State Form 41221 - Executive Document Summary

AGENCY INFORMATION

EXECUTIVE DOCUMENT SUMMARY

State Form 41221 (R9/1-04)

14. Name of agency:

15. Requisition Number:

Instructions for completing the EDS and the Contract process.

16. Address:

1. Please read the guidelines on the back of this form.

2. Please type all information.

3. Check all boxes that apply.

4. For amendments / renewals, attach original contract.

AGENCY CONTACT INFORMATION

5. Attach additional pages if necessary.

17. Name:

18. Telephone #:

1. EDS Number:

2. Date prepared:

19. E-mail address

3. CONTRACTS & LEASES

COURIER INFORMATION

__ Professional/Personal Services

___Contract for Procured Services

__Grant

___Maintenance

20. Name:

21. Telephone #:

__ Lease

___License Agreement

__ Attorney

___Amendment# ____

22. E-mail address:

__ MOU

___Renewal #_______

__ QPA

___Other ___________

VENDOR INFORMATION

FISCAL INFORMATION

23. Taxpayer Identification Number:

4. Account Number:

5. Account Name:

25. Telephone:

24. Name:

6. Total amount this action:

7. New contract total:

26. Address:

8. Revenue generated this action:

9. Revenue generated total contract:

27. E-mail address:

10. New total amount for each fiscal year:

Out of State

28. Is the vendor registered with the Secretary of State? (

Corporations, must be registered

Year ______ $ _______________

Year ______ $ ______________

) __ Yes __ No

29. Primary Vendor: M/WBE

30. If yes, list the %:

Year ______ $ _______________

Minority: __ Yes __ No

Minority: _________%

TIME PERIOD COVERED IN THIS EDS

Women:

__ Yes __ No

Women: ________ %

11. From (month, day, year):

12. To (month, day, year):

31. Sub Vendor: M/WBE

32. If yes, list the %:

Minority: __ Yes __ No

Minority: _________%

Women:

__ Yes __ No

Women: ________ %

13. Method of source selection:

__ Negotiated

__ Bid/Quotation

__ Emergency

__ Special Procurement

33. Is there Renewal Language in

34. Is there a “Termination for

__ RFP #______

__ Other (

specify

)_______________ _____________

the document?

Convenience” clause in the

__ Yes

__ No

document? __ Yes

__ No

35. Will the attached document involve data processing or telecommunications systems(s)? ___ Yes: ITOC or Delegate has signed off on contract

36. Statutory Authority (

Cite applicable Indiana or Federal Codes

Please give a brief description of the scope of work included in this agreement

37. Description of work and justification for spending money. (

.) N

38. Justification of vendor selection and determination of price reasonableness:

39. If this contract is submitted late, please explain why: (

Required if more than 30 days late

SIGNATURES

40. Agency fiscal officer or representative approval

41. Date Approved

42. Budget agency approval

43. Date Approved

44. Attorney General’s Office approval

45. Date Approved

46. Agency representative receiving from AG

47. Date Approved

State Form 41221 - Executive Document Summary - 2004

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