Form STD215 "Agreement Summary" - California

What Is Form STD215?

This is a legal form that was released by the California Department of General Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the California Department of General Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form STD215 by clicking the link below or browse more documents and templates provided by the California Department of General Services.

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Download Form STD215 "Agreement Summary" - California

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AGREEMENT NUMBER
AMENDMENT NUMBER
CHECK HERE IF ADDITIONAL PAGES ARE ATTACHED
2. FEDERAL I.D. NUMBER
1. CONTRACTOR'S NAME
3. AGENCY TRANSMITTING AGREEMENT
4. DIVISION, BUREAU, OR OTHER UNIT
5. AGENCY BILLING CODE
6a. CONTRACT ANALYST NAME
6b. EMAIL
6c. PHONE NUMBER
7. HAS YOUR AGENCY CONTRACTED FOR THESE SERVICES BEFORE?
No
Yes (If Yes, enter prior Contractor Name and Agreement Number)
PRIOR CONTRACTOR NAME
PRIOR AGREEMENT NUMBER
8. BRIEF DESCRIPTION OF SERVICES
9. AGREEMENT OUTLINE (Include reason for Agreement: Identify specific problem, administrative requirement, program need or other circumstances making
the Agreement necessary; include special or unusual terms and conditions.)
10. PAYMENT TERMS (More than one may apply)
Monthly Flat Rate
Quarterly
One-Time Payment
Progress Payment
Itemized Invoice
Withhold
%
Advanced Payment Not To Exceed
Reimbursement / Revenue
or
%
Other (Explain)
11. PROJECTED EXPENDITURES
FISCAL
PROJECTED
FUND TITLE
ITEM
CHAPTER
STATUTE
YEAR
EXPENDITURES
+
-
+
-
+
-
+
-
OBJECT CODE
AGREEMENT TOTAL
OPTIONAL USE
AMOUNT ENCUMBERED BY THIS DOCUMENT
PRIOR AMOUNT ENCUMBERED FOR THIS AGREEMENT
I certify upon my own personal knowledge that the budgeted funds for the current
TOTAL AMOUNT ENCUMBERED TO DATE
budget year are available for the period and purpose of the expenditure stated above.
ACCOUNTING OFFICER'S SIGNATURE
ACCOUNTING OFFICER'S NAME (Print or Type)
DATE SIGNED
AGREEMENT NUMBER
AMENDMENT NUMBER
CHECK HERE IF ADDITIONAL PAGES ARE ATTACHED
2. FEDERAL I.D. NUMBER
1. CONTRACTOR'S NAME
3. AGENCY TRANSMITTING AGREEMENT
4. DIVISION, BUREAU, OR OTHER UNIT
5. AGENCY BILLING CODE
6a. CONTRACT ANALYST NAME
6b. EMAIL
6c. PHONE NUMBER
7. HAS YOUR AGENCY CONTRACTED FOR THESE SERVICES BEFORE?
No
Yes (If Yes, enter prior Contractor Name and Agreement Number)
PRIOR CONTRACTOR NAME
PRIOR AGREEMENT NUMBER
8. BRIEF DESCRIPTION OF SERVICES
9. AGREEMENT OUTLINE (Include reason for Agreement: Identify specific problem, administrative requirement, program need or other circumstances making
the Agreement necessary; include special or unusual terms and conditions.)
10. PAYMENT TERMS (More than one may apply)
Monthly Flat Rate
Quarterly
One-Time Payment
Progress Payment
Itemized Invoice
Withhold
%
Advanced Payment Not To Exceed
Reimbursement / Revenue
or
%
Other (Explain)
11. PROJECTED EXPENDITURES
FISCAL
PROJECTED
FUND TITLE
ITEM
CHAPTER
STATUTE
YEAR
EXPENDITURES
+
-
+
-
+
-
+
-
OBJECT CODE
AGREEMENT TOTAL
OPTIONAL USE
AMOUNT ENCUMBERED BY THIS DOCUMENT
PRIOR AMOUNT ENCUMBERED FOR THIS AGREEMENT
I certify upon my own personal knowledge that the budgeted funds for the current
TOTAL AMOUNT ENCUMBERED TO DATE
budget year are available for the period and purpose of the expenditure stated above.
ACCOUNTING OFFICER'S SIGNATURE
ACCOUNTING OFFICER'S NAME (Print or Type)
DATE SIGNED
AGREEMENT NUMBER
AMENDMENT NUMBER
12. AGREEMENT
TERM
TERM
TOTAL COST OF
AGREEMENT
