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SOUTHERN UNIVERSITY SYSTEM CONTRACTUAL APPROVAL FORM (Southern University at Shreveport)

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REVISED OCTOBER 2016
SOUTHERN UNIVERSITY SYSTEM
REQUEST FOR PROFESSIONAL SERVICES
CONTRACTUAL APPROVAL FORM
DATE:
PURCHASING DEPARTMENT USE ONLY:
DEPARTMENT:
ENCUMBERED [ ] FUNDS AVAILABLE [ ]
DOC. I.D.#:
CAMPUS LOCATION:
DATE:
CAMPUS MAILING ADDRESS:
BY:
FRS VENDOR #
LINE NO.
CAMPUS
FUND
ACCOUNT
CODE
OBJECT
SUB-OBJECT
AMOUNT
01
74040
This is to certify that the attached contract between
of
NAME OF CONTRACTOR
Zip Code:
MAILING ADDRESS OF CONTRACTOR
And Southern University
Shreveport
in the amount of
$
has been prepared in accordance with State Regulations for the procurement of Professional, Personal, Social
and Consulting Services.
This contract covers the period
.
[ ] FEDERAL TAX IDENTIFICATION NO.
[ ] SOCIAL SECURITY NUMBER:
SIGNATURE OF REQUESTOR, END USER OR DEPARTMENTAL REPRESENTATIVE
TELEPHONE NO.
RECOMMENDATION FOR APPROVAL SIGNATURES:
STUDENT ADVISOR (IF APPLICABLE)
DIRECTOR OF HUMAN RESOURCES (PERSONNEL)
DIRECTOR OR DEPARTMENT HEAD
DIRECTOR OF PURCHASING
DEAN OR VICE CHANCELLOR
VICE CHANCELLOR FOR FINANCE & ADMINISTRATION
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REVISED OCTOBER 2016
Southern University
Shreveport, La 71107
LETTER OF CERTIFICATION
Dr. Ray L. Belton, President/Chancellor
Southern University System
Baton Rouge, Louisiana 70813
Dear Dr. Belton:
In reference to the enclosed contract, we do certify the following:
1. Either no employee of our agency is both competent and available to perform the services called for by
The proposed contract or the services called for are not the type readily susceptible of being performed
By persons who are employed by the state on a continuing basis;
2. The services are not available as a product of a prior or existing Professional, Personal, Consulting or
Social services contract;
3. When applicable, the requirements for consulting or social services contracts, as provided for under
Louisiana Revised Statutes’ Title 39:1595, have been complied with;
4. The Department has developed and fully intends to implement a
written plan providing for:
A. The assignment to to a monitoring and liaison function; and
B. The periodic review of interim reports or other indicia of performance to date; and
C. The ultimate use of the final product of the services.
5. A cost-benefit analysis has been conducted which indicates that obtaining such services from the private
sector is more cost-effective than providing such services by the agency itself or by an agreement with
another state agency and includes both a short-term and a long-term analysis and is available for review.
6. The cost basis for the proposed contract is justified and reasonable.
7. A description of the specific goals and objectives, deliverables, performance measures and a plan for
monitoring the services to be provided is contained in the proposed contract.
8. An inquiry has been conducted to determine if the contract outsources a key internal control of the
agency. The results have been documented in the agency’s files and are available for review, upon
request. If warranted, the RFP and contract have included provisions, which address the need for
assurances and/or monitoring of the key internal control.
9. The Board of Regents has been notified, in accordance with R.S. 39:136 of services that are the
type readily susceptible of being performed by persons who are employed by or who are students
of a postsecondary institution of the state.
