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auy") r 3�` ORANGE COUNTY-CONTRACT CONTROL SHEET <br /> Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk <br /> This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager <br /> determines the contract is not appropriate for Manager approvai the Manager shall submit the contract for BOCC approval. Contracts for <br /> BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should <br /> be completed through the levaI review process.prior to being routed for signature. <br /> De az Aent <br /> Party/Vendor Name: Piedmont Health Services Party/Vendor Corvact Person: Brian Toomey Contact Phone: 781-687-9500 <br /> Party/Vendor Address:229 Lloyd Street City Carrboro State: NC Zip: 27510 Department:Public Health Amount:N/A Purpose: <br /> Outside agency performance agreement Budget Code(s): 10414020-630000 Vendor#27898 (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes❑No® Contract Type: (Check one)New ® Renewal ❑ Amendment ❑ Effective Date July 1,2013 Approved <br /> by Board Yes❑No❑ Agenda Date: Title of Contract: Outside Agency Agreement <br /> If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No[:]. If submitted for bid were <br /> bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to <br /> technical content: <br /> Department Director's Signature: ~ Date: <br /> Director <br /> (Applicable only to hardware/software purchases or related se7vic•es)This contract has been reviewed and approved by the Information <br /> Technology Director as to technical content and information technology specifications: <br /> IT Director's Signature: Date: <br /> ll`:i�l. 'lan;�e►:rent <br /> Include the following coverages: i CGL; [Auto; �� •i i �I ofessional; ❑ Property; OR No Insurance Required ❑. Hold <br /> Contract pending receipt of Certificate of Insurance:; of Insurance provisions as shown,this contract is approved <br /> by the Risk Manager: <br /> Risk Manager's Signature: `� ' Date: �U � <br /> Financial Services <br /> This Contract is conditioned on appropriation by the Board of Commissioners Yes❑Noa. A budget amendment is necessary <br /> before approval Yes❑Nog.If budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the <br /> manner required by the Local Government Budgey and Fiscal Control Act: r <br /> Financial Services Director's Signature: Date: �O I <br /> Countv Attorney <br /> Approval by Board ❑ (Contracts $90,000 00 or more for goods or services, $250,000.00 or more for construction, or any BOCC <br /> consultant contract). Approv by Manager&(Most other contracts$1.,000 and above). Department Director approval only❑ (Under <br /> $1,000). This contract has e re e d and approved by the Atcnn:c y_s to legal form and sufficiency- <br /> Attorney's Signature _ _ Date: <br /> County Manager <br /> This contract has been reviewed and is approved by the County Manager YeADA00. <br /> This contract has been reviewed and is for sig re b the C it Yes❑No <br /> Manager's Signature: Date: <br /> lerk to the Board <br /> Approved by BOCC on the day of 20 . Submitted for Chair signature on the_day of 20 <br /> Clerk's Signature: Date: <br /> Revised March 2012 <br />