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• � ' . . <br /> . . ' � , <br /> ' Agreement No. 11 G513 5000 <br /> STATE OF ILLINOIS <br /> DEPARTMENT OF HUMAN SERVICES <br /> COMMUNITY SERVICES AGREEMENT <br /> Fiscal Year 2005 <br /> This Agreement is by and between the Illinois Department of Human Services, with its principal <br /> office at 535 West Jefferson, hereinafter referred to as the "Department" and, City of Decatur, <br /> hereinafter referred to as the "Provider" with its principal address at: 1 Gary K Anderson Plaza, <br /> Decatur, IL, 62523. <br /> WHEREAS, it is the intent of the parties herein to implement services consistent with all <br /> Attachments hereto and pursuant to the duties and responsibilities imposed by the Department <br /> under the laws of the State of Illinois and in accordance with the terms, conditions and <br /> provisions hereof, it is agreed as follows: <br /> 1. TERM <br /> This Agreement shall be effective July 1, 2004, and shall expire June 30, 2005, unless <br /> extended pursuant to the terms hereof. <br /> 2. TAXPAYER CERTIFICATION (Provider MUST complete) <br /> Under penalties of perjury, the Provider certifies that 376001308 is the Provider's <br /> correct Federal Taxpayer ldentification Number/Social Security Number (circle one). <br /> The Provider is doing business as a (please check one). <br /> Individual Nonresident Alien <br /> Sole Proprietorship Pharmacy-Non Corporate <br /> Partnership Pharmacy/Funeral <br /> Corporation(includes Not For Profit) Home/Cemetary Corporation <br /> Medical Corporation T�Exempt/HospitaUExtended Care Facility <br /> X Govemmental Unit <br /> Estate or Trust <br /> The Provider also certifies that it does and will comply with all provisions of the Federal <br /> Internal Revenue Code, the Illinois Revenue Act, and all rules promulgated thereunder, <br /> including withholding provisions and timely deposits of employee taxes and <br /> unemployment insurance taxes. <br /> 3. PAYMENT <br /> A. The estimated amount payable by the Department to the Provider under this <br /> Agreement is $60,000.00. The Provider agrees to accept DHS payment for <br /> services rendered as specified in the Attachments incorporated as part of this <br /> Agreement. <br /> -1- <br />