Xerox/DOL/Addl Serv/ •
Xerox Q /RC/ 41 ,496/.64-,
Legal Department-2
Appropriation#430-53004; P.O.#26719 l �
J
Contract Not To Exceed$484.17/per month
ADDITIONAL SERVICES AMENDMENT TO
AGREEMENT FOR PURCHASE OF GOODS AND SERVICES
THIS AMENDMENT TO THE GOODS AND SERVICES AGREEMENT (°Agreement°) entered into by and
between the City of Carmel and Xerox (the 'Vendor'), as City Contact number 10.17.07,04 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". Furthermore, the terms of the Agreement shall be amended
to include the E-verify requirement as stated in Indiana Code § 22-5-1.7 et seq., which is attached hereto and
incorporated herein as Exhibit°B°, as well as the required E-verify Affidavit, attached hereto and incorporated herein
as Exhibit°C'. Also, pursuant to I.C. §5-22-16.5, Xerox shall certify that in signing this document, it does not engage
In investment activities within the Country of Iran. 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
by and through its Board of Public
Works and Safety
By: B
y:e
er-etii
6tames Brainard, Presiding Officer Authorized Signature
Date: "C • !
Printed Name
M. Ant :urke, Me ber • �1
Date: _ — ; !1X' Man&seJ2
Title
iF -
Lori S. Watson(Member FID/TIN:
Date: U t 7 113
Last Four of SSN if Sole Proprietor.
ATTEST: a '� )
�1/�/j4 �— t% -fOi Date: /i2.6///2-/
Cordray, IAMC, lerk-Treasurer
bate: / /3 - _ RAIMONDO.AMVFHILL Y R
NOTARY PUBLIC,STATEOF NEW YORK
Resiseauce No.OI MU486247
_. - Qualified in Mooroe Canty
Commission Expires June 16,2014
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Xerox
Legal Department-2012
Appropriation#430-53004; P.O.#26719
Contract Not To Exceed 5484.17/per month
Exhibit"C'
E-Verify Affidavit
Ei'F.Q n C- 11 h ; (/ ,being first duly sworn,deposes and says that
he/she is familiar with and has personal knowledge of the facts herein and,if called as a witness in this
matter, could testify as follows:
1. I am over eighteen (18) years of age and am competent to testify to the facts contained
herein.
2. I am now and at all times relevant herein have been employed by Xerox (the"Vendor") in
the position of hie P-1441 art, . .
3. I am familiar with the employment policies, practices, and procedures of the Vendor and
have the authority to act on behalf of the Vendor.
4. The Vendor is enrolled and participates in the federal E-Verify program. Documentation of
this enrollment and participation is stated in the Addendum, "Exhibit B," to the original
City Contract#0723992001, and is incorporated herein.
5. The Vendor does not knowingly employ any unauthorized aliens.
6. To the best of my information and belief, the Vendor does not currently employ any
unauthorized aliens.
7. FURTHER AFFIANT SAYETH NOT.
((
EXECUTED on the Z day of Witc 'iv-u2cr , 20 AR .
. .. t ,Q =l
Printed: 6.--ii le en 04A1(/
I certify under the penalties for perjury under the laws of the United States of America and the State of
Indiana that the foregoing factual statements and representations are true and correct.
�..�P-�.J ore
Printed: Gt`/E'817 0.11A/V/
r..aYhtdNDG. a
NOTARY PUBLIC,STATE OF NEWY'ORK
Registration Ma OIMWB6i/71
Gnzlifitlt in Maus Comfy
Commission�Expims June 16,2014 , . _ . _
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