CHANGE IN CONTRACTOR IDENTITY FORM.docx

COMMONWEALTH OF MASSACHUSETTS

CHANGE IN CONTRACTOR IDENTITY FORM

This Change in Contractor Identity Form is jointly issued by the Executive Office for Administration and Finance (ANF), the Office of the Comptroller (CTR) and the Operational Services Division (OSD) for use by all Commonwealth Departments. Any changes or electronic alterations, by either the Department or the Contractor, to the official printed language of this form as published by ANF, CTR and OSD shall be void. Any transfer of Contract performance to a successor entity must be made consistent with the original procurement, executed contemporaneously with the Contractor change in identity and prior to the current scheduled termination date of the Contract.

Unless otherwise specified, the Department shall complete all information on this Form.

CURRENT CONTRACTOR NAME:

Vendor Code:

DEPARTMENT NAME:

ADDRESS:

ADDRESS:

INDICATE REASON FOR CONTRACTOR IDENTITY CHANGE

The Current Contractor is undergoing a structural change that will result in a change in its Tax Identification Number (TIN). Indicate structural change and resulting change in Contractor identity (e.g., merger, buyout, consolidation, etc.):

A justification statement explaining (a) the Contractor’s Change in Identity; (b) that the transfer of contract performance to the successor entity is consistent with original procurement; (c) and is in the best interest of the Department MUST be included in the Procurement File.

CURRENT CONTRACTOR INFORMATION:

________(Check here if multiple contracts are affected; leave this section blank and attach a completed “Contractor Change Schedule of Multiple Contracts” instead.)

Current Doc. ID Number of Contract Being Amended: __________________________________________

Current Total Contract Dates (Includes Original Contract Start Date and Amendments): START __________TERMINATION ________

Current Total Maximum Obligation of Contract: $ _________________________________ (Inclusive of ALL Previous Amendments)

CURRENT CONTRACTOR AMENDED INFORMATION

_________(Check here if multiple contracts are affected; leave this section blank and attach a completed “Contractor Change Schedule of Multiple Contracts” instead.)

Amended Termination Date of Contract Performance for Current Contractor: TERMINATION DATE: _____________________ Amended Estimated Maximum Obligation for Current Contractor: $________________________ (Reflects total of any obligations to date and final payments to be made. Final payments are based upon actual performance and the Department may adjust this remaining Maximum Obligation with written notice to the Current Contractor without further formal amendment.)

NEW CONTRACTOR (SUCCESSOR ENTITY) NAME:

Vendor Code:

ADDRESS:

NEW CONTRACTOR INFORMATION:

_________ (Check here if multiple contracts are affected; leave this section blank and complete the attached “Contractor Change Schedule of Multiple Contracts” instead.)

Doc. ID for New Contractor: ____________________________________________ (For remaining contract period with New Contractor)

Contract Performance Dates for New Contractor: START: ________________ TERMINATION: ____________________ (Start Date must comply with 801 CMR 21.00 or other applicable law.)

Estimated Maximum Obligation for New Contractor $ _________________________________ (This amount does not include remaining amounts to be paid by the Department to the Current Contractor indicated above. The total maximum obligation, transactions and payments will be based upon actual performance and any final payments made to the Current Contractor and the Department may adjust the Maximum Obligation and transactions accordingly with written notice to the New Contractor without further amendment.)

REQUIRED ADDITIONAL ATTACHMENTS FOR NEW CONTRACTOR

All applicable items below must be completed and executed by the New Contractor if not currently on file.

______ Commonwealth of Massachusetts Substitute W-9 Form, if not currently on file (mandatory) ______ Applicable Commonwealth Terms and Conditions (Standard or for Human and Social Services) is attached or has been filed with the Office of the Comptroller (mandatory) ______ Contractor Authorized Signatory Listing (mandatory) ______ Affirmative Market Program (AMP) Plan (if required under original RFR) ______ SOMWBA MBE/WBE Certification letter (if required under original RFR) ______ Consultant Contractor Mandatory Submission Form (only if Consultant Contract – HH, NN or UU object classes) ______ Written Disclosure of Current and Anticipated Related Parties Pursuant to 808 CMR 1.04 (if required under RFR)

Additional Requirements or Information:

IN WITNESS WHEREOF: The Department certifies that this Contractor Change is necessary for the completion of essential Contract performance and is in the best interests of the Department and is consistent with the original Contract Procurement for this Contract. The Department, the Current Contractor and the New Contractor hereby agree to the terms of this Change in Contractor Identity Form and certify under the pains and penalties of perjury that this Change in Contractor Identity Form and any information contained herein, or attached hereto, is complete and accurate and complies with all applicable laws and regulations, as evidenced by the execution by their authorized signatories which shall be effective as of the last date executed by all the parties below. The New Contractor agrees to perform all of the remaining requirements of this Contract in accordance with the terms, requirements and certifications in the applicable Contract under the original procurement, and any amendments thereto, as filed under the “Current Doc. ID Number of Contract” above, and in accordance with any additional terms or requirements included as part of this Change in Contractor Identity Form.

