TR-2013-47 GRANT FOR EMERG MNGMT � --�-.. --T- - -- -
TR-2013-47
A RESOLUTION ACCEPTING A GRANT FROM COMMONWEALTH OF
MASSACHUSETTS EMERGENCY MANAGEMENT AGENCY
PURSUANT TO MASSACHUSETTS GENERAL LAWS
CHAPTER 44, SECTION 53A TO AGAWAM EMERGENCY MANAGEMENT
(Sponsored by Richard A. Cohen)
WHEREAS, the Town of Agawam applied for and received a grant from
the Massachusetts Emergency Management Agency; and
WHEREAS, the Agawam Emergency Management desires to accept said
grant; and a
WHEREAS, the grant is in the amount of two thousand three hundrecondC,�
001100 ($2,300.00) dollars;
WHEREAS, Agawam Emergency Management will use the funds for 37`
emergency management planning; and
WHEREAS, it is in the best interests of the Town of Agawam to accept th��
grant from the Massachusetts Emergency Management Agency.
NOW THEREFORE, the Agawam City Council hereby resolves pursuant
to M.G.L. c.44, §53A to accept this grant from Massachusetts Emergency
Management Agency.
DATED THIS DAY OFUD- , 2013.
PER ORDER OF THE AGAWAM CITY COUNCIL CC— �, A 1)-h I
C)RC cc � rncr
Christopher C. J nson, President
APPROVED ASrTO FORM AND LEGALITY CC- AV
Vincent F. Gioscia, Solicitor
i
MAYORAL ACTION
Received this day of , 2013 from Council Clerk.
Signed by Council President this dA S4 day ok)G�6+tk , 2013.
APPROVAL OF LEGISLATION
By the powers vested in me pursuant to Article 3, Section 3-6 of the Agawam C arter, as
am e de , I hereby approve the passage of the above legislation on this day of
2013.
Richard A. Cohen, Mayor
DISAPPROVAL OF LEGISLATION
By the powers vested in me pursuant to Article 3, Section 3-6 of the Agawam Charter, as
amended, I hereby veto the passage of the above legislation on this day of
2013 for the following reason(s):
Richard A. Cohen, Mayor
RETURN OF LEGISLATION TO COUNCIL CLERK
Returned to Council Clerk this day of ' 2013,
COMMONWEALTH OF MASSACHUSETTS - STANDARD CONTRACT FORM
Y
This form is jointly issued and published by the Executive Office for Administration and Finance ANF} the Office of the Comeiroller(CTR}and the 0 erational Services Division OSD
as the default contract for all Commonwealth Departments when another form is not prescribed by regulation or policy. Any changes to the official printed language of this form shall be
void. Additional non-conflicting terms may be added by Attachment.Contractors may not require any additional agreements,engagement letters,contract forms or other additional terms
as part of this Contract without prior Department approval. Click on hypedinks for definitions,instructions and legal requirements that are incorporated by reference into this Contract. An
electronic copy of this form is available at www.mass.gov/osc under Guidance For Vendors-Forms or www.mass�ovlosd under OSD Forms.
CONTRACTOR LEGAL NAME: TOWN OF AGAWAM COMMONWEALTH DEPARTMENT NAME: Massachusetts Emergency Management
(and dlbla): Agawam MRC Agency
MMARS Department Code: CDA
Legal Address: 36 Main Street,Agawam,MA 01001 Business Mailin�Address: 400 Worcester Road,Framingham,MA 01702.5399
Contract Manager: Randall White Billing Address Of different):
E•Mail: rwhtte@agawam.ma.us Contract Manager.David Cruz
Phone: 413.786-04M f E-Mail: David.CruzOstate.ma.us
Contractor Vendor Code: VC6000191692 hone:50a-a20.2009 Fax: 50&a20.2030
Vendor Code Address ID(e.g."AD001"): AD001 MMARS Doc Us):FY14CCP12000000AGAWA
(Note:The Address Id Must be set up for EFT payments.) RFR/Procurement or Other ID Number 2012 SHSPICCP AGF:
X NEW CONTRACT CONTRACT AMENDMENT
PROCUREMENT OR EXCEPTION TYPE:(Check one option only) Enter Current Contract End Date Prior to Amendment ,20�
_Statewide Contract(OSO or an OSD-designated Department) Enter Amendment Amount:$ .(or'no change')
Collective Purchase(Attach 0SD approval,scope,budget) AMENDMENT TYPE:(Check one option only.Attach details of Amendment changes.)