Sincerely,
Name of Authorized Preparer
Title
REVISED OCTOBER 2016
State of Louisiana
PARISH OF CADDO
PROFESSIONAL SERVICES CONTRACT
BE IT KNOWN,
that on this day of
Southern University
System,
Shreveport, Louisiana 71107, hereinafter sometimes referred to as the “University” and
Whose address is:
City:
Atlanta
State:
GA
Zip:
Whose Telephone No. is:
Facsimile No.:
Cellular No.:
Email address:
, hereinafter sometimes referred to as “Contractor” does
hereby enter into contract under the following terms and conditions:
1.
SCOPE OF SERVICES:
Contractor hereby agrees to furnish the following services:
2.
SPECIFIC GOALS AND OBJECTIVES:
3.
MEASURES OF PERFORMANCE:
4.
MONITORING PLAN:
The contract monitor will be (
5.
PAYMENT TERMS
In consideration of the services described above, the University hereby agrees to pay to the contractor a maximum
fee of $
.
Payment will be made only on approval of
If progress and/or completion to the reasonable satisfaction of Southern University are obtained, payments are
scheduled as follows:
6.
TERMINATION FOR CONVENIENCE
The University may terminate this contract at any time by giving thirty (30) day’s written notice to the
contractor. The contractor shall be entitled to payment for deliverables in progress, to the extent work has been
performed satisfactorily.
7.
TERMINATION FOR CAUSE
REVISED OCTOBER 2016
The University may terminate this contract for cause based upon the failure of the contractor to comply with the
terms and/or conditions of the contract; provided that the University shall give the Contractor written notice
specifying the Contractor’s failure. If within thirty (30) days after receipt of such notice, the Contractor shall not
have either corrected such failure or, in the case of failure which cannot be corrected in thirty (30) days, begun in
good faith to correct said failure and thereafter proceeded diligently to complete such correction, then the
University may, at its option, place the Contractor in default and the Contract shall terminate on the date specified
in such notice. The Contractor may exercise any rights available to it under Louisiana Law to terminate for cause
upon the failure of the University to comply with terms and conditions of this contract; provided that the
Contractor shall give the University written notice specifying the University’s failure and a reasonable opportunity
for the University to cure the defect.
8.
REMEDIES FOR DEFAULT
Any claim or controversy arising out of this contract shall be resolved by the provisions of Louisiana Statutes
Annotated ( LSA) –Revised Statutes (R.S.) 39:1672.2-1672.4; 39:1524-1526.
9.
RECORD OWNERSHIP
Upon completion of this contract, or if terminated earlier, all records, reports, documents and other material
delivered or transmitted to Contractor by the University shall remain the property of the University, and shall be
returned by Contractor to the University, at Contractor’s expense, at termination or expiration of this contract. All
records, reports, worksheets, documents or other material related to this contract and/or prepared by Contractor in
connection with the performance of the services contracted for herein shall become the property of the University,
and shall, upon request, be returned by Contractor to the University, at Contractor’s expense, at termination or
expiration of this contract.
10.
NONASSIGNABILITY
No contractor shall assign any interest in this contract by assignment, transfer, or notation without prior written
consent of the University. This provision shall not be construed to prohibit the contractor from assigning his bank,
trust company, or other financial institution any money due or to become due from approved contracts without
such prior written consent. Notice of any such assignment or transfer shall be furnished promptly to the
University.
11.
AUDITORS
It is hereby agreed that the Legislative Auditor of the State of Louisiana and/or the Office of the Governor,
Division of Administration auditors shall have the option of auditing all accounts of contractor which relate to this
contract.
12.
FISCAL FUNDING
The continuation of this contract is contingent upon the appropriation of funds to fulfill the requirements of the
contract by the legislature. If the legislature fails to appropriate sufficient monies to provide for the continuation
of the contract, or if such appropriation is reduced by the veto of the Governor or by any means provided in the
appropriations act to prevent the total appropriation for the year exceeding revenues for that year, or for any other
lawful purpose, and the effect of such reduction is to provide insufficient monies for the continuation of the
contract, the contract shall terminate on the date of the beginning of the first fiscal year for which funds are not
appropriated.
13.
