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1__�f LISS <br /> 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 approval 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 legal review process prior to being routed for signature. <br /> Department <br /> Party/Vendor Name: NC Dept of Insurance Party/Vendor Contact Person: R Van Braxton Contact Phone:919-807-6900 Party/Vendor <br /> Address: 11 S Boylan Ave. City Raleigh State:NC Zip:27603 Department: Aging Amount: $1,739.00 Purpose: Senior Health <br /> Insurance Information Program(SHIIP Budget Code(s): 10432005-444104 Vendor# (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes❑No❑ Contract Type: (Check one)New❑ Renewal® Amendment ❑ Effective Date: 10/17/13 Approved by <br /> Board Yes❑No❑ Agenda Date: Title of Contract: RQ 17272304 <br /> If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No[j. 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 /> IT Director <br /> (Applicable only to hardware/software purchases or related services)This contract has been reviewed and apf roved by the Information <br /> Technology Director as to technical content and information technology specifications: <br /> IT Director's Signature: Date: <br /> Risk Management <br /> Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required Hold <br /> Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved <br /> by the Risk Manager: <br /> Risk Manager's Signature: Date: L Z Z L3 <br /> Financial Services <br /> This Contract is conditioned u n appropriation by the Board of Commissioners Yes❑ .No A bud,-,et amendment is necessary <br /> before approval Yes❑No�f budget amendment is necessary,please attach to this form. This instrumem:has been pre-audited in the <br /> manner required by the Local Government BudgeOft-il d Fiscal Control Act: <br /> Financial Services Director's Signature: f---�-' J✓�1; late: <br /> County 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). Approval by Manager&Most other contracts$1,000 and above). Department Director approval only❑(Under <br /> $1,000). This contract has evie d and approved by the Attorney as to legal form and sufficiency: <br /> Attorney's Signature Date: <br /> County Manager <br /> This contract has been reviewed and is a r d by the Co ; ty Manager Yes No❑. <br /> This contract has been reviewed is ig ature th hair. Yes❑No❑. <br /> Manager's Signature. Date: <br /> Clerk 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 />