Mississippi IHL - Finance and Administration - Attachment Form for Contract Agenda Items

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Attachment Form for Contract Agenda Items

Submitted through Budget, Finance and Audit Committee

Contract and attachment due the day after the Board Meeting to be considered for the next month's agenda. Required for contract amounts equaling $250,000 or more.

Institution Name

Submission Date	11/20/2009

Agenda Date

Contractor Name

Type of Contract

Start Date of Contract

End Date of Contract

Purpose of Contract

Additional Explanation Related to Purpose of Contract


Has contract been approved by MS Information for Technology Services (ITS)? Copy of ITS approval must be submitted with other documentation.


Does contract comply with State law and purchasing procedures?


*Complete either* Section A. or B. below based on Contract Type**
A. Expenditure Contract
Total Expenditure Contract Amount
	$

Cost of Contract by Fiscal Year
	FY $
	FY $
	FY $
	FY $
	FY $

Budget unit from which contract will be funded?


Were funds for this contract included in the original budget?


If the total contract amount is $5 million dollars or greater, has the Institution’s Executive Officer discussed the contract with the Commissioner of Higher Education?


B. Revenue Contract
Expected Revenue over period of contract
	$

If a new contract, how was objective previously met?



Explain Contractor Selection Process



Is Contractor a Certified Historically Underutilized Business (HUB)?


Dollar Value of work being subcontracted to HUB?
	$

Explain cost/benefit analysis method used to determine the cost-effectiveness of hiring outside workers versus utilizing in-house employees or hiring additional employees.


Is a written explanation on file addressing how this contract fits into the department’s mission, goals, and objectives?


Does the contract expressly stipulate that the contractor is an independent contractor and not an employee of the MS IHL?


Does the contract describe the scope of work and provide that payments are made after services are rendered?


Does the contract stipulate the standard or level of performance the contractor is required to meet?


Has it been confirmed there are no significant risks related to this contract?


Provide a list of all persons and entities which are financially interested in the contract. In addition, with respect to each entity that is financially interested in the contract, provide a statement identifying any entity that directly or indirectly owns 10% or more of the outstanding ownership interest in the identified entity, or provide a statement that that there are no such entities. Provide this same information/certification as to any parent corporations or entities of the identified entity financially interested in the contract.


Is the contract complete, with all pages, exhibits, schedules, etc. incorporated within the terms of the contract and attached?


Has the HUB Contractor List (identifies all HUB contractors who bid on this project) been completed and attached?


*Was YES* or NO checked for every question on this document?**


If NO was selected for any question, please explain why.


Institution's Contact Name

Official Job Title

Email Address

Phone Number

Institution's Chief Financial Officer


University Medical Center CFO (if applicable)


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