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COUNTY CLERK'S
CONTRACT COVERSHEET
102,4
CONTRACT #: 047 - 2010 -B f
ORIGINATING DEPARTMENT: Health & Human Services
PROCUREMENT OFFICER: Mitzi Ledingham PHONE #: 9205766
PROJECT NAME: HCF Grant Programs CONTRACTOR: Healthy Mountain
Communities
DOLLAR AMOUNT: $5,000.00 LINE ITEM # 113.85.00541.82164
CONTRACT EXECUTION DATE: 1/1/2012 CONTRACT END DATE: 12/31/2012
AUTOMATIC RENEWAL: ❑ YES ® NO TERM: annual
❑ 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: 7,- iSkf
❑ 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
(co: 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)
✓ ® 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 # 047 -2010 -B
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CHANGE ORDER/CONTRACT AMENDMENT
Change Order Number: 2 Ledger No.: 113.85.00541.82164
OWNER: Pitkin County HHS
c/o Mitzi Ledingham
0405 Castle Creek Rd. suite 7
Aspen, CO 81611
CONTRACTOR: Healthy Mountain Communities
P.O. Box 1582
Carbondale, CO 81623
Attn: Colin Laird
The 2010 Healthy Mountain Communities annual grant agreement (the "Agreement ") dated January 1st,
2010 between the Board of County Commissioners of Pitkin County (the "County ") and Executive
Services Corps (the "Contractor "), is hereby amended as follows:
Description of Change: continuation of contract terms for 2012 with funding at $5,000
Reason for Change: additional (second) 12 month extension of 2010 Agreement
Original Contract Price $ 10.000
Net Increase/Decrease in Contract Price (2011 change order) $ - $2.000
Net Increase/Decrease in Contract Price (2012 change order) $ - $3.000
Total Adjusted Contract Price (including this change order) $ $5.000
In all other respects the Agreement is in full force and effect and remains unchanged by this Amendment.
ft 4 4. 3
1.24.2012
Contractor Date
Authorized CountRepresentative Date
1