Lawrence cable amendment 5-20~1.doc

STATE OF ILLINOIS

CONTRACT AMENDMENT

The undersigned Agency and Vendor, Lawrence Correctional Center and Friendship Cable of Texas, Inc, (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

Vendor Name: Friendship Cable of Texas, Inc.

DBA Correctional Cable Address: 311 NNW Loop 323 Tyler, TX 75702

Date:

STATE OF ILLINOIS

City, State ZIP: Springfield, IL 62794

Printed Name: Jared Brunk

Official’s Title: CFO

Legal Printed Name: Click here to enter text.

Legal’s Title: Click here to enter text.

Fiscal’s Printed Name:

Fiscal’s Title: CFO

STATE USE ONLY

NOT PART OF CONTRACTUAL PROVISIONS

PBC# 18-000000108124

Project TitleLawrence CC Cable Contract Increase

Contract # 74IBF16001

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

IPB Ref. #

IPB Publication Date:

Award Code:

A

Subcontractor Utilization? Yes No

Subcontractor Disclosure? Yes No

Funding Source

Obligation #

CPO 33 – General Counsel Approval:

Signature

Printed Name

Date

1. CONTRACT DESCRIPTION (including Original Purchase Order or Contract Number): To procure a contract with Friendship Cable of Texas, Inc; DBA Correctional Cable to provide cable television service at Lawrence Correctional Center. Contract #74IBF16001

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: Click here to enter a date..

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 FORMCHECKBOX stay the same or change as follows: Click here to enter text.

3.3. The cost will be FORMCHECKBOX

increased, decreased or remain the same.

3.3.1. Original cost: $594,456.00

3.3.2. Amount of change: $66,028.72

3.3.3. Revised cost: $660,484.72.

3.4. The supplies or services to be provided will stay the same or FORMCHECKBOX be changed as follows: Addition of 5 channels to monthly service to include: Sony Movies, Independent Film Network, MGM Movies, Comedy and HGTV. Additon of these 5 channels will add approximately $995 to the initial monthly costs. This incremental rate will increase by 5% at the annual increase date of the original contract.

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 Cable of Texas, Inc. DBA Correctional Cable Taxpayer Identification Number:

Social Security Number: Click here to enter text.

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:

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