CTR077020_Pre-Contract_Docs.pdf

PUR-1031A FORFF (5-24) ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Financial Operations

Office of Procurement

PROCUREMENT ASSISTANCE (PA) REQUEST

1. PROCUREMENT UNIT NAME:

Team Saretha

2. PA NUMBER/SUB-NUMBER:

AzEIP25 / 004

3. REQUEST DATE:

04/21/2025

4. DIVISION/ ADMINISTRATION/PROGRAM:

OOO/AzEIP

5. DIVISION CONTACT PERSON:

AmyAeed

6. TELEPHONE NUMBER:

(602) 471-2452

7. TYPE OF REQUEST/ AGREEMENT (check all that apply):

D Scope of Work Review D Contract (Competitive Award) D Solicitation Iii Direct Contract D Cl /SS /NPTQ Review D Intergovernmental Agreement (IGA) D Amendment__________ D lnteragency Service Agreement (ISA) D Extension Yrs/Mos_______ D Memorandum of Understanding (MOU)

D Task Order

□ IT Agreement/EULA D Set-Aside

□ COOP

D Grant Agreement

D Corrective Action D If Exempt by Statute A.R.S. No.:

D Assignment

□ Other

8. DETAILED DESCRIPTION OF REQUEST OR NEED:

Submit Direct Contract draft scope of work. Additional attachments include: 1) copy of approved Competition Impracticable (Cl24008),

2) partially completed Procurement Compliance Checklist, 3) three PDS 120 forms (Binns, Hale, Aeed), 4) Exhibit B GSR, 5) Exhibit C Service Providing Agency Staffing Roster, 6) Exhibit D Home Visitor Safety Guidance Added: CTR049316 is ending 6/30/2025

9. OTHER DOCUMENTS AND INFORMATION:

D Certificate of Insurance (COi) Compliant and Included Iii If CI/ SS/NPTQ, No.: _c_12_4 _o_o _a ____________ _ D Business Associate Agreement/ Data Sharing Agreement Iii Central Registry Check/Fingerprinting AA 04/21/2025

Sign and Date when Checked

10. FUNDING SOURCE & AMOUNT (check the appropriate boxes): Iii Estimated aggregate spend $499K or less D Estimated aggregate spend $SOOK or more Iii Federal Iii State D Grant D Other

11. DESCRIPTION OF SERVICES OR CONTRACT TITLE:

Early Intervention Services

13. CONTRACTOR NAME/DBA:

The Learning Center for Families dba Root for Kids

15. CONTRACTOR CONTACT PERSON'S NAME AND TITLE:

Suzanne Leonelli - CEO

16. E-MAIL ADDRESS/TELEPHONE NO.:

sleonelli@rootforkids.org and 435.673.5353 x101

17. CONTRACT ORIGINAL START DATE:

19. CONTRACT CURRENT END DATE:

22. LEGAL AD AUTHORIZATION:

12. CONTRACT NUMBER:

14. FEIN NUMBER:

870525653

18.MAXIMUM END DATE: 3/31/2026

20.AMENDED END DATE:

21. SINGLE AUDIT STATUS:

IZI Contractor/Vendor D Subrecipient D N/A

FUNCTION CODE: _________ _ OBJECT CODE: _____ _ DEPARTMENT OBJECT CODE: _____ _

BA SIGNATURE FOR APPROVAL (Legal Ads): ______________________________

23. AUTHORIZATIONS (Signatures, NO Initials) & DATES:

24. AUTHORIZED DIVISION REQUESTOR:

Cna, A/. 8� Apr 24, 2025

26. ATTORNEY GENERAL (/GA, 3rd Party, etc.):

28. PROCUREMENT OFFICER COMMENTS:

25. FINANCIAL SERVICES ADMINISTRATION:

27. PROCUREMENT OFFICER:

CTR077020

7/01/2025 3/31/2026