Direct Contract Forms and Instructions - New York State Office of ...

Appendix X
(Corporation/Municipal Corporation)
Agency Code: 50000 Contract No. C-00 Amendment #
Period Contract Amount for Period $
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Office of
Mental Health, having its principal office at 44 Holland Avenue, Albany, New York 12229 (hereinafter
referred to as the STATE), and
(hereinafter
referred to as the CONTRACTOR), for modification of Contract Number C-00 , as amended in
attached Appendix(ices) .
All other provisions of said AGREEMENT shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing
under their signatures.
CONTRACTOR SIGNATURE
By:
STATE AGENCY SIGNATURE
By:
Printed Name Printed Name: Nancy P. Splonskowski
Title: Title: Director, Contracts and Claims Unit, CBFM
Date:
Date
State Agency Certification
"In addition to the acceptance of this contract, I also certify that original copies of this signature page will
be attached to all other exact copies of this contract."
STATE OF NEW YORK)
) SS.:
County of )
On this day of , 20 , before me personally came
, to me known, who being by me duly sworn, did depose and say that he/she
resides at
, and that he/she is
of the corporation or municipality described in and which executed the above instrument, and that
he/she executed the above instrument by order of the board of directors of the corporation and that he/she
signed his/her name thereto by like order, or that he/she was duly authorized by the municipal corporation
described in and which executed the above instrument, and that he/she executed the above instrument
pursuant to authority vested in him/her.
(Notary) _______________________________
STATE COMPTROLLER'S SIGNATURE
Thomas P. DiNapoli
State Comptroller
Date:
By:
Date:
2010-11 ATL Direct Contract Forms and Instructions 58