E-VERIFY
Contractor acknowledges and agrees to comply with the provisions of La. R.S. 38:2212.10 and federal law
pertaining to E-Verify in the performance of services under this contract.
14.
GOVERNING LAW
This contract shall be governed by and interpreted in accordance with the laws of the State of Louisiana, including
but not limited to La. R.S. 39:1551-1736; rules and regulations, executive orders; standard terms and conditions,
special terms and conditions, and specifications listed in the RFP (if applicable); and this contract. Venue of any
action brought, after exhaustion of administrative remedies, with regard to this contract shall be in the Nineteenth
Judicial District Court, Parish of East Baton Rouge, State of Louisiana.
REVISED OCTOBER 2016
15.
DISCRIMINATION CLAUSES
The contractor agrees to abide by the requirements of the following as applicable: Title VI of Civil Rights Act of
1964 and Title VII of the Civil Rights Act of 1964, as amended by the Equal Opportunity Act of 1972, Federal
Executive Order 11246 as amended, the Rehabilitation Act of 1973, as amended, the Vietnam Era Veteran’s
Readjustment Act of 1974, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975,
the Fair Housing Act of 1968 as amended, and contractor agrees to abide by the requirements of the Americans
with Disabilities Act of 1990.
Contractor agrees not to discriminate in its employment practices, and will render services under this contract
without regard to race, color, religion, sex, sexual orientation, national origin, veteran status, political affiliation,
disability, or age in any matter relating to employment. Any act of discrimination committed by Contractor, or
failure to comply with these statutory obligations when applicable shall be grounds for termination of this contract.
16.
CONTINUING OBLIGATION
Contractor has a continuing obligation to disclose any suspensions or debarment by any government entity,
including but not limited to General Services Administration (GSA). Failure to disclose may constitute ground
for suspension and/or termination of the contract and debarment from future contracts.
17.
ELIGIBILITY STATUS
Contractor and each tier of Subcontractors, shall certify that it is not on the list of Parties Excluded from Federal
Procurement or Non-Procurement Programs promulgated in accordance with E.O’s 12549 and 12689, “Debarment
and Suspension,” as set forth at 24CFR part 24.
18.
CONTRACTOR’S COOPERATION
The Contractor has the duty to fully cooperate with the University and provide any and all requested information,
documentation, etc., to the University when requested. This applies even if this contract is terminated and/or a
lawsuit is filed. Specifically, the contractor shall not limit or impede the State’s right to audit or shall not withhold
State owned documents.
19.
COMMISSIONER’S STATEMENTS
Statements, acts and omissions made by or on behalf of the Commissioner of Administration regarding the RFP or
RFP process, this contract, any contractor and/or any subcontractor of the Contractor shall not be deemed a
conflict of interest when the Commissioner is discharging his duties and responsibilities under law, including, but
not limited, to the Commissioner of Administration’s authority in procurement matters.
20.
TRAVEL EXPENSES
No more than ($ ) of the total maximum payable under this contract shall be paid or received as
reimbursement for travel and other reimbursable expenses; and Travel expenses shall be reimbursed in accordance
with Division of Administration Policy and Procedure Memorandum PPM #49.
21.
TAXES
Contractor hereby agrees that the responsibility for payment of taxes from the funds thus received under this
contract and/or Legislative appropriation shall be contractor’s obligation and identified under Federal Tax
Identification Number:
REVISED OCTOBER 2016
22.
TERM OF CONTRACT
This contract shall begin on
and shall terminate on
.
GENERAL AUTHORITY
This contract was prepared in accordance with the State of Louisiana, Revised Statute 39:1551-1736, 39:1595 and the Office of Contractual
Review, Division of Administration and Southern University System’s Administrative and Fiscal Policies and Procedures governing
Professional, Personal, Consulting and Social Services. Contracts prepared for a dollar amount that exceeds $20,000.00 shall require the
approval of the President of the Southern University System, Department of Civil Service and the Director of the Office of Contractual Review,
Division of Administration. NO CONTRACT SHALL BE VALID UNTIL ALL APPROVALS HAVE BEEN OBTAINED.
