Common use of Xxx Xxxxx Clause in Contracts

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract First Name Middle Initial Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLE

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract PART I First Name Middle Initial SSN# Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I II CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLENAME

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract PART I First Name Middle Initial SSN# Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I II CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: _ with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLENAME

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract PART I First Name Middle Initial SSN# Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLETITLE File folder: 626582 17 Contractor Initial: Lexipol, LLC Contract # MA-060-13011277 Attachment A - Amendment MA-060-16011406 to Contract MA-060-13011277 Page 26 of 36

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract PART I First Name Middle Initial SSN# Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLE

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract PART I First Name Middle Initial Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I II CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLENAME

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract First Name Middle Initial SSN# Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLE

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract PART I First Name Middle Initial Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I II CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLE

Xxx Xxxxx. xxx. To comply with the reporting requirements of, County procedures for contracting with independent CONTRACTORS mandate that the following information be completed and forwarded to the contracting agency/department immediately upon request: First Name, Middle Initial, and Last Name Social Security Number Address Start and expiration dates of contract Amount of contract PART I First Name Middle Initial Last Name SSN# Date of Birth Address Contract No. Start Date Expiration Date Dollar value of contract PART I CERTIFICATION (PART I must also be completed) I certify that is in full compliance with all applicable Federal and State reporting requirements regarding its employees and with all lawfully served Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in compliance throughout the term of Contract Number: with the County of Orange. I understand that failure to comply shall constitute a material breach of the contract and the failure to cure such breach within 60 calendar days of notice from the County shall constitute grounds for termination of the contract. AUTHORIZED SIGNATURE PRINTED NAME TITLETITLE Folder: 583487C010979 22 Contractor Initials: