STATE OF VERMONT CONTRACT SUMMARY AND CERTIFICATION – Form ...



STATE OF VERMONT CONTRACT SUMMARY AND CERTIFICATION - - - - - - - - - - - Form AA-14 (1/8/2019)Note: All sections must be completed. Incomplete forms will be returned to the originating department.I. CONTRACT INFORMATION: Agency/Department: FORMTEXT ?????/ FORMTEXT ?????Contract #: FORMTEXT ????? Amendment #: FORMTEXT ?????Vendor Name: FORMTEXT ?????VISION Vendor No: FORMTEXT ?????Vendor Address: FORMTEXT ?????Starting Date: FORMTEXT ????? Ending Date: FORMTEXT ?????Amendment Date: FORMTEXT ?????Summary of agreement or amendment: FORMTEXT ????? II. FINANCIAL & ACCOUNTING INFORMATIONMaximum Payable:$ FORMTEXT ????? Prior Maximum: $ FORMTEXT ?????Prior Contract # (If Renewal): FORMTEXT ?????Current Amendment:$ FORMTEXT ????? Cumulative amendments:$ FORMTEXT ?????% Cumulative Change: FORMTEXT ????? %Business Unit(s): FORMTEXT ?????; FORMTEXT ?????; FORMTEXT ????? - [notes: FORMTEXT ?????]VISION Account(s): FORMTEXT ?????; FORMTEXT ?????EstimatedFunding Split: FORMTEXT ????? % GF FORMTEXT ????? % TF FORMTEXT ????? % SF FORMTEXT ????? % GC FORMTEXT ????? % EF FORMTEXT ????? % FF FORMTEXT ????? % Other FORMTEXT ????? (name) III. PROCUREMENT & PERFORMANCE INFORMATIONIdentify applicable procurement process utilized. FORMCHECKBOX Standard Bid/RFP FORMCHECKBOX Simplified FORMCHECKBOX Sole Source (See B.) FORMCHECKBOX Qualification Based Selection FORMCHECKBOX StatutoryIf Sole Source Contract, contract form includes self-certification language? FORMCHECKBOX Yes FORMCHECKBOX N/AContract includes performance measures/guarantees to ensure the quality and/or results of the service? FORMCHECKBOX Yes FORMCHECKBOX NoIV. TYPE OF AGREEMENT (select all that apply) FORMCHECKBOX Personal Service FORMCHECKBOX Non-Personal Service FORMCHECKBOX Commodity FORMCHECKBOX Construction FORMCHECKBOX Arch/Eng. FORMCHECKBOX Marketing FORMCHECKBOX Info. Tech. FORMCHECKBOX Prof. Service FORMCHECKBOX Retiree/Former SOV EE FORMCHECKBOX Financial Trans FORMCHECKBOX Zero-Dollar FORMCHECKBOX Privatization FORMCHECKBOX OtherV. SUITABILITY FOR CONTRACT FOR SERVICE FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX n/aDoes this contract meet the determination of an Independent Contractor? If “NO”, the contractor must be set up and paid on payroll through the VTHR system.VI. CONTRACTING PLAN APPLICABLEIs any element of this contract subject to a pre-approved Agency/Dept. Contracting Waiver Plan? FORMCHECKBOX Yes FORMCHECKBOX NoVII. CONFLICT OF INTERESTBy signing below, I (Agency/Dept. Head) certify that no person able to control or influence award of this contract had a pecuniary interest in its award or performance, either personally or through a member of his or her household, family, or business. FORMCHECKBOX Yes FORMCHECKBOX NoIs there an “appearance” of a conflict of interest so that a reasonable person may conclude that this party was selected for improper reasons: (If yes, explain) FORMTEXT ?????VIII. PRIOR APPROVALS REQUIRED OR REQUESTED FORMCHECKBOX Yes FORMCHECKBOX NoAgreement must be Certified by the Attorney General under 3 V.S.A. § 342 (sign line #4 below) FORMCHECKBOX Yes FORMCHECKBOX NoAttorney General review As To Form is required ($25,000 and above) or otherwise requested: (AAG initial) FORMCHECKBOX Yes FORMCHECKBOX NoAgreement must be approved by the Secretary of ADS/CIO FORMCHECKBOX Yes FORMCHECKBOX NoAgreement must be approved by the CMO: for Marketing services over $25,000 FORMCHECKBOX Yes FORMCHECKBOX NoAgreement must be approved by Comm. Human Resources: for Privatization, Retirees, Former Employees, & if a Contract fails the IRS test. FORMCHECKBOX Yes FORMCHECKBOX NoAgreement must be approved by the Secretary of AdministrationIX. AGENCY/DEPARTMENT HEAD CERTIFICATION; APPROVALI have made reasonable inquiry as to the accuracy of the above information (sign in order):1-Date1-Agency/Department Head2-Date2-Agency Secretary (if required)3a-Date3a-CIO3b-Date3b-CMO3c-Date3c-Commissioner DHR4-Date4-Attorney General5-Date5-Secretary of Administration ................
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