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CONNECTICUT DEPARTMENT OF LABOR (CTDOL) MODIFICATION TO CONTRACT
A.
PARTIES
TO
CONTRACT
CONNECTICUT DEPARTMENT OF LABOR (CTDOL)
200 FOLLY BROOK BLVD
WETHERSFIELD, CT 06109
Telephone: (860) 263-6590
Fax: (860) 263-6216
Contract Number
Modification No.
Modification Effective Date
CONTRACTOR NAME AND ADDRESS:
Number of Pages
Contractor Representative:
Contractor Telephone:
B. TERMS AND CONDITIONS OF MODIFICATION:
The Contract between ________________________________________ (the Contractor) and the State of
Connecticut Department of Labor (the Department) which was executed by the parties on ______/______/______
(and subsequently amended on _____/_____/_____) is hereby (further) amended by mutual agreement as follows:
See next page for applicable language choice(s) to use to insert here for contract medication (amendment) reason and detail.
Attached is a detailed Budget Summary and other applicable information concerning this modification. All provisions of this
contract, as hereby (and previously) modified, except those provisions specifically changed by this (or prior Modifications(s), shall
remain in full force and effect.
C. STATUTORY AUTHORITY: Connecticut General Statutes (CGS) §§ 4-8, 31-250 and 31-253.
D. APPROVALS: In witness hereof, the parties have affixed their signatures on the day, month and year written below.
COLLECTIVE BARGAINING CONCURRENCE: [ ] NOT APPLICABLE [ ] YES (if YES, see attachment)
CONTRACTOR APPROVAL:
__________________________________________ _____________________
Signature of Contractor’s Authorized Officer Date
AFFIX CORPORATE SEAL HERE
IF NO SEAL, WRITE “L.S.”
IN A CIRCLE HERE
____________________________________________________________________
PRINTED Name and Title of Contractor’s Authorized Officer
CT DOL APPROVAL:
__________________________________________ _____________________
Signature of Labor Commissioner Date
Glenn Marshall, Commissioner of the Department of Labor
________________________________________ ___________
AS TO FORM (Office of the Attorney General) Date
___________________________________ ___________
CT DOL Business Management Date
(for Fund Availability)
DOL-50w (NEW 4/99)
