Consultant Agreement, Form 1420 Instruction/Checklist for filling out the Form 1420

Form 1420 must be typed and filled out by the requesting School or District Department, handwritten agreements and

hand written changes are not accepted with the exception of pages 5 & 6. Consultants are not allowed to have fillable

forms; they may handwrite pages 5 & 6 only.

All professional services received by the School District of Palm Beach County School or Department must have a Form

1420 Consultant Agreement regardless of Financial Impact. This is to document exactly what services are being provided

to the District and to confirm that the consultant/business/individual will adhere to the Terms and Conditions required by

the School Board of Palm Beach County.

Do not sign consultant/vendor quotes or contracts without first submitting to Purchasing to be reviewed by Legal in case

on contradictory terms. When in doubt call Purchasing.

Consultant agreements for multiple dates, events and/or services are encouraged to be done for an entire year for the same

vendor; do not put multiple vendors on the same Form 1420. By doing this it reduces the amount of personnel time spent

processing. If there are any questions on how to do this, please contact Purchasing.

For Full Information, Guidelines, Instructions and Contacts

The Guidelines and additional information (attached) specific to consultants is available on the Purchasing webpage here,

https://www.palmbeachschools.org/purchasing/bids/purch/consulta/ or contact Michelle Thissell in Purchasing.

Any insurance questions or requirements should be directed to Risk at https://www.palmbeachschools.org/riskmgmt/front-

page/ or contact Shannon Armstrong in Risk.

Intentionally Left Blank

Approximate Number to be ServedTarget Group/School/DepartmentPosition and AddressEducation

THE SCHOOL DISTRICT OF PALM BEACH COUNTY PURCHASING DEPARTMENT

School District Consultant Agreement

Agenda Item # Board Meeting Date

Contact PX

School / Department

Agreement between the School Board of Palm Beach County and:

THIS AGREEMENT is entered into this day of by and between the SCHOOL

BOARD OF PALM BEACH COUNTY, hereinafter referred to as ''Board'' and

, hereinafter referred to as ''Consultant''. WHEREAS, the Board desires to enter into this Agreement with the Consultant, providing, among other things, for the Consultant's services to the Board; and WHEREAS, the Consultant desires to enter into this Agreement with respect to his/her (hereinafter his) services to the Board, upon the terms and conditions hereinafter set forth; WHEREAS, the Consultant is specially trained and possesses the necessary skills, experience, education and competency, and licenses or credentials to perform the required services. NOW, THEREFORE, the Board and the Consultant agree as follows:

The term of this Agreement shall commence onTERM1. and shall end onRESPONSIBILITIES OF CONSULTANT2.A. The Consultant shall perform the following services:

B. Time, date, and location of services:

3. CONSULTANT BACKGROUND INFORMATIONName of individual who will perform the services

4. EVALUATION/FOLLOW-UP METHODEvaluation of the Consultant shall be provided by

TITLE OF THE CONSULTANT'S SUPERVISOR/EVALUATOR

the School District at regular intervals and in accordance with the attached evaluation tool, Exhibit ''B''.

FINANCIAL IMPACT

The financial impact is

The source of funds is

FUNDDEPT BUDG. MGR.ACCT AWARD YEARPROGRAMFUNC LOCAL CODE

PBSD 1420 (Rev. 6/29/2016) Page 1 of 7

, 20

1. Name 2. Phone #

3. Name, not #

4. Consultant's Business Name

6. Consultant's Business Name5.

7. Date 8. Date

9. Description of Services in Detail.

10. When & Where Services will be Performed

11. Name, if Known12. Only Applies to Professional Development Services

13. Consultant's Title (if any) and Business Address14. Grade, Etc. / School Name/Department Name

15. Estimated Number

16. Name of Evaluator, District Employee Only

17. Total Dollar Amount of Agreement including Travel if applicable

18. Name of Funding Source i.e. Internal Accounts, Budget, Grant, etc.

19. Required if Budget or Grant, Not Required for Internal Accounts

**THE CONSULTANT DOES NOT FILL OUT THE 1420, THE SCHOOL DOES. DO NOT GIVE A FILLABLE FORM TO A CONSULTANT.** THE CONSULTANT CAN HAND WRITE PAGE 5 & 6.**

Type as a full detailed description so anyone reading this will understand exactly what is services are being provided. If necessary, indicate see attached cost of services or quote whatever details this information. This is required by the District Legal, Risk Management Department and the District Superintendent's office. If you do not give a detailed description your agreement will be returned unapproved.

