CTR077023_Pre-Contract_Documents.pdf
PDF 5 MB Posted
- Attached to
- Master Agreement AZ|CTR077023
- Contract number
- CTR077023
- Issued by
- Arizona
About this file
This is a Procurement Assistance (PA) Request from the Arizona Department of Economic Security, specifically the Division of Financial Operations and Office of Procurement. The document involves a direct contract with Northland-Rural Therapy Associates LLC for the Arizona Early Intervention Program (AzEIP), located in Flagstaff, Arizona. The contract involves Team Saretha and is associated with PA Number AzEIP25/005, submitted on 04/21/2025.
The contract is for Early Intervention Services, with an original start date of 07/01/2025 and a maximum end date of 03/31/2026. The estimated aggregate spend is less than $499,000, funded through both federal and state sources. The contractor, Northland-Rural Therapy Associates LLC, has a FEIN of 861105135, and the primary contact is Shannon Cosner, the Business Manager/Owner. The contract number is CTR077023, and the company is based in Flagstaff, Arizona. Additional documentation includes a Competition Impracticable form (CI24008), Procurement Compliance Checklist, PDS 120 forms, and various exhibits detailing service providing agency staffing and home visitor safety guidance.
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Text version
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 / 005
3. REQUEST DATE:
04/21/2025
4. DIVISION/ ADMINISTRATION/PROGRAM:
OOO/AzEIP
5. DIVISION CONTACT PERSON:
Amy Aeed
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
9. OTHER DOCUMENTS AND INFORMATION:
D Certificate of Insurance (COi) Compliant and Included Iii If CI/ SS/NPTQ, No.: _c_12_ 4_o_0 _8 ____________ _ D Business Associate Agreement/ Data Sharing Agreement Iii Central Registry Check/Fingerprinting AA 04/21/2025
10. FUNDING SOURCE & AMOUNT (check the appropriate boxes):
Iii Federal Iii State D Grant D Other
11. DESCRIPTION OF SERVICES OR CONTRACT TITLE:
Early Intervention Services
13. CONTRACTOR NAME/DBA:
Northland-Rural Therapy Associates LLC
15. CONTRACTOR CONTACT PERSON'S NAME AND TITLE:
Shannon Cosner - Business Manager/Owner
16. E-MAIL ADDRESS/TELEPHONE NO.:
s_cosner@yahoo.com and 928. 779.1679 or 928.225.5457
Sign and Date when Checked
Iii Estimated aggregate spend $499K or less D Estimated aggregate spend $SOOK or more
12. CONTRACT NUMBER:
14. FEIN NUMBER:
861105135
17. CONTRACT ORIGINAL START DATE: 07/01/2025
19. CONTRACT CURRENT END DATE:
18.MAXIMUM END DATE: 03/31/2026
20.AMENDED END DATE:
21. SINGLE AUDIT STATUS:
IZI Contractor/Vendor D Subrecipient D N/A
22. LEGAL AD AUTHORIZATION:
FUNCTION CODE: _________ _ OBJECT CODE: _____ _ DEPARTMENT OBJECT CODE: _____ _
BA SIGNATURE FOR APPROVAL (Legal Ads): ______________________________
23. AUTHORIZATIONS (Signatures, NO Initials) & DATES:
24. AUTHORIZED DIVISION REQUESTOR: 25. FINANCIAL SERVICES ADMINISTRATION:
t11a gf1111s 4/21 /Zs Ena Binns 4/21/25 {Apr 21, 2025 D:59 PO I j
26. ATTORNEY GENERAL (/GA, 3rd Party, etc.): 27. PROCUREMENT OFFICER:
28. PROCUREMENT OFFICER COMMENTS:
CTR077023
03/31/2026
| AZEIP TBEIS PDS |
| AA AZEIP PDS |
| Binns AZEIP PDS |
| CTR077023 Debarment Check |
| NRTALLC ACC |
| NRTALLC OIG |
| NRTALLC Sam.gov |
| SPO Debarment |
File details come from the government source that posted it. Updated .