FIRST AMENDMENT TO AGREEMENT

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3 FIRST AMENDMENT TO AGREEMENT This First Amendment to Agreement ("First Amendment") is made by the County of Alameda ("County") and Terra Firma Diversion & Educational Services, ("Contractor") with respect to that certain agreement entered by them on (referred to herein as the "Agreement") pursuant to which Contractor provides Substance Abuse Testing and Treatment (SATT) Services to County. County and Contractor agree as follows: 1. For valuable consideration, the receipt and sufficiency of which are hereby acknowledged, County and Contractor agree to amend the Agreement in the following respects: a. Increase the current FY14-15 maximum award level by an additional $140,000, increasing the maximum award level from Two Hundred Forty Nine Thousand dollars ($249,000.00) to Three Hundred Eighty Nine Thousand dollars ($ ) thiough June 30, b. Increase the FY15-16 and FY16-17 current annual maximum award amount of $249,000 by an additional $25,000 each for a new maximum award amount of $274,000 per each fiscal year, increasing the current maximum total award of Seven Hundred Forty Seven Thousand ($747,000) to a new maximum total award ofnine Hundred Thirty Seven Thousands($ 937,000) over award period of July 1, 2014 through June 30, 2017 A Revised Exhibit A, Scope of Work, is attached to this First Amendment. A Revised Exhibit B, Payment Terms, is attached to this First Amendment. 2. The term of the Agreement is currently scheduled to expire on 06/30/2017. As of the Effective Date, the term of the Agreement still expires on 6/30/2017.

4 3. In consideration for Contractor' s additional services, the County shall pay Contractor an additional amount not to exceed One Hundred Ninety Thousand dollars ($190,000). As a result of these additional services the not to exceed amount has increased from Seven Hundred Forty Seven Thousand dollars ($747,000) to a new maximum total award of Nine Hundred Thirty Seven Thousand dollars ($937,000) over the term of the Agreement and any amendments. FY $389,000 maximum FY $274,000 maximum FY $274,000 maximum 4. Item 20 of the Standard Services Agreement has been amended as follows: TERMINATION: The County has and reserves the right to suspend, terminate or abandon the execution of any work by the Contractor without cause at any time upon giving to the Contractor prior written notice. In the event that the County should abandon, terminate or suspend the Contractor's work, the Contractor shall be entitled to payment for services provided hereunder prior to the effective date of said suspension, termination or abandonment. Said payment shall be computed in accordance with Exhibit B hereto, provided that the maximum amount payable to Contractor for its Professional Training Services shall not exceed $937,000 for payment for services provided hereunder prior to the effective date of said suspension, termination or abandonment. 5. Except as otherwise stated in this First Amendment, the terms and provisions of this First Amendment will be effective as of the date this First Amendment is executed by the County ("Effective Date"). 6. DEBARMENT AND SUSPENSION CERTIFICATION: a. By signing this First Amendment and Revised Exhibits A and B, Debarment and Suspension Certification, Contractor/Grantee agrees to comply with applicable federal suspension and debarment regulations, including but not limited to 7 Code of Federal Regulations (CFR) , 2

5 28 CFR 66.35, 29 CFR 97.35, 34 CFR 80.35, 45 CFR and Executive Order b. By signing this Agreement, Contractor certifies to the best of its knowledge and belief, that it and its principals: (1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded by any federal department or agency; (2) Shall not knowingly enter into any covered transaction with a person who is proposed for debarment under federal regulations, debarred, suspended, declared ineligible, or voluntarily excluded from participation in such transaction. 7. Except as expressly modified by this First Amendment, all of the terms and conditions of the Agreement are and remain in full force and effect. 3.

