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41/1CKIN Pitkin County
CoUNTir Contract Cover Sheet
Please complete the Contract Cover Sheet when the contract is completed and signed by Contractor and Pitkin County
Project Manager.
Return all Contract Cover Sheets and Contracts/Change Orders/Amendments to Procurement
(procurement help@a,pitkincounty.com).Any contracts$50,000 and over will be routed for signatures to County Manager
and Attorney's Office(if required)by Procurement&Contracts Manager.
Contract Information
Contract Number 223.2015 A
Project Name Provision of Public Health Consultant for County HHS
Contractor Keystone Policy Center
Budget Line Item 001.72.95615.82000
Additional Budget Line Item(s) Click here to enter text.
and special notes to Finance
Contract Start Date 11/15/2015
Contract End Date 6/30/2016
Automatic Renewal Yes ❑ No►
If Construction: Retainage Click here to enter text.
If this is a new contractor,please request they complete and submit to Finance a W-9 Form.
Contact Information:
Department Health and Human Services
Project Manager Sundeen Project Manager Click here to enter text.
Phone
Provide a brief description of the contract:
Include Task 4a,which was offered as part of the Contractor's Proposal in RFP process. This provides
additional stakeholder engagement meetings. The contract end date is revised to June 30,2016
Contract Value Summary:
Contract Amount $35,000.00
This Change order/Amendment amount(if applicable) $ 5,000.00
New Contract Total $40,000.00
Procurement Method:
None ❑ Informal Formal ►1 Sole Source 0 Emergency 0 Contract Renewal 0
Contract Type:
Services/Maintenance ►Z Construction 0 Goods,Equipment, Supplies 0
Change Order/Amendment 0 Other,please explain 0 Click here to enter text.
NOTE: CLERKS OFFICE WILL KEEP ORIGINAL DOCUMENTS IN COMPLIANCE WITH COLORADO STATE
ARCHIVES RETAINAGE SCHEDULE. ALL ATTACHMENTS MUST BE WITH THIS CHECKLIST.
Contract#bocc.con.223.2015 Rev. 8.31.11 jaa/js
Budget Line Item#001.72.95615.82000
CHANGE ORDER/CONTRACT AMENDMENT
Change Order Number: 223.2015A
OWNER: Pitkin County
405 Castle Creek Rd. Ste.#8
Aspen,Colorado 81611
CONTRACTOR:
The Provision of Public Health Consultant for County Health and Human Services (the "Agreement")
dated November 24, 2015 between the Board of County Commissioners of Pitkin County(the"County")
and Keystone Policy Center, 1628 Sts. John Road, Keystone, CO 80435 (the "Contractor"), is hereby
amended as follows:
Description of Change:
• County has elected to include the alternative offered in the main Contract. Task 4a which
provides for additional stakeholder engagement shall be included as part of the Scope of
Work.The additional funds added to the Contract shall be$5,000.00
• Contract duration shall be extended to June 30,2016.
Original Contract Price $ 35,000.00
Net Increase/Decrease in Contract Price(this change order) $ 5,000.00
*Total Adjusted Contract Price(including this change order) $40,000.00
In all other respects the Agreement is in full force and effect and remains unchanged by this
Amendment.
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Contractor Date
AuTzed Sign- Date
Co M. :"rte Date
*Increases over$25,000 and/or 10% (single increase or accumulative) of original contract must have
County Manager signature.