Agency Contact:	name/phone number

e-mail address

Carla Thompson (410) 260-6155

Carla.Thompson@maryland.gov

__-IT-MOD.	DEPARTMENT OF HEALTH & MENTAL HYGIENE

Program Name

Contract ID:	Contract Title

DHMH-OPASS Contract #; M00B______, COF______

Contract Approved:	DoIT Item # and BPW date

Contractor:	Vendor Name and State

Contract Description: Provide contract description.

Modification Description: Provide mod description.

Original Term:	start and end dates

Modification Term:	mod start and end dates

Original Amount:	enter approved amount

Modification Amount:	enter mod amount

Revised Total Contract Amount:	enter amount

Percent +/- (This Modification):	enter percent

Original Procurement Method:	enter procurement method

MBE Participation:	enter Goal

Remarks:	enter remarks

Fund Source:	enter fund source

Approp. Code:	enter

Resident Business:	enter

MD Tax Clearance:	enter

BOARD OF PUBLIC WORKS	THIS ITEM WAS:

APPROVED	DISAPPROVED	DEFERRED	WITHDRAWN

WITH DISCUSSION	WITHOUT DISCUSSION

DoIT 1D

Supplement D

Department of Information Technology

ACTION AGENDA

_________________, 20__

BPW Agenda Template - Contract Mod

Michael Meinl

2015-01-16

Srikanth Gadiyaram

Microsoft