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STATE OF ILLINOIS CONTRACT OF ILLINOIS CONTRACT ... Title: Click here to enter text. Email: Click here to enter text. ...

Jun 11, 2018

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  • STATEOFILLINOIS

    CONTRACTClick here to enter text.Click here to enter text.Click here to enter text.

    1StateofIllinoisDepartmentofHumanServicesContractV.13.4

    ThePartiestothiscontractaretheStateof IllinoisactingthroughtheundersignedAgency(collectivelytheState)andtheVendor. Thiscontract,consistingofthesignaturepageandnumberedsections listedbelowandanyattachmentsreferenced in this contract, constitute theentire contractbetween theParties concerning the subjectmatterof thecontract.Thiscontractsupersedesallpriorproposals,contractsandunderstandingsbetweenthePartiesconcerningthesubjectmatterofthecontract.ThiscontractcanbesignedinmultiplecounterpartsandsignaturemaybeelectronicordigitaluponagreementoftheParties.

    1. DESCRIPTIONOFSUPPLIESANDSERVICES

    2. PRICING

    3. TERMANDTERMINATION

    4. STANDARDBUSINESSTERMSANDCONDITIONS

    5. SUPPLEMENTALPROVISIONS

    6. STANDARDCERTIFICATIONS

    7. FINANCIALDISCLOSURESANDCONFLICTSOFINTEREST

    8. DISCLOSUREOFBUSINESSOPERATIONSWITHIRAN

    Inconsiderationofthemutualcovenantsandagreementscontained inthiscontract,andforothergoodandvaluableconsideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree to the terms andconditionssetforthhereinandhavecausedthiscontracttobeexecutedbytheirdulyauthorizedrepresentativesonthedatesshownonthefollowingCONTRACTSIGNATURESpage.

    BALANCEOFPAGEINTENTIONALLYLEFTBLANK

  • STATEOFILLINOIS

    CONTRACT

    2StateofIllinoisDepartmentofHumanServicesContractV.13.4

    CONTRACTSIGNATURESVENDOR

    VendorName:Clickheretoentertext. Address:Clickheretoentertext.

    Signature: Phone:Clickheretoentertext.

    PrintedName:Clickheretoentertext. Fax:Clickheretoentertext.

    Title:Clickheretoentertext. Email:Clickheretoentertext.

    Date:

    STATEOFILLINOIS

    ProcuringAgency:DepartmentofHumanServices(DHSorIDHS) Phone:

    StreetAddress: Fax:

    City,StateZIP:

    OfficialSignature: Date:

    PrintedName:

    OfficialsTitle:

    DesigneeSignature: Date:

    DesigneePrintedName:

    DesigneesTitle:

    OtherApproversSignature: Date:

    OtherApproversPrintedName:

    OtherApproversTitle:

  • 3StateofIllinoisDepartmentofHumanServicesContractV.13.4

    AGENCY/UNIVERSITYUSEONLY NOTPARTOFCONTRACTUALPROVISIONS

    AgencyorUniversityReference# ProjectTitle

    Contract# ProcurementMethod(IFB,RFP,Small,etc):

    IPBRef.# IPBPublicationDate: AwardCode:

    SubcontractorUtilization? Yes No SubcontractorDisclosure? Yes No

    FundingSource Obligation#

    SmallBusinessSetAside? Yes No

    MinorityOwnedBusiness? Yes No Percentage

    FemaleOwnedBusiness? Yes No Percentage

    PersonsWithDisabilitiesOwnedBusiness? Yes NoPercentage

    OtherPreferences?

    BALANCEOFPAGELEFTINTENTIONALLYBLANK

  • 4StateofIllinoisDepartmentofHumanServicesContractV.13.4

    1. DESCRIPTIONOFSUPPLIESANDSERVICES

    1.1 SUPPLIESAND/ORSERVICESREQUIRED:Clickheretoentertext

    1.2 MILESTONESANDDELIVERABLES:Clickheretoentertext

    1.3 VENDOR/STAFFSPECIFICATIONS:Clickheretoentertext

    1.4 TRANSPORTATIONANDDELIVERY:Clickheretoentertext

    1.5 SUBCONTRACTING

    SubcontractorsChooseanitem.allowed.

    Forpurposesof this section, subcontractorsare those specificallyhired toperformallorpartof theworkcoveredbythecontract.Ifsubcontractorswillbeutilized,Vendormustidentifybelowthenamesandaddressesofallsubcontractorsitwillbeenteringintoacontractualagreementwithatotalvalueof$50,000ormore in theperformanceof thisContract, togetherwithadescriptionof thework tobeperformedbythesubcontractorandtheanticipatedamountofmoneytotheextenttheinformationisknownthateachsubcontractorisexpectedtoreceivepursuanttotheContract.

    1.5.1. Willsubcontractorsbeutilized? Yes No

    SubcontractorName:Clickheretoentertext

    Amounttobepaid:Clickheretoentertext

    Address:Clickheretoentertext

    Descriptionofwork:Clickheretoentertext

    SubcontractorName:Clickheretoentertext

    Amounttobepaid:Clickheretoentertext

    Address:Clickheretoentertext

    Descriptionofwork:Clickheretoentertext

    All subcontracts must include the Subcontractor Standard Certifications and FinancialDisclosuresandConflictsofInterestcompletedandsignedbythesubcontractor.

    1.5.2. If at any timeduring the termof theContract,Vendor adds or changes any subcontractors,Vendorwillbe required topromptlynotify,bywrittenamendment to theContract, theStatePurchasing Officer or the Chief Procurement Officer of the names and addresses and theexpectedamountofmoney thateachnewor replacedsubcontractorwill receivepursuant totheContract. Any subcontractsentered intoprior toawardof theContract aredoneat theVendorsandsubcontractorsrisk.

  • 5StateofIllinoisDepartmentofHumanServicesContractV.13.4

    1.6 WHERESERVICESARETOBEPERFORMED: Unlessotherwisedisclosed inthissectionallservicesshallbeperformedintheUnitedStates.IftheVendorperformstheservicespurchasedhereunderinanothercountry in violation of this provision, such actionmay be deemed by the State as a breach of thecontractbyVendor.

    Vendorshalldisclose the locationswhere theservices requiredshallbeperformedand theknownoranticipatedvalueof theservices tobeperformedateach location. If theVendor receivedadditionalconsiderationintheevaluationbasedonworkbeingperformedintheUnitedStates,itshallbeabreachofcontractiftheVendorshiftsanysuchworkoutsidetheUnitedStates.

    Locationwhereserviceswillbeperformed:Clickheretoentertext

    Valueofservicesperformedatthislocation:Clickheretoentertext

    Locationwhereserviceswillbeperformed:Clickheretoentertext

    Valueofservicesperformedatthislocation:Clickheretoentertext:

  • 6StateofIllinoisDepartmentofHumanServicesContractV.13.4

    2. PRICING

    2.1 FORMATOFPRICING:

    2.1.1 Vendorshallsubmitpricingintheformatshownbelow,basedonthetermsandconditionssetforthinsection1ofthisContract.

    2.1.2 Pricingshallbesubmittedinthefollowingformat: Clickheretoentertext.

    2.2 TYPEOF PRICING: The IllinoisOffice of the Comptroller requires the State to indicatewhether thecontractpricing isfirmorestimatedatthetime it issubmittedforobligation. PricingpursuanttothiscontractisChooseanitem..

    2.3 EXPENSESALLOWED:Expenses arenotallowed areallowedasfollows:Clickheretoentertext..

    2.4 DISCOUNT:TheStatemayreceivea Clickheretoentertext.%discountforpaymentwithinClickheretoentertext.daysofreceiptofcorrectinvoice.

    2.5 TAXES:PricingshallnotincludeanytaxesunlessaccompaniedbyprooftheStateissubjecttothetax.Ifnecessary,Vendormay request theapplicableagencys Illinois taxexemptionnumberand federal taxexemptioninformation.

    2.6 VENDORSPRICING: Attachadditionalpages ifnecessaryor iftheformatofpricingspecifiedabove inSection2.1requiresadditionalpages.

    2.6.1 VendorsPricefortheInitialTerm:Clickheretoentertext.

    2.6.2 RenewalCompensation:Ifthecontractisrenewed,thepriceshallbeatthesamerateasfortheinitial term unless a different compensation or formula for determining the renewalcompensationisstatedinthissection.

    2.6.2.1 Agency/UniversityFormula forDeterminingRenewalCompensation: Clickhere toentertext.

    2.6.2.2 VendorsPriceforRenewal(s):Clickheretoentertext.

  • 7StateofIllinoisDepartmentofHumanServicesContractV.13.4

    3. TERMANDTERMINATION

    3.1 TERMOFTHISCONTRACT: Thiscontracthasan initialtermofClickheretoentertexttoClickheretoentertext.Ifastartdateisnotidentified,thetermshallcommenceuponthelastdatedsignatureoftheParties.

