AMD RE DIETETIC INTERNSHIP PRGRM WITH ADHS.PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) 1740 West Adams, Room 303
AMENDMENT Phoenix, Arizona 85007
(602) 542-1040 MAIN
(602) 542-1741 FAX
CONTRACT No.: ADHS15-084210 AMENDMENT No.: 2 Jacqueline PROCUREMENT S. Ortega-Avila OFFICER
DIETETIC INTERNSHIP
Effective October 1, 2016, it is mutually agreed that the Contract referenced is amended as follows:
1. Pursuant to the Terms and Conditions, Provision Twenty (20), THE FEDERAL FUNDING ACCOUNTABILITY AND
TRANSPARENCY ACT (FFATA OR TRANSPARENCY ACT - P.L.109-282, AS AMENDED BY SECTION 6202(A)
OF P.L. 110-252), FOUND AT https://www.fsrs.gov/ is hereby added to read as follows:
20. If applicable, the Contractor/Grantee shall submit to ADHS via email the Grant Reporting Certification Form.
This form and the instructions can be downloaded from the ADHS Procurement website at
http://www.azdhs.gov/operations/financial-services/procurement/index.php#ffata and must be returned to the
ADHS by the 15th of the month following that in which the award was received. The form shall be completed
electronically, and submitted using the steps outlined in the Grant Reporting Certification Form Instructions to
the following email address: ADHS_Grant@azdhs.gov. All required fields must be filled including Top Employee
Compensation, if applicable. Completing the Grant Reporting Certification Form is required for compliance with
the Office of Management and Budget (OMB), found at http://www.whitehouse.gov/omb/open. Failure to timely
submit the Grant Reporting Certification Form could result in the loss of funds. This requirement applies to all
subcontractors/sub-awardees utilized by the Contractor/Grantee for amounts exceeding $30,000.00 during the
term of the Award.
CONTINUED ON NEXT PAGE
CONTRACTOR SIGNATURE
MARICOPA COUNTY BY AND THROUGH ITS
MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH
Contractor Name Contractor Authorized Signature
4041 NORTH CENTRAL AVENUE, SUITE 1400 Clint L. Hickman
Address Printed Name
PHOENIX ARIZONA 85012 Chairman, Maricopa County Board of Supervisors
City State Zip Title
CONTRACTOR ATTORNEY SIGNATURE This Intergovernmental Agreement Amendment shall be effective the
Pursuant to A.R.S. § 11-952, the undersigned public agency attorney date indicated. The Public Agency is hereby cautioned not to commence
has determined that this Intergovernmental Agreement is in proper any billable work or provide any material, service or construction under
form and is within the powers and authority granted under the laws of this IGA until the IGA has been executed by an authorized ADHS
the State of Arizona. signatory.
State of Arizona
Signed this ______ day of _______________________ 20___
Signature Date
Printed Name Procurement Officer
Attorney General Contract No. P0012014000078, which is an RESERVED FOR USE BY THE SECRETARY OF STATE
Agreement between public agencies, has been reviewed pursuant to
A.R.S. § 11-952 by the undersigned Assistant Attorney General, who Under House Bill 2011, A.R.S. § 11-952
has determined that it is in proper form and is within the powers and
authority granted under the laws of the State of Arizona. was amended to remove the requirement
that Intergovernmental Agreements be filed
with the Secretary of State.
Signature Date
Assistant Attorney General
Printed Name:
ATTEST:
____________________________________________________
Clerk of the Board Date

ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) 1740 West Adams, Room 303
AMENDMENT Phoenix, Arizona 85007
(602) 542-1040 MAIN
(602) 542-1741 FAX
CONTRACT No.: ADHS15-084210 AMENDMENT No.: 2 Jacqueline PROCUREMENT S. Ortega-Avila OFFICER
2. The Dietetic Internship Price Sheet in Amendment One (1) is hereby amended with the revised Dietetic
Internship Price Sheet of this Amendment Two (2). The total of the Dietetic Internship Price Sheet budget
amount is $150,000.00 with the following changes:
2.1. Personnel Costs/Salary Expenses decreased by $288.00 due to Salary Expenses.
2.2. Employee Related Expenses increased by $1,997.00 due to an increase in Employee Related Expenses.
2.3. Professional and Outside Expenses increased by $2,580.00 due to an increase in Outside Service expenses.
2.4. Travel Expenses decreased by $823.00 due to a decrease in travel costs.
2.5. Occupancy Expenses increased by $356.00 due to an increase in Occupancy Expenses.
2.6. Other Operating Expenses decreased by $3,823.00 due to a decrease in Other Operating Expenses.
2.7. Capital Outlay Expenses increased by a $1.00 to open a line item.
2.8. Indirect Cost Expenses will remain in the same dollar amount of $20,466.00.
3. In ProcureAZ the “Items” Tab of the Master Blanket Purchase Order will be revised to reflect the pricing upon
execution of this Amendment Two (2).
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ARIZONA DEPARTMENT OF
HEALTH SERVICES
INTERGOVERNMENTAL AGREEMENT (IGA) 1740 West Adams, Room 303
AMENDMENT Phoenix, Arizona 85007
(602) 542-1040 MAIN
(602) 542-1741 FAX
CONTRACT No.: ADHS15-084210 AMENDMENT No.: 2 Jacqueline PROCUREMENT S. Ortega-Avila OFFICER
DIETETIC INTERNSHIP
REVISED PRICE SHEET
OCTOBER 1, 2016 TO SEPTEMBER 30, 2017
LINE ITEM BUDGET AMOUNT
2.1 PERSONNEL COSTS/SALARY EXPENSES $75,078.00
2.2 EMPLOYEE RELATED EXPENSES $31,523.00
2.3 PROFESSIONAL & OUTSIDE EXPENSES $7,315.00
2.4 TRAVEL EXPENSES $2,177.00
2.5 OCCUPANCY EXPENSES $4,356.00
2.6 OTHER OPERATING EXPENSES $9,084.00
2.7 CAPITAL OUTLAY EXPENSES $1.00
2.8 INDIRECT COST EXPENSES (IF AUTHORIZED) $20,466.00
TOTAL $150,000.00
LINE ITEM BUDGET TRANSFERS
Upon receipt of written authorization from the ADHS Program Manager, the Contractor is authorized to transfer up to a
maximum of ten percent (10%) of the Total Budgeted Amount between funded line items. Transfers of funds are only
allowed between funded line items. Transfers exceeding ten percent (10%) or to a non-funded line item shall require a
Contract Amendment.
INDIRECT COSTS EXPENSES
Any changes in indirect expenses will require submission of supporting documentation and written approval from ADHS.
ALL OTHER PROVISIONS OF THIS AGREEMENT SHALL REMAIN IN THEIR ENTIRETY.
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