HomeMy WebLinkAboutSt. Vincent Health Wellness and Preventive Care Institute/CFD/$96,000/CITYO-0150414 - Ascension Signed AmendmentSt. Vincent Health, Wellness and Preventive Care Institute, Inc.
Fire Department - 2021
Appropriation # 1120 43-407.01 Fund; P.O. #105134
Contract Not To Exceed $96,000.00
ADDITIONAL SERVICES AMENDMENT TO
AGREEMENT FOR GOODS AND SERVICES
THIS AMENDMENT TO THE AGREEMENT FOR GOODS AND SERVICES (“Agreement”) entered into by
and between the City of Carmel and St. Vincent Health, Wellness and Preventive Care Institute, Inc., (the “Vendor”),
as City Contract dated August 7, 2019 shall amend the terms of the Agreement by adding the additional services to
be provided by Vendor consistent with the Scope of Work attached hereto and incorporated herein as Exhibit “A”.
The terms and conditions of the Agreement shall not otherwise be affected by this Additional Services Amendment
and shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have made and executed this Amendment as follows:
CITY OF CARMEL, INDIANA St. Vincent Health, Wellness and Preventive Care
by and through its Board of Public Institute, Inc.
Works and Safety
By: By:
James Brainard, Presiding Officer Authorized Signature
Date:
Printed Name
Mary Ann Burke, Member
Date:
Title
Lori S. Watson, Member FID/TIN:
Date:
Last Four of SSN if Sole Proprietor:
ATTEST:
Date:
Sue Wolfgang, Clerk
Date:
S:\\Contracts\\Prof.Svcs & Goods Svcs\\Fire Dept\\2021\\St. Vincent Health, Wellness and Preventive Care Institute, Inc. ASA.doc:4/1/2021 2:11 PM\]
Jonathan Nalli
CEO, St. Vincent Health, Inc.
7/19/2021
By Jon Oberlander at 9:37 am, Aug 13, 2021
DocuSign Envelope ID: 590D0BF9-FB77-43A8-955D-3B08FBF84A88
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8/18/2021
8/18/2021
8/18/2021
Not Present
FYIJCJU
B
DocuSign Envelope ID: 590D0BF9-FB77-43A8-955D-3B08FBF84A88
FYIJCJU
B
DocuSign Envelope ID: 590D0BF9-FB77-43A8-955D-3B08FBF84A88
FYIJCJU
B
DocuSign Envelope ID: 590D0BF9-FB77-43A8-955D-3B08FBF84A88
FYIJCJU
B
Jonathan Nalli
CEO, St. Vincent Health, Inc.
7/19/2021
DocuSign Envelope ID: 590D0BF9-FB77-43A8-955D-3B08FBF84A88
Page 1 of 1INDIANARETAILTAXEXEMPT
PURCHASE ORDER NUMBERCERTIFICATENO. 003120155 0020CityofCarmel
FEDERAL EXCISE TAX EXEMPT 105134
35-6000972 THIS NUMBER MUST APPEAR ON INVOICES, A/PONECIVICSQUARE
VOUCHER, DELIVERY MEMO, PACKING SLIPS, CARMEL, INDIANA 46032-2584 SHIPPING LABELS AND ANY CORRESPONDENCEFORMAPPROVEDBYSTATEBOARDOFACCOUNTSFORCITYOFCARMEL - 1997
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
Department Firefighter Physicals3/31/2021372939
ASCENSION ST VINCENT PUBLIC SAFETY Carmel Fire Department
VENDORSHIP6612E75THSTREET 10701 N. College Avenue, Ste A
TOSUITE200 Carmel, IN 46032-
INDIANAPOLIS, IN 46250 -
PURCHASE ID BLANKET CONTRACT PAYMENT TERMS FREIGHT
55189
QUANTITYUNIT OF MEASUREDESCRIPTIONUNIT PRICEEXTENSION
Department:Fund: 1120101General Fund
Account: 43-407.01
1Each2021 Firefighter Physicals - Not to Exceed$96,000.00$96,000.00
Sub Total 96,000.00
Send Invoice To:
Carmel Fire Department
2Civic Square
Carmel, IN 46032-
PLEASE INVOICE INDUPLICATE
DEPARTMENTACCOUNTPROJECTPROJECT ACCOUNTAMOUNT
96,000.00PAYMENT
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE ASHIPPINGINSTRUCTIONSPARTOFTHEVOUCHERANDEVERYINVOICEANDVOUCHERHASTHEPROPERSWORN
SHIP PREPAID. AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
C.O.D. SHIPMENT CANNOT BE ACCEPTED.THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER.
PURCHASE ORDER NUMBER MUST APPEAR ON ALL SHIPPING LABE
THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 194
ORDERED BYANDACTSAMENDATORYTHEREOFANDSUPPLEMENTTHERETO.
Denise SnyderJames Crider
TITLE Accreditation/Budget AdministratorDirector of Administration
CONTROL NO. 105134 CONTROLLER
DocuSign Envelope ID: 590D0BF9-FB77-43A8-955D-3B08FBF84A88