CURRENT CONTRACTOR: _________________________________ DEPARTMENT: _______________________________________

NAME: ___________________________________________________ NAME: _______________________________________________

TITLE: ___________________________________________________ TITLE: _______________________________________________

DATE: ___________________________________________________ DATE: ________________________________________________

NEW CONTRACTOR:_______________________________________

X:_________________________________________________________ (Signature)

NAME: ____________________________________________________

TITLE: ____________________________________________________

DATE: ____________________________________________________

The Department must file the original record copy of any Change in Contractor Identity Form with the original record copy of the Contract being amended.

INSTRUCTIONS

This form should be used when a Contractor has a material change in identity due to a structural business change such as a merger, buyout, consolidation or other business arrangement, and the Department has chosen to transfer the remaining performance of the Contractor to the successor entity resulting from the identity change (referred to as the “New Contractor”). Please refer to the Guidelines on Material Changes in Contractor’s Identity in the Procurement Information Center procurement policies and procedures for assistance in determining whether a transfer of Contract performance is appropriate.

This single form replaces the need do an amended contract to terminate the current Contract or execute a new Contract for the transfer of remaining Contract performance. This form also serves to document transaction and historical contract identification information to track both current and new Contracts as part of the Contract Procurement File. Both the Current and New Contractor (Successor Entity) execute this Form which is then approved by the Department’s execution of the Form.

If the Change in Identity affects “Multiple” Contracts, please complete information for EACH Contract using the “Contractor Change Schedule of Multiple Contracts.”

Current Contractor Information - As the Contract Appears Before the Contractor Identity Change Current Contractor Name and Address: Enter the name and address of the Current Contractor as it appears on the Contract(s) with the Department before the Contractor Identity Change.

Indicate Reason For Contractor Identity Change: Identify the type of structural business change (such as a merger, buyout, consolidation, etc.) that will result in a change in the Current Contractor’s identity requiring a new Tax Identification Number. (If just the Legal Name of the Contractor is changing, without an underlying business change, this form is not needed. See the Procurement Information Center procurement policies and procedures.

Current Doc. ID of Contract Being Amended: Enter the number which identifies the Current Contract as it appears before the Contractor Identity Change.

Current Total Contract Dates: Enter the effective start and termination dates as these appear on the Current Contract, including any amendments that have previously been made to these dates, before the Contractor Identity Change.

Current Total Maximum Obligation of Contract: Enter the current Maximum Obligation of the Contract (including any amendments that have been made to date) as it appears before the Contractor Identity Change. Enter “N/A” for a contract with no Maximum Obligation, i.e., rate contract, statewide contract or qualified list contract without a Maximum Obligation.

Current Contractor Amended Information - Termination Date and Remaining Payments Under Current Contract Amended Termination Date: Enter the date that the Current Contractor will terminate performance.

Amended Estimated Maximum Obligation for Current Contractor: Enter any amounts that are due or are anticipated to be due to the Current Contractor for completed performance up until the amended Termination Date. Payments are based upon actual performance and may be adjusted by the Department with written notice to the Current Contractor without a formal amendment. Enter “N/A” for a contract with no Maximum Obligation, i.e., rate contract, statewide contract or qualified list contract without a Maximum Obligation.

New Contractor Information - Transfer of Remaining Contract Performance to Successor Entity New Contractor (Successor Entity) Name and Address: Enter the name of the successor entity or resulting entity after the structural business change to the Current Contractor. Enter the Vendor Code number of the new contractor, if known.

Doc. ID for New Contractor: Enter a number which identifies the Contract for the transfer of remaining Contract performance to the New Contractor. There may be instances where the New Contractor is technically not “new” but rather is an existing Contractor with a contract for the same type of services that the department decides to amend to incorporate the transfer of remaining contract performance.

Contract Performance Dates for New Contractor: Enter effective start and termination dates for the transfer of remaining Contract performance to the New Contractor, which must comply with 801 CMR 21.00, other applicable law and the original procurement. Please note that for contracts subject to M.G.L. c.29 s.29A or s.29B, the original Secretariat authorization for services remains valid and no new Contract Encumbrance Document (CT) or Recurring Payment Order Encumbrance Document (RPO) is required.

Estimated Maximum Obligation for New Contractor: Enter the Maximum Obligation for the transfer of remaining Contract performance to the New Contractor. Enter “N/A” for a contract with no Maximum Obligation, i.e., rate contract, statewide contract or qualified list contract without a Maximum Obligation. Payments are based upon actual performance and may be adjusted by the Department with written notice to the New Contractor without a formal amendment.

Attachments: New Contractor must complete all required attachments if not currently on file.

COMMONWEALTH OF MASSACHUSETTS

CHANGE IN CONTRACTOR IDENTITY FORM

Updated 1/23/08 Sensitivity level - low Updated 1/23/08 Sensitivity level - low CHANGE IN CONTRACTOR IDENTITY FORM - CONTRACTOR CHANGE SCHEDULE OF MULTIPLE CONTRACTS (Complete Information Under Each Section for Each Separate Contract. Attach as Many Additional Copies of this Form as Necessary.)

DEPARTMENT______________________________________

The total Maximum Obligation, transactions and payments will be based upon actual performance by the Current and New Contractor and the Department may adjust the Maximum Obligation and transactions accordingly with written notice to the Current and New Contractor (as applicable) without further amendment.

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