X Department Procurement(includes State or Federal grants 815 CMR 2.00} Amendment to Scone or Budaet(Attach updated scope and budget)
(Attach RFR and Response or Other procurement supporting documentation) Interim Contract(Attach justification for Interim Contract and updated scapetbudget)
—Ememepg Contract (Attach justification for emergency,scope,budget) Contract Emolovee(Attach any updates to scope or budget)
—Contract Emplovee(Attach Employment Status Form,scope,budget) —
—LegislativelLegal or Other.(Attach authorizing language4ustification,scope and Legislative ggal or Other(Attach authorizing languagetjustification and updated
budget) — scope and budget)
The following COMMONWEALTH TERMS AND CONDITIONS(T&C)has been executed,filed with CTR and is incorporated by reference Into this Contract
X Commonwealth Terms and Conditions Commonwealth Terms and Conditions For Human and Social Services
COMPENSATION:(Check ONE option):The Department certifies that payments for authorized performance accepted in accordance with fie terms of this Contract will be supported
in the state accounting system by sufficient appnopriatim or other non-appropriated funds,subject to intercept for Commonw eafth owed debts under 815 CMR 9.00.
Rate Contract(No Maximum Obligation. Attach detaits.of all rates,units,calculations,conditions or temps and any changes if rates or temps are being amended.)
X Maximum Obligation Contract Enter Total Maximum Obligation for total duration of this Contract(or new Total it Contract is being amended).SZ300A0
PROMPT PAYMENT DISCOUNTS fPPD): Commonwealth payments are issued through EFT 45 days from invoice receipt Contractors requesting accelerated payments rrxust
identify a PPD as follows: Payment issued within 10 days_%PPD;Payment issued within 15 days—%PPD;Payment issued within 20 days—%PPD;Payment issued within 30
days—%PPD. If PPD percentages are W blank,identify reason: agree to standard 45 day cycle—statutwyllegat or Ready Payments(G.L,c.29,S 23A); Z( only initial
p2yment su uent payments scheduled to support standard EFT 45 daX payment gde.See Prompt Pay Discounts Poll
BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT:(Enter the Contract title,purpose,fiscal years)and a detailed description of the scope of
performance or what is being amended for a Contract Amendment Attach all supporting documentation and jmustificabons.) Funding forthis grant is provided through the
FFY2012 Emergency Management Program Performance grant. The catalogue of Federal Domestic Assistance(CFDA)number Is 97442. The entity intends to conduct
Lanni .
ANTICIPATED START DATE: (Complete ONE option only)The Departs ent and Contractor certify for this Contract,or Contract Amendment that Contract obligations:
X 1.may be incurred as of the Effective Date(latest signature data below)and no obligations have been incurred prior to the Ebc ive Date.
_2.may be incurred as of .20_,a date LATER than the Effective Date below and no obligations have been incurred p or to the Effective Data.
—
3.were incurred as of ,20_,a date PRIOR to the Effective Date below,and the parties agree that payments for any oblgatiorms Incurred prior to the EffeCtive Date are
authorized to be made either as settlement payments or as authorized reimbursement payments,and that the details and circumstances of all obligations under this Contract are
attached and Incorporated into this Contract. Acoe tance of Ls forever releases the Commonwealth Iron further daunts related to these obf ations.
r
TRACT END DATE: Contract performance shall terminate as of M 3a x 1 2014,with no new obligations being incurred after this date unless the Contract is properly amended,
ided that the terms of this Contract and performance expectations and obligations shall survive its temnination fior the purpose of resolving any claim or dispute,forcompleting any
tiated terms and warranties,to allow any dose out or transition performance,reporting,invoicing or final payments,or during any lapse bebteen amendments.
