Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 11/4/2024
2) Contract Type: Other
3) Renewal Contract: Yes
4) Department Name: Human Resources
5) Department Contact: Rebecca Gilliam
6) Description: Service Agreement with One America
7) PEID No: TBD
8) Req No: N/A
9) Orgkey: N/A
10) Object Code: N/A
11) Vendor: One America
12) Vendor Contract No: G74855, G76941, G73331
Expenditure Budget/Revenue Projections
13) Fund Name: N/A
14) Fund #: N/A
15) Current Year Budgeted: N/A
16) Current Year Projected: N/A
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals: N/A
To Be Completed by Purchasing Department
22) Contract Start Date: 1/1/2025
23) Auto Renewal Contract: No
24) Bid No: NA
25) Contract End Date: 12/31/2026
26) Contract # Issued by Purchasing Department: CM25039
NOTES: PEID is TBA - HB1295 to be requested