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WHAT PROVISION Of THE CONmeCT. PROCUREMENT
CHANGE?

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OR OTHER LAW eUIHQRI?FP nus

Section 1.2025 of the standard procurement rule which is the sole source.
All other tenns and conditions shall rvmain the Barna.
IN WITNeSS WHEREOF, the AGENCY and the VENOOR have caused this AMENDMENT 10 be executed on
the dates shown below by representatives authorized to bInd the respective PARTIES.
AGENCY

VENDOR

Consolidated Communications
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Prlnted Name

Signature

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Printed Name

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Data

12 10-2004

Address

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Mattoon. II· 6' 9 38

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ILLINOIS OEPARTMENT OF CENTRAL
MANAGEMENT_SERVI~

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Date:
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STATE USE ONLY
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CERTIFICATIONS
LEGAL ABILITY TO CONTRACT: Vendor certifies it is under no legal prOhibition on
contracting with the State of Illinois, has no known conflicts of interest and further
specifically certifies that:
a)

b)
c)

d)
e)

f)

g)

h)

i)

.

Vendor, its employees and subcontractors will comply with applicable provisions of
the U.S. Civil Rights Act. Section 504 of the Federal Rehabilitation Act. the
Americans with Disabilities Act (42 U.S.C. § 12101 et seq.) and applicable rules in
performance under this Contract.
Vendor is not in default on an educational loan (5ILCS 385/3).
Vendor has informed the director of the AgencylBuyer in writing if he/she was
formerly employed by that agency and has received an early retirement incentive
prior to 1993 under Section 14-108.3 or 16-133.3 of the Illinois Pension Code, 40
ILCS 5114-108.3 and 40 ILCS 5118-133.3, and acknowledges that contracts made
without the appropriate filing with 1tle Auditor General are not payable from the
·contractual services" or other appropriation line items. Vendor has not received an
early retirement incentive in or after 2002 under Section 14-108.3 or 16-133.3 of the
illinois Pension Code, 40 ILCS 5114-108.3 and 40 ILCS 5116-133.3, and acknowfedges
that oontracls in violation of Section 15a of the State Finance Act are not payable
from ·the "contractual services" or other appropriation line items (30 ILCS
105/15a).
Vendor has not been convicted of bribing or attempting to bribe an officer or
employee of the State of Illinois or any other State. nor has made an admission Or'!
the record of having so bribed or attempted to bribe (30 ILCS 500/50-5).
If Vendor has been convicted of a felony, at least five years have passed after the
date of completion of the sentence for such felony, unless no pen;on held responsible
by a prosecutor's office for the facts upon which the conviction was based
continues to have any involvement with the business (30 ILCS 500/50-10).
If Vendor, or any officer. director, partner, or other managerial agent of Vendor,
has been convicted of a felony under the Sarbanes-Oxley Act of 2002. or a Class 3
or Class 2 felony under the Illinois Securities Law of 1953. at least 5 years have
passed since the date of the conviction. Vendor further certifies that it is not barred
from being awarded a contract and acknowtedges that the contracting State
Agency/Buyer shall declare the contract void if this certification is false (30 ILCS
500/50-10.5).
Vendor and its afflUates are not delinquent in the payment of any debt to the State (or
if defnquent has entered into a deferred payment plan to pay the debt), and
Vendor and its affiliates acknowledge the contracting State Agency/Buyer may
declare the contract void if this certification is false (30 ILCS 500/50-11) or if Vendor
or an affiliate la ter becomes delinquent and has not entered into a deferred payment
plan to payoff the debt (30 Iles 500/50-60).
Vendor and all affiliates shall collect and remit Illinois Use Tax on all sales of
tangible personal property into the State of Illinois in accordance with provisions
of the Illinois Use Tax Act (30 ILes 500151).12) and acknowledge that failure to
comply can result in the contract being declared void.
Vendor certifies that It has not committed a willful or knowing Violation of the
Environmental Protection Act (relating to Civil Penalties under the Environmental
Protection Act) within the last five (S) years, and is therefore not barred from
being awarded a contract. If the State later determines that this certification was

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falsely made by the Vendor, the Vendor acknowledges that the contracting State
AgencylBuyer may declare the contract void. (30 IlCS 500/50-14)
.
Vendor has not paid any money or valuable thing to induce any person to refrain
from bidding on a State contract, nor has Vendor accepted any money or other
valuable thing, or acted upon the promise of same, for not bidding on a State
contract (30 IlCS 500/50-25).
Vendor is not in violation of the -Revolving Door" section of the Illinois Procurement
Code (30 IlCS SOO/50-30).
Vendor \YIII report to the Illinois Attomey General and the Chief Procurement Officer
any suspec.1ed collusion or other antl-eompetitlve practice among any bidders,
offerors, contractors, proposers or employees of the State (30 ILCS 500150-40,

50-45, 50..50).
m)