    3.1.1 Innoeventwillthetotaltermofthecontract,includingtheinitialterm,anyrenewaltermsandanyextensions,exceed10years.

    3.1.2 Vendorshallnotcommencebillableworkinfurtheranceofthecontractpriortofinalexecutionofthecontract.

    3.2 RENEWAL:

    3.2.1 Any renewal is subject to the same terms and conditions as the original contract unlessotherwiseprovidedinthepricingsection.TheStatemayrenewthiscontractforanyoralloftheoptionperiodsspecified,mayexerciseanyoftherenewaloptionsearly,andmayexercisemorethanoneoptionatatimebasedoncontinuingneedandfavorablemarketconditions,when inthebestinterestoftheState.ThecontractmayneitherrenewautomaticallynorrenewsolelyattheVendorsoption.

    3.2.2 Pricing for the renewal term(s),or the formula fordeterminingprice, is shown in thepricingsectionofthiscontract.

    3.2.3 TheStatereservestherighttorenewforatotalofClickheretoentertextyears inanyoneofthefollowingmanners:

    3.2.3.1 Onerenewalcoveringtheentirerenewalallowance;

    3.2.3.2 Individualoneyearrenewalsuptoandincludingtheentirerenewalallowance;or

    3.2.3.3 Anycombinationoffullorpartialyearrenewalsuptoandincludingtheentirerenewalallowance.

    3.3 TERMINATIONFORCAUSE: TheStatemay terminate this contract, inwholeor inpart, immediatelyuponnoticetotheVendor if: (a)theStatedeterminesthattheactionsor inactionsoftheVendor, itsagents,employeesorsubcontractorshavecaused,orreasonablycouldcause,jeopardytohealth,safety,or property, or (b) the Vendor has notified the State that it is unable or unwilling to perform thecontract.

    IfVendor fails to perform to the States satisfaction anymaterial requirement of this contract, is inviolation of amaterial provision of this contract, or the State determines that theVendor lacks thefinancialresourcestoperformthecontract,theStateshallprovidewrittennoticetotheVendortocuretheproblem identifiedwithintheperiodoftimespecified intheStateswrittennotice.Ifnotcuredby

  • 8StateofIllinoisDepartmentofHumanServicesContractV.13.4

    thatdatetheStatemayeither:(a)immediatelyterminatethecontractwithoutadditionalwrittennoticeor(b)enforcethetermsandconditionsofthecontract.

    ForterminationduetoanyofthecausescontainedinthisSection,theStateretainsitsrightstoseekanyavailablelegalorequitableremediesanddamages.

    3.4 TERMINATIONFORCONVENIENCE: TheStatemay,for itsconvenienceandwith30dayspriorwrittennotice toVendor, terminate thiscontract inwholeor inpartandwithoutpaymentofanypenaltyorincurringanyfurtherobligationtotheVendor.

    3.4.1 Thiscontract iscontingentuponandsubjecttotheavailabilityof funds. TheState,at itssoleoption,mayterminateorsuspendthiscontract,inwholeorinpart,withoutpenaltyorfurtherpaymentbeing required, if the IllinoisGeneralAssemblyor the federal fundingsource fails tomakeanappropriationsufficienttopaysuchobligation,or iffundsneededare insufficientforanyreason.30ILCS500/2060.

    3.4.2 TheVendorshallbeentitled tocompensationuponsubmissionof invoicesandproofofclaimforsuppliesandservicesprovidedincompliancewiththiscontractuptoandincludingthedateoftermination.

  • 9StateofIllinoisDepartmentofHumanServicesContractV.13.4

    4. STANDARDBUSINESSTERMSANDCONDITIONS

    4.1 PAYMENTTERMSANDCONDITIONS:

    4.1.1 LatePayment: Payments, including latepaymentcharges,willbepaid inaccordancewiththeStatePromptPaymentActandruleswhenapplicable.30ILCS540;74III.Adm.Code900.ThisshallbeVendors sole remedy for latepaymentsby the State. Payment terms containedonVendorsinvoicesshallhavenoforceandeffect.

    4.1.2 MinorityContractorInitiative:AnyVendorawardedacontractunderSection2010,2015,2025or2030oftheIllinoisProcurementCode(30ILCS500)of$1,000ormoreisrequiredtopayafeeof$15.TheComptrollershalldeductthefeefromthefirstcheckissuedtotheVendorunderthecontractanddepositthefeeintheComptrollersAdministrativeFund.15ILCS405/23.9.

    4.1.3 Expenses: TheStatewillnotpay forsuppliesprovidedorservicesrendered, includingrelatedexpenses, incurredprior to theexecutionof this contractby thePartieseven if theeffectivedateofthecontractispriortoexecution.

    4.1.4 PrevailingWage:AsaconditionofreceivingpaymentVendormust(i)beincompliancewiththecontract,(ii)payitsemployeesprevailingwageswhenrequiredbylaw,(iii)payitssuppliersandsubcontractorsaccordingtothetermsoftheirrespectivecontracts,and(iv)providelienwaiversto the State upon request. Examples of prevailing wage categories include public works,printing, janitorial, window washing, building and grounds services, site technician services,naturalresourceservices,securityguardandfoodservices.TheprevailingwagesarerevisedbytheDepartmentofLaborandareavailableontheDepartmentsofficialwebsite,whichshallbedeemedpropernotificationofanyratechangesunderthissubsection.Vendorisresponsibleforcontacting the Illinois Department of Labor to ensure understanding of prevailing wagerequirementsat2177826206or(http://www.state.il.us/agency/idol/index.htm).

    4.1.5 FederalFunding:ThiscontractmaybepartiallyortotallyfundedwithFederalfunds.Iffederalfunds are expected to be used, then the percentage of the good/service paid using FederalfundsandthetotalFederalfundsexpectedtobeusedwillbeprovidedintheawardnotice.

    4.1.6 Invoicing:Bysubmittinganinvoice,Vendorcertifiesthatthesuppliesorservicesprovidedmeetallrequirementsofthecontract,andtheamountbilledandexpensesincurredareasallowedinthe contract. Invoices for supplies purchased, services performed and expenses incurredthroughJune30ofanyyearmustbesubmittedtotheStateno laterthanJuly31ofthatyear;otherwise Vendormay have to seek payment through the Illinois Court of Claims. 30 ILCS105/25.Allinvoicesaresubjecttostatutoryoffset.30ILCS210.

    4.1.6.1 VendorshallnotbillforanytaxesunlessaccompaniedbyproofthattheStateissubjecttothetax.Ifnecessary,VendormayrequesttheapplicableAgency/Universitystatetaxexemptionnumberandfederaltaxexemptioninformation.

    4.1.6.2 Vendor shall invoice at the completion of the contract unless invoicing is tied in thecontract tomilestones,deliverables,orother invoicing requirementsagreed to in thecontract.

  • 10StateofIllinoisDepartmentofHumanServicesContractV.13.4

    Sendinvoicesto:

    Agency/University: Clickheretoentertext

    Attn: Clickheretoentertext.

    Address: Clickheretoentertext.

    City,StateZip Clickheretoentertext.

    4.2 ASSIGNMENT:Thiscontractmaynotbeassigned,transferredinwholeorinpartbyVendorwithoutthepriorwrittenconsentoftheState.

    4.3 SUBCONTRACTING:Forpurposesofthissection,subcontractorsarethosespecificallyhiredtoperformallorpartoftheworkcoveredbythecontract.Vendormustreceivepriorwrittenapprovalbeforeuseofanysubcontractorsintheperformanceofthiscontract.Vendorshalldescribe,inanattachmentifnotalreadyprovided,thenamesandaddressesofallauthorizedsubcontractorstobeutilizedbyVendorinthe performance of this contract, togetherwith a description of thework to be performed by thesubcontractor and the anticipated amount ofmoney that each subcontractor is expected to receivepursuanttothiscontract. Ifrequired,Vendorshallprovideacopyofanysubcontractswithin15daysafter execution of this contract. Vendor shall notify the State of any additional or substitutesubcontractorshiredduringthetermofthiscontract. Ifrequired,VendorshallprovidetotheStateacopyofallsuchsubcontractswithin15daysafterexecutionofthesubcontract. Allsubcontractsmustinclude the same certifications thatVendormustmakeasa conditionof this contract. Vendor shallinclude ineach subcontract the subcontractor certificationsas shownon theStandardSubcontractorCertificationformavailablefromtheState.IfatanytimeduringthetermoftheContract,Vendoraddsorchangesanysubcontractors,Vendormustpromptlynotify,bywrittenamendmentto theContract,the State PurchasingOfficer or the Chief ProcurementOfficer of the names and addresses and theexpected amount ofmoney that each new or replaced subcontractor will receive pursuant to theContract.

