CMS Estimate for Repairs 57377~1.doc

ESTIMATE INFORMATION

ODOMETER (if applicable):

(manufacturer, model, serial number, feature, etc.)

Page Total: $

Estimate Total (if multiple pages): $

This Estimate must include (1) charges for parts, labor, and diagnostic test(s); (2) description of parts; (3) disclosure of whether parts are new or used; (4) statement of whether repairs are required or suggested; (5) Date, odometer reading (if applicable), and length of time needed to complete repair (if more than one day); and (6) method for calculation of labor cost

ADDITIONAL INFORMATION / REFERENCES / ATTACHMENTS (TO INCLUDE REPAIR WARRANTY INFORMATION) SIGNATURES: The undersigned parties agree to these terms and conditions.

Vendor

State of Illinois Vendor Name:

State Agency:

Signature:

Signature agency representative:

Printed Name:

Printed Name:

Title:

Title:

Date:

Date:

I certify that:

The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

I am a U.S. person (including a U.S. resident alien).

· If you are an individual, enter your name and SSN as it appears on your Social Security Card.

· If you are a sole proprietor, enter the owner’s name on the name line followed by the name of the business and the owner’s SSN or EIN.

· If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s name on the name line and the D/B/A on the business name line and enter the owner’s SSN or EIN.

· If the LLC is a corporation or partnership, enter the entity’s business name and EIN and for corporations, attach IRS acceptance letter (CP261 or CP277).

· For all other entities, enter the name of the entity as used to apply for the entity’s EIN and the EIN.

Name:

Business Name:

Taxpayer Identification Number:

Social Security Number:

or

Employer Identification Number:

Legal Status (check one):

Individual

Governmental

Nonresident alien Sole Proprietor

Estate or trust Partnership

Pharmacy (Non-Corp.)

Legal Services Corporation

Pharmacy/Funeral Home/Cemetery (Corp.)

Tax-exempt

Limited Liability Company Corporation providing or billing medical and/or health care services (select applicable tax classification)

C = corporation Corporation NOT providing or billing medical and/or health care services P = partnership

Signature of Authorized Representative:

Date:

STATE OF ILLINOIS

ESTIMATE FOR REPAIRS

The terms and conditions of this Estimate, including those terms and conditions set forth in the additional documents referenced below, and any continuation sheets, constitute the entire Estimate between the parties with respect to the subject matter of this Estimate. State documents will prevail in the event of a conflict between State and Vendor documents. This Estimate will be:

(1) An itemized estimate separating parts and labor, and materials which the Vendor may not exceed without prior written authorization.

In no event shall the cost exceed the original cost estimate without prior written approval of the CMS Agency Purchasing Officer or Designee. The Vendor shall include the original estimate along with the add-on estimate including parts, labor, and materials

Any repairs exceeding this Estimate must be authorized in writing by the State Agency named in this Estimate prior to Vendor proceeding with such repairs. The Vendor will not invoice the State, nor will the State pay the Vendor, for repairs exceeding this Estimate that Vendor undertakes and/or completes without obtaining the required authorization. Oral authorization is not permitted.

CONTACT INFORMATION

Vendor Name:

Address:

Contact: Phone #:

Email: Fax #:

State Agency Name: Central Management Services/Division of Vehicles

Address: 1104 Eastport Plaza Drive, Collinsville, IL 62234

Contact: Sara Seger Phone #: 618.346.5190

Email: sara.seger@illinois.gov

DATE:

THIS ESTIMATE WILL BE VALID FOR _____ DAYS FROM THE DATE PROVIDED IN THIS SECTION.

ASSOCIATED CONTRACT (if Applicable)

Contract #: 24-416CMS-AGSV4-B-41058

Action: New

Acquisition Type: Small Purchase

Payment Cycle: One-Time Purchase

Terms and Conditions: Standard Terms & Conditions

Subcontracting Allowed: ______ Yes _______No

Approp. Account Code: 41645

Detailed Expenditure Object Code: 1893

Award Code: C

Original Procurement Method: Small Purchase

Subcontractors Utilized? No

Subcontractors Disclosed? No

STATE USE ONLY

Reference Number: 57377

Source Selection Method: Small Purchase

Is Financing Needed? No

Using Agency Funding Source:

Fiscal Year: 2024

Type: State

State of Illinois Estimate for Repairs V3 (3/13/23) Page 1