6 IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the Agreement as of the day and year first above written. COUNTY OF ALAMEDA CONTRACTOR/COMPANY NAME Terra Firma Diversion :J~&_Si-~-a-tu, r By:, Name: SCOTI HAGGERTY (Printed) Title: President of the Board of Supervisors Name: 8e{~~ \<_, ~e_\\~( (Printed) Title: E"'f. e ~""~I~.(. ejef, c.e._k. Date: ~ { 2- { \ S Approved as to Form: Approved as to Form DON R ZIE BY.~-+-~~-+... i=.-~~;..._---- B y: Print Name VA\ --lj County Counsel Signature By signing above, signatory warrants and represents that he/she executed this Agreement in his/her authorized capacity and that by his/her signature on this Agreement, he/she or the entity upon behalf of which he/she acted, executed this Agreement 4

7 REVISED EXHIBIT A Last revised: 1/27/15 Scope of work: Except as expressly modified by this Revised Exhibit A, all of the work scope and terms description of the original Exhibit A - Scope of work remain in full force and effect. The goal of the Department of Children and Family Services Substance Abuse Testing and Treatment Services (SA TT) program is to relieve and reduce the incidence of child abuse or neglect of children, 0-18 years old, due to the substance abuse of family members. In FY 14-15, the Department of Children and Family Services (CFS). contracted with three community-based SATT programs to provide a standardized client assessment, substance abuse testing and group counseling, as appropriate, for CFS clients in need of substance abuse testing and treatment. Prior to the FY RFP process, CFS SATT services were analyzed for best practices. As a result of this assessment, the RFP included enhancements to the SATT program scope of work. These enhancements included a standardized client assessment for all referred CFS clients, the development of a Client Recovery Plan as well as measurable Results Based Accountability (RBA) objectives that address client engagement, assess the client's understanding of the impact of their substance abuse has on their family/children, as well as the client's overall satisfaction with SATT program services. Progress towards these goals is monitored by SSA Contracts and CFS Program staff through the monthly submission ofrba documents by the providers, periodic site visits, monthly CFS/Provider Collaborative Meetings and fiscal monitoring. In order to promote cost effective operations, SATT providers will bill Medi-Cal for all eligible client services related to the provision of substance abuse treatment For CFS clients. Contractor will regard Alameda County CFS, as the payer of last resort. Contractor will screen for Medi-Cal eligibility and establish Medi-Cal eligibility on a monthly basis, for each referred CFS client. Contractor will bill Medi-Cal, first, for all SA TT eligible clients and services related to this contract. Contractor will only perform confirmatory drug testing, on a positive or negative drug testing result, at the written request of the CWW and/or other designated CFS staff. The CWW and/or other designated CFS staff will have the exclusive authority to authorize confirmatory or other "repeated" testing on a single sample. At no time should confirmatory testing be done at the request of the client or at the discretion of the provider without prior CFS staff approval. 5

8 .REVISED EXHIBIT B Payment Terms and Conditions Revised 1/27/15 1. Except as expressly modified by this Revised Exhibit B, all of the terms and conditions of the original Exhibit B - Payment Terms are and remain in full force and effect. 2. The total maximum contract amount authorized during the period of this agreement is $937,000 through June 30, The total maximum Contract amount for each fiscal year is as follows: FY $389,000 FY $274,000 FY $274, This contract payment shall be Services As Needed (SAN) Reimbursements based on the number of client referrals in each service category. There shall be no minimum or maximum service units set for any service category. Reimbursement shall follow the rate schedule below. The billable services must reflect the following breakdown/category of service: Service Category Service Rate/Unit Cost Intake/ Assessment $70 ASI Lite Drug Testing: UA In-house $35 Drug Testing: UA Lab/Confirmatory $45 Drug Testing: UA EtG $30 Drug Testing: Hair Follicle. $120 Treatment: Group Counseling $30 CDAC Specialist Consultation $40/hour* Casework Support $48/hour* *billed in 15 minute increment No changes m the service rate may be permitted without pnor approval from the County. Any change shall be decided by mutual agreement between the County and Contractor. 6

