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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: NC Department of Insurance Party/Vendor Contact Person: R. Van Braxton Contact Phone: <br /> 919-807-6900 Party/Vendor Address: SHIM Division, 11 S.Boylan Ave. City Raleigh State: NC Zip: 27603 <br /> Department: Aging Amount: $3,340 Purpose: Senior Health Insurance Information Program Budget Code(s): <br /> 10432005444104 Vendor# 173 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract <br /> Type: (Check one)New❑ Renewal® Amendment ❑ Effective Date 07/01/2014 Approved by Board Yes[:] <br /> Nor-1 Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> Department Director's Signature Date: <br /> Information Technologies <br /> (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is <br /> approved as to information technology content and specifications: <br /> Office of the Chief Information Officer Date: <br /> Risk a ement f� <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirement U <br /> Office of the Risk Management Officer Date: FNOV U 2014 <br /> By <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: <br /> Office of the Chief Financial Officer C �• Date: �4 L <br /> Legal Services <br /> This agreement is approved as to lega and sufficiency: <br /> Office of the County Attorney Date: 1 �' <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd(dWan eg coun nc.gov <br /> The following signature block is for hard copies only and is not required for Docusign contracts: <br /> Office of the Clerk to the Board Date: <br />