Page 1

1. Type Name of the District Employee who can answer any questions regarding this agreement i.e. services, dates,

amount, etc. This may not be another consultant.

2. Type Phone number for the District Employee name above.

3. Type the actual Name of the School or District Department requesting the consultant.

4. Type the name of the consultant’s business. Must be the full legal name as shown by consultant on page 6 of 7 -

Beneficial Interest.

5. Type the date the agreement is Entered into. This is either the date the consultant signs the agreement or the date of the

Board Meeting (if Board approval is required)

6. Type the name of the consultant’s business. Must be the full legal name as shown by consultant on page 6 of 7 -

Beneficial Interest.

7. Section 1. Term, must be the first date that services will actually be performed by the consultant. Not the same date as

the Entered into date. Please be sure to make this agreement for the entire year if there will be multiple visits by this

vendor throughout the year. Changes can always be made using the Amendment Form 1843.

8. Section 1. Term, must be the last date that services will actually be performed by the consultant. Please be sure to make

this agreement for the entire year if there will be multiple visits by this vendor throughout the year. Changes can always

be made using the Amendment Form 1843.

9. Section 2. A. Services, this must be a fully detailed description of the actual services, activities, performances,

presentations) to be performed. Do not use the consultant’s promotional ad. Everyone reading this agreement must be able

to understand the exact services being performed and what is involved with those services. This is required by the District

Legal, Risk Management Department and the District Superintendent's office. If you do not give a detailed description

your agreement will be returned unapproved.

10. Section 2. B. Time, Date & Location, if exact dates are known you can fill that in. If you only know the number of

visits during the Term, then just put “X” number of visits To Be Determined.

11. Section 3, first line: The exact name of the consultant’s performing the services, if know. Otherwise use consultant’s

business name here.

12. Section 3, second line: This only applies to Professional Development services. Otherwise just fill in with “N/A”.

13. Section 3, third line: This is the consultant’s title, if any and the consultant’s business address.

14. Section 3, fourth line: This is the grade, class, etc. / Name of the School or District Department.

15. Section 3, fifth line: This is the estimated number of students or teachers receiving the service on this agreement.

16. Section 4. This is the name, not title, of the District Employee who will evaluate the service received on this

agreement. They will fill out page 7 of 7 of this agreement. This may not be another consultant.

17. Financial Impact: This is the total dollar amount of the agreement including travel costs. Example: $3,500.00. Do not

put $3,000 + $500 travel. This should be one amount only. If there is no cost for the service, then use “Zero Cost Service”

and skip to Section 6 on page 2.

18. Source of Funds: The name of the Funding I.e. Internal Accounts, Budget, Budget Title, Grant, etc.

19. Fund Strip box: Required to be fully filled out if funding from a Budget/Grant source. This is not required for Internal

Accounts.

I grant permission for any or all parts of this presentation to be videotaped. Yes No✔

Page 2 of 7

6. COMPENSATIONThe School Board shall pay the Consultant the maximum sum of (write out amount)

), for a maximum of($ hours which is based upon the following rate schedule.

Daily Rate: Half Day Rate: Hourly Rate:

Flat Rate:

No payment shall be made unless and until the Board verifies that all services for which payment is requested have been fully and satisfactorily performed. The Consultant shall submit to the Board any documentation necessary to substantiate the full and satisfactory performance of the services for which payment is requested. The administrator who will verify the services have been performed and approve the invoice is:

B.

A.

7. CONFIDENTIALITY OF STUDENT RECORDSThe Consultant is subject to all School Board obligations relating to compliance with student records confidentiality laws.By signing thisAgreement, the Consultant acknowledges and agrees to comply with the Family Educational Rights and Privacy Act (FERPA) and allState and Federal Laws relating to the confidentiality of student records.✔ Consultant will not receive student Information.

Consultant will receive student Information and Release or Transfer of Student Information (PBSD 0313) will be completed prior to Consultant receiving student information.Consultant will receive student Information. Since parental consent will not be obtained and Consultant has legitimate educational interests in the information, Consultant shall hereby be deemed a "school official" in accordance with School Board Policy 5.50 and shall enter into the Addendum concerning student information (PBSD 2220) which is attached hereto and incorporated herein as Exhibit C.