TIFICATIQNS: Notwithstanding verbal or other representations by the parties,the"Effective Date"of this Contract or Amendment shall be the latest date that this Contract or
Amendment has been executed by an authorized signatory of the Contractor,the Department,or a later Contract or Amendment Start Date specified above,subject to any required
approvals. The Contractor makes all certifications required under the attached Contractor Certfications(incorporated by reference 9 not attached hereto) under the pains and
penalties of perjury,agrees to provide any required documentation upon request to support compliance,and agrees that all terms goveming performance of this Contract and doing
business in Massachusetts are attached or incorporated by reference herein according to the following hierarchy of document precedence,the applicable Commonwealth Tema and
Conditions,this Standard Contract Form including the Instructions and Contractor Certifications,the Request for Response(RFR)or other solicitation,the Contractor's Response,and
additional negotiated terms,provided that additional negotiated terms will take precedence over the relevant terms in the RFR and the Contractor's Response only if made using the
process outlined in 801 CMR 21.07 incorporated herein,provided that any amended RFR or Response terms result in best value,lower costs,or more cast effective Contract
AUTHOR G SIGNATURE FOR THE C TRACTOR: AUTHORIZING SIGNATURE FOR THE COMMONWEALTH:
X. . Date: .Zy--C- . w6 X: Date:
Isignatup and Date Must Be Handpritten_At Time of Signature) (Signature and Date Must Be Handwritten At Time of Signature)
Print Name: 14�/Po 4 y� .. Print Name: David Mahr
Print Title: Print Title: Chief Fiscal Officer
(Updated 6/2 712 0 1 1) Page 1 of 3
Issued May
COMMONWEALTH OF MASSACHUSETTS 200004
CONTRACTOR AUTHORIZED SIGNATORY LISTING
CONTRACTOR LEGAL NAME :
CONTRACTOR VENDOR/CUSTOMER CODE:
INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a
listing of individuals who are authorized as legal representatives of the Contractor who can sign contracts and
other legally binding documents related to the contract on the Contractor's behalf. In addition to this listing, any
state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof
of authenticity of signature (a notarized signature that the Department can use to verify that the signature and
date that appear on the Contract or other legal document was actually made by the Contractor's authorized
signatory, and not by a representative,designee or other individual.)
NOTICE: Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by
the Contractor challenging the existence of a valid Contract due to an alleged lack of actual authority to
execute the document by the signatory.
For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank
account numbers, social security numbers, driver's licenses, home addresses, social security cards or any other
personally identifiable information that you do not want released as part of a public record. The Commonwealth
reserves the right to publish the names and titles of authorized signatories of contractors.
AUTHORIZED SIGNATORY NAME TITLE
�o EiV l:'r Yee
I certify that I am the President, Chief Executive Officer, Chief Fiscal Officer, Corporate Clerk or Legal Counsel
for the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals
identified on this listing are current as of the date of execution below and that these individuals are authorized to
sign contracts and other legally binding documents related to contracts with the Commonwealth of
Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that
this listing is immediately updated and communicated to any state department with which the Contractor does
business whenever the authorized signatories above retire, are otherwise terminated from the Contractor's
employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with
the Commonwealth or whenever new signatories are designated.
Date:
Signature
- zy�c�r,ZPI3
Title: M A 'f 109 Telephone: y/3- 18tf Y,52,0
Fax: V/.3-'7�(,`- 99X,7 Email: /?'IfI eX �f1Gflwrlin./YJfj. VS
[Listing can not be accepted without all of this information completed.]
A copy of this listing must be attached to the "record copy" of a contract filed with the department.
(c) The undersigned shall require that the language of this certification be
included in the award documents for all sub-awards at all tiers
(including sub-grants, contracts under grants and cooperative
agreements, and subcontracts)and that all sub-recipients shall certify
and disclose accordingly.
