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DocuSign Envelope ID:08FFF9DF-E68C-4766-AOEF-6FB69555BF48 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Zoll Data Systems Inc Party/Vendor Contact Person: Darlene Forney Contact Phone: 303-801- <br /> 1714 Party/Vendor Address: 11802 Ridge Parkway, Ste 400 City Broomfield State: CO Zip: 80021 Department: Tax <br /> Administration Amount: $999 Purpose: Custom Medicaid Cost Report Budget Code(s): 10335020-630000 Vendor# <br /> 57181 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No❑ Contract Type: (Check one) New <br /> Renewal❑ Amendment ❑ Effective Date 11/06/2016 Approved by Board Yes❑No❑ Agenda Date:N/A <br /> This agreement is approved as to technical form and content: <br /> DocuSigned,¢by: <br /> Department Director's Signature E5EDD78428EB34BF ula t, }5jVVUS6y u Date: 10/20/2016 <br /> ... <br /> Information Technologies <br /> (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is <br /> approved as to information technology content and specifications: <br /> DocuSign d by: <br /> W <br /> �llM <br /> Office of the Chief Information Office Date: 10/21/2016 <br /> C11 BA91E73A64DF... <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards, specifications,and requirements: <br /> [—DocuSigned by: 11i1 <br /> Office of the Risk Management Officer allSA. (,6ntt l b Date: 10/24/2016 <br /> 7FDCF9176800498... <br /> Financial Services <br /> This instrument has been pre-audited in thebo njSj$quired by the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer E7D4E5181ACC1409�"N Date: 10/24/2016 <br /> . <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency: <br /> ocuSigned by: <br /> Office of the County Attorney ,66, r6ufs Date: 10/25/2016 <br /> EAAMKEDM8465... <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Donna Lloyd upon completion @ Dollod(cr�,oran eg countvnc og_v <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 6/16 5 <br />