Contract is between the State of Wisconsin Department of Health Services (DHS), at 1 West Wilson Street, Madison, Wisconsin 53703, and Sentry Security Fasteners at 8208 North University Street, Peoria, IL. With the exception of the terms being modified by this Contract modification, all other terms and conditions of the existing contract, including funding, remain in full force and effect. This Modification, including any and all attachments herein and the existing contract, collectively, are the complete contract of the parties and supersede any prior contracts or representations. DHS and the Contractor acknowledge that they have read the Modification and understand and agree to be bound by the terms and conditions of the existing contract as modified by this action. This Modification becomes null and void if the time between the earlier dated signature and the later dated signature exceeds sixty (60) days, unless waived by DHS.

Contract ID Number: 435252-O19-786DLDOOR-02 R3

DOA Contract Number: 435505-W23-FJC1195-00

Contract Amount: Not to Exceed $55,000.00

Contract Term: 7/1/2022-12/31/2022

Optional Renewal Terms: None

DHS Division: DCTS

DHS Contract Administrator: Lana Warwick

DHS Contract Manager: Robert Stanley

Contractor Contract Administrator: Thomas E. Ferre

Contractor Telephone: 888-693-2646 x112

Contractor Email: tom@sentrysf.com

Modification Description: Contract extension term 7/1/2022 to 12/31/2022. All other terms remain the same.

Revision: 7/27/2020 (previous versions obsolete)

State of Wisconsin Contractor

Department of Health Services Contractor Name:

Authorized Representative Authorized Representative

Name:

Name:

Title: Title:

Signature: Signature:

Date: Date:

SUPPLIER DIVERSITY AMENDMENT

The Wisconsin Department of Health Services (DHS) and Contractor agree to the below change to the Agreement. The below Agreement amendment is hereby incorporated by reference into the

Agreement and is enforceable as if restated therein in its entirety.

The Agreement is hereby amended by incorporating and adding the following Section:

SUPPLIER DIVERSITY AND REPORTING REQUIREMENTS

Minority-Owned Business Enterprises (MBE) and Disabled Veteran-Owned Businesses (DVB) are certified by the

Wisconsin Department of Administration (DOA). This program can be found at:

https://doa.wi.gov/Pages/DoingBusiness/SupplierDiversity.aspx

The State of Wisconsin is committed to the promotion of MBEs and DVBs in the State's purchasing program. The

Contractor is strongly urged to use due diligence to further this policy by awarding Subcontracts to MBEs and

DVBs or by using such enterprises to provide goods and services incidental to this Agreement.

The Contractor shall furnish appropriate monthly information about its efforts to subcontract with MBEs and

DVBs, including the identities of such businesses certified by the Wisconsin Supplier Diversity Program, their contract amount, and spend for each period to DHS. A listing of certified MBEs and DVBs, as well as the services and goods they provide, is available at: https://wisdp.wi.gov/Search.aspx

In accordance with WI Stats. Ch. 16.75 (3m), after completion of this contract, the Contractor shall report to DHS any amount of this contract that was subcontracted to DOA certified MBEs and DVBs.

DHS shall have the right to request any information regarding the use of subcontractors including, but not limited to, MBEs and DVBs. The Contractor shall provide any such information as requested by DHS and within a time period that is specified by DHS.

The Contractor shall submit monthly reports of efforts to subcontract with MBEs, DVBs, and other diverse entities/suppliers to DHS. A link to the Supplier Diversity PowerForm for submitting these reports can be found on the DHS Compliance Documentation page found here: https://www.dhs.wisconsin.gov/business/compliance.htm

For the duration of this Agreement, the Contractor shall provide monthly reporting of efforts to subcontract with

MBEs and DVBs no later than the 15th of the following month.

For questions about reporting, please contact DHS Contract Compliance at

DHSContractCompliance@dhs.wisconsin.gov

Sentry Security Fasteners, Inc

President

Thomas E. Ferre

6/16/2022

Assistant Administrator DCTS

6/16/2022

Holly Audley https://doa.wi.gov/Pages/DoingBusiness/SupplierDiversity.aspx https://wisdp.wi.gov/Search.aspx https://www.dhs.wisconsin.gov/business/compliance.htm mailto:DHSContractCompliance@dhs.wisconsin.gov

CERTIFICATION REGARDING LOBBYING

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, 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 any Federal

Contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal Contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal 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, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal Contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including Subcontracts, subgrants, and Contracts under grants, loans and cooperative agreements) and that all subrecipients 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. Submission of 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.

