IL 401-0105

State of IllinoisJune 18, 2014

Order for DeliveryAgency OFD #

Vendor
ILLINOIS CORRECTIONAL INDUSTRIES
1301 Concordia Court
Springfield, Il 62794
1-800-634-0213
/ Ship To(Transportation Charges to be Prepaid)
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Bill To

Object CodeAgency Phone Number and ext.

Fiscal Year / Transaction Code / Contract / Obligation Number / Transaction Date / Nine Digit Taxpayer Identification Number / Legal Status
14
Contract Action / Class Code / Governor’s Release Number / Current Fiscal Year of Contract / Contract Amount
1.New
2.Change
3.Delete / (Do Not Use) / (Do Not Use) / From To
Month/Day/YearMonth/Day/Year / (Do Not Use)
Appropriation Account Code / Obligation Amount
Item No. / Description of Article / Quantity / Unit of
Measure / Unit
Price / Total
Price
1 / ea / $0.00
2 / $0.00
3 / $0.00
4 / $0.00
5 / $0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Add 8.5% tax if applicable / $0.00
TOTAL / $0.00
Method of Compensation / Award Code / Date – Merchandise Received / Date – Checked Against Inventory
(If Multiple Rates, Specify)
Per
(Rate) (Time) / 1.Bids Required
2.Exempt From Bid
3.Exempt / Bids
Obtained
4.Emergency
Delivery:CompleteIncomplete / Invoice No.
The Merchandise or Service Billed Above Has Been Received
And Complies With Our Specifications or Request:
Storekeeper / Other Than Storekeeper

Requested ByApproved By P.O. or Authorization No.

See Certification Compliance on Back of Form

Certification for Qualified Vendors are on File That:

(A)The vendor is not barred from receiving state contracts as a result of bribery, attempting to bribe or admitting to bribing an officer or employee of the State of Illinois, (Section 10.1 of the Illinois Purchasing Act see ILL. Statutes 30 ILCS 505/10.1), and

(B)That if the vendor has been convicted of a felony, at least one year has passed since completion of the sentence as of the date for opening of bids or proposals, or the date of the contract if there is no opening date schedule, and

(C)The vendor is not a person barred from bidding on or receiving state or local government unit contracts as a result of illegal bid rigging or bid rotating as defined in the criminal code, and

(D)If this contract is with an individual or individuals, that such individual or individuals are not barred from receiving state contracts as a result of default on any education loan, and

(E)The vendor certifies that is the vendor’s correct Federal Taxpayer Identification number. The vendor is doing business as a (please check one):

IndividualCorporation

PartnershipSale Proprietorship

Not-for-Profit CorporationTrust or Estate

Real Estate AgentGovernmental Entity

Tax Exempt OrganizationMedical and Health Care

(IRC 501 (a) only)Services Provider Group

(F)Vendor certifies that it has read and is, or will be, in compliance with the drug free workplace act (ILL. Statues 30 ILCS 580/1) on the effective date of this contract or January 1, 1992, whichever is later. If this contract is with an individual, or an individual doing business in the form of a sole proprietorship, the individual will not engage in the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance in performance of the contract, and

(G)Is compliant with all applicable provisions of the Illinois Human Rights Act, the Public Works Employment Discrimination Act, the U.S. Civil Rights Act and Section 504 of the Federal Rehabilitation Act, and Americans with Disabilities Act, as well as all applicable regulation, and

(H)Has established written sexual harassment policies in compliance with Illinois State Statues.

(I)Vendor Certifies he/she has informed the director of the agency in writing if he/she was formerly employed by that agency and has received an early retirement incentive under Section 14-108.3 or 16-133.3 of the Illinois Pension Code. Vendor acknowledges and agrees that if such early retirement incentive was received, this contract is not valid unless the official executing the contract has made the appropriate filing with the Auditor General prior to execution.

Retention of Records

Vendor shall maintain, for a minimum of five years after completion of the contract, adequate books, records and supporting documents to verify the amounts, recipients and uses of all contracts; that the contract and all books, records and supporting documents related to the contract shall be available for review and audit by the Auditor General; and that the contractor agrees to cooperate fully with any audit conducted by the Auditor General and to provide full access to all relevant materials. Failure to maintain the books, records and supporting documents required by this Section shall establish a presumption in favor of the State for the recovery of any funds paid by the State under the contract for which adequate books, records, and supporting documentation are not available to support their purported disbursement.