Contract Amendment Cable Contract~1.doc

STATE OF ILLINOIS

CONTRACT AMENDMENT

The undersigned Agency and Vendor, Click here to enter text., (the Parties) agree that the following shall amend the Contract referenced herein. All terms and conditions set forth in the original Contract, not amended herein, shall remain in full force and effect as written. In the event of conflict, the terms of this Amendment shall prevail.

IN WITNESS WHEREOF, the Agency and the Vendor cause this Amendment to be executed on the dates shown below by representatives authorized to bind the respective PARTIES.

VENDOR

Date:

STATE OF ILLINOIS

City, State ZIP: Springfield, IL 62794

Printed Name: Jared Brunk

Official’s Title: Deputy Director of Finance

Legal Printed Name: Click here to enter text.

Legal’s Title: Click here to enter text.

Fiscal’s Printed Name: Click here to enter text.

Fiscal’s Title: Click here to enter text.

STATE USE ONLY

NOT PART OF CONTRACTUAL PROVISIONS

PBC# 16-96396

Project Title IL River Cable TV Contract Amendment #69IBF1103 Contract #19-426-DOC-ILRIV-P-8633

Procurement Method (IFB, RFP, Small, etc): IFB

IPB Ref. #22020699

IPB Publication Date:

1-26-11

Award Code:

A

Subcontractor Utilization? X Yes No

Subcontractor Disclosure? Yes X No

Funding Source

CIBF

Obligation # 69IBF1103

CPO 33 – General Counsel Approval:

Signature

Printed Name

Date

1. CONTRACT DESCRIPTION (including Original Purchase Order or Contract Number): To amend the cable television contract for Illinois River Correctional Center PBC#16-96396 Bid Buy Contract #19-426-DOC-ILRIV-P-8633 to add .

2. CHANGE ORDER: Is this amendment a change order as defined in 30 ILCS 500/1-15.12 and 720 ILCS 5/33E?

FORMCHECKBOX

Yes No

3. DESCRIPTION OF AMENDMENT (Check all that apply, complete blanks and explain as necessary):

3.1. The completion date will be extended, shortened or FORMCHECKBOX remain the same.

3.1.1. Original completion date: 03-10-2021.

3.1.2. Revised completion date: Click here to enter a date..

3.2. The method of determining compensation (e.g., hourly rate, fixed fee, etc.) will stay the same or FORMCHECKBOX change as follows: the current monthly payment is 4,053.84 through 3-10-20, under the amended contract that will increase to 7,743.84 per month. The current contract states that the monthly payment from 3-10-20 through 3-10-21 will be 4,160.24, under the amended contract that will increase to 8,131.03. There is a 5% incremental increase in the original contract. The year 9 total will increase from 48,646.08 to 67,096.08. The year 10 total will increase from 49,922.88 to 97,572.36. Total contract increase amount of 66,099.48.

3.3. The cost will be FORMCHECKBOX

increased, decreased or remain the same.

3.3.1. Original cost: $

465,138.33

3.3.2. Amount of change: 66,099.48

3.3.3. Revised cost: 531,237.81

3.4. The supplies or services to be provided will stay the same or FORMCHECKBOX be changed as follows: Addition of 14 channels to include: BET, VH1, CMT, Fox News, FX Movies, Travel, Food Network, Investigative Discovery, Comdedy, FUSE, Big Ten Network, CBS Sports Network, Guide us TV, AMC. Addition of these channels will add 3690.00 to the monthly cost for approximately the first 5 months, and 3874.50 per month for the final 12 months of the contract, adding a total of 66,099.48 to the contract that was originally 465,138.33.

3.5. Subcontractors are being added, deleted, or FORMCHECKBOX remain the same?

· Subcontractor Name: Click here to enter text.

added deleted Amount to be paid: Click here to enter text.

Address: Click here to enter text.

Description of work: Click here to enter text.

· Subcontractor Name: Click here to enter text.

added deleted Amount to be paid: Click here to enter text.

Address: Click here to enter text.

Description of work: Click here to enter text.

3.5.1. All contracts with the subcontractors identified above must include the Standard Certifications and Financial Disclosures and Conflicts of Interest completed and signed by the subcontractor.

3.5.2. If the annual value of any of the subcontracts is more than $50,000, then the Vendor must provide to the State the Financial Disclosures and Conflicts of Interest for that subcontractor.

3.5.3. If the subcontractor is registered in the Illinois Procurement Gateway (IPG) and the Vendor is using the subcontractor’s Standard Certifications or Financial Disclosures and Conflicts of Interest from the IPG, then the Vendor must also provide a completed Forms B for the subcontractor.

3.5.4. If at any time during the term of the Contract, Vendor adds or changes any subcontractors, Vendor will be required to promptly notify, in writing, the State Purchasing Officer or the Chief Procurement Officer of the names and addresses and the expected amount of money that each new or replaced subcontractor will receive pursuant to the Contract. Any subcontracts entered into prior to award of the Contract are done at the Vendor’s and subcontractor’s risk.

4. EFFECTIVE DATE OF AMENDMENT: Upon final signature.

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: Click here to enter text.

Business Name: Friendship of Cable of Texas, Inc DBA Correctional Cable .

Taxpayer Identification Number:

Social Security Number:

or

Employer Identification Number : 75-2237583 Legal Status (check one):

Individual

Governmental

Sole Proprietor

Nonresident alien

Partnership

Estate or trust

Legal Services Corporation

Pharmacy (Non-Corp.)

Tax-exempt

Pharmacy/Funeral Home/Cemetery (Corp.)

Corporation providing or billing

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

FORMCHECKBOX

Corporation NOT providing or billing C = corporation medical and/or health care services P = partnership Signature of Authorized Representative:

Date: Click here to enter a date State of Illinois Chief Procurement Office

Contract Amendment with Certifications (< $50K) V.15.2

State of Illinois Chief Procurement Office

Contract Amendment with Certifications (< $50K) V.15.2