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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: NC Dept of Insurance Division of SHIIP Party/Vendor Contact Person: Contact Phone: <br /> Party/Vendor Address: 11 S. Boylan Ave. City Raleigh State: NC Zip: 27603 Department: Aging Amount: <br /> $1,773.25 Purpose: SH11P Budget Code(s): 10432020 Vendor # 173 (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes ❑ No❑ Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date <br /> 10/01/20141' Approved by Board Yes❑No❑ 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 Management <br /> This agreement is approved for sufficiency of insurance standards,specifications,and requirements: <br /> Office of the Risk Management Officer Date: <br /> Financial Services <br /> This instrument has been pre-audited in theipanner required by the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer j00" C/�0 Date: <br /> Legal Services <br /> This agreement is approved as to legal form,and ufficiency:. <br /> r ..'. ....-_L.Date: <br /> Office of the County Attorney <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd(a-),oran eg countync.Q,tov <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 /> Revised 10/14 4 <br />