SUMMARY OF CONTRACTUAL SERVICES AGREEMENT/PURCHASE ORDER

ATTACHMENT A

SUMMARY OF CONTRACTUAL SERVICES AGREEMENT/PURCHASE ORDER

DELIVER TO: BUREAU OF COMPTROLLER, 914 TURLINGTON BUILDING, CONTRACTUAL PAYMENTS SECTION

OLO/Department:	480000/DEPARTMENT OF EDUCATION	Agency Contact:
Contract/PO #:		Telephone #:

Contractor/Vendor/Payee:
Total Contract Amount:

Contract Start Date:

Contract End Date:

CONTRACT LAST SIGNED DATE:

CONTRACT SIGNED BY NAME:

JOB TITLE:

Type of Services:

Method of Payment:

Fixed Rate

Lump Sum

Cost Reimbursement

Cost Plus (any combination)

Advance Funded

YES NO

Deliverables Including Minimum Performance Standards	Payment Amount

Method of Procurement:

ITB

RFP

ITN

Ref #

Single/Sole Source

Emergency Certification

Other (Specify)

*AGENCY MANAGEMENT CERTIFICATION:

I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions

of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require

additional documentation and/or to conduct periodic post-audits of any agreements.

Management Name printed:		Job Title:
Management Signature:		Date:

Invoice Number:

Invoice Period:

Total Amount of Previous Payments:

Contract Manager certification:

I certify, by evidence of my signature below, the above information is true and correct; the goods and services have been satisfactorily

received and payment is now due. I understand that the office of the State Chief Financial Officer reserves the right to require additional

documentation and/or to conduct periodic post-audits of any agreements.

Contract Manager Name printed:

Contract Manager Signature:

Date:

Attachment A

Amendments/Renewals

OLO/Department:		Agency Contact:
Contract/PO #:		Telephone #:

Contractor/Vendor/Payee:

Original Contract Start Date:

Original Contract End Date:

Amendment 1

renewal

CONTRACT LAST SIGNED DATE:

CONTRACT SIGNED BY NAME:

JOB TITLE:

TOTAL CONTRACT AMOUNT:

AMENDMENT 2

CONTRACT LAST SIGNED DATE:

CONTRACT SIGNED BY NAME:

JOB TITLE:

TOTAL CONTRACT AMOUNT:

AMENDMENT 3

CONTRACT LAST SIGNED DATE:

CONTRACT SIGNED BY NAME:

JOB TITLE:

TOTAL CONTRACT AMOUNT:

Instructions to complete the Summary of Contractual Services Agreement/Purchase Order Form:

This form should be completed in its entirety, signed and dated by the appropriate agency personnel and submitted with each payment request. Please ensure each field on the form is completed according to the guidance provided.

OLO/Department: Agencies numeric identifier (i.e. 640000/Department of

Health).

Agency Contact: Agency designated personnel to answer questions regarding payment.

Telephone #: Designated personnel phone number.

Total Contract Amount: Provide the contract amount; amount must equal the total amount of the

contract; including amendments and/ or renewals.

Total Amount of Previous Payments: Provide the cumulative total of the payments to date, excluding current

invoice amount (s).

Contract/Agreement/PO/DO#: Identify number assigned to agreement.

Contractor/Vendor/Payee: Identify Vendor/Payee (including d/b/a if applicable).

Contract Start Date: Identify date contract begins.

Contract End Date: Identify date contract ends.

Contract Last Signed Date: Identify date of execution.

Contract Signed by Name: Identify the individual who executed the contract.

Job Title: Identify the job title of the individual who executed the contract.

Type of Services: Provide a brief description of the services being provided.

Method of Payment: Check the appropriate method of payment.

Invoice Number: Identify the invoice number associated with this payment request.

Invoice Period: Identify the invoice period this payment request covers.

Deliverables…Min Performance: All deliverables and minimum performance standards as stated

in the agreement must be provided. Pages from the agreement referencing the deliverables and minimum performance standards may be attached.

Payment Amount
	Identify the payment criteria (compensation) for each deliverable.

Method of Procurement:	Check the appropriate procurement method; identify specific ITB, RFP or ITN number. If first payment is being submitted on a competitively procured agreement, provide documentation evidencing procurement (e.g. bid tab). If Other is selected provide the specific exemption, statute, CSFA, CFDA or GAA line item.

*Agency Management Certification:
This section is to be completed by the level of management Bureau Chief (or equivalent) or higher that has direct knowledge of the contract document and can attest to the information provided on this form is true and correct and accurately reflects the terms and conditions in the executed contract document.

Management Name:	Print name of the appropriate agency personnel.

Job Title:	Print job title of the appropriate agency personnel signing form.

Management Signature:	Signature of the appropriate agency personnel.

Date:	Enter the date signed by the appropriate agency personnel.

Contract Manager Certification:	This section is to be completed by the employee designated by the agency to function as the contract manager and is approving the identified invoice for payment based on direct knowledge of satisfactory receipt of the goods or services. If the individual completing this section is not the designated contract manager, please provide justification or delegation of authority for the individual to sign this form.

Contract Manager Name:
	Print name of the appropriate agency personnel.

Contract Manager Signature:
	Signature of the appropriate agency personnel.

Date: Enter the date signed by appropriate agency personnel.

ATTACHMENT A

AMENDMENTS/RENEWAL: This page is to be used to identify any amendments that have been

executed. Additional records may be entered as necessary.

Contract Last Signed Date: Identify date of execution.

Contract Signed by Name: Identify the individual who executed the contract.

Job Title: Identify the job title of the individual who executed the contract.

Total Contract Amount: Provide the contract amount; amount must equal the total amount of the

contract; including amendments and/ or renewals.