36. Debarment, Suspension,and Other Responsibilities. As required by Executive Order
12549, Debarment and Suspension, and implemented at 28 CFR Part 67, for prospective
participants in primary covered transactions, as defined at 28 CFR Part 67, Section
67.510—
A. The applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, sentenced to a denial of Federal benefits by a State
or Federal court, or voluntarily excluded from covered transactions by
any Federal department or agency;
(b) Have not within a three-year period preceding this application been
convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with
obtaining,attempting to obtain, or performing a public(Federal, State,
or local)transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making
false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly
charged by a governmental entity(Federal, State, or local)with
commission of any of the offenses enumerated in paragraph(1)(b) of
this certification; and
(d) Have not within a three-year period preceding this application had one
or more public transactions(Federal, State, or local)terminated for
cause or default; and
B. Where the applicant is unable to certify to any of the statements in this
certification, he or she shall attach an explanation to this application.
37. Internet Access. Sub-recipients must have Internet access.
38. Email addresses. Sub-recipient project directors of grant programs must have individual
email addresses.
As the duly authorized representative of the sub-recipient,I hereby certify that the sub-
recipien will comply with the ove conditions.
=' rIf
Signature of Authorized Signatory Date
Rt A eoff Aq Yo
Printed Name Title
7
Issued May
COMMONWEALTH OF MASSACHUSETTS 200004
CONTRACTOR AUTHORIZED SIGNATORY LISTING
CONTRACTOR LEGAL NAME :
CONTRACTOR VENDOR/CUSTOMER CODE:
PROOF OF AUTHENTICATION OF SIGNATURE
This page is optional and is available for a department to authenticate contract signatures.
It is recommended that Departments obtain authentication of signature for the signatory
who submits the Contractor Authorized Listing.
This Section MUST be completed by the Contractor Authorized Signatory in presence of notary..-
Signatory's full legal name(print or type): Ci
Title:
Signature as it will appear on contract or other document(Complete only in presence of notary):
AUTFIEN. ICATED BY NOTARY OR CORPORATE CLERK(PICK ONLY ONE) AS FOLLOWS:
(NOTARY)as a notary public certify that t witnessed
the signature of the aforementioned signatory above and I verified the individual's identity on this date:
f ( `� 20 3
My commission expires on: t` + j
AFFIX NOTARY SCAL
I, (CORPORATE CLERK)certify that I witnessed the
signature of the aforementioned signatory above,that I verified the individual's identity and confirm the individual's
authority as an authorized signatory for the Contractor on this date:
20 1 3
AFFIX CORPORATE SEAL
J
TR-2013-47
A RESOLUTION ACCEPTING A GRANT FROM COMMONWEALTH OF
MASSACHUSETTS EMERGENCY MANAGEMENT AGENCY
PURSUANT TO MASSACHUSETTS GENERAL LAWS
CHAPTER 44, SECTION 53A TO AGAWAM EMERGENCY MANAGEMENT
(Sponsored by Richard A. Cohen)
WHEREAS, the Town of Agawam applied for and received a grant from
the Massachusetts Emergency Management Agency; and
WHEREAS, the Agawam Emergency Management desires to accept said
grant; and
WHEREAS, the grant is in the amount of two thousand three hundred and
001100 ($2,300.00) dollars;
WHEREAS, Agawam Emergency Management will use the funds for
emergency management planning; and
WHEREAS, it is in the best interests of the Town of Agawam to accept the
grant from the Massachusetts Emergency Management Agency.
NOW THEREFORE, the Agawam City Council hereby resolves pursuant
to M.G.L. c.44, §53A to accept this grant from Massachusetts Emergency
Management Agency.
DATED THIS DAY OF , 2013.