9 .. EXHIBITD COUNTY OF ALAMEDA DEBARMENT AND SUSPENSION CERTIFICATION The contractor, under penalty of perjury, certifies that, except as noted below, contractor, its principals, and any named or unnamed subcontractor: Is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any federal agency; Has not been suspended, debarred, voluntarily excluded or determined ineligible by any federal agency within the past three years; Does not have a proposed debarment pending; and Has not been indicted, convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three years. If there are any exceptions to this certification, insert the exceptions in the following space. Exceptions will not necessary result in denial of award, but will be considered in determining contractor responsibility. For any exception noted above, indicate below to whom it applies, initiating agency, and dates of action. Notes: Providing false information may result in criminal prosecution or administrative sanctions. The above certification is part of the Standard Services Agreement. Signing this Standard Services Agreement on the signature portion thereof shall also constitute signature of this Certification. CONTRACTOR: Terra Firma Diversion ---- PRINCIPAL~:: C<lklf TITLE: Erc...rr\"-L 6'ffic'ee_ SIGNATU~1: f::j1w\ DATE : ez ( '2-( \ S "

10 .. RFP No., Master Contract No, Procurement Contract No. _ EXHIBITO COUNTY OF ALAMEDA RFP/QNo.900xxx for BidTitle THE IRAN CONTRACTING ACT (ICA) OF 2010 For Procurements of$1,000,000 or more The California Legislature adopted the Iran Contracting Act (ICA) to respond to policies of Iran in a uniform fashion (PCC 2201(q)). The ICA prohibits persons engaged in investment activities in Iran from bidding on, submitting proposals for, or entering into or renewing contracts with public entities for goods and services of one million dollars ($1,000,000) or more (PCC 2203(a)). A person who "engages in investment activities in Iran" is defined in either of two ways: 1. The person provides goods or services of twenty million dollars ($20,000,000) or more in the energy sector of Iran, including a person that provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transport oil or liquefied natural gas, for the energy sector of Iran; or 2. The person is a financial institution (as that term is defined in 50 U.S.C. 1701) that extends twenty million dollars ($20,000,000) or more in credit to another person, for 45 days or more, if that person will use the credit to provide goods or services in the energy sector in Iran and is identified on a list created by the California Department of General Services (DGS) pursuant to PCC 220 I (b) as a person engaging in the investment activities described in paragraph I above. By signing below, I hereby certify that as of the time of bidding or proposing for a new contract or renewal of an existing contract, neither I nor the company I own or work for are identified on the DGS list of ineligible persons and neither I nor the company I own or work for are engaged in investment activities in Iran in violation of the Iran Contracting Act of2010. If either I or the company I own or work for are ineligible to bid or submit a proposal or to renew a contract, but I believe I or it qualifies for an exception listed in PCC 2202(c), I have described in detail the nature of the exception: NAME: Terra Firma Diversion PRmCIPAL ~!e ~M SIGNATURE:, "'-- TITLE: ~ CvT ~U e_ DATE: _ { _'2-...(,_ ( 5" _

