R 2016-665-E HR - Selerix Systems, Inc. for ACA filing terms and conditions

Browse Search

DocuSign Envelope ID:9786A36A-88C6-45C6-8299-B927DCBC8AFC ORANGE COUNTY—DEPARTMENT USE ONLY Department 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: $12,792.00 Purpose: ACA Filing Terms and Conditions Amendment Budget Code(s): 10250020/630000 Vendor# 63369 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal❑ Amendment ® Effective Date 11/1/16 Approved by Board Yes❑No® Agenda Date: This agreement is approved as to to ��€mrnrl end content: Department Director's Signature Date: 11/11/2016 - 9Fes4ef... I' Information Technologies i (Applicable only to hardware/softivare purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficienc /ok bv& standards,specifications,and requirements: QUSA r,Orv�c 116 11/14/2016 Office of the Risk Management Officer �er�,��see4 Date: Financial Services This instrument has been pre-audited in yw-g§iuired by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer Date: 11/18/2016 7D4E5181ACC1409... Legal Services This agreement is approved as to 1 DfVfmdvsufficiency: Office of the County Attorney Date: 11/18/2016 Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd a oran ecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: Revised 6/16 5