Form Ss-21b - Purchase Of Service Contract

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PURCHASE OF SERVICE CONTRACT
SS-21B (Rev. 4-83)
Physical or Psychological Evaluations(s)
1. This contract, made this______ day of ____________, 20____by and between the
______________________ County Department of Social Services, _________________
(address)
_________________________hereinafter called “County” and ____________________
(name)
_________________________________________hereinafter called “Contractor.”
2. This contract shall be effective from ________________________________until
______________________________________.
3. County agrees to purchase and Contractor agrees to furnish _______________of
(Number)
__________________________________________ at a cost of $___________________
(Type of Evaluation)
per evaluation. The total amount of this contract may not exceed $__________________
4. County agrees:
a. To pay Contractor after satisfactory completion of one or more evaluations
and receipt of Contractor billing.
b. To determine the eligibility for services and provide information
c. To assure that the service described herein has been accomplished and
a report received prior to payment to Contractor.
5. Contractor agrees:
a. Not to assign any provision of this contract to a subcontractor.
b. Not to change clients any fees related to services provided under this contract.
c. To hold the necessary license(s) which permits the performance of the service to
be purchased herein.
d. To comply with the requirements of the Civil Rights Act of 1964, and Section
504, Rehabilitation Act of 1973 concerning discrimination on the basis of color,
sex, age, religion, political beliefs, national origin, or handicap, and requirements
for safeguarding client information in accordance with rules of the State
Department.
e. To provide access by county, state, and federal officials to such records as are
necessary to document the cost and delivery of service.
f. To provide the service described herein at cost not greater than that charged to
other persons in the same community.
6. Termination: Either party may terminate this contract by 30 days prior notification in
writing.
7. __________________________
___________________________________
County Director Signature/Date
Contractor Signature/Date and Title
SS-21B (R 3/01)

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