8. BACKGROUND CHECKS/FINGERPRINTINGThe Jessica Lunsford Act: All individuals who are permitted access on school grounds when students are present,individuals who willhave direct contact with children or any student of the School District, or who will have access to or control of school funds must befingerprinted and background checked. Consultant agrees to undergo a background check and fingerprinting if he/she is an individualwho meets any of the above conditions and to require that all individuals in the organization who meet any of the conditions to submit to abackground check, including fingerprinting by the School District's Police Department, at the sole cost of Consultant. Consultant shall notbegin providing services contemplated by this Agreement until Consultant receives notice of clearance by the School District. The Board,nor its members, officers, employees, or agents, shall not be liable under any legal theory for any kind of claim whatsoever for therejection of Consultant (or discontinuation of Consultant's services) on the basis of these compliance obligations. Consultant agrees thatneither the Consultant, nor any employee, agent or representative of the Consultant who has been convicted or who is currently underinvestigation for a crime delineated in FS §435.04 will be employed in the performance of this Agreement.

PBSD 1420 (Rev. 6/29/2016)

C.

5. COMPLIANCE WITH POLICIES AND LAWS/INSPECTOR GENERALThe Consultant shall comply with all current School Board of Palm Beach County's Policies. The School Board's policies are located athttp://www.palmbeachschools.org/ or www.boarddocs.com/fl/palmbeach/Board.nsf/Public and are incorporated herein. It shall be theConsultant's responsibility to comply with all School Board Policies as they may be modified from time to time during the term of thisAgreement. The Consultant shall abide by all applicable federal, state and local laws.

Policy 1.092(4)(d)(i) Accessibility to and Cooperation with Inspector General and Staff. The Office of Inspector General shall haveimmediate, complete and unrestricted access to all papers, books, records, documents, information, personnel, processes (includingmeetings), data, computer hard drives, emails, instant messages, facilities or other assets owned, borrowed, or used by the District, whichincludes information regarding District vendors or any other partnership, corporation or organization that may be involved with the District,as deemed necessary in performing investigative and/or audit activities and other requested information, including automated orelectronic data, pertaining to the business of the School Board and District within their custody.

9. PUBLIC RECORDS COMPLIANCECONSULTANT shall:A. Keep and maintain public records that ordinarily and necessarily would be required by the School Board of Palm Beach County in order

to perform the service to the Board under this agreement.B. Upon request from the Board's custodian of public records, provide the Board with a copy of the requested records or allow the

reocrds to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in Chapter 119,Florida Statutes or as otherwise provided by law.

C. Ensure that the public records that are exempt or confidential and exempt from public records disclosure requirements ae notdisclosed except as authorized by law for the duration of the Agreement term and following completion of the Agreement if theConsultant does not transfer the records to the Board.

20. Total Amount of Service Fee written out in words (do not include Travel, if applicable)21. $00.00 22.

23.23.

23. 23.

24.

25.

26.

Page 2

20. Section 6. A.: Write Out Amount – This is where you write out the total dollar amount of the service, do not include

the travel amount in this if you are going to use Section 14. If there is no cost for the service, then use “Zero Cost Service”

and fill in all spaces with “N/A”.

21. Section 6. A.: ($________) – this is where you fill in the total dollar amount not including any travel amounts you will

be using in Section 14.

22. Section 6. A.: If you know how many hours the services will be in total, you may fill it in here. If not, fill this in with

“N/A”. If you choose the “Hourly Rate” then you must fill in the hours and the number of hours’ times the Hourly Rate

must equal the total amount of Compensation in Section 6.

23. Section 6. A.: You must choose a Rate, you may only choose one rate, do not use multiple rate sections. If the fee is

not a daily, Half Day or Hourly Rate then you should use the Flat Rate. If you have multiple events with each event being

a different amount then just use the Flat Rate and list the different rates in parenthesis; Example: Flat Rate: $1,000.00

(includes $300, $400, $ 250, $50 / event).

24. Section 6. B.: The consultant needs to give permission for the District to video record any part or all of their service.

This does not give permission to the consultant to video record.

