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”. 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-toexceed 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.
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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: AGREED: DHS AUTHORIZED REPRESENTATIVE By: REVIEWED: DHS OFFICE OF CONTRACTS and PROCUREMENT By: Date: Date: Date:
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