PER ORDER OF THE AGAWAM CITY COUNCIL
Christopher C. Johnson, President
APPROVE7A& FORM AND LEGALITY
Vincent . Gioscia, Solicitor
` COMMONWEALTH OF MASSACHUSETTS -- STANDARD CONTRACT FORM
This form is jointly issued and published by the Executive Office for Administration and Finance(ANFi,the Office of the Comptroller(CTR1 and the Operational Services Division I05D]
as the default contract for all Commormrealth Departments when another farm is not prescribed by regufation or policy. Any changes to the official printed language of this form shall be
void. Additional non-conflicting terms may be added by Attachment.Contractors may not require any additional agreements,engagement letters,contract farms or other additional terms
as part of this Contract without prior Department approval. Click on hypedinks for definitions,instructions and legal requirements that are incorporated by reference into this Contract An
electronic copy of this form is available atwww,mass.gov/os under Guidance For Vendors-Forms or www.mass.Qov/osd under 0 D Form
CONTRACTOR LEGAL NAME: TOWN OF AGAWAM COMMONWEALTH DEPARTMENT NAME: Massachusetts Emergency Management
(and dlbla): Agawam MRC Agency
MMARS Department Code: CDA
Legal Address: 36 Main Street,Agawam,MA 01001 Business Mailing Address: 400 Worcester Road,Framingham,MA 01702.5399
Contract Manager: Randall White Billing Address(if different):
E-Mail: rwhte@agawam.ma.us Contract Manager.David Cruz
Phone: 413.786-M Fax: EAM. David.Cruz@state.ma.us
Contractor Vendor Code: VC6000191692 Phone:508420-2009 Fax: 508.M2030
Vendor Code Address ID(e g."A0001'): AD001_ MMARS Doc ID(s):FY14CCP12000000AGAWA
(Note:The Address Id Must be set up for EFT payments.) RFR1Pracurement or Other ID Number 2012 SHSPiCCP AGF:
x NEW CONTRACT i CONTRACT AMENDMENT
PROCUREMENT OR CEPTtO TYPE:{Check one option Doty) Enter Current Contract End Date Priorto Amendment: 20�
_Statewide Contract(OSD or an OSD-designated Department) Enter Amendment Amount:$ .(or'no change')
Collective Purchase(Attach OSD approval,scope,budget) AMENDMENT TYPE:(Check one option only.Attach details of Amendment changes.)
X Department Procurement(mdudes State or Federal grants 815 CMR 2.001 Amendment to Scop2 or Budget(Attach updated scope and budget)
(Attach RFR and Response or other procurement supportingcum doentation) —Interim Contract(Attach justification for Interim Cont lbudg Contract and updated scopeet)
_Ernemency Contra (Attach justification for emergency,scope,budget) —
Contract Fmplovee(Attach Errtolnvment Status Form,scope,budget) _Contract Employee(Attach any updates to scope or budget)
Legislativell-egaI or Other.(Attach authorizing languagerustificabon,scope and _LegisUtWelLenal or Other.(Attach authorizing languagerjustification and updated
^'budget) scope and budget)
The following COMMONWEALTH TERMS AND CONDITIONS(T&C)has been executed,filed with CTR and is incorporated by reference Into this Contract
X Commonwealth Terms and Conditions _Commonwealth Terms and Conditions For Human and Social Services
COMPENSATION:(Check ONE option):The Department certifies that payments for authorized performance accepted in accordance with the terms of this Contract will be supported
in the state accounting system by sufficient appropriations or other non-appropriated funds,subod to intercept for Commonwealth owed debts under 815 CMR 9.00.
Rate Contract(No Maximum Obligation. Attach detaffs.of all rates,units,calculations,conditions or terms and any changes if rates or temps are being amended.)
-&MaximumObligatiQn Contract Enter Total Maximum Obligation for total duration of this Contract(or new Total if Contract is being amended)."0.00
PROMPT PAYMENT DISCOUNTS(PPDi: Commonwealth payments are issued through EFT 45 days from invoice receipt Contractors requesting accelerated payments must
Identify a PPD as follows: Payment issued within 10 days_%PPD:Payment issued within 15 days_%PPD;Payment issued within 2D days %PPD;Payment Issued within 30
days—%PPD. If PPD percentages are left blank,identify reason: agree to standard 45 day cycle_statuloryflegal or Ready Payments(G.L.C.29,§23A:X( only initial
pa=nt(subsquenl payments scheduled to supmrl standard EFT 45 day t cycle.See Prompt-Pay Discounts Pot
BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT:(Enter the Contract title,purpose,fiscal years)and a detailed description of the scope of
perfannance or what is being amended for a Contract Amendment Attach all supporting documentation and justifications.) Funding for this grant is provided through the
FFY2012 Emergency Management Program Performance gram The catalogue of Federal Domestic Assistance(CFDA)number is 97-N2. The entity intends ter conduct
planning.