25. Section 6. C.: Name of the District Employee who will review and approve the invoice(s) for this service. This may

not be another consultant.

26. Section 7. Confidentiality of Students Records: This section is very important. If the consultant will have access to any

student data other than first names, then the second or third box must be checked and the referenced form therein needs to

be filled out and submitted with the consultant agreement. If the consultant will not have access to any student data other

than first names the first box should be checked.

Section 8.3 Background Checks/Fingerprinting

If a consultant has a vendor/contractor badge it does not mean they are an approved vendor. It only means they have been

fingerprinted and background checked by the District’s School Police Department. The “Vendor/Contractor” on the badge

is just a category description of what type of person they are; i.e. District employee (lists Department or School), or

vendor.

10. INDEPENDENT CONTRACTORThe Consultant is, for all purposes arising under this Agreement, an independent contractor. The Consultant and its officers, agents oremployees may not, under any circumstances, hold themselves out to anyone as being officers,agents or employees of the Board. Noofficer, agent or employee of the Consultant or Board shall be deemed an officer,agent or employee of the other party. Neither theConsultant nor Board, nor any officer, agent or employee thereof, shall be entitled to any benefits to which employees of the other partyare entitled, including, but not limited to, overtime, retirement benefits, workers compensation benefits, injury leave, or other leavebenefits.

11. OWNERSHIPA. All reports, studies, information, data, statistics, forms, designs, plans, procedures, systems, and other materials produced by the

Consultant under this Agreement shall be the sole and exclusive property of Board. No such materials produced, either in whole or inpart, under this Agreement shall be subject to private use, copyright or patent right by the Consultant in the United States or in any othercountry without the express written consent of Board.

B. Board shall have unrestricted authority to publish, disclose, distribute and otherwise use, copyright or patent any such materialsproduced by the Consultant under this Agreement.

PBSD 1420 (Rev. 6/29/2016) Page 3 of 7

Failure of Consultant to abide by the terms of this provisions shall be deemed a material breach of this Agreement. This provision shall survive any termination or expiration of this Agreement. In the event of a dispute regarding the enforcement of this provision where the Consultant has unlawfully refused comply with the public records request within a reasonable time, the School Board shall be entitled to recover its reasonable costs of enforcement, including reasonable attorney's fees from the vendor as authorized by 119.0701, Fla. Stat.

IF THE CONSULTANT HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONSULTANT'S DUTY TOPROVIDE PUBLIC RECORDS RELATING TO THIS AGREEMENT, HE OR SHE MUST CONTACT THE PUBLIC RECORDS MANAGEMENT COORDINATOR FOR THE SCHOOL DISTRICT OF PALM BEACH COUNTY BY PHONE AT 561-629-8585, BY EMAIL AT PUBLICRECORDS@PALMBEACHSCHOOLS.ORG, OR BY MAIL AT 3300 FOREST HILL BLVD., SUITE C-110, WEST PALM BEACH, FL33406.

Upon completion of the Agreement, transfer, at no cost, to the Board all public records in possession of the Consultant or keep and maintain public records required by the Board to perform the service. If the Consultant transfers all public records to the Board upon completion of the Agreement, the Consultant shall destroy any duplicate records that are exempt or confidential and exempt from public records disclosure requirements. If the Consultant keeps and maintains public records upon completion of the Agreement, the Consultant shall meet all applicable requirements for retaining public records. All records storedelectronically must be provided to the Board, upon request from the Board's custodian of public records, in a format that is compatible with the information technology systems of the Board.

D.

12. INDEMNIFICATION/HOLD HARMLESSThe Consultant shall, in addition to any other obligation to indemnify the Board and to the fullest extent permitted bylaw, protect, defend,indemnify and hold harmless the Board, its agents, officers, elected officials and employees from and against all claims, actions,liabilities, losses (including economic losses), costs arising out of any actual or alleged bodily injury, sickness, disease or death, or injuryto or destruction of tangible property including the loss of use resulting there from, or any other damage or loss arising out of, or claimedto have resulted in whole or in part from any actual or alleged act or omission of the Consultant, or anyone directly or indirectly employedby them, or of anyone for whose acts any of them may be liable in the performance of the work; or violation of law, statute, ordinance,governmental administration order, rule or regulation in the performance of the work; claims or actions made by the Consultant or otherparty performing the work. The indemnification obligations hereunder shall not be limited to any limitation on the amount, type ofdamages, compensation or benefits payable by or for Consultant under workers' compensation acts; disability benefit acts, otheremployee benefit acts or any statutory bar. Any cost or expenses, including attorney's fees, incurred by the Board to enforce thisAgreement shall be borne by the Consultant. The Consultant recognizes the broad nature of this indemnification and hold harmlessarticle, and voluntarily makes this covenant for good and valuable consideration provided by the Board in support of this indemnificationin accordance with the laws of the State of Florida. This article will survive the termination of this Agreement.

