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. � " , <br /> Agreement No. 311 G3135000 <br /> STATE OF ILLINOIS <br /> DEPARTMENT OF HUMAN SERVICES <br /> COMMLTNITY SERVICES AGREEMENT <br /> FISCAL YEAR 2003 <br /> This Agreement is by and between the Illinois Department of Human Services,with its principal oflice at <br /> 535 West Jefferson,hereinafter referred to as the"Department"and,City of Decatur,hereinafter referred to <br /> as the"Provider"with its principal address at: 1 Gary K Anderson Plaza,Decatur,IL, 62523. <br /> WHEREAS, it is the intent of the parties herein to implement services consistent with all Attachments <br /> hereto and pursuant to the duties and responsibilities imposed by the Department under the laws of the State <br /> of Illinois and in accordance with the terms,conditions and provisions hereof,it is agreed as follows: <br /> 1. TE�RN <br /> This Agreement shall be effective October 1,2002,and sha11 expire June 30,2003, unless <br /> extended puisuant to the tern�s hereof. <br /> 2. TAXPAYER CERTIFICATION (Provider MUST complete) <br /> Under penalties of perjury,the Provider certifies that 376001308 is the Provider's correct Federal <br /> Tu�payer ldentification Number/Social Security Number(circle one). T'he Provider is doing business <br /> as a(please check one). <br /> _Individual _Pharmacy-Non Corporate <br /> _Sole Proprietorship _Nonresident Alien <br /> _Partnership _Phannacy/Funeral Home/Cemetery <br /> —Corporation(includes Not For Profit) Corporation <br /> _Medical Corporation _Tax Exempt/HospitaUExtended Care <br /> X Governmental Unit Facility <br /> _Estate or Trust <br /> The Provider also certifies that it does and will comply with all provisions of the Federal Internal <br /> Revenue Code, the Illinois Revenue Act,and a11 rules promulgated thereunder,including withholding <br /> provisions and timely deposits of employee taxes and unemployment inswance taxes. <br /> 3. PAYMENT <br /> A. The estimated amount payable by the Department to the Provider under this Agreement is <br /> $30,000.00. The Provider agrees to accept DHS payment for services rendered as <br /> specified in the Attachments incorporated as part of this Agreement. <br /> -1- <br />