ADHS14-071224 STD AMD 4 (04).PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 150 N. 18th Avenue, Suite 280
Phoenix, Arizona 85007
(602) 542-1040
C-86-15-020-3-04 (602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS14-071224 Amendment No. 4
Delilah Gonzalez
SEXUAL TRANSMITTED DISEASE (STD) PROGRAM
Effective upon signature, it is mutually agreed that the Contract referenced is amended as follows:
1. Pursuant to Terms and Conditions, Provision Six (6), Contract Changes, Item (6.1) Amendments, Purchase
Orders and Change Orders, the Contract is amended as follows:
1.1 Scope of Services, Provision Seven (7) State Provided Items, section 7.8 is deleted in its entirety.
1.2 The Price Sheet is revised and replaced with the Price Sheet in this Amendment. The Total Price Sheet
remains the same, the line item changes are due to a decrease in Personnel. New line item added due to
collaboration with other organizations to implement STD promotion and prevention educations activities.
ALL OTHER PROVISIONS OF THIS AGREEMENT REMAIN UNCHANGED.
CONTRACTOR SIGNATURE
MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH
Contractor Name Contractor Authorized Signature
4041 NORTH CENTRAL, SUITE 1400 Clint Hickman
Address Printed Name
PHOENIX ARIZONA 85012 Chairman, Board of Supervisors
City State Zip Title
CONTRACTOR ATTORNEY SIGNATURE This Intergovernmental Agreement Amendment shall be effective
Pursuant to A.R.S. § 11-952, the undersigned public agency attorney has the date indicated. The Public Agency is hereby cautioned not to
determined that this Intergovernmental Agreement is in proper form and is commence any billable work or provide any material, service or
within the powers and authority granted under the laws of the State of Arizona. construction under this IGA until the IGA has been executed by an
authorized ADHS signatory.
State of Arizona
Signed this ______ day of _______________________ 2016.
Signature Date
Printed Name Procurement Officer
RESERVED FOR USE BY THE SECRETARY OF STATE
Attorney General Contract No. P0012014000078, which is an Agreement
between public agencies, has been reviewed pursuant to A.R.S. § 11-952 by
the undersigned Assistant Attorney General, who has determined that it is in
proper form and is within the powers and authority granted under the laws of
the State of Arizona.
Signature Date
Assistant Attorney General
Printed Name:
ATTEST:_____________________________________________________
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ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 150 N. 18th Avenue, Suite 280
Phoenix, Arizona 85007
(602) 542-1040
(602) 542-1741 Fax
Procurement Specialist
Contract No: ADHS14-071224 Amendment No. 4 Delilah Gonzalez
Price Sheet
ACCOUNT CLASSIFICATION AMOUNT
Personnel Services and ERE $401,061.00
Professional & Outside Services $ 0.00
Travel Expense $ 0.00
Occupancy Expense $ 0.00
Other Operating Expenses $ 1.00
Capital $ 0.00
Other $63,368.00
TOTAL $464,430.00
Description QTY. Rate per unit Unit Amount
Redeemed
Clinic Visits 300 $20.00 Outreach $6,000.00
Voucher
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