75H71019P01135_-_Social_Vision.pdf

30a. SIGNATURE OF OFFEROR/CONTRACTOR

KI 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

❑ 29. AWARD OF CONTRACT: OFFER

DATED . YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

HEREIN, IS ACCEPTED AS TO ITEMS:

30b. NAME AND TITLE OF SIGNER (Type or print) 31b. NAM S F CONTRACTIN L OFFICER (Type or print)

TANYA M. JOHNSON

31c. DATE SIGNED

06/28/2019

30c. DATE SIGNED

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

1. REQUISITION NUMBER

IHS1378963

PAGE OF

2. CONTRACT NO. 3. AWARD/

EFFECTIVE DATE

4. ORDER NUMBER

75H71019P01135

5. SOLICITATION NUMBER 6. SOLICITATION

ISSUE DATE

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

SHEILA DENNY

b. TELEPHONE NUMBER (No collect calls)

928-697-4027

8. OFFER DUE DATE/LOCAL TIME

9. ISSUED BY CODE 51 10. THIS ACQUISITION IS Z UNRESTRICTED OR El SET ASIDE: % FOR:

0 SMALL BUSINESS 0 (WOSB) ELIGIBLE UNDER THE WO

WOMEN-OWNED SMALL BUSINESSMEN-OWNED

El HUBZONE SMALL SMAI I Rt ISIKIFSS PROnRAM

NAICS:541611

SMALL BUSINESS

BUSINESS 0 EDWOSB

Gallup Indian Medical Center Acquisition Department 1808 W. Aztec Avenue Gallup NM 87301

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

Kl SEE SCHEDULE

12. DISCOUNT TERMS

IHS NET 30P 0 13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

ERFQ El IFB 0 RFP

15. DELIVER TO CODE IHSGALLUP 16. ADMINISTERED BY CODE 51

Gallup Indian Medical Center Acquisition Department 1808 W. Aztec Avenue Gallup NM 87301

Gallup Indian Medical Center 516 E. Nizhoni Blvd.

Gallup NM 87301

17a. CONTRACTOR/ CODE

OFFEROR

1487522 1 FACILITY

CODE

18a. PAYMENT WILL BE MADE BY CODE IHSNAVAJO

IHSNAVAJO

P.O. BOX 9020

WINDOW ROCK AZ 86515

SOCIAL VISION 1487522

SOCIAL VISION

1719 NOTRE DAME NE

ALBUQUERQUE NM 871061009

TELEPHONE NO.

017b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

IS CHECKED 0SEE ADDENDUM

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

The contractor shall provide Non-Personal Consultant Service to Domestic Violence

Services will be in accordance with Performance Work Statement.

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

2019.J54DV9D.25302

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

$30,000.00

0 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

D ARE 0 ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

IX ARE ❑ ARE NOT ATTACHED.

AUTHORIZED FOR LOCAL REPRODUCTION

STANDARD FORM 1449 (REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER

37. CHECK NUMBER

FINALPARTIAL

36. PAYMENT

FINALPARTIAL

35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER33. SHIP NUMBER

COMPLETE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)

42b. RECEIVED AT (Location)

42a. RECEIVED BY (Print)

41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

STANDARD FORM 1449 (REV. 2/2012) BACK

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

******************NOTE TO VENDOR*****************

PLEASE REFERENCE THE PURCHASE ORDER NUMBER LISTED

IN BLOCK #4 ON ALL INVOICES AND PACKING SLIPS

ASSOCIATED WITH THIS ORDER.

INVOICE SUBMISSION INSTRUCTIONS: The Contractor shall submit invoices in accordance with FAR

Clause 52.212-4(g) by regular postal mail to:

Gallup Indian Medical Center

P.O. Box 1337

Gallup, NM 87301

Delivery: 09/30/2019

Appr. Yr.: 2019 CAN: J54DV9D Object Class: 25302

Period of Performance: 06/28/2019 to 09/30/2019

1 THE FOLLOWING PHASE WILL IN IMPLEMENTED: 30,000.00

PHASE ONE (1): PLANNING PHASE

PHASE TWO (2): IMPLEMENTATION PHASE

PHASE THREE (3): EVALUATION PHASE

SERVICES PROVIDED AT AN ALL-INCLUSIVE TOTAL COST

Continued ...