    4.4 AUDIT/RETENTION OF RECORDS: Vendor and its subcontractors shallmaintain books and recordsrelatingtotheperformanceofthecontractorsubcontractandnecessarytosupportamountschargedtotheStatepursuantthecontractorsubcontract. Booksandrecords, including informationstored indatabasesorothercomputer systems, shallbemaintainedby theVendor foraperiodof threeyearsfromthelaterofthedateoffinalpaymentunderthecontractorcompletionofthecontract,andbythesubcontractorforaperiodofthreeyearsfromthelateroffinalpaymentunderthetermorcompletionofthesubcontract. Iffederalfundsareusedtopaycontractcosts,theVendorand itssubcontractorsmustretain itsrecordsforfiveyears. Booksandrecordsrequiredtobemaintainedunderthissectionshall be available for review or audit by representatives of: the procuring Agency/University, theAuditorGeneral,theExecutiveInspectorGeneral,theChiefProcurementOfficer,StateofIllinoisinternalauditorsorothergovernmentalentitieswithmonitoringauthority,uponreasonablenoticeandduringnormalbusinesshours.Vendoranditssubcontractorsshallcooperatefullywithanysuchauditandwithanyinvestigationconductedbyanyoftheseentities.FailuretomaintainbooksandrecordsrequiredbythissectionshallestablishapresumptioninfavoroftheStatefortherecoveryofanyfundspaidbytheState under the contract for which adequate books and records are not available to support thepurported disbursement. The Vendor or subcontractors shall not impose a charge for audit orexaminationoftheVendorsbooksandrecords.30ILCS500/2065.

  • 11StateofIllinoisDepartmentofHumanServicesContractV.13.4

    4.5 TIMEISOFTHEESSENCE:TimeisoftheessencewithrespecttoVendorsperformanceofthiscontract.Vendor shall continue to perform its obligationswhile any dispute concerning the contract is beingresolvedunlessotherwisedirectedbytheState.

    4.6 NOWAIVEROFRIGHTS:Exceptasspecificallywaivedinwriting,failurebyaPartytoexerciseorenforcearightdoesnotwaivethatPartysrighttoexerciseorenforcethatorotherrightsinthefuture.

    4.7 FORCEMAJEURE: Failure by either Party to perform its duties and obligationswill be excused byunforeseeablecircumstancesbeyonditsreasonablecontrolandnotduetoitsnegligence,includingactsofnature,actsof terrorism,riots, labordisputes, fire, flood,explosion,andgovernmentalprohibition.ThenondeclaringPartymaycancelthecontractwithoutpenaltyifperformancedoesnotresumewithin30daysofthedeclaration.

    4.8 CONFIDENTIAL INFORMATION: Each Party, including its agents and subcontractors, to this contractmayhaveorgainaccesstoconfidentialdataorinformationownedormaintainedbytheotherPartyinthecourseofcarryingoutitsresponsibilitiesunderthiscontract.Vendorshallpresumeallinformationreceived from the Stateor towhich itgainsaccesspursuant to this contract is confidential. Vendorinformation, unless clearly marked as confidential and exempt from disclosure under the IllinoisFreedomofInformationAct,shallbeconsideredpublic.Noconfidentialdatacollected,maintained,orusedinthecourseofperformanceofthecontractshallbedisseminatedexceptasauthorizedbylawandwiththewrittenconsentofthedisclosingParty,eitherduringtheperiodofthecontractorthereafter.ThereceivingPartymustreturnanyandalldatacollected,maintained,createdorusedinthecourseoftheperformanceofthecontract,inwhateverformitismaintained,promptlyattheendofthecontract,orearlierattherequestofthedisclosingParty,ornotifythedisclosingPartyinwritingofitsdestruction.The foregoingobligations shallnotapply to confidentialdataor information lawfully in the receivingPartyspossessionpriorto itsacquisitionfromthedisclosingParty;received ingoodfaithfromathirdParty not subject to any confidentiality obligation to the disclosing Party; now is or later becomespublicly known through no breach of confidentiality obligation by the receiving Party; or isindependently developed by the receiving Partywithout the use or benefit of the disclosing Partysconfidentialinformation.

    4.9 USEANDOWNERSHIP:AllworkperformedorsuppliescreatedbyVendorunderthiscontract,whetherwritten documentsordata, goodsordeliverables of any kind, shallbedeemedwork forhireundercopyright lawandall intellectualpropertyandother laws,andtheStateof Illinois isgrantedsoleandexclusiveownershiptoallsuchwork,unlessotherwiseagreedinwriting.VendorherebyassignstotheStateallright,title,and interest inandtosuchwork includinganyrelated intellectualpropertyrights,and/orwaivesanyandall claims thatVendormayhave to suchwork includingany socalled "moralrights"inconnectionwiththework.VendoracknowledgestheStatemayusetheworkproductforanypurpose. Confidentialdataor information contained in suchwork shallbe subject to confidentialityprovisionsofthiscontract.

    4.10 INDEMNIFICATIONANDLIABILITY: TheVendorshall indemnifyandholdharmlesstheStateofIllinois,its agencies, officers, employees, agents and volunteers from any and all costs, demands, expenses,losses, claims, damages, liabilities, settlements and judgments, including inhouse and contracted

  • 12StateofIllinoisDepartmentofHumanServicesContractV.13.4

    attorneys fees and expenses, arising out of: (a) any breach or violation by Vendor of any of itscertifications,representations,warranties,covenantsoragreements;(b)anyactualorallegeddeathorinjurytoanyperson,damagetoanypropertyoranyotherdamageorlossclaimedtoresultinwholeorinpartfromVendorsnegligentperformance;or(c)anyact,activityoromissionofVendororanyofitsemployees, representatives, subcontractors or agents. Neither Party shall be liable for incidental,special,consequentialorpunitivedamages.

    4.11 INSURANCE: Vendor shall, at all time during the term and any renewalsmaintain and provide aCertificateof Insurancenaming the State as additional insured for all requiredbonds and insurance.Certificatesmaynotbemodifiedor canceleduntil at least30daysnoticehasbeenprovided to theState.Vendorshallprovide:(a)GeneralCommercialLiabilityoccurrenceforminamountof$1,000,000per occurrence (Combined Single Limit Bodily Injury and Property Damage) and $2,000,000 AnnualAggregate;(b)AutoLiability, includingHiredAutoandNonownedAuto,(CombinedSingleLimitBodilyInjuryandPropertyDamage) inamountof$1,000,000peroccurrence;and(c)WorkersCompensationInsuranceinamountrequiredbylaw.InsuranceshallnotlimitVendorsobligationtoindemnify,defend,orsettleanyclaims.

    4.12 INDEPENDENT CONTRACTOR: Vendor shall act as an independent contractor and not an agent oremployeeof,orjointventurewiththeState.AllpaymentsbytheStateshallbemadeonthatbasis.

    4.13 SOLICITATIONANDEMPLOYMENT:VendorshallnotemployanypersonemployedbytheStateduringthetermofthiscontracttoperformanyworkunderthiscontract.Vendorshallgivenoticeimmediatelyto theAgencysdirector ifVendor solicitsor intends to solicit Stateemployees toperformanyworkunderthiscontract.

    4.14 COMPLIANCEWITHTHELAW:TheVendor,itsemployees,agents,andsubcontractorsshallcomplywithallapplicablefederal,state,and local laws,rules,ordinances,regulations,orders,federalcircularsandalllicenseandpermitrequirementsintheperformanceofthiscontract.Vendorshallbeincompliancewithapplicabletaxrequirementsandshallbecurrentinpaymentofsuchtaxes.Vendorshallobtainatitsownexpense,alllicensesandpermissionsnecessaryfortheperformanceofthiscontract.

    4.15 BACKGROUNDCHECK: Whenever the Statedeems it reasonablynecessary for security reasons, theStatemay conduct, at its expense, criminal and driver history background checks of Vendors andsubcontractorsofficers,employeesoragents. Vendororsubcontractorshallreassign immediatelyanysuchindividualwho,intheopinionoftheState,doesnotpassthebackgroundcheck.

    4.16 APPLICABLELAW: Thiscontractshallbeconstrued inaccordancewithand issubjectto the lawsandrulesoftheStateofIllinois.TheDepartmentofHumanRightsEqualOpportunityrequirements(44Ill.Adm.Code750)areincorporatedbyreference.AnyclaimagainsttheStatearisingoutofthiscontractmustbefiledexclusivelywiththeIllinoisCourtofClaims.705ILCS505/1.TheStateshallnotenterintobinding arbitration to resolve any contract dispute. The State of Illinois does notwaive sovereignimmunitybyenteringintothiscontract.Theofficialtextofcitedstatutesisincorporatedbyreference.Anunofficialversioncanbeviewedat(www.ilga.gov/legislation/ilcs/ilcs.asp).

