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COUNTY CLERK'S
CONTRACT COVERSHEET
CONTRACT #: 055- 2010 -B
ORIGINATING DEPARTMENT: Health & Human Services
PROCUREMENT OFFICER: Mitzi Ledingham PHONE #: 9205766
PROJECT NAME: HCF Grant Programs CONTRACTOR: Family Visitor Programs -
Aspen to Parachute Dental Health Alliance
DOLLAR AMOUNT: $20,000.00 LINE ITEM # 113.85.00000.84037
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:
❑ Services/Maintenance ❑ Employment
❑ License/Use ❑ Intergovernmental Agreement (Resolution Required)
❑ Lease ® Non - Profit
El Construction ❑ Quasi - Public (e.g. -AVH)
❑ Goods, Equipment, Supplies ❑ Grant Agreements (Notify Finance & Resolution Required)
❑ Other (e.g. revenue) ❑ Change Order /Contract Amendment
(CIO: 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:
✓ -1 No Pages Missing ✓ -1 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 (f 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 # 055 -2010 -B
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CHANGE ORDER/CONTRACT AMENDMENT
Change Order Number: 2 Ledger No. 113.85.00000.84037
OWNER: Pitkin County HHS
c/o Mitzi Ledingham
0405 Castle Creek Rd. suite 7
Aspen, CO 81611
CONTRACTOR: Family Visitor Programs
Aspen to Parachute Dental Health Ali+cAt.e
P.O. Box 1845
Glenwood Springs, CO 81602
The 2010 Family Visitor Programs Aspen to Parachute Dental Health Alliurnce grant agreement (the
"Agreement ") dated January 1st, 2010 between the Board of County Commissioners of Pitkin County
(the "County ") and Aspen to Parachute Dental Health 1{11art c/o the Family Visitor Programs (the
"Contractor "), is hereby amended as follows:
Description of Change: continuation of contract terms for 2012 with funding level of $20,000
Reason for Change; additional 12 month extension of 2010 Agreement
Original Contract Price $ 30,000
Net Increase/Decrease in Contract Price (2011 change order) $ - 10,000
Total Adjusted Contract Price (including this change order) $ 20,000
In all other respects the Agreement is in full force and effect and remains unchanged by this
Amendment.
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Authorized Cou Representative Date
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