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

5 2 of

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

3 5

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

SOCIAL VISION 1487522

(A) (B) (C) (D) (E) (F)

75H71019P01135

OF $30,000.00

Contracting Officer (CO): Sheila Denny, Contract

Specialist, telephone 928-697-4027, Sheila.Denny@ihs.gov.

Contracting Officer (CO): is the only individual to authorize modifications to the purchase order and/or terms and conditions.

Per FAR Subpart 1.602-2(d), the CO determines that this order requires a Contracting Officer

Representative (COR).

Contracting Officer Representative (COR): Aaron

Yuselew, GIMC Diagnostic Medical Imaging

Supervisor, Telephone 505-722-1164, Aaron.Yuselew@ihs.gov.

Contracting Officer Representative (COR): is primarily responsible for monitoring the technical progress including surveillance and assessment of performance under this task order.

Point of Contact (SPOC): Marlene L. Jasperse, GIMC HPDP Specialist, 505-722-1631, Marlene.Jasperse@ihs.gov

52.232-18 Availability of Funds (APR 1984)

Funds are not presently available for this contract. The Government's obligation under this contract is contingent upon the availability of appropriated funds from which payment for contract purposes can be made. No legal liability on the part of the Government for any payment may arise until funds are made available to the Contracting Officer for this contract and until the Contractor receives notice of such availability, to be confirmed in writing by the

Contracting Officer.

FAR 52.204-9 Personal Identity Verification of

Contractor Personnel (Jan 2011)

Continued ...

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

4 5

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

SOCIAL VISION 1487522

(A) (B) (C) (D) (E) (F)

75H71019P01135

(a) The Contractor shall comply with agency personal identity verification procedures identified in the contract that implement

Homeland Security Presidential Directive-12

(HSPD-12), Office of Management and Budget (OMB) guidance M-05-24 and Federal Information

Processing Standards Publication (FIPS PUB)

Number 201.

(b) The Contractor shall account for all forms of

Government-provided identification issued to the

Contractor employees in connection with performance under this contract. The Contractor shall return such identification to the issuing agency at the earliest of any of the following, unless otherwise determined by the Government:

(1) When no longer needed for contract performance.

(2) Upon completion of the Contractor employee's employment.

(3) Upon contract completion or termination.

(c) The Contracting Officer may delay final payment under a contract if the Contractor fails to comply with these requirements.

(d) The Contractor shall insert the substance of this clause, including this paragraph (d), in all subcontracts when the subcontractor's employees are required to have routine physical access to a

Federally-controlled facility and/or routine access to a Federally-controlled information system. It shall be the responsibility of the prime Contractor to return such identification to the issuing agency in accordance with the terms set forth in paragraph (b) of this section, unless otherwise approved in writing by the

Contracting Officer.

Federal Tax Reporting: The Contractor shall submit a written quarterly report giving evidence that the Contractor has made the required payment on their federal, state & local taxes, including applicable employment taxes for all days that services were provided. This report shall be delivered to the Contracting Officer as follows:

Continued ...

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

5 5

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

SOCIAL VISION 1487522

(A) (B) (C) (D) (E) (F)

75H71019P01135

a. For services provided during the calendar quarter of July through September, the report is due no later than 15 Oct showing that Federal taxes have been paid for July through September.

Nonpayment of Federal taxes or the failure to submit the required report shall become the formal basis for a cure notice, show cause notice, withholding of payments, and possible termination for default. Final contract payment will be withheld until the required report has been submitted to and accepted by the Contracting

Officer.

Additional Applicable Federal Acquisition Clauses:

52.204-7 System Award Management (Oct 2018)

52.224-1 Privacy Act Notification (Apr 1984)

52.224-2 Privacy Act (Apr 1984)

52.229-3 Federal, State, and Local Taxes (Feb

2013)

52.232-33 Payment by Electronic Funds Transfer -

System for Award Management (Jul 2013)

52.237-2 Protection of Government Buildings, Equipment, and Vegetation (Aug 1984)

52.237-3 Continuity of Services (Jan 1991)

52.249-4 Termination for Convenience for the

Government (Services)(Short Form) (Apr 1984)

The total amount of award: $30,000.00. The obligation for this award is shown in box 26.

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)