BID, SOLE SOURCE, EXEMPT
FROM
THROUGH
THIS TRANSACTION
+
-
+
-
+
-
13. BIDDING METHOD USED
Request for Proposal (RFP) (Attach justification if secondary method is used)
Use of Master Service Agreement
Invitation for Bid (IFB)
Exempt from Bidding (Give authority for exempt status)
Sole Source Contract (Attach STD. 821)
Other (Explain)
Note: Proof of advertisement in the State Contracts Register or an approved form STD. 821, Contract Advertising Exemption Request, must be attached
14. SUMMARY OF BIDS (List of bidders, bid amount and small business status) (If an amendment, sole source, or exempt, leave blank)
15. IF AWARD OF AGREEMENT IS TO OTHER THAN THE LOWER BIDDER, EXPLAIN REASON(S) (If an amendment, sole source, or exempt, leave blank)
16. WHAT IS THE BASIS FOR DETERMINING THAT THE PRICE OR RATE IS REASONABLE?
17a. JUSTIFICATION FOR CONTRACTING OUT (Check one)
Contracting out is justified based on Government Code 19130(b). When this box
Contracting out is based on cost savings per Government Code
is checked, a completed JUSTIFICATION - CALIFORNIA CODE OF
19130(a). The State Personnel Board has been so notified.
REGULATIONS, TITLE 2, SECTION 547.60 must be attached to this document.
)
Not Applicable (Interagency / Public Works / Other
17b. EMPLOYEE BARGAINING UNIT NOTIFICATION
By checking this box, I hereby certify compliance with Government Code section 19132(b)(1).
AUTHORIZED SIGNATURE
SIGNER'S NAME (Print or Type)
DATE SIGNED
18. FOR AGREEMENTS IN EXCESS OF $5,000: Has the letting of the agreement
22. REQUIRED RESOLUTIONS ARE
No
Yes
N/A
been reported to the Department of Fair Employment and Housing?
ATTACHED
No
Yes
N/A
19. HAVE CONFLICT OF INTEREST ISSUES BEEN IDENTIFIED AND RESOLVED
No
Yes
N/A
AS REQUIRED BY THE STATE CONTRACT MANUAL SECTION 7.10?
23. IS THIS A SMALL BUSINESS AND/OR
20. FOR CONSULTING AGREEMENTS: Did you review any
A DISABLED VETERAN BUSINESS
None on file
No
Yes
N/A
contractor evaluations on file with the DGS Legal Office?
CERTIFIED BY DGS?
21. IS A SIGNED COPY OF THE FOLLOWING ON FILE AT YOUR AGENCY FOR THIS CONTRACTOR?
No
Yes
A. Contractor Certification Clauses
B. STD 204 Vendor Data Record
SB/DVBE Certification Number:
No
Yes
N/A
No
Yes
N/A
24. ARE DISABLED VETERANS BUSINESS ENTERPRISE GOALS
% of Agreement
No (Explain below)
Yes
REQUIRED? (If an amendment, explain changes if any)
25. IS THIS AGREEMENT (WITH AMENDMENTS) FOR A PERIOD OF TIME
No
Yes (If Yes, provide justification below)
LONGER THAN THREE YEARS?
AGREEMENT NUMBER
AMENDMENT NUMBER
I certify that all copies of the referenced Agreement will conform to the original agreement sent to the Department of General Services.
SIGNATURE
NAME/TITLE (Print or Type)
DATE SIGNED
AGREEMENT NUMBER
AMENDMENT NUMBER
JUSTIFICATION - CALIFORNIA CODE OF REGULATIONS, TITLE 2, SECTION 547.60
In the space provided below, the undersigned authorized state representative documents, with specificity and
detailed factual information, the reasons why the contract satisfies one or more of the conditions set forth in
Government Code section 19130(b). Please specify the applicable subsection. Attach extra pages if necessary.
The undersigned represents that, based upon his or her personal knowledge, information or belief the above justification correctly
reflects the reasons why the contract satisfies Government Code section 19130(b).
SIGNATURE
NAME/TITLE(Print or Type)
DATE SIGNED
PHONE NUMBER
STREET ADDRESS
EMAIL
CITY
STATE
ZIP
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