11 Fonn Rev 10/31/14 (Page 1 of2) REQUEST TO ENCUMBER, ADD, LIQUIDATE FUNDS OR PAY CONTRACTOR PART I: REQUEST FROM CONTRACTING DEPARTMENT l. Contractor's Name: Terra Pinna (Diversion/Educational Services) 2. Remittance Address: Mission Blvd, Hayward CA Contractor's Vendor ID: Master Contract #: NIA 5. Procurement Contract #: ----'l'-"0=5-"--98= Description of Contract: Substance Abuse Treatment 7. Procurement Contract Begin Date: 7/1/ Procurement Contract Expire Date: _6=/=3=0 /-=2=0~17"' Elation Project Info: A. D Sub-Contractor Compliance Required B. D Labor Compliance Required 10. Board Waiver #: n/a GSA Waiver #: n/a Federal Fund Waiver #: NIA 11. ENCUMBER FUNDS IN A NEW PURCHASE ORDER Date of Board Minute Order: File/Item/Contract Number: Tot al Amount Authorized By Board: Amount to be Encumbered: Justification if partial encumbrance requested: 12. ADD FUNDS TO AN EXISTING PURCHASE ORDER PO Number: _ Date of Board Minute Order: File/Item/Contract Number: Total Amount Authorized By Board: Amount to be Encumbered:.$_, Justification if partial encumbrance requested: 13. LIQUIDATE FUNDS FROM A PURCHASE ORDER Purchase Order Number: Amount to be Liquidated: Liquidation Justification: PAY CONTRACTOR -ATTACH INVOICE PO#: PO Type: Business Unit: Voucher #: Invoice #: Amount Due $: Service Period: 15. Pax..ment Handling (See Reverse): [8J US-Mail D DP-Return to Department D SP-Department Pick Up LJAA-Mail w/attachments D 3rd Party CBAP Pay Comments 16. Dept. Claims Processor: Dept. Claims Approver: Authorized signatory below certifies that contractor has provided goods/services as invoiced and verifies the mathematical accuracy of \the invoice; that all financial provisions of the contract have been met (including the rates charged); that all invoiced items are specifically authorized by the contract and no contract limits have been exceeded (in total, by month or by expense category. 17. ACCOUNTING INFORMATION Business Unit Account Fund De t Pro ram BY Subclass Pro'/Grant Amount SOCS A $140, A. Send Response to:.:...:..:::..o..:.=:...="-7 'o;..:.;>,,,,,...-a-- - B. QIC: C. Phone: Total $140, or 19. A. Authorized Signature: C. Date:~---+.,., ,_~ 20. Print Name of Authorized Signatory: PART II: RESPONSE FROM AUDITOR-CONTROLLER D The Auditor-Controller encumbered in a new PO. The PO Number is D The Auditor-Controller added to PO Number The Auditor-Controller liquidated from PO Number D Contractor payment Approved D Contractor payment Denied-Reason: _ D This fonn is being returned to you due to insufficient funds in the appropriation account. D The following infonnation is needed before this request can be processed. Signature of Contract Processor/Claims Approver Date:

12 FIRST AMENDMENT TO AGREEMENT This First Amendment to Agreement ("First Amendment") is made by the County of Alameda ("County") and Terra Firma Diversion & Educational Services, ("Contractor") with respect to that certain agreement entered by them on (referred to herein as the "Agreement") pursuant to which Contractor provides Substance Abuse Testing and Treatment (SATT) Services to County. County and Contractor agree as follows: 1. For valuable consideration, the receipt and sufficiency of which are hereby acknowledged, County and Contractor agree to amend the Agreement in the following respects: a. Increase the current FY14-15 maximum award level by an additional $140,000, increasing the maximum award level from Two Hundred Forty Nine Thousand dollars ($249,000.00) to Three Hundred Eighty Nine Thousand dollars ($ ) thiough June 30, b. Increase the FY15-16 and FY16-17 current annual maximum award amount of $249,000 by an additional $25,000 each for a new maximum award amount of $274,000 per each fiscal year, increasing the current maximum total award of Seven Hundred Forty Seven Thousand ($747,000) to a new maximum total award ofnine Hundred Thirty Seven Thousands($ 937,000) over award period of July 1, 2014 through June 30, 2017 A Revised Exhibit A, Scope of Work, is attached to this First Amendment. A Revised Exhibit B, Payment Terms, is attached to this First Amendment. 2. The term of the Agreement is currently scheduled to expire on 06/30/2017. As of the Effective Date, the term of the Agreement still expires on 6/30/2017.