13. WAIVER OF SUBROGATIONIn the event of loss, damage or injury to the Consultant and/or the Consultant's property, the Consultant shall look solely to any insurancein its favor without making any claim against the School Board of Palm Beach County. The Consultant hereby waives any right ofsubrogation against the School Board of Palm Beach County, for loss, damage or injury within the scope of the Performer's insurance,and on behalf of itself and its insurer, waives all such claims against the School Board of Palm Beach County. NOTE: The terms and conditions of this agreement shall apply with respect to Consultant’s operations for any school or ancillaryowned by the School Board of Palm Beach County.

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14. TRAVELTravel is is not✔ allowable for this Agreement. Estimated travel expense is not to exceedfor the term of the Agreement. The Consultant agrees to submit all necessary documentation and proof of expenses in accordancewith F. S. § 1 12.061 and School Board Policy #6.01. The Consultant further agrees that reimbursement for travel must besubmitted on travel reimbursement forms with the rates determined by F.S. § 112.061 and School Board Policy 6.01 and must beauthorized by the appropriate administrator(s).

15. AMENDMENTThis Agreement may be amended only with the mutual consent of the parties. All amendments must be in writing and must beapproved by the Board.

16. ASSIGNMENTNeither the Consultant nor the Board may assign or transfer any interest in this Agreement without the prior written consent of the other party.

17. GOVERNING LAW AND VENUEThis Agreement shall be construed in accordance with the laws of the State of Florida. Any dispute with respect to this Agreementis subject to the laws of Florida, venue in Palm Beach County, Florida. Each Party shall be responsible for its own attorney's feesand costs incurred as a result of any action or proceeding under this Agreement.

18. TERMINATIONThe Board reserves the right to terminate this Agreement at any time and for any reason, upon giving thirty (30) days notice to theother party. If said Agreement should be terminated for convenience as provided herein, the Board will be relieved of all obligationsunder said Agreement and the Board will only be required to pay that amount of the Agreement actually performed to the date oftermination with no payment due for unperformed work or lost profits. In the event School Board determines that the Consultant'sservices are not being performed as agreed upon, the Consultant shall be deemed to be in default and the Board reserves the rightto cancel this Agreement with five (5) days notice and to withhold all monies due the Consultant until such time as the Board, in itssole discretion shall determine whether to have the contract services completed by others or to cease obtaining the services. In theevent that the Board determines to have the Agreement completed by others, the Consultant shall be liable for any costs ofcompletion in excess of that called for in this Agreement. In the event that the Board determines not to have the contractcompleted by others, the Consultant shall be paid for the services that it satisfactorily performed prior to the termination but, in noevent, shall the Consultant be paid for any work not actually performed or for lost profits. In the event that it is determined that atermination for cause was unjustified, the termination shall be deemed a termination for convenience and the Consultant shall beentitled to payment only for work actually performed prior to the termination and to any additional sums.

19. MINORITY STATUSThe Board strongly encourages active minority/women business enterprise participation with all professional services.The Consultant certifies that: This business is minority owned and operated (minimum 51%) Yes No✔

If a consultant not representing a firm, I am a minority Yes No

20. COMMERCIAL NONDISCRIMINATIONConsultant shall not discriminate on the basis of race, gender, gender identity or expression, religion, national origin, ethnicity, sexualorientation, age or disability in the solicitation, selection, hiring, or treatment of sub-consultants, vendors, suppliers, or commercialcustomers. Consultant shall provide equal opportunity for sub-consultants to participate in all of its public sector and private sector sub-consulting opportunities, provided that nothing contained in this clause shall prohibit or limit other wise lawful efforts to remedy the effectsof marketplace discrimination that has occurred or is occurring in the marketplace, such as those specified in the Palm Beach CountySchool Board Policy 6.143. Consultant understands and agrees that violation of this clause is a material breach of the contract and mayresult in contract termination, debarment, or other sanctions.