IN WITNESS WHEREOF, the parties have executed this agreement as of this day of
.
CONTRACTOR
SOUTHERN UNIVERSITY SYSTEM – Shreveport
By:
By:
Signature of Contractor
CHANCELLOR
Printed or Typed Name of Above
Printed or Typed Name of Above
WITNESSED:
WITNESSED:
By:
By:
Signature
Signature
Print or Type Name
Print or Type Name
WITNESSED:
WITNESSED:
By:
By:
Signature
Signature
Print or Type Name
Print or Type Name
APPROVED:
__________________________________________
SOUTHERN UNIVERSITY SYSTEM
WITNESSED:
__________________________________________
WITNESSED:
_________________________________________
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REVISED OCTOBER 2016
Date
CONSULTANT AUTHORIZATION FORM
TO BE COMPLETED IN SUPPORT OF ALL REQUESTS FOR PAYMENT OF CONTRACTUAL EXPENSES.
The
is hereby requesting approval to employ the
NAME OF DEPARTMENT, GRANT OR PROGRAM
Individual identified below as a consultant on Account Number:
Name of person/company:
CONSULTANT’S PRESENT
JOB TITLE
FEDERAL TAX IDENTIFICATION NO.
SOCIAL SECURITY NUMBER:
EMPLOYER:
[ ]
PART TIME
[ ]
FULL TIME
BUSINESS ADDRESS:
CITY
Atlanta
STATE
GA
ZIP
HOME ADDRESS
CITY
STATE
ZIP
PLACE OF SERVICE
DATE(S)OF SERVICE(S)
AMOUNT TO BE PAID:
A. GIVE PURPOSE OR STATE NEED OF CONSULTATION SERVICE (STATE SPECIFIC SERVICE TO BE
PERFORMED OR RENDERED):
B. GIVE METHOD OR REASONS FOR SELECTION OF THE ABOVE CONSULTANT:
C. INDICATE HOW FEE AMOUNT WAS DETERMINED. (INDICATE AMOUNT OF HOURLY OR DAILY RATE OF
PAY):
D. INDICATE WHY PERSONS PRESENTLY ON SOUTHERN UNIVERSITY PAYROLL CANNOT PROVIDE
SERVICE(S):
E. IS THIS INDIVIDUAL AN EMPLOYEE OF THE FEDERAL GOVERNMENT? YES NO xx
IS THIS INDIVIDUAL AN EMPLOYEE OF THE UNIVERSITY? YES NO
IS THIS INDIVIDUAL A RETIRED UNIVERSITY EMPLOYEE? YES NO (if yes, what is effective date)
F. LIST NAMES OF ALL CONSULTANTS OR CONTRACTORS CONSIDERED:
AS PRINCIPAL INVESTIGATOR, I HEREBY CERTIFY THAT:
1. THESE SERVICES ARE ESSENTIAL AND CANNOT BE OR PROVIDED BY PERSONS RECEIVING SALARY
ON THE GRANT OR OTHERWISE COMPENSATED FOR THEIR SERVICES.
2. A SELECTION PROCESS HAS BEEN EMPLOYED TO SECURE THE QUALIFIED PERSON AVAILABLE.
3. THE CHARGE IS APPROPRIATE CONSIDERING THE QUALIFICATION OF THE CONSULTANT, HIS NORMAL
CHARGES, AND THE NATURE OF THE SERVICE RENDERED.
4. IF THE CONSULTANT IS A SOUTHERN UNIVERSITY EMPLOYEE, CONSULTATION IS ACROSS DEPARTMENTAL
LINES AND IN ADDITION TO REGULAR DUTIES AND/OR INVOLVES A SEPARATE OR REMOTE OPERATION
AND IS IN ADDITION TO THE CONSULTANT’S REGULAR DEPARTMENTAL WORKLOAD.