(Signature of Official Authorized to Sign Application) (Date)

(Print Name) (Title)

(Agency / Contractor Name) (Title of Program)

DHS 435252-O19-786DLDOOR-02 R3

Disclosure of Lobbying Activities (Standard Form-LLL)

PresidentThomas E. Ferre

6/16/2022

DEPARTMENT OF HEALTH SERVICES

Division of Enterprise Services F-01788 (03/2022)

STATE OF WISCONSIN

CERTIFICATION REGARDING DEBARMENT AND SUSPENSION

Federal Executive Order (E.O.) 12549 “Debarment“ requires that all contractors receiving individual awards, using Federal funds, and all subrecipients certify that the organization and its principals are not debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency from doing business with the Federal Government. By signing this document you certify that your organization and its principals are not debarred. Failure to comply or attempts to edit this language may disqualify your bid. Information on debarment is available at www.sam.gov.

Your signature certifies that neither you nor your principal is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

SIGNATURE – Official Authorized to Sign Application Date Signed

For (Name of Vendor) Unique Entity Identifier (UEI), if applicable

INTERNAL USE ONLY

Contract #:

Contract Description:

The Office/Division of has searched the above named Vendor against the System for Award Management system (SAM) and has confirmed as of Date the Vendor is not debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency from doing business with the Federal Government.

SIGNATURE – Contract Administrator Date Signed

806057105

6/16/2022 http://www.sam.gov/

Certificate Of Completion Envelope Id: 1257A77303C8488CB1419177101C2F68 Status: Completed

Subject: RUSH DHS - Sentry Security Fasteners - Detention Lock - 435252-O19-786DLDOOR-02 R3

Source Envelope:

Document Pages: 5 Signatures: 5 Envelope Originator:

Certificate Pages: 5 Initials: 0 Mark Zeihen

AutoNav: Enabled

EnvelopeId Stamping: Enabled

Time Zone: (UTC-06:00) Central Time (US & Canada)

1 West Wilson St.

Madison, WI 53703 mark.zeihen1@dhs.wisconsin.gov

IP Address: 165.189.255.23

Record Tracking Status: Original

6/14/2022 11:01:53 AM

Holder: Mark Zeihen mark.zeihen1@dhs.wisconsin.gov

Location: DocuSign

Security Appliance Status: Connected Pool: StateLocal

Storage Appliance Status: Connected Pool: DHS Location: DocuSign

Signer Events Signature Timestamp Cody Wagner

CodyW.Wagner@dhs.wisconsin.gov

Office of Legal Counsel

Wisconsin Department of Health Services

Security Level: Email, Account Authentication (None)

Signature Adoption: Uploaded Signature Image

Signed by link sent to

CodyW.Wagner@dhs.wisconsin.gov

Using IP Address: 165.189.255.23

Sent: 6/14/2022 11:06:01 AM

Viewed: 6/15/2022 5:06:04 PM

Signed: 6/15/2022 5:15:17 PM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

Thomas E. Ferre tom@sentrysf.com

President

Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style

Signed by link sent to tom@sentrysf.com

Using IP Address: 73.50.177.230

Sent: 6/15/2022 5:15:19 PM

Viewed: 6/16/2022 9:09:39 AM

Signed: 6/16/2022 11:37:25 AM

Electronic Record and Signature Disclosure:

Accepted: 6/16/2022 9:09:39 AM ID: ac5518ab-c480-4d52-88a7-1bdf7fcccb0c

Holly Audley hollyo.audley@dhs.wisconsin.gov

Assistant Administrator DCTS

Division of Care and Treatment Services

Signing Group: DCTS Authorized Signatory

Security Level: Email, Account Authentication (None)

Signature Adoption: Pre-selected Style

Signed by link sent to hollyo.audley@dhs.wisconsin.gov

Using IP Address: 165.189.255.23

Sent: 6/16/2022 11:37:27 AM

Viewed: 6/16/2022 11:38:54 AM

Signed: 6/16/2022 11:38:59 AM

Electronic Record and Signature Disclosure:

Accepted: 12/20/2018 8:33:44 AM ID: 787edf75-1d5b-47a3-b918-902af7757358

In Person Signer Events Signature Timestamp

Editor Delivery Events Status Timestamp

Agent Delivery Events Status Timestamp

Intermediary Delivery Events Status Timestamp

Certified Delivery Events Status Timestamp

Carbon Copy Events Status Timestamp Lana Warwick

Lana.Warwick@dhs.wisconsin.gov

Security Level: Email, Account Authentication (None)

Sent: 6/14/2022 11:06:01 AM

Electronic Record and Signature Disclosure:

Accepted: 6/13/2022 2:56:39 PM ID: 2fdee335-fd04-460b-9b3c-7ef7cb007e4a

Kersten Simon

Kersten.Simon@dhs.wisconsin.gov

Budget and Policy Analyst

Wisconsin Department of Health Services

Security Level: Email, Account Authentication (None)

Sent: 6/14/2022 11:06:01 AM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

DCTS Contracts

DHSDCTSContracts@dhs.wisconsin.gov

DCTS Contracts Inbox

Wisconsin Department of Health Services

Security Level: Email, Account Authentication (None)

Sent: 6/16/2022 11:39:01 AM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

DHS BPC Purchasing

DHSBPCPurchasing@dhs.wisconsin.gov

Security Level: Email, Account Authentication (None)

Sent: 6/16/2022 11:39:01 AM

Electronic Record and Signature Disclosure:

Accepted: 5/26/2022 1:45:49 PM ID: 3ea1cfb0-c623-46e8-85cb-30312dfde467

Witness Events Signature Timestamp

Notary Events Signature Timestamp

Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 6/14/2022 11:06:01 AM

Certified Delivered Security Checked 6/16/2022 11:38:54 AM

Signing Complete Security Checked 6/16/2022 11:38:59 AM

Completed Security Checked 6/16/2022 11:39:01 AM

Payment Events Status Timestamps

Electronic Record and Signature Disclosure

ELECTRONIC RECORD AND SIGNATURE DISCLOSURE

From time to time, Wisconsin Department of Health Services (we, us or Company) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the

DocuSign system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to this Electronic Record and

Signature Disclosure (ERSD), please confirm your agreement by selecting the check-box next to

‘I agree to use electronic records and signatures’ before clicking ‘CONTINUE’ within the

DocuSign system.

Getting paper copies

At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after the signing session and, if you elect to create a DocuSign account, you may access the documents for a limited period of time

(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to send you paper copies of any such documents from our office to you, you will be charged a

$0.00 per-page fee. You may request delivery of such paper copies from us by following the procedure described below.

Withdrawing your consent

If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below.

Consequences of changing your mind

If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to receive required notices and consents electronically from us or to sign electronically documents from us.

All notices and disclosures will be sent to you electronically

Electronic Record and Signature Disclosure created on: 12/19/2018 8:24:51 AM Parties agreed to: Thomas E. Ferre, Holly Audley, Lana Warwick, DHS BPC Purchasing

Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you through the DocuSign system all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given

us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us.

How to contact Wisconsin Department of Health Services:

You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows:

To contact us by email send messages to: DHSContractCentral@dhs.wisconsin.gov

To advise Wisconsin Department of Health Services of your new email address

To let us know of a change in your email address where we should send notices and disclosures electronically to you, you must send an email message to us at DHSContractCentral@dhs.wisconsin.gov and in the body of such request you must state: your previous email address, your new email address. We do not require any other information from you to change your email address.

If you created a DocuSign account, you may update it with your new email address through your account preferences.

To request paper copies from Wisconsin Department of Health Services

To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must send us an email to DHSContractCentral@dhs.wisconsin.gov and in the body of such request you must state your email address, full name, mailing address, and telephone number. We will bill you for any fees at that time, if any.

To withdraw your consent with Wisconsin Department of Health Services

To inform us that you no longer wish to receive future notices and disclosures in electronic format you may:

i. decline to sign a document from within your signing session, and on the subsequent page, select the check-box indicating you wish to withdraw your consent, or you may;

ii. send us an email to DHSContractCentral@dhs.wisconsin.gov and in the body of such request you must state your email, full name, mailing address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process..

Required hardware and software

The minimum system requirements for using the DocuSign system may change over time. The current system requirements are found here: https://support.docusign.com/guides/signer-guide-signing-system-requirements.

Acknowledging your access and consent to receive and sign documents electronically

To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please confirm that you have read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for your future reference and access; or (ii) that you are able to email this ERSD to an email address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format as described herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before clicking ‘CONTINUE’ within the DocuSign system.

By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm that:

You can access and read this Electronic Record and Signature Disclosure; and

You can print on paper this Electronic Record and Signature Disclosure, or save or send this Electronic Record and Disclosure to a location where you can print it, for future reference and access; and

Until or unless you notify Wisconsin Department of Health Services as described above, you consent to receive exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you by Wisconsin Department of Health Services during the course of your relationship with Wisconsin Department of Health Services.

https://support.docusign.com/guides/signer-guide-signing-system-requirements https://support.docusign.com/guides/signer-guide-signing-system-requirements

SUPPLIER DIVERSITY AND REPORTING REQUIREMENTS