Page 4 of 7PBSD 1420 (Rev. 6/29/2016)

21. LEGAL REVIEWThe parties hereto represent that they have reviewed the Agreement and have sought legal advice concerning the legal significanceand ramifications of the provisions contained herein.

27.

28.

Page 4

27. Section 14 Travel: If travel (i.e. lodging, plane tickets, etc.) will be billed as a separate cost then you would check that

travel “is” allowable here and then fill in the maximum amount allowed in dollars. It is important to let the consultant

know that any travel costs listed here must conform to the District Travel Policy & Rates and reimbursement may only be

made by filling out the District’s Travel Reimbursement Form and including the receipts as noted in this Section. If there

is a standard travel fee but it is included in the overall rate then you would mark Travel as “not allowable”; Example:

South Florida Science Center has a $29 travel fee, this should be included in the overall rate not as a separate Travel

charge.

28. Section 19 Minority Status: Please confirm with the consultant if their business is minority owned and check yes if it

is.

Address

22. NOTICESAny notice permitted or required under this Agreement shall be in writing and signed by the party giving or serving the same, andshall be served either by personal delivery or certified mail to the following persons and at the following addresses:

Consultant SCHOOL BOARD OF PALM BEACH COUNTY, FLORIDAPurchasing Department3300 Forest Hill Boulevard, Suite A 323West Palm Beach, Florida 33406

Telephone # ( ) - Extension #

Consultant E-mail (Required)

23. MANDATORY CONTRACT DOCUMENTSThis Agreement includes the terms and conditions set forth in this document, and set forth in the following additional documentsattached hereto and incorporated herein: (approval will not be granted without these mandatory attachments)

Exhibit A - Beneficial Interest and Disclosure of Ownership Affidavit (PBSD 1997). See Page 6.Exhibit B - Provide Consultant Evaluation (PBSD 2075). See Page 7.

•$5,000 or less per vendor/fiscal year/location requires consultant and principal/director signature only.

•$5,001 to $25,000 per vendor/fiscal year/location requires signature of consultant, principal/director, regional/ assistantsuperintendent, legal services, chief academic/operating officer, deputy superintendent/chief of schools andsuperintendent.

Signature of Consultant Date Print Name of Consultant

Signature of Principal/Director Date Print Name of Principal/Director

Print Name of Regional/Assistant SuperintendentSignature of Regional/Assistant Superintendent Date

Print Name of Chief Academic/Operating OfficerSignature of Chief Academic/Operating Officer Date

Signature of Deputy Superintendent/Chief of Schools Date

Signature of Superintendent Date Signature of School Board Chairman Date

Page 5 of 7PBSD 1420 (Rev. 6/29/2016)

Signature of Legal Services Designee Date

29. Consultant's Business Name

30. Consultant's Business Address

31.32. Email Address Required

33.

34.

35.

REQUIRED SIGNATURES ARE LISTED HERE BASED All consultant contracts over $25,000 must be approved by the Legal Department before going to the Board.

The Board Chairman will sign the contract after Board Approval.

NOW, THEREFORE, the parties hereto have affixed their signatures on the day and year first above written.

ON • ACCUMULATED DOLLAR AMOUNT.

=================================================================================================================================================================================================================================

==============================================================**ALL SIGNATURES BELOW THIS LINE WILL BE OBTAINED BY THE PURCHASING DEPARTMENT, IF APPLICABLE**

Page 5

29. The name of the consultant’s business. Must be the full legal name as shown by consultant on page 6 of 7 - Beneficial

Interest. Not the name of the individual from the consultant’s business performing the service. Example: Joey’s Bounce

Houses, Not Joe Smith, the owner.

30. The consultant’s business address. This is used to confirm the vendor you use in PeopleSoft is the correct one to

receive this agreement and PO.

31. The consultant’s business phone number. This is required in case of changes, rescheduling, etc.

32. The consultant’s business email address. This is required so the District’s PO may be emailed to the consultant. And if

there are any other required forms that need to be filled out.