Vendor will, pursuant to the Drug Free Workplace Act, provide a drug free
workplace, and if an individual shall not engage in the unlawful manufacture,
distnbution, dispensation, possession or use of a controlled substance in the
performance of the Contract. This certification applies to contracts of $5000 or
more with: individuals; and to entities with twenly-five (25) or more employees (30

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Neither Vendor nor any substantially owned affiliate Is participating or shall
participate in an International boycott in violation of the U.S. Export
Administration Act of 1979 or the applicable regulations of the U.S. Department
of Commerce. This certification applies to contracts that exceed $10,000 (30

0)

Vendor has not been convicted of the offense of bid rigging or bid rotating or any
similar offense of any State or of the United States (720 ILCS SI33E-3, S/33E-4).
Vendor complies with the Illinois Department of Human Rights Act and rules
applicable to public contracts, Including equal employment opportunity, refraining
from unlawful discrimination, and having written sexual harassment policies (775

ILCS 580).

IlCS 582).
p)

IlCS 512-105).
q)

r)

s)

Vendor does not pay dues to, or reimburse or subsidize payments by its employees
for, any dues or fees to any -discriminatory club- (775 ILes 25/2).
Vendor complies with the State Prohibition of Goods from Forced Labor Act, and
certifies that no foreign-made equipment, matenals. or supplies furnished to the
State under the contract have been or will be produced in whole or in part by forced
labor, convic.1labor, or indentured labor under penal sanction (PA 93-0307).
CONFLICTS OF INTEREST: Vendor has disclosed. and agrees it is under a
continuing obligation to disclose to the Agency/Buyer, financial or other interests
(public or private, direct or indirect) that may be a potential conflict of interest or
which would prohibit Vendor from having or contJnuing the Contract. This includes.
but is not limited to conflicts under thE! "Infrastructure Task Force Fee ProHbition"
section of the State Finance Act (30 ILCS 105/18.40). Artide 50 of the Illinois
Procurement Code (30 I lCS 500150). or those which may conflict in any manner with
the Vendor's obligation under this Contract. Vendor shall not employ any person
with a conflict to perform under this Contract. If any conflict under Section 50-13
exists no contract may be issued without an exemption from the Govemor
pursuant to Section 50-20 of the Illinois Procurement Code. An exempUon is
necessary If:
1)
the person intending to contract with the Stale, their spouse or child: (i)
holds an elective office in Illinois: (ii) holds a seat in the Illinois General
Assembly; (iii) is an officer or employee of the Capital Development Board or
the Illinois Toll Highway Authority: or holds an appointed position or is
employed In any of the offices or agencies of the State government and who

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receives compensation for such employment in excess of 60% of the salary of
the Governor (currently $90,414.60). (The conflict of interest threshold of
60% of the Governor's salary set rorth in Section 50-13 does not apply to
elective office holders. legislators, and officees or employees of the Capital
Development Board or the Illinois Toll Highway Authority.);
the contract is with a firm. partnership, association or corporation in which a
person referenced in 4.1.3.1 above receives more than 7.5% of the total
distributable income or an amount In excess of the salary or the Govemor

(currently $150,691.00).
the contract is with a firm, partnership, association or corporation in whim a
person referenced in 4.1.3.1 above, together with their spouse. or minor
child, receives more than 15% in the aggregate of the total distributable
income or an amount in excess of 2 times the salary of the Governor
(currently S301,382.00) from the firm, partnership, association or
corporation.

VENDOR (show Company name and DBA)

Consolidated Comm~nications
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Signature_
Printed Name_ _
TItle Vice President Date

Address

121

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17th

12-10-2004

st.

Mattoon, IL 61938

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TAXPAYER IDENTIFICATION NUMBER
I certify that

1. The number shown on this form is my correct taxpayer identification number (or I
am waiting for a number to be issued to me), and
2. I am not 8u.bject to backup withholding because: (a) I am exempt from backup
withholding, or (b) I have not been notified by the Internal Revenue Service (IRS)
that I am subject to backup withholding 8S a result of a failure to report all interest
or dividends. or (c) the IRS has notified me that I am no longer subject to backup
withholding, and
3. I am 8 U.S. person (including a u.s. resident allen).

Name (Printed):

Consolidated Communications Public Services, Inc.

Taxpayer Identification Number.
Social Security Number
or
Employer Identiflcatlon Number

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_

Legal Status (check one):
_Individual

_Govemmental

_ _Sole

_ _Nonresident alien

Proprieto~hlp

_ _Partnership/Legal Corporation

_ _Estate or Trust

_Tax-exempt

_Pharmacy (norrcorporate)

_ _Corporation providing or
billing medical and lor
health care services

_ _Pharmacy/Funeral Home/Cemetery (Corp.)

-x'-corporatJon NOT proViding

_ _Olher

or billing medical and I or
health care services

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