  • 13StateofIllinoisDepartmentofHumanServicesContractV.13.4

    4.17 ANTITRUSTASSIGNMENT:IfVendordoesnotpursueanyclaimorcauseofactionithasarisingunderfederalorstateantitrust lawsrelatingtothesubjectmatterofthecontract,thenuponrequestoftheIllinoisAttorneyGeneral,VendorshallassigntotheStaterights,titleandinterestinandtotheclaimorcauseofaction.

    4.18 CONTRACTUALAUTHORITY:TheAgencythatsignsfortheStateofIllinoisshallbetheonlyStateentityresponsibleforperformanceandpaymentunderthecontract.WhentheChiefProcurementOfficerorauthorizeddesigneesigns inaddition toanAgency, theydosoasapprovingofficerandshallhavenoliability toVendor. When theChiefProcurementOfficerorauthorizeddesignee,orStatePurchasingOfficersignsamastercontractonbehalfofStateagencies,onlytheAgencythatplacesanorderwiththeVendorshallhaveanyliabilitytoVendorforthatorder.

    4.19 NOTICES:Noticesandothercommunicationsprovidedforhereinshallbegiveninwritingbyregisteredorcertifiedmail,returnreceiptrequested,byreceiptedhanddelivery,bycourier(UPS,FederalExpressorothersimilarandreliablecarrier),byemail,orbyfaxshowingthedateandtimeofsuccessfulreceipt.Noticesshallbesenttotheindividualswhosignedthecontractusingthecontactinformationfollowingthe signatures. Each such notice shall be deemed to have been provided at the time it is actuallyreceived.Bygivingnotice,eitherPartymaychangethecontactinformation.

    4.20 MODIFICATIONS AND SURVIVAL: Amendments,modifications andwaiversmust be in writing andsignedbyauthorized representativesof theParties. Anyprovisionof this contractofficiallydeclaredvoid, unenforceable, or against public policy, shall be ignored and the remaining provisions shall beinterpreted,as faraspossible, togiveeffect to theParties intent. Allprovisions thatby theirnaturewouldbeexpectedtosurvive,shallsurvivetermination. IntheeventofaconflictbetweentheStatesand theVendors terms, conditions and attachments, the States terms, conditions and attachmentsshallprevail.

    4.21 PERFORMANCE RECORD / SUSPENSION: Upon request of the State, Vendor shallmeet to discussperformance or provide contract performance updates to help ensure proper performance of thecontract. TheStatemayconsiderVendorsperformanceunderthiscontractandcompliancewith lawand rule todeterminewhether tocontinue thecontract,suspendVendor fromdoing futurebusinesswith the State for a specified period of time, or to determinewhether Vendor can be consideredresponsibleonspecificfuturecontractopportunities.

    4.22 FREEDOMOFINFORMATIONACT:Thiscontractandallrelatedpublicrecordsmaintainedby,providedtoorrequiredtobeprovidedtotheStatearesubjecttotheIllinoisFreedomofInformationAct(FOIA)(50ILCS140)notwithstandinganyprovisiontothecontrarythatmaybefoundinthiscontract.

    4.23 SCHEDULE OF WORK: Any work performed on State premises shall be done during the hoursdesignated by the State and performed in amanner that does not interferewith the State and itspersonnel.

    4.24 WARRANTIESFORSUPPLIESANDSERVICES:

  • 14StateofIllinoisDepartmentofHumanServicesContractV.13.4

    4.24.1. Vendor warrants that the supplies furnished under this contract will: (a) conform to thestandards,specifications,drawing,samplesordescriptions furnishedbytheStateor furnishedbytheVendorandagreedtobytheState,includingbutnotlimitedtoallspecificationsattachedas exhibits hereto; (b) bemerchantable, of good quality and workmanship, and free fromdefectsforaperiodoftwelvemonthsor longer ifsospecified inwriting,andfitandsufficientfor the intended use; (c) complywith all federal and state laws, regulations and ordinancespertaining to themanufacturing,packing, labeling, saleanddeliveryof thesupplies; (d)beofgoodtitleandbefreeandclearofall liensandencumbrancesand;(e)notinfringeanypatent,copyrightorother intellectualpropertyrightsofany thirdparty. Vendoragrees toreimbursetheStateforany losses,costs,damagesorexpenses, includingwithout limitations,reasonableattorneysfeesandexpenses,arisingfromfailureofthesuppliestomeetsuchwarranties.

    4.24.2. Vendor shall insure that allmanufacturerswarranties are transferred to the State and shallprovideacopyof thewarranty. Thesewarrantiesshallbe inaddition toallotherwarranties,express, impliedorstatutory,andshallsurvivetheStatespayment,acceptance, inspectionorfailuretoinspectthesupplies.

    4.24.3. Vendorwarrantsthatallserviceswillbeperformedtomeettherequirementsofthecontractinanefficientandeffectivemannerby trainedandcompetentpersonnel. Vendorshallmonitorperformances of each individual and shall reassign immediately any individual who is notperforminginaccordancewiththecontract,whoisdisruptiveornotrespectfulofothersintheworkplace,orwhoinanywayviolatesthecontractorStatepolicies.

    4.25 REPORTING,STATUSANDMONITORINGSPECIFICATIONS:

    4.25.1. Vendor shall immediately notify the State of any event thatmay have amaterial impact onVendorsabilitytoperformthecontract.

    4.25.2. By August 31 of each year, Vendor shall report to the Agency orUniversity the number ofqualified veterans and certain exoffenders hired during Vendors last completed fiscal year.Vendormaybeentitledtoemploymenttaxcreditforhiringindividualsinthosegroups.35ILCS5/216,5/217.

    4.26 EMPLOYMENT TAX CREDIT: Vendorswho hire qualified veterans and certain exoffendersmay beeligiblefortaxcredits.30ILCS500/4567and4570.PleasecontacttheIllinoisDepartmentofRevenue(telephone#:2175244772)forinformationabouttaxcredits.

  • 15StateofIllinoisDepartmentofHumanServicesContractV.13.4

    5. SUPPLEMENTALPROVISIONS

    5.1 STATESUPPLEMENTALPROVISIONS:

    Agency/UniversityDefinitions

    Clickheretoentertext.

    RequiredFederalClauses,CertificationsandAssurances

    Clickheretoentertext.

    PublicWorksRequirements(constructionandmaintenanceofapublicwork).820ILCS130/4.

    Clickheretoentertext.

    PrevailingWage (janitorial cleaning,window cleaning, building and grounds, site technician,naturalresources,foodservices,andsecurityservices,ifvaluedatmorethan$200permonthor$2,000peryearorprinting)30ILCS500/2560.

    Clickheretoentertext.

    Agency/UniversitySpecificTermsandConditions

    5.1.1TRAVELEXPENSES:DHSwillnotcompensate theVendor forexpenses related to travel,lodgingormeals.5.1.2 INDEPENDENT CONTRACTOR: The Vendor is an independent contractor under thisContractandneither theVendornoranyemployeeoragentoftheVendor isanemployeeofDHSanddoesnotacquireanyemploymentrightswithDHSortheStateof IllinoisbyvirtueofthisContract.TheVendorwillprovidetheagreedservicesandachievethespecifiedresultsfreefromthedirectionorcontrolofDHSastothemeansandmethodsofperformance.TheVendorwillberequiredtoprovide itsownequipmentandsuppliesnecessarytoconduct itsbusiness;provided that in the event that, for its convenience or otherwise, DHS makes any suchequipment, suppliesorbothavailable to theVendor, theVendorsuseof suchequipmentorsuppliesprovidedbyDHSpursuant to thisContract shallbe strictly limited toofficialDHSorStateofIllinoisbusinessandnotforanyotherpurpose,includinganypersonalbenefitorgain.5.1.3LAWSUITS:IndemnificationwillbegovernedbytheStateEmployeeIndemnificationAct(5ILCS350/1etseq.)asinterpretedbytheIllinoisAttorneyGeneral.DHSmakesnorepresentationthattheVendor,anindependentcontractor,willqualifyorbeeligibleforindemnificationundersaidAct.5.1.4REDUCTIONSINAMOUNTSPAYABLE:UnlessotherwiseprovidedinanyAttachmentorExhibitmadeaparthereof,theamountpayable,orestimatedamountpayable,totheVendorunderthisContractissubjecttoareductionasnecessaryoradvisable,baseduponactualorprojectedbudgetaryconsiderations,atthesolediscretionofDHS,orasmaybedirectedbytheOfficeoftheGovernor.Ifsuchareductionoccurs,DHSshallnegotiateingoodfaithregardinganyreductioninthesuppliesand/orservicesrequiredbythisContract.