33. Requesting School or District Department must obtain the consultant’s signature on this page.

34. Requesting School’s Principal or District Department Director must sign this page.

35. If the accumulated amount for this vendor for this year is over for this school or District department is over $5,000,

you must obtain this signature as well. All other signatures below this will be done by Purchasing.

Processing Time and Signature Requirements

Internal Accounts - $5,000 or less allow 5 days processing time, from receipt of agreement by Purchasing. Budget - $5,000 or less allow 10 days processing time, from receipt of requisition and agreement by Purchasing. Form 1420 Consultant Agreement must be attached to the Special Request Requisition to allow for processing and PO issuance, originals not needed. Budget or Internal Accounts - $5,001 to $25,000 accumulated allow 2 - 3 weeks processing time, from receipt of agreement and/or requisition by Purchasing. Form 1420 Consultant Agreement must be attached to the Special Request Requisition to allow for processing, it is recommended the original be sent to Purchasing for the additional approvals and signatures. This is due to the requirement for additional signatures per vendor/fiscal year/location requires signature of consultant, principal/director, regional/ assistant superintendent, legal services, chief academic/operating officer, deputy superintendent/chief of schools and superintendent. Budget or Internal Accounts - $25,001 and up allow 6 weeks processing time, from receipt of agreement and/or requisition. Form 1420 Consultant Agreement must be attached to the Special Request Requisition to allow for processing and the original must be sent to Purchasing for the additional approvals and Board signatures. This is due to the requirement for Board approval and signature. If Board approval has already been obtained, the Board date and Agenda item number should be included with the fully executed agreement attached to the requisition, the original is not required to be sent to Purchasing in this case. It is very important to know that the dollar amounts are accumulated. So if you have multiple agreements throughout the year with the same consultant that have an accumulated total equaling over $5,001 or $25,001 it then requires those additional approvals. It is the School/Department’s responsibility to track their own agreement totals with each vendor in order to monitor their own accumulated spend.

THE SCHOOL DISTRICT OF PALM BEACH COUNTY

Beneficial Interest and Disclosure of Ownership Affidavit

Bid No. Project No./Title

Corporate Name

Tax FEIN No.

Before me, the undersigned authority, personally appeared, , ("Corporate

Representative") this day of , 20 , who, first being duly sworn, as required by law,subject to the penalties prescribed for perjury, deposes and says:

1) Corporate Representative has read the contents of this Affidavit, has actual knowledge of the facts contained herein, andstates that the facts contained herein are true, correct, and complete.

2) The following is a list of every "person" (as defined in Section 1.01(3), Florida Statues to include individuals, childrenfirms, associates, joint adventures, partnerships, estates, trusts, business trusts, syndicates,fiduciaries, corporations andall other groups and combinations) holding 5% or more of the beneficial interest in the disclosing entity: (If more space isneeded, attach separate sheet)A. Persons or corporate entities owning 5% or more:

Name Address Percentage

B. Persons or corporate entities who hold by proxy the voting power of 5% or more:Name Address Percentage

C. Stock held for others and for whom held:1. Name / 2. From Whom Held Address Percentage

2.1.

2.1.

2.1.

CORPORATE REPRESENTATIVE

By:

SWORN TO and subscribed before me this day of , 20 , by

Such person(s) (Notary Public must check applicable box).is/are personally known to me. produced a current driver license(s). produced as identification.

Notary Public

(Print, Type or Stamp Name of Notary Public) Page 6 of 7PBSD 1420 (Rev. 6/29/2016)

PURCHASING DEPARTMENT

N/A CONSULTANT AGREEMENT

36.

**NOT OPTIONAL, THIS PAGE REQUIRED****If consultant has a Tax ID (FEIN) number then this page must be filled out and

notarized.

Page 6 REQUIRED

36. The Beneficial Interest and Disclosure of Ownership Affidavit is required aa part of your agreement.

If the consultant has a Tax ID (Corporation, LLC, Inc., Not for Profit), this form must be filled out, signed by

them and notarized.

If the consultant is using their SSN, this form is not required to be filled out. Just write “N/A – INDIVIDUAL”

across the top of the page. DO NOT PUT THE ACTUAL SSN ON THE FORM. This page is still required to be

included with the packet regardless.

If the consultant is a Government Agency (Town, City, County, State), State/County College or University this

form is not required to be filled out. Just write “N/A – GOVERNMENT AGENCY” across the top of the page.

