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�, d <br /> , . , t <br /> Agreement No. 11G4135000 <br /> STATE OF ILLINOIS <br /> DEPART'MENT OF HUMAN SERVICES <br /> COMMUlVITY SERVICES AGREEMENT - <br /> FISCAL YEAR 2004 <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 provisions <br /> hereof, it is agreed as follows: <br /> 1. T'ERM <br /> This Agreement shall be effective July 1, 2003, and shall expire June 30, 2004, 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 correct <br /> Federal Taxpayer ldentification Number/Social Security Number(circle one). The Provider is <br /> 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/Cemetery Corporation <br /> Medical Corporation Tax Exempt/HospitaUExtended Care Facility I <br /> X Governmental 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 unemployment ', <br /> insurance taxes. ' <br /> 3. PAYMENT ' <br /> A. The estimated amount payable by the Deparhnent to the Provider under this Agreement <br /> is $60,000.00. The Provider agrees to accept DHS payment for services rendered <br /> as specified in the Attachments incorporated as part of this Agreement. � <br /> -1- � <br />