R 2015-562-E HR - Selerix Systems, Inc. for ACA Subscription Agreement

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DocuSign Envelope ID:OEOA76BA-2BO7-4AD5-99B1-F7542931DD8A ORANGE COUNTY—CONTRACT CONTROL SHEET Routing Order: (1)Department, (2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should be completed through the legal review process prior to being routed for signature. Deuartment Party/Vendor Name: Selerix Systems,Inc. Party/Vendor Contact Person: Michelle DeShong Contact Phone:214-856-4211 Party/Vendor Address:2851 Craig Drive, Suite 300 City McKinney State: TX Zip: 75070 Department: Amount: 8,500.00 Purpose: ACA Reporting Module to Orange County Budget Code(s): 70395210/999999 Vendor 4 63369 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New ® Renewal ❑ Amendment ❑ Effective Date 1/1/2015 Approved by Board Yes❑No® Agenda Date: Title of Contract: ACA Subscription Agreement If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No®. If submitted for bid were bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to technical content: DocuSigned by: y ��' ba '"""�� hm(o 10/21/2015 Department Director's Signature: e1c93DZ69FO143F... Date: IT Director (Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information Technology Director as to technical content and information technology specifications: IT Director's Signature: Date: Risk Management Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required ❑. Hold Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown, this contract is approved by the Risk Manager: DocuSigned by: QUs& (hm,&6 10/22/2015 Risk Manager's Signature: �FDCF9ns3oo49a... Date: Financial Services This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑No❑. A budget amendment is necessary before approval Yes❑ No❑. If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal bWSAQk by: Financial Services Director's Signature: � N Date: 10/22/2015 ,�o„,�,�,/,�,� Countv Attornev Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC consultant contract). Approval by Manager❑ (Most other contracts$1,000 and above). Department Director approval only ❑ (Under $1,000). This contract wbwaiieudwed and approved by the Attorney as to legal form and sufficiency: Attorney's Signatures Date: 10/23/2015 Countv Manager This contract has been reviewed and is approved by the County Manager Yes❑No❑. This contract has been re E' 1�duRi%&#)Fbr signature by the Chair Yes❑No❑. OVuLAU �auhw�t VS 10/23/2015 Manager's Signature: 06379946755E477... Date: Clerk to the Board Approved by BOCC on the day of 20 . Submitted for Chair signature on the day of 120 Clerk's Signature: Date: Revised March 2012