13 3. In consideration for Contractor' s additional services, the County shall pay Contractor an additional amount not to exceed One Hundred Ninety Thousand dollars ($190,000). As a result of these additional services the not to exceed amount has increased from Seven Hundred Forty Seven Thousand dollars ($747,000) to a new maximum total award of Nine Hundred Thirty Seven Thousand dollars ($937,000) over the term of the Agreement and any amendments. FY $389,000 maximum FY $274,000 maximum FY $274,000 maximum 4. Item 20 of the Standard Services Agreement has been amended as follows: TERMINATION: The County has and reserves the right to suspend, terminate or abandon the execution of any work by the Contractor without cause at any time upon giving to the Contractor prior written notice. In the event that the County should abandon, terminate or suspend the Contractor's work, the Contractor shall be entitled to payment for services provided hereunder prior to the effective date of said suspension, termination or abandonment. Said payment shall be computed in accordance with Exhibit B hereto, provided that the maximum amount payable to Contractor for its Professional Training Services shall not exceed $937,000 for payment for services provided hereunder prior to the effective date of said suspension, termination or abandonment. 5. Except as otherwise stated in this First Amendment, the terms and provisions of this First Amendment will be effective as of the date this First Amendment is executed by the County ("Effective Date"). 6. DEBARMENT AND SUSPENSION CERTIFICATION: a. By signing this First Amendment and Revised Exhibits A and B, Debarment and Suspension Certification, Contractor/Grantee agrees to comply with applicable federal suspension and debarment regulations, including but not limited to 7 Code of Federal Regulations (CFR) , 2

14 28 CFR 66.35, 29 CFR 97.35, 34 CFR 80.35, 45 CFR and Executive Order b. By signing this Agreement, Contractor certifies to the best of its knowledge and belief, that it and its principals: (1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded by any federal department or agency; (2) Shall not knowingly enter into any covered transaction with a person who is proposed for debarment under federal regulations, debarred, suspended, declared ineligible, or voluntarily excluded from participation in such transaction. 7. Except as expressly modified by this First Amendment, all of the terms and conditions of the Agreement are and remain in full force and effect. 3.

15 IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the Agreement as of the day and year first above written. COUNTY OF ALAMEDA CONTRACTOR/COMPANY NAME Terra Firma Diversion :J~&_Si-~-a-tu, r By:, Name: SCOTI HAGGERTY (Printed) Title: President of the Board of Supervisors Name: 8e{~~ \<_, ~e_\\~( (Printed) Title: E"'f. e ~""~I~.(. ejef, c.e._k. Date: ~ { 2- { \ S Approved as to Form: Approved as to Form DON R ZIE BY.~-+-~~-+... i=.-~~;..._---- B y: Print Name VA\ --lj County Counsel Signature By signing above, signatory warrants and represents that he/she executed this Agreement in his/her authorized capacity and that by his/her signature on this Agreement, he/she or the entity upon behalf of which he/she acted, executed this Agreement 4

16 REVISED EXHIBIT A Last revised: 1/27/15 Scope of work: Except as expressly modified by this Revised Exhibit A, all of the work scope and terms description of the original Exhibit A - Scope of work remain in full force and effect. The goal of the Department of Children and Family Services Substance Abuse Testing and Treatment Services (SA TT) program is to relieve and reduce the incidence of child abuse or neglect of children, 0-18 years old, due to the substance abuse of family members. In FY 14-15, the Department of Children and Family Services (CFS). contracted with three community-based SATT programs to provide a standardized client assessment, substance abuse testing and group counseling, as appropriate, for CFS clients in need of substance abuse testing and treatment. Prior to the FY RFP process, CFS SATT services were analyzed for best practices. As a result of this assessment, the RFP included enhancements to the SATT program scope of work. These enhancements included a standardized client assessment for all referred CFS clients, the development of a Client Recovery Plan as well as measurable Results Based Accountability (RBA) objectives that address client engagement, assess the client's understanding of the impact of their substance abuse has on their family/children, as well as the client's overall satisfaction with SATT program services. Progress towards these goals is monitored by SSA Contracts and CFS Program staff through the monthly submission ofrba documents by the providers, periodic site visits, monthly CFS/Provider Collaborative Meetings and fiscal monitoring. In order to promote cost effective operations, SATT providers will bill Medi-Cal for all eligible client services related to the provision of substance abuse treatment For CFS clients. Contractor will regard Alameda County CFS, as the payer of last resort. Contractor will screen for Medi-Cal eligibility and establish Medi-Cal eligibility on a monthly basis, for each referred CFS client. Contractor will bill Medi-Cal, first, for all SA TT eligible clients and services related to this contract. Contractor will only perform confirmatory drug testing, on a positive or negative drug testing result, at the written request of the CWW and/or other designated CFS staff. The CWW and/or other designated CFS staff will have the exclusive authority to authorize confirmatory or other "repeated" testing on a single sample. At no time should confirmatory testing be done at the request of the client or at the discretion of the provider without prior CFS staff approval. 5