  • 16StateofIllinoisDepartmentofHumanServicesContractV.13.4

    5.1.5HEALTHINSURANCEPORTABILITYandACCOUNTABILITYACT:Ifapplicable,theVendorcertifiesthatitisincompliancewiththeHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)Pub.Law104191,45CFRParts160,162and164,theSocialSecurityAct42U.S.C.1320d2through1320d7,inthatitmaynotuseordiscloseprotectedhealthinformationotherthanaspermittedorrequiredbylawandagreestouseappropriatesafeguardstopreventuseordisclosureoftheprotectedhealthinformation.TheVendorfurthercertifiesthatitisincompliancewithallapplicableStateandFederalrecordretentionprovisions,including,butnotlimitedto,thoseofHIPAA.

    Other(describe)

    DHSmayhaveperformancemeasuresandstandardsapplicabletothisContract.Ifso,thoseareidentifiedinthissubsection.

    5.2 VENDORSUPPLEMENTALPROVISIONS

    VendorSupplementalProvisions:

    Clickheretoentertext.

  • StateofIllinoisDepartmentofHumanServices 17ContractV.13.4

    6. STANDARDCERTIFICATIONS

    Vendoracknowledgesandagreesthatcompliancewiththissubsectioninitsentiretyforthetermofthecontractandanyrenewals isamaterialrequirementandconditionofthiscontract. ByexecutingthiscontractVendorcertifies compliance with this subsection in its entirety, and is under a continuing obligation to remain incomplianceandreportanynoncompliance.

    This subsection, in its entirety, applies to subcontractors used on this contract. Vendor shall include theseStandard Certifications in any subcontract used in the performance of the contract using the StandardSubcontractorCertificationformprovidedbytheState.

    If this contract extendsovermultiple fiscal years, including the initial term and all renewals,Vendor and itssubcontractorsshallconfirmcompliancewiththissectioninthemannerandformatdeterminedbytheStatebythedatespecifiedbytheStateandinnoeventlaterthanJuly1ofeachyearthatthiscontractremainsineffect.

    IfthePartiesdeterminethatanycertificationinthissectionisnotapplicabletothiscontractitmaybestrickenwithoutaffectingtheremainingsubsections.

    6.1. Aspartofeachcertification,VendoracknowledgesandagreesthatshouldVendororitssubcontractorsprovide false information, or fail to be or remain in compliance with the Standard Certificationrequirements,oneormoreofthefollowingsanctionswillapply:

    thecontractmaybevoidbyoperationoflaw,

    theStatemayvoidthecontract,and

    theVendorand itsubcontractorsmaybesubjecttooneormoreofthefollowing:suspension,debarment,denialofpayment,civilfine,orcriminalpenalty.

    Identifyingasanctionorfailingtoidentifyasanctioninrelationtoanyofthespecificcertificationsdoesnotwaiveimpositionofothersanctionsorprecludeapplicationofsanctionsnotspecificallyidentified.

    6.2. Vendorcertifies itand itsemployeeswillcomplywithapplicableprovisionsof theUnitedStatesCivilRights Act, Section 504 of the Federal Rehabilitation Act, the Americans with Disabilities Act, andapplicablerulesinperformanceofthiscontract.

    6.3. Vendor,ifanindividual,soleproprietor,partneroranindividualasmemberofaLLC,certifieshe/sheisnotindefaultonaneducationalloan.5ILCS385/3.

    6.4. Vendor,ifanindividual,soleproprietor,partneroranindividualasmemberofaLLC,certifiesithe/shehasnotreceived (i)anearlyretirement incentivepriorto1993underSection14108.3or16133.3oftheIllinoisPensionCodeor(ii)anearlyretirementincentiveonorafter2002underSection14108.3or16133.3oftheIllinoisPensionCode.30ILCS105/15a;40ILCS5/14108.3;40ILCS5/16133.

    6.5. VendorcertifiesthatitisalegalentityauthorizedtodobusinessinIllinoispriortosubmissionofabid,offer,orproposal.30ILCS500/1.15.8,2043.

  • StateofIllinoisDepartmentofHumanServices 18ContractV.13.4

    6.6. To the extent therewas a current Vendor providing the services covered by this contract and theemployees of that Vendor who provided those services are covered by a collective bargainingagreement,Vendorcertifies (i) that itwilloffer toassume thecollectivebargainingobligationsof theprior employer, including any existing collective bargaining agreement with the bargainingrepresentativeofanyexistingcollectivebargainingunitorunitsperformingsubstantiallysimilarworktotheservicescoveredbythecontractsubjecttoitsbidoroffer;and(ii)thatitshallofferemploymenttoallemployeescurrentlyemployedinanyexistingbargainingunitwhoperformsubstantiallysimilarworkto thework thatwill be performed pursuant to this contract. This does not apply to heating, airconditioning,plumbingandelectricalservicecontracts.30ILCS500/2580.

    6.7. VendorcertifiesithasneitherbeenconvictedofbribingorattemptingtobribeanofficeroremployeeoftheStateofIllinoisoranyotherState,normadeanadmissionofguiltofsuchconductthatisamatterofrecord.30ILCS500/505.

    6.8. IfVendorhasbeenconvictedofafelony,Vendorcertifiesatleastfiveyearshavepassedafterthedateofcompletionofthesentenceforsuchfelony,unlessnopersonheldresponsiblebyaprosecutorsofficeforthefactsuponwhichtheconvictionwasbasedcontinuestohaveanyinvolvementwiththebusiness.30ILCS500/5010.

    6.9. IfVendororanyofficer,director,partner,orothermanagerialagentofVendorhasbeenconvictedofafelonyundertheSarbanesOxleyActof2002,oraClass3orClass2felonyundertheIllinoisSecuritiesLawof1953,Vendorcertifiesat leastfiveyearshavepassedsincethedateoftheconviction. Vendorfurthercertifies that it isnotbarred frombeingawardedacontractandacknowledges that theStateshalldeclarethecontractvoidifthiscertificationisfalse.30ILCS500/5010.5.

    6.10. Vendor certifies it is not barred from having a contract with the State based upon violating theprohibitionsrelatedtoeithersubmitting/writingspecificationsorprovidingassistancetoanemployeeoftheStateof Illinoisbyreviewing,drafting,directing,orpreparingany invitation forbids,arequest forproposal,or requestof information,or similarassistance (exceptaspartofapublic request for suchinformation).30ILCS500/5010.5(e),amendedbyPub.ActNo.970895(August3,2012).

    6.11. VendorcertifiesthatitanditsaffiliatesarenotdelinquentinthepaymentofanydebttotheState(orifdelinquenthasentered into adeferredpaymentplan topay thedebt),andVendorand itsaffiliatesacknowledge the Statemay declare the contract void if this certification is false or if Vendor or anaffiliatelaterbecomesdelinquentandhasnotenteredintoadeferredpaymentplantopayoffthedebt.30ILCS500/5011,5060.

    6.12. Vendorcertifies that itandallaffiliates shallcollectand remit IllinoisUseTaxonall salesof tangiblepersonalproperty intotheStateofIllinois inaccordancewithprovisionsoftheIllinoisUseTaxActandacknowledgesthatfailuretocomplymayresultinthecontractbeingdeclaredvoid.30ILCS500/5012.

    6.13. VendorcertifiesthatithasnotbeenfoundbyacourtorthePollutionControlBoardtohavecommittedawillful or knowing violation of the Environmental Protection Actwithin the last five years, and isthereforenotbarredfrombeingawardedacontract.30ILCS500/5014.

    6.14. Vendorcertifies ithasneitherpaidanymoneyorvaluable thing to induceanyperson torefrain frombiddingonaStatecontract,noracceptedanymoneyorothervaluablething,oracteduponthepromiseofsame,fornotbiddingonaStatecontract.30ILCS500/5025.

    6.15. VendorcertifiesitisnotinviolationoftheRevolvingDoorprovisionsoftheIllinoisProcurementCode.30ILCS500/5030.

  • StateofIllinoisDepartmentofHumanServices 19ContractV.13.4

    6.16. Vendorcertifies that ithasnot retainedapersonorentity toattempt to influence theoutcomeofaprocurement decision for compensation contingent in whole or in part upon the decision orprocurement.30ILCS500/5038.

    6.17. Vendor certifies itwill report to the IllinoisAttorneyGeneral and theChiefProcurementOfficer anysuspected collusion or other anticompetitive practice among any bidders, offerors, contractors,proposers,oremployeesoftheState.30ILCS500/5040,5045,5050.

    6.18. Vendorcertifiessteelproductsusedorsuppliedintheperformanceofacontractforpublicworksshallbe manufactured or produced in the United States, unless the executive head of the procuringAgency/Universitygrantsanexception.30ILCS565.

