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Page 7 of 6 <br />Revised 5/2016 <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br />Department <br /> <br />Party/Vendor Name: Empowerment, Inc.Party/Vendor Contact Person: Sairta Nwachukwu Contact Phone: 919-967- <br />8779 Party/Vendor Address: 109 N. Graham Street #200 City Chapel Hill State: NC Zip: 27516 Department: <br />Health Amount: $238,724 Purpose: Provide Zone 6 Navigator Services Budget Code(s): 10412020-630000- <br />71453Vendor # 39185 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check <br />one) New Renewal X Amendment Effective Date 7/1/18 Approved by Board Yes No Agenda <br />Date: 5-15-18 <br /> <br />This agreement is approved as to technical form and content: <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br /> <br /> <br />Information Technologies <br /> <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 /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br /> <br />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to Sherri Ingersoll upon completion @ Singeroll@orangecountync.gov <br /> <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br /> <br />DocuSign Envelope ID: 142010D9-C369-4B74-8D8D-CE32D6CD555E <br /> <br /> <br /> <br />