DEPARTMENTAL CHAIRPERSON
PRINCIPLE INVESTIGATOR OR REQUESTOR
PRINT OR TYPE NAME
PRINT OR TYPE NAME
INSTITUTIONAL REPRESENTATIVE - CHANCELLOR
DATE
REVISED OCTOBER 2016
SOUTHERN UNIVERSITY
3050 Martin Luther King, Jr. Drive
Shreveport, LA 71107
TIME SHEET
GRANT NUMBER OR
DEPARTMENTAL CODE
DEPARTMENT
Date(s) of Service(s): Time Period of Service(s) Hours-C. S. T:
I HEREBY CERTIFY THAT SERVICES WERE RENDERED BY ME ON THE DATE(S) AND THE
TIME PERIOD AS SPECIFIED ABOVE.
SOCIAL SECURITY NUMBER
SIGNATURE
(THE NAME OF A PERSON WRITTEN WITH HIS/HER HAND)
MAILING ADDRESS:
TYPE OR PRINT NAME
DIRECTOR/DEPARTMENT HEAD SIGNATURE
DIRECTOR OF HUMAN RESOURCES (PERSONNEL)
(THIS FORM MUST BE SUBMITTED TO THE HUMAN RESOURCES OFFICE UPON COMPLETION
OF SERVICES) PLEASE ATTACH A COPY OF APPROVED CONTRACT, WHEN APPLICABLE.
AMOUNT:
$
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REVISED OCTOBER 2016
SEE SEPARATE PAGE FOR W-9 FORM - SEE ATTACHED FILLABLE PDF
REVISED OCTOBER 2016
CONTRACTUAL PERFORMANCE EVALUATION FORM
PROFESSIONAL, PERSONAL, CONSULTING AND SOCIAL SERVICES
SOUTHERN UNIVERSITY SYSTEM
Beginning and Ending Dates of Contract
Name of Contractor:
From:
To:
DEPARTMENT:
Date of Evaluation:
Signature of Program
Monitor/Evaluator:
SU CONTRACT NO.
Approved by:
DOA CONTRACT
NO.
DEPARTMENT HEAD
AGENCY CONTRACT NUMBER:_____________________________ CFMS CONTRACT NO.________________________________
CONTRACT AMOUNT: $____________________________________ ACTUAL AMOUNT PAID: $____________________________
PURCHASE REQUISITION NO:______________________________ PURCHASE ORDER NO:_______________________________
CONTRACTUAL COST BASIS:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
CONTRACTUAL MODIFICATIONS:
NUMBER:______________
Reason(s):__________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
DESCRIPTION OF SERVICES (WHAT WERE THE SERVICES BEING PROVIDED ?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
DELIVERABLE PRODUCTS:
(What were the final products ? _______________________________________________________________________________________
(Were they delivered on time ? ) _______________________________________________________________________________________
(Were they usable ? If so, how ? If not, why not ?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PROBLEMS ENCOUNTERED:
OVERALL PERFORMANCE (CHECK ONE ): SATISFACTORY UNSATISFACTORY
Weak Points:______________________________________________________________________________________________
______________________________________________________________________________________________
Strong Points:_____________________________________________________________________________________________
_____________________________________________________________________________________________
Would you hire this contractor again? _________________________________________________________________________
NAME AND TELEPHONE NUMBER OF PROGRAM OFFICIAL RESPONSIBLE FOR MONITORING AND FINAL
ACCEPTANCE:____________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
(THIS FORM MUST BE SUBMITTED TO THE PURCHASING DEPARTMENT UPON COMPLETION OF SERVICES)
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SOUTHERN UNIVERSITY SYSTEM CONTRACTUAL APPROVAL FORM (Southern University at Shreveport)

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Completed 17 September 2020

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