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ORANGE COUNTY—DEPARTMENT USE ONLY /� ^ I `�— <br /> / <br /> Department t <br /> Party/Vendor Name: NC Department of Insurance,Division of SHIIP Party/Vendor Contact Person: Van Braxton <br /> Contact Phone: 919-807-6900 Party/Vendor Address: 11 S Boylan Ave City Raleigh State: NC Zip: 27603 <br /> Department: Aging Amount: $4,201 Purpose: Senior Health Insurance Information Program Budget Code(s): <br /> 10432005-444104 Vendor# 173 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract <br /> Type: (Check one)New❑ Renewal® Amendment ❑ Effective Date 07/01/2015 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 Management <br /> This agreement is approved for sufficiency of insurance standards, specifications,and requirements: <br /> Office of the Risk Management Officer_ / (,Tr �Date: Ilk <br /> Financial Services <br /> This instrument has been pre-audited in the er re ' ed by he ocal Government Budget and Fiscal Control <br /> Act: <br /> Office of the Chief Financial Officer Date: <br /> Legal Services <br /> r <br /> This agreement is approved as to lega fb nd su i cy: <br /> Office of the County Attorney Date: Z� <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydg-oran ecountync.gov <br /> The following signature block is for hard copies on t requ d for Docusign contracts: <br /> Office of the Clerk to the Board Date: kyllf- <br />