    6.19. DrugFreeWorkplace

    6.19.1 IfVendoremploys25ormoreemployeesandthiscontractisworthmorethan$5,000,VendorcertifiesitwillprovideadrugfreeworkplacepursuanttotheDrugFreeWorkplaceAct.

    6.19.2 IfVendor isan individualand thiscontract isworthmore than$5000,Vendorcertifies itshallnot engage in the unlawfulmanufacture, distribution, dispensation, possession, or use of acontrolledsubstanceduringtheperformanceofthecontract.30ILCS580.

    6.20. Vendor certifies that neither Vendor nor any substantially owned affiliate is participating or shallparticipate inan internationalboycott inviolationoftheU.S.ExportAdministrationActof1979ortheapplicableregulationsoftheUnitedStates.DepartmentofCommerce.30ILCS582.

    6.21. Vendor certifies ithasnotbeen convictedof theoffenseofbid riggingorbid rotatingorany similaroffenseofanystateoroftheUnitedStates.720ILCS5/33E3,E4.

    6.22. Vendorcertifies itcomplieswith the IllinoisDepartmentofHumanRightsActand rulesapplicable topublic contracts, which include providing equal employment opportunity, refraining from unlawfuldiscrimination,andhavingwrittensexualharassmentpolicies.775ILCS5/2105.

    6.23. Vendorcertifies itdoesnotpaydues toorreimburseorsubsidizepaymentsby itsemployees foranyduesorfeestoanydiscriminatoryclub.775ILCS25/2.

    6.24. Vendorcertifies thatno foreignmadeequipment,materials,or supplies furnished to theStateunderthecontracthavebeenorwillbeproducedinwholeorinpartbyforcedlabororindenturedlaborunderpenalsanction.30ILCS583.

    6.25. Vendorcertifies thatno foreignmadeequipment,materials,or supplies furnished to theStateunderthecontracthavebeenproducedinwholeorinpartbythelabororanychildundertheageof12.30ILCS584.

    6.26. Vendor certifies that any violation of the Lead Poisoning Prevention Act, as it applies to owners ofresidentialbuildings,hasbeenmitigated.410ILCS45.

    6.27. Vendorwarrantsandcertifiesthatitand,tothebestofitsknowledge,itssubcontractorshaveandwillcomplywithExecutiveOrderNo.1(2007). TheOrdergenerallyprohibitsVendorsandsubcontractorsfromhiringthethenservingGovernorsfamilymemberstolobbyprocurementactivitiesoftheState,oranyotherunitofgovernmentinIllinoisincludinglocalgovernmentsifthatprocurementmayresultinacontract valued at over $25,000. This prohibition also applies to hiring for that same purpose anyformer State employee who had procurement authority at any time during the oneyear periodprecedingtheprocurementlobbyingactivity.

  • StateofIllinoisDepartmentofHumanServices 20ContractV.13.4

    6.28. Vendor certifies that information technology, includingelectronic information, software, systemsandequipment,developedorprovidedunderthiscontractcomplywiththeapplicablerequirementsoftheIllinoisInformationTechnologyAccessibilityActStandardsaspublishedat(www.dhs.state.il.us/iitaa)30ILCS587.

    6.29. Vendorcertifiesthatithasread,understands,andisincompliancewiththeregistrationrequirementsoftheElectionsCode (10 ILCS5/935)and the restrictionsonmakingpoliticalcontributionsand relatedrequirementsoftheIllinoisProcurementCode.30ILCS500/20160and5037.Vendorwillnotmakeapoliticalcontributionthatwillviolatetheserequirements.

    Inaccordancewithsection20160oftheIllinoisProcurementCode,Vendorcertifiesasapplicable:

    VendorisnotrequiredtoregisterasabusinessentitywiththeStateBoardofElections.

    or

    Vendorhas registeredwith theStateBoardofElections. Asa registeredbusinessentity,VendoracknowledgesacontinuingdutytoupdatetheregistrationasrequiredbytheAct.

    6.30. Vendor certifies that if it is awarded a contract through the use of the preference required by theProcurementofDomestic ProductsAct, then it shallprovideproductspursuant to the contractor asubcontractthataremanufacturedintheUnitedStates.30ILCS517.

    6.31. Aperson(otherthananindividualactingasasoleproprietor)mustbeadulyconstitutedlegalentityandauthorizedtodobusinessinIllinoispriortosubmittingabidoroffer.30ILCS500/2043.Ifyoudonotmeetthesecriteria,thenyourbidorofferwillbedisqualified.

    Vendormustmakeoneofthefollowingfourcertificationsbycheckingtheappropriatebox.IfCorDischecked,thenVendormustattachtothisformtherequesteddocumentation.A. Vendorcertifiesitisanindividualactingasasoleproprietorandisthereforenotsubjecttothe

    requirementsofsection2043oftheProcurementCode.

    B. Vendorcertifiesthat it isa legalentity,andwasauthorizedtodobusiness in Illinoisasofthedate for submitting this bid or offer. The Statemay require Vendor to provide evidence ofcompliancebeforeaward.

  • StateofIllinoisDepartmentofHumanServices 21ContractV.13.4

    C. Vendorcertifiesitisalegalentity,andisaforeigncorporationperformingactivitiesthatdonotconstitute transactingbusiness in Illinoisasdefinedby IllinoisBusinessCorporationsAct (805ILCS5/13.75).AvendorclaimingexemptionundertheActmustincludeadetailedexplanationof the legalbasis for the claimwith itsbidoroffer andmustprovide additionaldetailuponrequest.IfVendorfailstoprovidethemandatorydocumentationwiththebidoroffer,ordoesnotprovideadditionaldetailuponrequestwithinthetimeframespecifiedinsaidrequest,thentheStatemaydeemtheVendorasbeingnonresponsiveornotresponsibleandmaydisqualifytheVendor.

    D. Vendorcertifies it isa legalentity,and isanentityotherwise recognizedunder Illinois lawaseligible for a specific form of exemption similar to those found in the Illinois BusinessCorporationAct (805 ILCS5/13.75). A vendor claimingexemptionunder a specific lawmustprovide adetailedexplanationof the legalbasis for the claimwith itsbidoroffer andmustprovideadditionaldetailuponrequest.IfVendorfailstoprovidethemandatorydocumentationwiththebidoroffer,ordoesnotprovideadditionaldetailuponrequestwithinthetimeframespecified insaidrequest,thentheStatemaydeemtheVendorasbeingnonresponsiveornotresponsibleandmaydisqualifytheVendor.

  • 22StateofIllinoisDepartmentofHumanServicesContractV.13.4

    7. FINANCIALDISCLOSURESANDCONFLICTSOFINTEREST

    FinancialDisclosuresandConflictsofInterestforms(forms)mustbeaccuratelycompletedandsubmittedbythevendor,anyparententity(ies)andanysubcontractors.Thereareninestepstothisformandeachmustbecompletedasinstructedinthestepheading,unlessotherwiseprovided.Abid,offer,orproposalthatdoesnotinclude this form shall be considered nonresponsive. The Agency/Universitywill consider this formwhenevaluatingthebid,offer,orproposalorawardingthecontract.The requirement of disclosure of financial interests and conflicts of interest is a continuing obligation. Ifcircumstanceschangeandthepreviouslysubmittedformisnolongeraccurate,disclosingentitiesmustprovideanupdatedform.Separateformsarerequiredforthevendor,anyparententity(ies)andanysubcontractors.Subcontractor forms must be provided with a copy of the subcontract, if required, within 15 days afterexecutionoftheStatecontractorafterexecutionofthesubcontract,whicheverislater,forallsubcontractswithanannualvalueofmorethan$50,000.Thisdisclosureissubmittedfor:

    Vendor

    VendorsParentEntity(ies)(100%ownership)

    Subcontractor(s)>$50,000

    SubcontractorsParentEntity(ies)>$50,000

    ProjectNameandIllinoisProcurementBulletinNumber

    Clickheretoentertext.

    VendorName Clickheretoentertext.DoingBusinessAs(DBA) Clickheretoentertext.ParentEntity Clickheretoentertext.Subcontractor Clickheretoentertext.InstrumentofOwnershiporBeneficialInterest

    Chooseanitem. IfyouselectedOther,pleasedescribe:Clickheretoentertext.

    EP1

  • 23StateofIllinoisDepartmentofHumanServicesContractV.13.4

    STEP1SUPPORTINGDOCUMENTATIONSUBMITTAL

    (Allvendorscompleteregardlessofannualbid,offer,orcontractvalue)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    Youmustselectoneofthesixoptionsbelowandselectthedocumentationyouaresubmitting.Youmustprovidethedocumentationtheapplicablesectionrequireswiththisform.

