Contract Number: [000000]
State of Oregon
Department of Human Services
Children, Adults and Families Division
SHORT FORM PERSONAL/PROFESSIONAL SERVICES CONTRACT AMENDMENT
FOR
TRADITIONAL AND NON-TRADITIONAL PROVIDERS
In Compliance with the Americans with Disabilities Act, this document is available in alternate formats such as Braille, large
print, audio tape, oral presentation and computer disk. To request an alternate format call the State of Oregon, Department of
Human Services, Office of Forms and Document Management at (503) 373-0333.
AMENDMENT [#] TO
PERSONAL/PROFESSIONAL SERVICES CONTRACT
1. This is Amendment No. [#] to Contract No. [Contract #] between the State of Oregon, acting by and through its
Department of Human Services; hereafter called "DHS," and [Contractor Name or DBA, if applicable], hereinafter
called “Contractor”.
2. The Contract is hereby amended as follows:
a. Amend the sentence that begins “This Contract is between” to change the Contractor’s name from
[Contractor Name Used on the Original Contract] to [Contractor’s Legal Entity Name] to
accurately reflect the legal contracting entity, which was previously stated incorrectly.
b. Amend the sentence that begins “This Contract will become” to change the contract expiration date from
[Current Expiration Date] to [New Expiration Date].
c. Amend the section entitled Statement of Work and Consideration to change the maximum not-to-
exceed compensation amount from [Current Amount] to [New Amount].
d. Amend EXHIBIT A Statement of Work and Outcome to correct the Case # and Person Letter which
was previously stated incorrectly to the following: [Case # and Person Letter].
e. Amend EXHIBIT A Statement of Work and Outcome, Section entitled PAYMENT PROVISIONS,
subsection 1., only to change the not-to-exceed amount from [Current Amount] to [New Amount] and
to change current number of units from [Current # of Units] to [New # of Units].
f. Amend EXHIBIT A Statement of Work and Outcome to replace the “Client” names to the following
[Insert Names], which were previously stated incorrectly.
g. Amend EXHIBIT A Statement of Work and Outcome, Section entitled STATEMENT OF WORK
to Choose One: services as follows:
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3. DHS’s performance under the Contract is conditioned upon Contractor's compliance with the provisions of ORS
279B.220, 279B.225, 279B230, 279B235, and 279B.270. which are incorporated by reference herein. Contractor shall, to
the maximum extent economically feasible in the performance of this Contract, use recycled paper (as defined in ORS
279A.010(gg)), recycled PETE products (as defined in ORS 279A.010(hh)), and other recycled products (as “recycled
product” is defined in ORS 279A.010(ii)).
4. The number shown in CONTRACTOR DATA AND CERTIFICATON of original contract or as amended is Contractor's
correct taxpayer identification and all other information provided in CONTRACTOR DATA AND CERTIFICATON is
true and accurate;
5. Except as expressly amended above, all other terms and conditions of the original contract and any previous amendments
are still in full force and effect. Contractor certifies that the representations, warranties and certifications contained in the
original contract are true and correct as of the effective date of this Amendment and with the same effect as though made
at the time of this Amendment.
This Amendment will become effective upon signature of all the parties.
Certification: The individual signing on behalf of the Contractor hereby certifies and swears under penalty of perjury (a)
Contractor is not subject to backup withholding because (i) Contractor is exempt from backup withholding, (ii) Contractor
has not been notified by the IRS that Contractor is subject to backup withholding as a result of a failure to report all interest
or dividends, or (iii) the IRS has notified Contractor that Contractor is no longer subject to backup withholding; (b) s/he is
authorized to act on behalf of Contractor, s/he has authority and knowledge regarding Contractor’s payment of taxes, and to
the best of his or her knowledge, Contractor is not in violation of any Oregon tax laws (including, without limitation, the
following pursuant to OAR 150-305-0385(6)-(B): For purposes of this certification, “Oregon tax laws” means the tax laws
names is ORS 305.380 (4), including without limitation the state inheritance tax, gift tax, personal income tax, withholding
tax, corporation income and excise taxes, amusement device tax, timber taxes, cigarette tax, other tobacco tax, 9-1-1
emergency communications tax, the homeowners and renters property tax relief program and local taxes administered by the
Department of Revenue (Multnomah County Business Income Tax, Lane Transit District Tax, Tri-Metropolitan Transit
District Employer Payroll Tax, and Tri-Metropolitan Transit District Self-Employment Tax), and (c) Contractor is an
independent contractor as defined in ORS 670.600.
CONTRACTORS: YOU WILL NOT BE PAID FOR SERVICES RENDERED PRIOT TO NECESSARY SATE
APPROVALS.
AGREED: CONTRACTOR
By: Date:
AGREED: DHS AUTHORIZED REPRESENTATIVE
By: Date:
REVIEWED: DHS OFFICE OF CONTRACTS and PROCUREMENT
By: Date:
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