ANTICIPATED START DATE: (Complete ONE option only)The Department and Contractor certify for this Contract or Contract Amendment,that Contract obligatons:
x 1,may be incurred as of the Effective Date(latest signature date below)and no obligations have been incurred odor to the Effective Date,
2.may be incurred as of .20_,a date LATER than the Effective Date below and no obligations have been incurred rigor to the EftecM Date.
r_3,were roamed as of ,20_,a date PRIOR to the Effective Date below,and the parties agree that payments for any obligations Incurred prior to the Ell *e Date are
authorized to be made either as settlement payments or as authorized reimbursement payments,and that the details and circumstances of all obligations under this Contract are
attached and incorporated into this Contract Acceptance of payments forever releases the Commonwealth from further claims related to these obi attons.
CONTRACT END DATE: Contract performance shaft terminate as of May 31,2014,with no new obligations being incurred after this date unless the Contract Is property amended,
provided that the terms of this Contract and performance expectations and obligations shaft survive its termination for the purpose of resolving any claim or dispute,for completing any
negotiated terns and warranties,to allow any dose out or transition performance,reporting,invoicing or final payments,or during any lapse between amendments.
CERTIFICATIONS: Notwithstanding verbal or other representations by the parties,the"Effective Date"of this Contract or Amendment shall be the latest date that this Contract or
Amendment has been executed by an authorized signatory of the Contractor,the Department or a later Contract or Amendment Start Date specified above,subject to any required
approvals. The Contractor makes all certifications required under the attached Contractor Certifications (incorporated by reference If not attached hereto) under the pains and
penalties of perjury,agrees to provide arty required documentation upon request to support compliance,and agrees that all terms governing performance of this Contract and doing
business in Massachusetts are attached or incorporated by reference herein according to the following hierarchy of document precedence,the applicable CommoMalth Terms and
Conditions,this Standard Contract Form including the Instructions jnd Contractor Certifications,the Request for Response(RFR)or other solicitation,the Contractor's Response,and
additional negotiated terms,provided that additional negotiated terms will take precedence over the relevant terms in the RFR and the Contractor's Response only i(made using the
process outlined in 801 CMR 21.07,incorporated herein,provided that any amended RFR or Response terms result in best value,lower costs,or a more cost affective Contract,
AU HOR G SIGNATURE FOR THE C TRACTOR: AUTHORIZING SIGNATURE FOR THE COMMONWEALTH:
K. Date: zY '°T,2°/3 x: Date:
(Signatu and Date Must Be Han en At Time of Signature)
�/� �0 � (Signature and Date Must Be Handwrirten At Time of Signature)
Print Name: _ Print Name: David Mahr
Print Title: Print Title: Chief Fiscal Officer
(Updated 6/27/2011) Page 1 of 3
• Issued May
COMMONWEALTH OF MASSACHUSETTS 2004
CONTRACTOR AUTHORIZED SIGNATORY LISTING
CONTRACTOR LEGAL NAME :
CONTRACTOR VENDOR/CUSTOMER CODE:
INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a
listing of individuals who are authorized as legal representatives of the Contractor who can sign contracts and
other legally binding documents related to the contract on the Contractor's behalf In addition to this listing, any
state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof
of authenticity of signature (a notarized signature that the Department can use to verify that the signature and
date that appear on the Contract or other legal document was actually made by the Contractor's authorized
signatory,and not by a representative,designee or other individual.)
