25-41SCMS-BOSS4-P-75647:659

DOC - Corrections Release Order Number

Purchase Order

Vendor Number: V00005019 Shelby County Community Services, INC.

E 1810 W South 3rd N Shelbyville, IL 62565

D sccsprod@'10g , (217) 774-2924

VENDOR INSTRUCTIONS:

PURCHASE ORDER REQUIREMENTS - STATE OF ILLINOIS AGENCIES

Prior to commencement of billable work, delivery of supplies or rendering of any service on a Purchase Order:

--Initial Purchase Order/Contract - All parties, including the State and vendor, must fully execute the contract in its entirety.

--Release from an existing Purchase Order/Contract - The vendor must receive a Purchase Order signed by the State Agency and attached in BidBuy. Note, for any additional requirements see specific State Agency instruction.

PURCHASE ORDERS REQUIREMENTS - OTHER PURCHASING ENTITIES

--Please see specific requirements provided by the purchasing entity.

25-416CMS-BOSS4-P-

75647:659

Master Contract? Y

Master Con/Ref #: 9100001917

Contract/PO #: P-75647

Michelle Grogan s 4017 E. 2603rd Road Melissa Morsch

H Sheridan, IL 60551

I US

p Email: Michelle.grogan@illinois.gov

(815) 496-2181

T

Michelle Grogan

B 4017 E. 2603rd Road Melissa Morsch Sheridan, IL 60551

L US

L Email: Michelle.grogan@illinois.gov

(815) 496-2181

Shipping Method: Freight Terms:

Shipping Terms: Payment Terms:

Solicitation (Bid) No.: N/A

Release Begin Date: 08/19/2026 Release End Date: 12/06/2026 Delivery Calendar Day(s) A.R.O.: 1

Item # 1

Class- Item 640-50

Med. Weight Spork - 1000 per case

I Quantity I Unit Price UOM I Discount % 'Total Discount' Tax Rate

I jTax Amounti

I Freight

I Total Cost Amt.

60.00 $ 12.69 CV 0.00 % $0.00 $0.00 $0.00 $761.40

TAX: $0.00

FREIGHT: $0.00

TOTAL: $ 761.40

25-4T6CMS-BOSS4-P-75647:659

The undersigned agree to the Terms and Conditions as acknowledged by the Vendor and maintained in the State of Illinois a-procurement system. This agreement consists of all terms as maintained in the state's e-procurement system inclusive of attached documents. The Vendor affirms that the Certifications and Financial Disclosures and Conflicts of Interest are true and accurate as of the date of the Vendor's execution of this Agreement. State documents will prevail in the event of a conflict between State and Vendor documents and information. The undersigned agree to the Terms and Conditions of this agreement:

OFFICIAL SIGNATURES:

Vendor Name:

Vendor Signature: ______________________________________

Printed Name

Title:

Phone #:

Email:

Date:

State of Illinois Agency or Other Purchasing Entity Procuring State Agency or Entity ___________

Official Signature:

Printed Name: jv L(lñ tji c1t5 Title:

Designee Signature: ___________________________

Printed Name: ________________________________

Title:

Date:

Legal Signature: -

Printed Name:

Title: ________

Date:

Fiscal Signature: -

Printed Name:

Title: ________

Date:

FOR STATE OF ILLINOIS USE ONLY:

Acq. Type: ________________Source Sel. Method: _______________

Using Agency Funding Source:_______________________________________ Detailed Expenditure Object Code:_______________________________ Approp. Acct Code: _____________________________________________ Award Code:

Original Proc. Method:__________________________________________ Subcontractors Disclosed:__________________________________________ Subcontractors Utilized:___________________________________________ Publication Date:_____________________ Financing Needed:_______ IPG Cert/Disclosure Yes_________ No__________________________

APPROVED

By: Amanda Crisman

Phone#: (R15l 49R-21R1

BUYER