Contract Review Permanent Legislative Oversight Committee
Alabama State House --- Montgomery, Alabama 36130
C O N T R A C T R E V I E W R E P O R T
(Separate review report required for each contract)
Name of State Agency:________________________________________________________________________
Name of Contractor:__________________________________________________________________________
__________________________________________________ |
_________________________ |
________ |
Contractor’s Physical Street Address (No P.O. Box Accepted) |
City |
ST |
Is Contractor a Sole Source? YES ______ NO ______ (IF YES, ATTACH LETTER)
Is Contractor organized as an Alabama Entity in Alabama? YES ______ NO ______
Is Contractor a minority and/or woman-owned business? YES ______ NO ______
If so, is Contractor certified as such by the State of Alabama? YES ______ NO ______
Check all that apply: ALDOT ______ ADECA ______ OTHER (Name) _____________________________________________
Is Contractor Registered with Alabama Secretary of State to do Business as a Corporation in Alabama? YES ______ NO ______
IF LLC, GIVE NAMES OF MEMBERS: _____________________________________________________________________
Is Act 2001-955 Disclosure Form Included with this Contract? YES ______ NO ______
Does Contractor have current member of Legislature or family member of Legislator employed? YES ______ NO ______
Was a Lobbyist/Consultant used to secure this Contract OR affiliated with this Contractor? YES ______ NO ______
IF YES, GIVE NAME: ________________________________________________________________________________
Contract Number: _C_ ___ ___ ___ ___ ___ ___ ___ ___ (See Fiscal Policies & Procedures Manual, Page 5-8)
Contract/Amendment Amount: $___________________ (PUT AMOUNT YOU ARE ASKING FOR TODAY ONLY)
% State Funds: ________ % Federal Funds: _________ % Other Funds: _________**
**Please Specify Source of Other Funds (Fees, Grants, etc.) __________________________________________
Date Contract Effective: __________________________ |
Date Contract Ends: __________________________ |
Type Contract: NEW: ______ RENEWAL: ______ |
AMENDMENT: ______ |
If Renewal, was it originally Bid? YES ______ NO ______ |
If AMENDMENT, Complete A through C: |
|
[A] ORIGINAL contract amount |
$ _________________________ |
[B] Amended total prior to this amendment |
$ _________________________ |
[C] Amended total after this amendment |
$ _________________________ |
Was Contract Secured through Bid Process? YES ______ NO ______ Was lowest Bid accepted? YES ______ NO ______
Was Contract Secured through RFP Process? YES ______ NO ______ Date RFP was awarded: ______________________
Posted to Statewide RFP Database at http://rfp.alabama.gov/Login.aspx? YES ______ NO ______
If NO, give a brief explanation as to why not: ________________________________________________________
Summary of Contract Services to be Provided: ____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Why Contract Necessary AND why this service cannot be performed by merit employee: __________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I certify that the above information is correct. |
|
___________________________________________ |
_________________________________________ |
Signature of Agency Head |
Signature of Contractor |
___________________________________________ |
_________________________________________ |
Printed Name of Agency Head |
Printed Name of Contractor |
Agency Contact: ________________________________________________ Phone:_____________________