ED-48
(REV. 9/15)
SERVICE AGREEMENT
I,
of
1
(complete name as it appears on your social security card or SS-4)
2
City
Mailing Street Address
agree to perform the following services for the:
State
Zip Code
WV Department of Education
(organization name)
at
3
(location)
4
5
(detailed description of services to be performed – if WV certified teacher, please state in this section and complete certification below)
*Attach a WV-50 – See Following Page*
Date(s) of service:
From:
The rate of pay shall be $
The rate of pay shall be $
The rate of pay shall be $
To:
per6
per7
per8
0.00
0.00
0.00
0
0
0
not to exceed $
not to exceed $
not to exceed $
0.00
0.00
0.00
10
Authorized Travel Expense 9: (check only one box)
Total: $
Will not be reimbursed.
Will be reimbursed upon proper documentation in accordance with the travel
regulations of the Agency not to exceed $
0.00
.
Please check the appropriate box below 11: (check only one box)
I am not currently a full-time employee of the State of West Virginia or a county board of education.
I am currently a full-time employee of the State of West Virginia. - Complete Certification 1
I am currently a full-time employee of
BOE - Complete Certification 2
(enter county name)
WV DEPARTMENT OF EDUCATION
Authorizing Signature12
1
VENDOR
Date13
Vendor’s Signature14
Date15
Print Name16
Taxpayer Identification Number (SSN/FEIN) 17
Originating Office Name
Office of Internal Operations
CERTIFICATION: Full-time employees of the State of West Virginia must complete.
It is hereby certified that the services to be performed under this agreement will not interfere with or detract from the full-time duties of the
employee. The amount of annual compensation received by
(above named vendor) from the State
of West Virginia for full-time employment during the current fiscal year will be $
The vendor serves as
with the title of
(position)
(title)
Signature of Vendor’s Supervisor/Agency Head
2
Title
Agency Name
CERTIFICATION: Full-time employees of the WV Boards of Education must complete.
We certify that the time period covered under this contract is one of the below – check only one box: (Employee is REQUIRED to sign below)
That there is no compensation for the services covered by this contract; (i.e. travel only)
That the services covered by this contract occur outside the hours in which this employee receives compensation; or
That both this employee and our organization are in compliance with Title 158, Series 14, regarding the filing of verified time records (If you check this box, then supervisor MUST also sign))
(Signatures of Employee’s Supervisor)
(Signature of Employee)
WVDE USE ONLY
Document ID # :18
Vendor #19:
Acct:
Program20
Check here if approval is required by the Attorney General .
 Approved:
PPC21
Unit22
Fund23
Approp24
State of West Virginia
Department of Education
AGREEMENT QUESTIONNAIRE
Doc. ID #
Vendor #
1.
Briefly describe the project scope of work to be completed or the problem to be solved by
executing this agreement purchase order with
Vendor Name
2.
What results do you expect to achieve using this agreement?
3.
What would be the effects on you, the agency, if this agreement was not implemented?
4.
What specialized or professional skill will be provided that is not available within your own
or some other agency?
5.
Is this agreement related to any other project being undertaken within your agency? If so,
briefly describe.
6.
Describe the methodology and evaluation criteria utilized to select this vendor.
7.
What other vendors were considered for this work? Explain why this particular vendor was
selected over those considered.
8.
Is this agreement associated with providing any software, hardware, or data processing
related services? If yes, written verification of IS&C approval is required and must be
attached.
ED- 50 (REV. 2/16)
1 Enter the individual’s name or agency name who is providing a service; a service is not a tangible product. If agency, enter the agency name, then add the agency representative in parentheses. Example: Enthused Learning (Elizabeth Sattes)
2 Enter the remit to address where individual or agency receives mail.
3 Enter the address (city, state only) of WVDE location.
4 Enter a detailed description of services being provided.
5 Enter the service dates here. The services provided under this agreement HAVE to fall within these referenced dates, including travel dates. If these vendor’s services are required for a period of a year within a grant funding period, you can use
6 Acceptable: per hour, per day, per speech, per training session, per unit completed, etc. Unacceptable: per invoice, per contract, per agreement.
7 Acceptable: per hour, per day, per speech, per training session, per unit completed, etc. Unacceptable: per invoice, per contract, per agreement.
one service agreement for the full year. If this is the case, in the “not to exceed $0.00” section, enter ‘open end’ instead of the $ amount.
8 Acceptable: per hour, per day, per speech, per training session, per unit completed, etc. Unacceptable: per invoice, per contract, per agreement.
9 Enter an X in the appropriate box. If travel is to be reimbursed under this agreement, please estimate the maximum amount to be paid.
10 Enter the total from the above rate of pay line items. (<=$5000) signed by Office Director or Division Chief; (>$5000 through $10,000) initialed by Office Director and signed by Division Chief; (>$10,000 through $25,000) initialed by Office Director and Division Chief; then, signed by Chief of Staff; and (>$25,000) initialed by Office Director, Division Chief, and Chief
11 Enter an X in the appropriate box.
12 (<=$5000) signed by Office Director or Division Chief; (>$5000 through $10,000) initialed by Office Director and signed by Division Chief; (>$10,000 through $25,000) initialed by Office Director and Division Chief; then, signed by Chief of Staff ; and (>$25,000) initialed by Office Director, Division Chief, and Chief of Staff; then, signed by State Superintendent.
13 Enter date of signature.
14 Signed by individual listed on this form; or, if agency, signed by a representative. If agency, be sure to list both agency and representative
15 Enter date of signature.
16 Type name of authorizing signature.
17 THIS FIELD MUST BE COMPLETED. If individual, SSN; if agency, FEIN number.
18 If ED-4 was completed, enter the assigned Document ID #. If no ED-4 was completed, then the Finance Office will complete.
19 Originating office will insert vendor number.
20 Enter
21 Enter
22 Enter
23 Enter
24 Enter
Program. Example: 03CXR.0
PPC - fiscal year which services are rendered. Example F2015 or S2015
Unit: Example: 0025
Fund. Example: 0313
Approp. Example: 13000
name in the top section as indicated.
of Staff; then, signed by State Superintendent.