    Option1PubliclyTradedEntities

    1.A. Complete Step 2,OptionA for each qualifying individual or entity holding any ownership ordistributive incomeshare inexcessof5%oranamountgreaterthan60%($106,447.20)oftheannualsalaryoftheGovernor.

    OR1.B. AttachacopyoftheFederal10K,andskiptoStep3.

    Option2PrivatelyHeldEntitieswithmorethan200Shareholders2.A. Complete Step 2,OptionA for each qualifying individual or entity holding any ownership or

    distributive incomeshare inexcessof5%oranamountgreaterthan60%($106,447.20)oftheannualsalaryoftheGovernor.

    OR2.B. CompleteStep2,OptionAforeachqualifyingindividualorentityholdinganyownershipshare

    inexcessof5%andattach the informationFederal10K reportingcompaniesare required toreportunder17CFR229.401.

    Option3AllotherPrivatelyHeldEntities,notincludingSoleProprietorships3.A. Complete Step 2,OptionA for each qualifying individual or entity holding any ownership or

    distributive incomeshare inexcessof5%oranamountgreaterthan60%($106,447.20)oftheannualsalaryoftheGovernor.

    Option4ForeignEntities4.A. Complete Step 2,OptionA for each qualifying individual or entity holding any ownership or

    distributive incomeshare inexcessof5%oranamountgreaterthan60%($106,447.20)oftheannualsalaryoftheGovernor.

    OR4.B. AttachacopyoftheSecuritiesExchangeCommissionForm20For40FandskiptoStep3.

    Option5NotforProfitEntities

    CompleteStep2,OptionB.

    Option6SoleProprietorships

    SkiptoStep3.

  • 24StateofIllinoisDepartmentofHumanServicesContractV.13.4

    STEP2DISCLOSUREOFFINANCIALINTERESTORBOARDOFDIRECTORS

    (Allvendors,exceptsoleproprietorships,mustcompleteregardlessofannualbid,offer,orcontractvalue)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    CompleteeitherOptionA(forallentitiesotherthannotforprofits)orOptionB(fornotforprofits). Additionalrowsmaybeinsertedintothetablesoranattachmentmaybeprovidedifneeded.

    OPTIONAOwnershipShareandDistributiveIncomeOwnershipShareIfyouselectedOption1.A.,2.A.,2.B.,3.A.,or4.A.inStep1,providethenameandaddressofeachindividualandtheirpercentageofownershipifsaidpercentageexceeds5%,orthedollarvalueoftheirownershipifsaiddollarvalueexceeds$106,447.20.

    Checkhere if includinganattachmentwith requested information ina format substantially similar to the formatbelow.TABLEX

    Name Address PercentageofOwnership $ValueofOwnership

    Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.

    Distributive Income IfyouselectedOption1.A.,2.A.,3.A.,or4.A. inStep1,provide thenameandaddressofeachindividualandtheirpercentageofthedisclosingvendorstotaldistributiveincomeifsaidpercentageexceeds5%ofthetotal distributive income of the disclosing entity, or the dollar value of their distributive income if said dollar valueexceeds$106,447.20.

    Checkhere if includinganattachmentwith requested information ina format substantially similar to the formatbelow.TABLEY

    Name Address %ofDistributiveIncome $ValueofDistributiveIncome

    Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext. Clickheretoentertext. Clickheretoentertext.

  • 25StateofIllinoisDepartmentofHumanServicesContractV.13.4

    Pleasecertifythatthefollowingstatementsaretrue.

    Ihavedisclosedall individualsorentities thatholdanownership interestofgreater than5%orgreater than$106,447.20.

    Yes NoIhavedisclosedallindividualsorentitiesthatwereentitledtoreceivedistributiveincomeinanamountgreaterthan$106,447.20orgreaterthan5%ofthetotaldistributiveincomeofthedisclosingentity.

    Yes No

    OPTIONBDisclosureofBoardofDirectors(NotforProfits)

    IfyouselectedOption5inStep1,listmembersofyourboardofdirectors.Pleaseincludeanattachmentifnecessary.

    TABLEZ

    Name AddressClickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext.Clickheretoentertext. Clickheretoentertext.

    STEP3DISCLOSUREOFLOBBYISTORAGENT

    (Completeonlyifbid,offer,orcontracthasanannualvalueover$25,000)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    Yes No.IsyourcompanyrepresentedbyordoyouemployalobbyistorotheragentrequiredtoregisterundertheLobbyistRegistrationAct(lobbyistmustberegisteredpursuanttotheActwiththeSecretaryofState)orotheragentwho is not identified through Step 2, Option A above and who has communicated, is communicating, or maycommunicatewithanyState/PublicUniversityofficeroremployeeconcerningthebidoroffer? Ifyes,please identifyeachlobbyistandagent,includingthenameandaddressbelow.

    Name Address RelationshiptoDisclosingEntityClickheretoentertext. Clickheretoentertext. Clickheretoentertext.

    Describe all costs/fees/compensation/reimbursements related to the assistance provided by each representativelobbyistorotheragenttoobtainanAgency/Universitycontract:Clickheretoentertext.

  • 26StateofIllinoisDepartmentofHumanServicesContractV.13.4

    STEP4PROHIBITEDCONFLICTSOFINTEREST

    (Allvendorsmustcompleteregardlessofannualbid,offer,orcontractvalue)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    Step4mustbecompletedforeachpersondisclosedinStep2,OptionAandforsoleproprietorsidentifiedinStep1,Option6above.Pleaseprovidethenameofthepersonforwhichresponsesareprovided:Clickheretoentertext.

    1. DoyouholdorareyouthespouseorminorchildwhoholdsanelectiveofficeintheStateofIllinoisorholdaseatintheGeneralAssembly?

    Yes No

    2. Haveyou,yourspouse,orminorchildbeenappointedtooremployedinanyofficesoragenciesofStategovernmentandreceivecompensationforsuchemploymentinexcessof60%($106,447.20)ofthesalaryoftheGovernor?

    Yes No

    3. AreyouorareyouthespouseorminorchildofanofficeroremployeeoftheCapitalDevelopmentBoardortheIllinoisTollHighwayAuthority?

    Yes No

    4. Haveyou,yourspouse,oranimmediatefamilymemberwholivesinyourresidencecurrentlyorwholivedinyourresidencewithinthelast12monthsbeenappointedasamemberofaboard,commission,authority,ortaskforceauthorizedorcreatedbyStatelaworbyexecutiveorderoftheGovernor?

    Yes No

    5. Ifyouansweredyestoanyquestionin14above,pleaseanswerthefollowing:Doyou,yourspouse,orminorchildreceivefromthevendormorethan7.5%ofthevendorstotaldistributableincomeoranamountofdistributableincomeinexcessofthesalaryoftheGovernor($177,412.00)?

    Yes No

    6. Ifyouansweredyestoanyquestionin14above,pleaseanswerthefollowing:Isthereacombinedinterestofselfwithspouseorminorchildmorethan15%($354,824.00)intheaggregateofthevendorsdistributableincomeoranamountofdistributableincomeinexcessoftwotimesthesalaryoftheGovernor?

    Yes No

    STEP5POTENTIALCONFLICTSOFINTERESTRELATINGTOPERSONALRELATIONSHIPS

    (Completeonlyifbid,offer,orcontracthasanannualvalueover$25,000)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    Step5mustbecompleted foreachpersondisclosed inStep2,OptionAand forsoleproprietors identified inStep1,Option6above.

    Pleaseprovidethenameofthepersonforwhichresponsesareprovided:Clickheretoentertext.

    1. Doyoucurrentlyhave,orintheprevious3yearshaveyouhadStateemployment,includingcontractualemploymentofservices?

    Yes No

    2. Has your spouse, father, mother, son, or daughter, had State employment, includingcontractualemploymentforservices,intheprevious2years?

    Yes No

  • 27StateofIllinoisDepartmentofHumanServicesContractV.13.4

    3. Doyouholdcurrentlyorhaveyouheldintheprevious3yearselectiveofficeoftheStateofIllinois,thegovernmentoftheUnitedStates,oranyunitoflocalgovernmentauthorizedbytheConstitutionoftheStateofIllinoisorthestatutesoftheStateofIllinois?

    Yes No

    4. Do you have a relationship to anyone (spouse, father,mother, son, or daughter) holdingelectiveofficecurrentlyorintheprevious2years?

    Yes No

    5. Doyouholdorhaveyouheld in theprevious3yearsanyappointivegovernmentofficeoftheStateofIllinois,theUnitedStatesofAmerica,oranyunitoflocalgovernmentauthorizedbytheConstitutionoftheStateofIllinoisorthestatutesoftheStateofIllinois,whichofficeentitlestheholdertocompensationinexcessofexpensesincurredinthedischargeofthat?