NOTICE: Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by
the Contractor challenging the existence of a valid Contract due to an alleged lack of actual authority to
execute the document by the signatory.
For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank
account numbers, social security numbers, driver's licenses, home addresses, social security cards or any other
personally identifiable information that you do not want released as part of a public record. The Commonwealth
reserves the right to publish the names and titles of authorized signatories of contractors.
AUTHORIZED SIGNATORY NAME TITLE
M Iq
I certify that I am the President, Chief Executive Officer, Chief Fiscal Officer, Corporate Clerk or Legal Counsel
for the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals
identified on this listing aie current as of the date of execution below and that these individuals are authorized to
sign contracts and other legally binding documents related to contracts with the Commonwealth of
Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that
this listing is immediately updated and communicated to any state department with which the Contractor does
business whenever the authorized signatories above retire, are otherwise terminated from the Contractor's
employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with
the Commonwealth or whenever new signatories are designated.
Date:
Signature
Title: M AVDR Telephone: Y13-
Fax: y/3-. ;Wg-- 99a27 Email: 17919yele
[Listing can not be accepted without all of this information completed.]
A copy of this Iisting trust be attached to the "record copy" of a contract filed with the department.
(c) The undersigned shall require that the language of this certification be
included in the award documents for all sub-awards at all tiers
(including sub-grants, contracts under grants and cooperative
agreements, and subcontracts)and that all sub-recipients shall certify
and disclose accordingly.
36. Debarment,Suspension,and Other Responsibilities. As required by Executive Order
12549, Debarment and Suspension, and implemented at 28 CFR Part 67, for prospective
participants in primary covered transactions,as defined at 28 CFR Part 67, Section
67.510----
A. The applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, sentenced to a denial of Federal benefits by a State
or Federal court, or voluntarily excluded from covered transactions by
any Federal department or agency;
(b) Have not within a three-year period preceding this application been
convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal gffense in connection with
obtaining, attempting to obtain, or performing a public(Federal, State,
or local)transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making
false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly
charged by a governmental entity(Federal, State, or local) with
commission of any of the offenses enumerated in paragraph (1)(b) of
this certification; and
(d) Have not within a three-year period preceding this application had one
or more public transactions(Federal, State, or Iocal)terminated for
cause or default;and
B. Where the applicant is unable to certify to any of the statements in this
certification, he or she shall attach an explanation to this application.
37. Internet Access. Sub-recipients must have Internet access.
38. Email addresses. Sub-recipient project directors of grant programs must have individual
email addresses.
As the duly authorized representative of the sub-recipient,I hereby certify that the sub-
recipien will comply with the ove conditions.
_ �' � o2y ScPrzo�3
Signature otAuthorized Signatory Date
12tGl� D CotN- - - - M)q
Printed Name Title
7
• Issued May
COMMONWEALTH OF MASSACHUSETTS zooa
CONTRACTOR AUTHORIZED SIGNATORY LISTING
CONTRACTOR LEGAL NAME :
CONTRACTOR VENDOR/CUSTOMER CODE:
PROOF OF AUTHENTICATION OF SIGNATURE
This page is optional and is available for a department to authenticate contract signatures.
It is recommended that Departments obtain authentication of signature for the signatory
who submits the Contractor Authorized Listing.
This Section MUST be completed by the Contractor Authorized Signatory in presence of notary. f
Signatory's full legal name(print or type): e,
r
Title: VD K
X
Signature as it will appear on contract or other document(Complete only in presence of notary):
AUTHEN ICATED BY NOTARY OR CORPORATE CLERK(PICK ONLY ONE) AS FOLLOWS:
(NOTARY)as a notary public certify that I witnessed
the signature of the aforementioned signatory above and I verified the individual's identity on this date:
• ( J 20 3
My commission expires on:
AFFIX NOTARY SEAL
I, (CORPORATE CLERK)certify that I witnessed the
signature of the aforementioned signatory above, that I verified the individual's identity and confirm the individual's
authority as an authorized signatory for the Contractor on this date:
, 20
AFFIX CORPORATE SEAL