17 .REVISED EXHIBIT B Payment Terms and Conditions Revised 1/27/15 1. Except as expressly modified by this Revised Exhibit B, all of the terms and conditions of the original Exhibit B - Payment Terms are and remain in full force and effect. 2. The total maximum contract amount authorized during the period of this agreement is $937,000 through June 30, The total maximum Contract amount for each fiscal year is as follows: FY $389,000 FY $274,000 FY $274, This contract payment shall be Services As Needed (SAN) Reimbursements based on the number of client referrals in each service category. There shall be no minimum or maximum service units set for any service category. Reimbursement shall follow the rate schedule below. The billable services must reflect the following breakdown/category of service: Service Category Service Rate/Unit Cost Intake/ Assessment $70 ASI Lite Drug Testing: UA In-house $35 Drug Testing: UA Lab/Confirmatory $45 Drug Testing: UA EtG $30 Drug Testing: Hair Follicle. $120 Treatment: Group Counseling $30 CDAC Specialist Consultation $40/hour* Casework Support $48/hour* *billed in 15 minute increment No changes m the service rate may be permitted without pnor approval from the County. Any change shall be decided by mutual agreement between the County and Contractor. 6

18 .. EXHIBITD COUNTY OF ALAMEDA DEBARMENT AND SUSPENSION CERTIFICATION The contractor, under penalty of perjury, certifies that, except as noted below, contractor, its principals, and any named or unnamed subcontractor: Is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any federal agency; Has not been suspended, debarred, voluntarily excluded or determined ineligible by any federal agency within the past three years; Does not have a proposed debarment pending; and Has not been indicted, convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three years. If there are any exceptions to this certification, insert the exceptions in the following space. Exceptions will not necessary result in denial of award, but will be considered in determining contractor responsibility. For any exception noted above, indicate below to whom it applies, initiating agency, and dates of action. Notes: Providing false information may result in criminal prosecution or administrative sanctions. The above certification is part of the Standard Services Agreement. Signing this Standard Services Agreement on the signature portion thereof shall also constitute signature of this Certification. CONTRACTOR: Terra Firma Diversion ---- PRINCIPAL~:: C<lklf TITLE: Erc...rr\"-L 6'ffic'ee_ SIGNATU~1: f::j1w\ DATE : ez ( '2-( \ S "

19 .. RFP No., Master Contract No, Procurement Contract No. _ EXHIBITO COUNTY OF ALAMEDA RFP/QNo.900xxx for BidTitle THE IRAN CONTRACTING ACT (ICA) OF 2010 For Procurements of$1,000,000 or more The California Legislature adopted the Iran Contracting Act (ICA) to respond to policies of Iran in a uniform fashion (PCC 2201(q)). The ICA prohibits persons engaged in investment activities in Iran from bidding on, submitting proposals for, or entering into or renewing contracts with public entities for goods and services of one million dollars ($1,000,000) or more (PCC 2203(a)). A person who "engages in investment activities in Iran" is defined in either of two ways: 1. The person provides goods or services of twenty million dollars ($20,000,000) or more in the energy sector of Iran, including a person that provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transport oil or liquefied natural gas, for the energy sector of Iran; or 2. The person is a financial institution (as that term is defined in 50 U.S.C. 1701) that extends twenty million dollars ($20,000,000) or more in credit to another person, for 45 days or more, if that person will use the credit to provide goods or services in the energy sector in Iran and is identified on a list created by the California Department of General Services (DGS) pursuant to PCC 220 I (b) as a person engaging in the investment activities described in paragraph I above. By signing below, I hereby certify that as of the time of bidding or proposing for a new contract or renewal of an existing contract, neither I nor the company I own or work for are identified on the DGS list of ineligible persons and neither I nor the company I own or work for are engaged in investment activities in Iran in violation of the Iran Contracting Act of2010. If either I or the company I own or work for are ineligible to bid or submit a proposal or to renew a contract, but I believe I or it qualifies for an exception listed in PCC 2202(c), I have described in detail the nature of the exception: NAME: Terra Firma Diversion PRmCIPAL ~!e ~M SIGNATURE:, "'-- TITLE: ~ CvT ~U e_ DATE: _ { _'2-...(,_ ( 5" _

