DMH SOW template Guardianship RFR final1-23.docx

Commonwealth of Massachusetts Department of Mental Health Statement of Work

PROJECT Rate or HOURLY Fixed Price or COST Reimbursement DMH Master Agreement MMARS Doc. ID_______________________ DMH Contract/SOW MMARS Doc ID: __________________________

|_| New |_| Continuation |_| Amended

Vendor Name:

Contract Manager Name:

Email:

Phone Number:

DMH Contract Manager Name:

Email:

Phone Number:

New Dates of Service:

Start Date: End Date:_________*(Drafter – specify a date or “June 30, 2033, or upon the date of the first to the following 2 events to occur (1) termination of the vendor’s court appointment (described below) as Fiduciary or (2) termination of the vendor’s DMH Contract.”)

Continuation Original Start Date: Current End Date:

New End Date: (Drafter – specify a date or “June 30, 2033, or upon the date of the first to the following 2 events to occur (1) termination of the vendor’s court appointment (described below) as Fiduciary or (2) termination of the vendor’s DMH Contract.”)

Name of Person-Served:

Required Guardship Service:

__ Temporary Guardian __ Guardian __ Temporary Conservator __ Conservator

Court Information Probate Court:_______________________ Case Number: _______________________ Date of Appointment:__________________ Copy of Appointment ____ Attached

Legal Office Contact/Responsible for Monitoring DMH Legal Office responsible for the Legal case:_________________________ Assistant General Counsel:___________________________________________ Phone #:____________________________ Email:________________________ Paralegal_______________________________________________________________ Phone #:____________________________ Email:________________________

Services are to be provided as specified in the above Reference RFR and Contract and the Court Appointment: Additional terms and conditions: ___ Yes __No. IF yes, please state additional terms and conditions here:

Available Annual funding Summary

The Contractor may bill up to the following amount per state fiscal year:

Hours:

_____ hours of Service (note to drafters need the approval of the office General Counsel for more than 20 hours a Fiscal Year. THE SOW can be amended if more are needed, but again approval of the office of the General Counsel will be needed. The amendment must be executed before any extra hours can be billed. Hours x $60___= _______________

Mileage and Ancillary Costs:

Cannot exceed $150.00 per State Fiscal Year, unless agreed to by the Office of the DMH General Counsel and the SOW is amended before any additional cost are incurred

Travel Time:

Cannot exceed $200.00 per State Fiscal Year unless agreed to by the Office of the DMH General Counsel and the SOW is amended before any additional cost are incurred.

Estimated Total Amount per State Fiscal Year: $____________________* This amount may NOT BE EXCEEDED.

The vendor is responsible for timely invoicing DMH for hours of Services and time and for allowable costs. Invoices to be sent my email to:

DMH_CO_Vendor_Billing_and_Contracts@MassMail.State.MA.US

Funding: Funding for this engagement is subject to the appropriation of funds by the Massachusetts Legislature or the Federal Government for the year(s) in which services are delivered.

*A SOW for multiple Fiscal Years may be terminated early if funding is not available.

Changes to Scope and/or Terms: Any changes to this engagement must be agreed upon in writing in advance by both parties.

Termination: The Department, upon prior written notice, may terminate this engagement without cause and without penalty, or may terminate or suspend an engagement if the vendor breaches any material term or condition or fails to perform or fulfill any material obligation required by this engagement, or in the event of an elimination of an appropriation or absence of sufficient funds for the purposes of an engagement, or in the event of an unforeseen public emergency mandating immediate department action.

Authorized Vendor Signature and Date (Must be handwritten or Verified Electronic Signature. Typed text in cursive font is not allowable)

Print Name and Title

Date

Authorized DMH Signature and Date (Must be handwritten or Verified Electronic Signature. Typed text in cursive font is not allowable)

Print Name and Title

Date