This page is still required to be included with the packet regardless.

THE SCHOOL DISTRICT OF PALM BEACH COUNTY

Consultant EvaluationPO Number

School/Department

Name of Consultant

From ToContract PeriodRating: 5 - Superior 4 - Satisfactory Plus 3 - Satisfactory 2 - Satisfactory Minus 1- UnsatisfactoryJOB KNOWLEDGE AND SKILL

1. Technical and procedural know-how to complete the project2. Knowledge of his/her specialty area3. Ingenuity, creativity, and innovation4. General quality of the work performed5. Student Assessment

1. Services provided matched the specifications of the contract2. Results produced3. Ability to meet goals as scheduled4. Success of the project

PRODUCTIVITY

COMMUNICATION1. Listening skills2. Returned phone calls, follow-up information, etc. in a timely manner

3. Overall communication skills4. Overall accessibility/availability

INTERACTION1. Working relationships with teachers and/or students2. Ability to work as part of a team3. Status updates and information received as the project progressed

RATING: A - Agree D - Disagree N/A - Not Applicable

1. Demonstrates dependability

2. Demonstrates ingenuity/creativity/innovation3. Performs well under pressure4. Effective when presenting ideas orally5. Expresses ideas clearly and uses correct grammar in written communication

6. Listens effectively7. Provides feedback in a constructive and timely manner

8. Is self-reliant and requires little or no supervision9. Treats staff and/or students with fairness, respect and integrity.

I would hire this consultant again. Yes No

Page 7 of 7

Signature of Evaluator Date

Print Name of Evaluator

A D NA

5 4 3 2 11.

2.3.4.

5.

4.3.2.

1.

4.3.2.

1.

1.

2.3.

5.

4.3.2.

1.

6.

7.8.9.

ORIGINAL - Department of PurchasingPBSD 1420 (Rev. 6/29/2016)

PURCHASING DEPARTMENT

37. School or Dept & Division Name here.38. Consultant's Business Name

39. Date of Service 40. Date of Service

**NOT OPTIONAL, THIS PAGE REQUIRED**** THE HEADER OF THIS PAGE MUST BE FILLED OUT & INCLUDED WITH YOUR

AGREEMENT**

Page 7 REQUIRED

37. Type in the Requesting School or District Department’s Name here.

38. Type the consultant’s business name here.

39. Type the first day services were performed here.

40. Type the last day services were performed here.

The Process

Internal Accounts Funded Consultant Agreements

Accumulated agreements under $5,000 are approved once signed by the consultant and requesting school’s Principal or

District Department Director. These are kept on file at the school or District Department.

Once your accumulated agreements for a specific vendor/location (school or department)/fiscal year have reached $5,000

you are required to obtain your Regional/Assistant Superintendent’s signature and forward the agreement with all prior

agreements to Purchasing to be processed and approved by the District Superintendent.

Once approved and fully executed you will receive email notification of the approval with an electronic copy of the fully

executed agreement. Your original agreement will be mailed back to you for your records.

Budget Funded Consultant Agreements

You must issue a Special Request Requisition and attach your signed consultant agreement to it in order for Purchasing to

process it and issue a PO.

Deficiencies

If your Form 1420 is returned to you with deficiencies, after correction email it back to the Purchasing Agent who

originally sent it to you. This will expedite the processing time. If you have a requisition and try to attach the corrected

agreement, it will remove all approvals from your requisition and delay processing by Purchasing as it will have to go

through the entire approval process again.

Consultant Agreement and PO Approval

Email notifications are sent upon PO Approval & Dispatch with an electronic copy of the fully executed agreement, if

applicable. If the PO is over $25,000 it may take a couple of days before you receive notification due to the additional

approvers needed for larger PO's. Any original agreements over $5,000 will be mailed back to you for your records.

Invoices

Invoices should be sent by the consultant/vendor/individual to Accounts Payable per the instructions included on every

PO issued. If you receive an invoice you may write the PO number on it and forward to Accounts Payable as a pdf. file to:

apinvoice@palmbeachschools.org (One invoice per .pdf file), in order to assure payment.

Attaching the invoice to your requisition is not submitting them to Accounts Payable. Do not expect them to be forwarded

to Accounts Payable.