IDOC Academy Laundry Amend Contract.docx

STATE OF ILLINOIS

TAXPAYER IDENTIFICATION NUMBER

The undersigned Agency and Vendor, Captial City Cleaners, (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 62794-9277

Printed Name: Rob Jeffreys/James Deen

Official’s Title: Acting Director/CFO

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.

X

CPO 33 – General Counsel Approval:

STATE OF ILLINOIS

CONTRACT AMENDMENT

Contract Amendment with Certifications (< $50K) V.15.2 State of Illinois Chief Procurement Office 2 Contract Amendment with Certifications (< $50K) V.15.2

1. CONTRACT DESCRIPTION (including Original Purchase Order or Contract Number): IDOC Training Academy Laundry Services – 21-426DOC-SOURC-P-24255

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

|X| Yes |_| No

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

3.1. The completion date will be |X| extended, |_| shortened or |_| remain the same.

3.1.1. Original completion date: June 30, 2022.

3.1.2. Revised completion date: October 31, 2022.

3.2. The method of determining compensation (e.g., hourly rate, fixed fee, etc.) will |X| stay the same or |_| change as follows: Click here to enter text.

3.3. The cost will be |X| increased, |_| decreased or |_| remain the same.

3.3.1. Original cost: $75,000.

3.3.2. Amount of change: $19,950.

3.3.3. Revised cost: $94,950.

3.4. The supplies or services to be provided will |X| stay the same or |_| be changed as follows: Click here to enter text..

3.5. Subcontractors are being |_| added, |_| deleted, or |X| 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: July 1, 2022.

State of Illinois Chief Procurement Office 3 Contract Amendment V.15.2 State of Illinois Chief Procurement Office 4 Contract Amendment V.15.2 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: Click here to enter text.

Taxpayer Identification Number:

Social Security Number: Click here to enter text.

or Employer Identification Number : Click here to enter text.

Legal Status (check one):

Signature of Authorized Representative:

Date: Click here to enter a date State of Illinois Chief Procurement Office 5 Taxpayer Identification Number V.15.2 image1.wmf image2.wmf image3.wmf image4.wmf