AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

2. AMENDMENT/MODIFICATION NO. 3. EFFECTIVE DATE

POOOO l See Block 16C 6. ISSUEDBY CODE FMPS CONSUMER PRODUCT SAFETY COMMISSION DIV OF PROCUREMENT SERVICES 4330 EAST WEST HWY ROOM 523 BETHESDA MD 20814

8. NAME ANO ADDRESS OF CONTRACTOR (No., "-'· wvnty, S"'• a11d ZIPC-J

D 1 I

ICKINSON CO HEALTHCARE SYSTEM 721 S STEPHENSON AVENUE RON MOUNTAIN MI 49801-3637

, 1. CONTRACT ID CODE I PAGE OF PAGES

i I 4 4. REQUISITION/PURCHASE REQ. NO. 15 PROJECT NO. (If •ppfic•blltl

REQ-4310- 18- 0007 7. ADMINISTERED BY (If other than /l~m 6) CODE j

i!2. 9A. AMENDMENT OF SOLICITATION NO.

98. DATED (SEE ITEM 11)

x 10A. MODIFICATION OF CONTRACT/ORDER NO. CPSC- N- 17 - 000 4

108. DATED (SEE ITEM 13)

CODE FACILITY CODE 12/05/2016 11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

0 The above numbered solicoladon is amended as sel fOl1h ln Item 14. The hour and dale specified for r-pt of Olfers D os e•tended. O is not extended.

Oft'ers must acknowledge receipt of lhia amendment prior lo lhe hour 11nd date specifled In ttte solicitation "' as emended , by one of the lollowir\g methods: (a) By completlng

Items 8 and 15. and returning eopie& of the amendment: (b) By aeknowledging receipt ol lhis amendment on each copy ol the ofter submitled : or (C} By

separate letter or telegram which includes e reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOIM..EDGEMENT TO BE RECEIVED AT

THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR ANO DATE SPECIFIED MAY RESULT IN REJECTION Of YOUR OFFER ti by virtue ol lhis .. enc:tment you desire to ch•nge an ofter aln!edy submitted, such change may be med• by telegram or letter. provided each telegram or letter melln reference to In! llOlicilation and this amendment, and is received prior to tl\e opening hour and date specified .

12. ACCOUNTINGANOAPPROPRIATION DATA(lfrequiredJ Net Increase; See Schedule

$51,777.00

13. THIS lTUI ONLY APPLIES TO MODIACATIOfll OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED JN ITEM 1'.

CHECl<ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Spe<;iry authOrlty) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (sUCll IS changes in payingoflk:ft. 1ppropnation date, etc.) SET FORTH IN ITEM 14. PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENT AL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modilicalfon and authority)

X FUNDING ACTION - UNILATERAL MODIFICAT ION FAR 43. 103 (b)

E. IMPORTANT: Contrector i!l ls not. 0 Is required to sign this oooumenl and return ------- copies lo tho lnuing ol!ice .

14. DESCRIPTION OF AMENDMENT/MOOIFICATION (Organized by UCF section heading&. including solicilatfonleontract subj«:t matter wlle'9 feasible.)

DUNS Nwnber: HOSPITAL ID#: (4V164055 - Dickinson Cty Healthcare System) COR: Dennis B. Wierdak PHONE: (301) 504-74 30 EMAIL: dwierdak@cpsc.gov

Modification POOOOl to contract CPSC-N-17-0004 is hereby issued to provide additional funding for option period one and to exercise option period two as follows:

1- The funded quantity for line item 0004 is increased by 3,500 to a new total quantity of 6,000. Continued E•cept es provided herein, an terms and conditions of the da<:ument referenced in Item 9 Ao• 1 OA, as heretofore changed, oemalns unchanged and in lull force and e!!ed .

15A. NAME ANO TITLE OF SIGNER (Type or print) 16A. NAME AND TITLE Of CONTRACTING OFFICER (Type or ptinQ

t 5B. CONTRACTORIOFFEROR

(SlgM ll.ue of person authorfzed 10 SignJ

NSN 7540·01· 152.S070 Previous edition unusable

l 5C DATE SIGNED

Greg A. Grayson

STANDARD FORM 30 (REV. 10-83)

Prescrit>eel by GSA

FAR (48 CFR) 53.243

REFERENCE NO. OF DOCUMENT 8EING CONTINUED

CONTINUATION SHEET CPSC-N-17-0004/POOOOl

NAME Of OFFEROR OR CONTRACTOR

DICKINSON CO HEALTHCARE SYSTEM

ITEM NO.

