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11010, COUNTY CLERK'S
CONTRACT COVERSHEET
CONTRACT #: 004 - 2011 -A
ORIGINATING DEPARTMENT: Health & Human Services
PROCUREMENT OFFICER: Mitzi Ledingham PHONE #: 9205766
PROJECT NAME: HCF Grant Programs CONTRACTOR: Roaring Fork School Health
Centers
DOLLAR AMOUNT: $10,000.00 LINE ITEM # 113.85.00000.84029
CONTRACT EXECUTION DATE: 1/1/2012 CONTRACT END DATE: 12/31/2012
AUTOMATIC RENEWAL: ❑ YES ® NO TERM: biennial
❑ BOCC AGENDA ITEM (Grants, IGA) ® STAFF AUTHORIZED SIGNATURE
(Requires BOCC Signature) (Per Revised Procurement Code 7/2005)
❑ OVER $50,000 (Requires Section Leader & County Manager's Signature)
✓ CHECK PROCUREMENT TYPE:
® None ❑ Informal ❑ Formal ❑ Sole Source ❑ Emergency ❑ Outside Agency /State Bid
❑ Compliance with C.R.S. 8 -17 -5 -101, 102 as amended (Immigration Form) ❑ Exempt
❑ Contract Renewal
✓ CHECK CONTRACT TYPE: fq-$
❑ Services/Maintenance ❑ Employment
❑ License/Use ❑ Intergovernmental Agreement (Resolution Required)
❑ Lease ® Non -Profit
❑ Construction ❑ Quasi - Public (e.g. -AVH)
❑ Goods, Equipment, Supplies ❑ Grant Agreements (Notify Finance & Resolution Required)
❑ Other (e.g. revenue) ❑ Change Order /Contract Amendment
(C /O: 10% or $25K whichever is the lesser must have County Manager signature)
All Contracts should be proofed and all exhibits and notices must be attached for the following:
✓ ® No Pages Missing ✓® All Other Blanks Filled In
✓ ❑ If Page Left Intentionally Blank —Note on Page ✓❑ All Exhibits Attached
✓ ® Page numbered consecutively ✓❑ All Legal Descriptions attached (f applicable)
✓ E All Original Signatures Affixed ✓❑ Notice of Award/Notice to Proceed Attached (if applicable
✓ ® All Dates Filled In ✓❑ Warranty (if applicable)
✓ ® Special Instructions for Finance Department: see contract payment worksheet
✓ ® Authorized Procurement Officer's Name: Mitzi Ledingham
BY CHECKING ABOVE AND ENTERING NAME, THE AUTHORIZED STAFF PERSON INDICATES THAT
THE ATTACHED DOCUMENT HAS BEEN PROOFED AND READY FOR SCANNING.
NOTE: CLERK'S OFFICE WILL KEEP ORIGINAL DOCUMENTS IN COMPLIANCE WITH COLORADO STATE
ARCHIVES RETAINAGE SCHEDULE. ALL ATTACHMENTS MUST BE WITH THIS CHECKLIST!
Contract A 004.-2011A
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CIIANGE ORDER/CONTRACT AMENDMENT
Change Order Number: I Ledger No. J13 85.00 84029
OWNER Pitkin County HHS
eft) Atitgi Ledittghatn
eA05 Castle Creek Rd. suite 7
Aspen, CO 81611
f'ONl'RAC:TOR. Roaring Fork SchcxJ111ealttt t" enters
151 E. Cottonwood Drive
Basalt, CO 8 1621
The 2011 -2012 Roaring Fork School Health Centers biennial grant agreement (the "Agreement ') dated
January 1st. 2011 between the Board of County Commissioners of Pitkin Country (the "County and
Roaring Fork School Health C :enters (the `Contractor "), is hereby amended as follows.
Description of Chan .e. continuation of aintraci terms for 2012 as written at same funding level
Relkun l Change_ second year of two -year biennial agreement
Original Contract Pace $ 10.000
Net Increase) cease in Contract Price ( this change order) $ cime level through Dec 2012
Total Adjusted Contract Price (including this change order) $ _,same level thrsnteh Fttc2a :
In all other respects the Agreement is in full force and effect and remains unchanged by this
Amendment.
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Contra Anne E. Taylor, Director late
Rocky Mountain Youth Clinics
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Authorized Coun R cprescntativ - e Date
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