20 Fonn Rev 10/31/14 (Page 1 of2) REQUEST TO ENCUMBER, ADD, LIQUIDATE FUNDS OR PAY CONTRACTOR PART I: REQUEST FROM CONTRACTING DEPARTMENT l. Contractor's Name: Terra Pinna (Diversion/Educational Services) 2. Remittance Address: Mission Blvd, Hayward CA Contractor's Vendor ID: Master Contract #: NIA 5. Procurement Contract #: ----'l'-"0=5-"--98= Description of Contract: Substance Abuse Treatment 7. Procurement Contract Begin Date: 7/1/ Procurement Contract Expire Date: _6=/=3=0 /-=2=0~17"' Elation Project Info: A. D Sub-Contractor Compliance Required B. D Labor Compliance Required 10. Board Waiver #: n/a GSA Waiver #: n/a Federal Fund Waiver #: NIA 11. ENCUMBER FUNDS IN A NEW PURCHASE ORDER Date of Board Minute Order: File/Item/Contract Number: Tot al Amount Authorized By Board: Amount to be Encumbered: Justification if partial encumbrance requested: 12. ADD FUNDS TO AN EXISTING PURCHASE ORDER PO Number: _ Date of Board Minute Order: File/Item/Contract Number: Total Amount Authorized By Board: Amount to be Encumbered:.$_, Justification if partial encumbrance requested: 13. LIQUIDATE FUNDS FROM A PURCHASE ORDER Purchase Order Number: Amount to be Liquidated: Liquidation Justification: PAY CONTRACTOR -ATTACH INVOICE PO#: PO Type: Business Unit: Voucher #: Invoice #: Amount Due $: Service Period: 15. Pax..ment Handling (See Reverse): [8J US-Mail D DP-Return to Department D SP-Department Pick Up LJAA-Mail w/attachments D 3rd Party CBAP Pay Comments 16. Dept. Claims Processor: Dept. Claims Approver: Authorized signatory below certifies that contractor has provided goods/services as invoiced and verifies the mathematical accuracy of \the invoice; that all financial provisions of the contract have been met (including the rates charged); that all invoiced items are specifically authorized by the contract and no contract limits have been exceeded (in total, by month or by expense category. 17. ACCOUNTING INFORMATION Business Unit Account Fund De t Pro ram BY Subclass Pro'/Grant Amount SOCS A $140, A. Send Response to:.:...:..:::..o..:.=:...="-7 'o;..:.;>,,,,,...-a-- - B. QIC: C. Phone: Total $140, or 19. A. Authorized Signature: C. Date:~---+.,., ,_~ 20. Print Name of Authorized Signatory: PART II: RESPONSE FROM AUDITOR-CONTROLLER D The Auditor-Controller encumbered in a new PO. The PO Number is D The Auditor-Controller added to PO Number The Auditor-Controller liquidated from PO Number D Contractor payment Approved D Contractor payment Denied-Reason: _ D This fonn is being returned to you due to insufficient funds in the appropriation account. D The following infonnation is needed before this request can be processed. Signature of Contract Processor/Claims Approver Date:

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