(A)

0004

SUPPLIES/SERVICES

(B)

2- As a result, funding is added for line item 0004 in the amount of $17,675.00.

3- The funded quantity for line item 0005 is increased by 800 to a new total quantity of 1, 350 .

4- As a result, funding is added for line item 0005 in the amount of $3,032.00.

5- As a result of the above, funding for option period one (July l, 2017 through June 30, 2018) is increased by $20,707.00 to a new total of $36,916.50.

6- In accordance with FAR Clause 52.217-9, Option to Extend the Term of the Contract, the Consumer Product Safety Commi ssion hereby exercises option period two for the period beginning July 1, 2018 through June 30, 2019. Pricing is in accordance with line items 0006-0007.

7- The funded quantity for line item 0006 is increased from 0 to a new total quantity of 5, 000 .

8- As a result, funding is added for line item 0006 in the amount of $26,000.00.

9- The funded quantity for line item 0007 is increased from Oto a new total quantity of 1, 300 .

10- As a result, funding is added for line item 0007 in the amount of $5,070.00.

11- As a result of the above, funding is added in the amount of $31,070.00 for option period two (July 1, 2018 through June 30, 2019). Additional funding may be provided via modification at a later date should funding become available.

Cha nge Item 0004 to read as follows(amount shown is the obligated amount):

OPTION PERIOD ONE JULY 1, 2017 THROUGH JUNE 30, 2018

No t to Exceed: 6,000

NEISS Surveillance Reports and Special Survey Reports in accordance with the attached statement Continued ...

N$N 7!>40-01-152·8067

QUANTITY UNIT UNIT PRICE

(C) (0) (E)

3500 EA 5 . 05

OF

AMOUNT

(F)

4

17,675.00

OPTIONAL FORM 338 (4·811) Spon•orod by GSA

FAR r•a CFRl 53.11 D

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT 8EING CONTINUED

CPSC-N-17-0004/POOOOl

NAME OF OFFEROR OR CONTRACTOR

DICKINSON CO HEALTHCARE SYSTEM

ITEM NO. SUPPLIES/SERVICES

(A) (B)

of work.

Accounting Info: 0100Al7DSE- 2017-1117900000-EXHR004310-252EO Funded: $0.00 Accounting Info: 0100Al8DSE-2018-1117900000-EXHR004310-252EO Funded: $17, 675. 00

Change Item 0005 to read as follows(amount shown is the obligated amount}:

0005 No t To Exceed: 1,350

NEISS Supplemental I Special Study Reports in accordance with the attached statement of work.

Ac counting Info: 0100A17DSE-2017-1117900000-EXHR004310-252EO Funded: $0.00 Accounting Info: 0100A18DSE-2018-1117900000-EXHR004310-252EO Funded: $3,032.00

Change Item 0006 to read as follows(amount shown is the obligated amount) :

OPT I ON PERIOD TWO JULY 1 1 2018 THROUGH JUNE 30, 2019

0006 Not To Exceed: 5,000

NEISS Surveillance Reports and Special Survey Reports in accordance with the attached statement of work.

Accounting Info: 0100A18DSE-2018-1117900000-EXHR004310-252EO Funded: $26,000.00

Change Item 0007 to read as follows(amount shown is the obligated amount) :

0007 Not To Exceed: 1,300

NEISS Supplemental I Special Study Reports in accordance with the attached statement of work.

Accounting Info: 0100A18DSE-2018-1117900000-EXHR004310-252EO Continued ...

NSN 754().01· 152·6067

QUANTITY UNIT UNIT PRICE

(Cl (D) (El

800 EA 3. 79

5000 EA 5 . 20

1300 EA 3 . 90

OF

4

AMOUNT

{Fl

3,032.00

26,000.00

5,070.00

OPTIONAL FORM 3JQ ( .. 66) Sponsoted by GSA

FAR 146 CFRl S3 110

REFERENCE NO. OF DOCUMENT BEING CONTINUED CONTINUATION SHEET CPSC-N-17-0004/POOOOl

NAME OF OFFEROR OR CONTRACTOR

DICKINSON CO HEALTHCARE SYSTEM

ITEM NO. SUPPLIES/SERVICES

(Al (B)

Fund ed : $5 , 070 . 00 All other terms and conditions shall remain unchanged and in full force and effect.

NSN 75'10-01-152-$067

QUANTITY UNIT UNIT PRICE

(Cl ( D ) {E)

OF

AMOUNT

{F)

OPTIONAL FORM 3J6 (.._86) Spo<>sorod by GSA FAR f48 CFRl 53 HO

4