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CONTRACT STATUS FORM VED
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DATE: December 02, 2024 DEC 0 3 2024 FRESH
DIVISION(S): Administration DEPARTMENT OF UBOC
(Lead Division listed first)
SECTIO
CONTRACTOR: STATE: DEPARTMENT OF HEALTH CARE SER ICES
SERVICES: Intergovernmental Transfer Certification for MCIP FY 2023-24
CONTRACT TERM: 7/1/24 to 6/30/25
ADDITIONAL INFO:
ORGANIZATION #(s): 56201683
CONTRACT AMOUNT: $371,638.00
Contract#: A-24-398 State/Vendor#:
Lead Dept: DPH Other Dept(s):
Complete the information below and return to DPH Contracts by:March 1, 2025
Extend contract through: 20
With no changes in terms or conditions.
With the following change(s):
❑ Evergreen: Continue contract through: 20
,
Cancel contract effective: 1 / , 20 .
Additional Information (e.g., anticipated effective date/term, contract extension, etc.): ,
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Approved by. 0_� �
Program Supervisor/Staff Analyst. -- �� Date: 3
Division Manager: Date:
Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090