    Yes No

    6. Do you have a relationship to anyone (spouse, father,mother, son, or daughter) holdingappointiveofficecurrentlyorintheprevious2years?

    Yes No

    7. Doyoucurrentlyhaveor in theprevious3yearshademploymentasorbyany registeredlobbyistoftheStategovernment?

    Yes No

    8. Do you currently have or in the previous 2 years had a relationship to anyone (spouse,father,mother,son,ordaughter)thatisorwasaregisteredlobbyist?

    Yes No

    9. Do you currently have or in the previous 3 years had compensated employment by anyregisteredelectionor reelection committee registeredwith the Secretaryof Stateoranycountyclerk intheStateof Illinois,oranypoliticalactioncommitteeregisteredwitheithertheSecretaryofStateortheFederalBoardofElections?

    Yes No

    10. Do you currently have or in the previous 2 years had a relationship to anyone (spouse,father,mother,son,ordaughter)whoisorwasacompensatedemployeeofanyregisteredelectionorreelectioncommitteeregisteredwiththeSecretaryofStateoranycountyclerkintheStateofIllinois,oranypoliticalactioncommitteeregisteredwitheithertheSecretaryofStateortheFederalBoardofElections?

    Yes No

    STEP6EXPLANATIONOFAFFIRMATIVERESPONSES

    (Allvendorsmustcompleteregardlessofannualbid,offer,orcontractvalue)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    IfyouansweredYesinStep4orStep5,pleaseprovideonanadditionalpageadetailedexplanationthatincludes,butisnotlimitedtothename,salary,Stateagencyoruniversity,andpositiontitleofeachindividual.

  • StateofIllinoisDepartmentofHumanServices 28ContractV.13.4

    STEP7POTENTIALCONFLICTSOFINTEREST

    RELATINGTODEBARMENT&LEGALPROCEEDINGS(Completeonlyifbid,offer,orcontracthasanannualvalueover$25,000)

    (Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    This stepmust be completed for each person disclosed in Step 2, Option A, Step 3, and for each entity and soleproprietordisclosedinStep1.

    Pleaseprovidethenameofthepersonorentityforwhichresponsesareprovided:Clickheretoentertext.

    1. Within the previous ten years, have you had debarment from contracting with anygovernmentalentity?

    Yes No

    2. Withintheprevioustenyears,haveyouhadanyprofessionallicensurediscipline? Yes No

    3. Withintheprevioustenyears,haveyouhadanybankruptcies? Yes No

    4. Withintheprevioustenyears,haveyouhadanyadverseciviljudgmentsandadministrativefindings?

    Yes No

    5. Withintheprevioustenyears,haveyouhadanycriminalfelonyconvictions? Yes No

    IfyouansweredYes,pleaseprovideadetailedexplanationthatincludes,butisnotlimitedtothename,Stateagencyoruniversity,andpositiontitleofeachindividual.Clickheretoentertext.

  • 29 StateofIllinoisDepartmentofHumanServicesContractV.13.4

    STEP8DISCLOSUREOFCURRENTANDPENDINGCONTRACTS

    (Completeonlyifbid,offer,orcontracthasanannualvalueover$25,000)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    IfyouselectedOption1,2,3,4,or6inStep1,doyouhaveanycontracts,pendingcontracts,bids,proposals,orotherongoingprocurementrelationshipswithunitsofStateofIllinoisgovernment? Yes No.

    IfYes,pleasespecifybelow.Attachanadditionalpageinthesameformatasprovidedbelow,ifdesired.

    Agency/University ProjectTitle Status Value ContractReference/P.O./IllinoisProcurementBulletin#

    Clickheretoentertext.

    Clickheretoentertext. Clickheretoentertext.

    Clickheretoentertext.

    Clickheretoentertext.

    Pleaseexplaintheprocurementrelationship:Clickheretoentertext.

    STEP9SIGNTHEDISCLOSURE

    (Allvendorsmustcompleteregardlessofannualbid,offer,orcontractvalue)(Subcontractorswithsubcontractannualvalueofmorethan$50,000mustcomplete)

    This disclosure is signed, andmade under penalty of perjury for all forprofit entities, by an authorized officer oremployeeonbehalfofthebidderorofferorpursuanttoSections5013and5035oftheIllinoisProcurementCode.Thisdisclosureinformationissubmittedonbehalfof:

    NameofDisclosingEntity:Clickheretoentertext.

    Signature: Date:Clickheretoentertext.PrintedName:Clickheretoentertext.Title:Clickheretoentertext.PhoneNumber:Clickheretoentertext.EmailAddress:Clickheretoentertext.

  • 30StateofIllinoisDepartmentofHumanServicesContractV.13.4

    8. DISCLOSUREOFBUSINESSOPERATIONSWITHIRAN

    Inaccordancewith30ILCS500/5036,eachbid,offer,orproposalsubmittedforaStatecontract,otherthanasmallpurchasedefinedinSection2020oftheIllinoisProcurementCode,shallincludeadisclosureofwhetherornot thebidder,offeror,orproposingentity,oranyof its corporateparentsor subsidiaries,within the24monthsbeforesubmissionofthebid,offer,orproposalhadbusinessoperationsthatinvolvedcontractswithorprovisionofsuppliesorservicestotheGovernmentofIran,companiesinwhichtheGovernmentofIranhasanydirectorindirectequityshare,consortiumsorprojectscommissionedbytheGovernmentofIranand:

    more than 10% of the companys revenues produced in or assets located in Iran involve oilrelatedactivitiesormineralextractionactivities;lessthan75%ofthecompanysrevenuesproducedinorassetslocated in Iran involve contractswith or provision of oilrelated ormineral extraction products orservicestotheGovernmentofIranoraprojectorconsortiumcreatedexclusivelybythatGovernment;andthecompanyhasfailedtotakesubstantialaction;or

    the company has, on or after August 5, 1996,made an investment of $20million ormore, or anycombinationof investmentsofat least$10millioneach that in theaggregateequalsorexceeds$20million inany12monthperiod thatdirectlyorsignificantlycontributes to theenhancementof IransabilitytodeveloppetroleumresourcesofIran.

    A bid, offer, or proposal that does not include this disclosure shall not be considered responsive.Wemayconsiderthisdisclosurewhenevaluatingthebid,offer,orproposalorawardingthecontract.

    Therearenobusinessoperationsthatmustbedisclosedtocomplywiththeabovecitedlaw.

    Thefollowingbusinessoperationsaredisclosedtocomplywiththeabovecitedlaw:

    Clickheretoentertext.

  • STATEOFILLINOIS

    TAXPAYERIDENTIFICATIONNUMBERATTACHMENTAA

    31StateofIllinoisDepartmentofHumanServicesAttachmentAA:TaxpayerIdentificationNumberV.13.4

    Icertifythatthenumbershownonthisformismycorrecttaxpayeridentificationnumber(orIamwaitingforanumbertobeissuedtome),andIamnotsubjecttobackupwithholdingbecause:(a)Iamexemptfrombackupwithholding,or(b)IhavenotbeennotifiedbytheInternalRevenueService(IRS)thatIamsubjecttobackupwithholdingasaresultofafailure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backupwithholding.

    IcertifythatIamaU.S.person(includingaU.S.residentalien).

    Ifyouarean individual, thenenteryournameandSocialSecurityNumber (SSN)as itappearsonyourSocialSecurityCard.

    Ifyouareasoleproprietor,thenentertheownersnameonthenamelinefollowedbythenameofthebusiness

    andtheownersSSNorEmployerIdentificationNumber(EIN).

    IfyouareasinglememberLLCthatisdisregardedasanentityseparatefromitsowner,thenentertheownersnameonthenamelineandtheD/B/AonthebusinessnamelineandentertheownersSSNorEIN.

    IftheLLC isacorporationorpartnership,thenentertheentitysbusinessnameandEINandforcorporations,

    attachIRSacceptanceletter(CP261orCP277).

    Forallotherentities,enterthenameoftheentityasusedtoapplyfortheentitysEINandtheEIN.

    Name:Clickheretoentertext.BusinessName:Clickheretoentertext.TaxpayerIdentificationNumber

    SocialSecurityNumber:Clickheretoentertext. Or

    EmployerIdentificationNumber:Clickheretoentertext.LegalStatus(checkone):

    Individual GovernmentalSoleProprietor NonresidentalienPartnership EstateortrustLegalServicesCorporation Pharmacy(NonCorp.)Taxexempt Pharmacy/FuneralHome/Cemetery(Corp.)Corporationprovidingorbilling LimitedLiabilityCompany

    medicaland/orhealthcareservices (selectapplicabletaxclassification)CorporationNOTprovidingorbilling D=disregardedentity

    medicaland/orhealthcareservices C=corporation P=partnership

    SignatureofAuthorizedRepresentative:

    Date:Clickheretoenteradate

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