R 2010-067 Co Manager - Piedmont Health Services outside agency agreement

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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. Department Party/Vendor Name: Piedmont Health Services,Inc. Party/Vendor Contact Person: Brian Toomey Contact Phone: 919-933-8494 Party/Vendor Address: 299 Lloyd St. City Carrboro State:NC Zip: 27510 Department: Outside Agency Amount: $10,000 Purpose: Budget Code(s): 10495050 719021 Vendor#800035 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New❑ Renewal ® Amendment ❑ Effective Date July 1,2010 Approved by Board Yes®No[] Agenda Date: June 15,2010 Title of Contract: 2010-11 Outside Agency Performance 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 T a t as been reviewed and approved by the Department Director as to technical content: Department Director's Signature: � e: V T Dire to (Applicable only to hardware/software purchases or related services)This co act has een reviewed and approved by the Information Technology Director as to technical content and information technology specifica IT Director's Signature: Date: Risk Manallement Include the following coverages: �CGL; [:4-Auto; [JWC; FLI Professional; ❑ Property; ❑ OR No Insurance Required El Hold Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved by the Risk Manager: Risk Manager's Signature: e Date: Financial Services This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑Nox. A budget amendment is necessary before approval Yes❑ Nox. 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 Control Act: r ices Director's Si a'�A W J, -. Date: $�23 W Financial S� nature:v Signature: Attorney Approval by Board [K(Contracts over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant contract). Approval by Ma er ❑ (All other contracts). This contract has been reviewed and approved by the Attorney as to legal form and sufficiency: Attorney's Signature Date: a2o� County Manager This contract has been reviewed and is approved by the County Manager Yes,2140❑. This contract has been reviewed and is to be submitted for OCC consider tion Yes o c �. Manager's Signature: I Date: ZS v Clerk to the Board Approved by BOCC on the day o ,20 . Submitted for Chair signature on the 3d day of ,20_/b.Clerk's Signature: Date: 25 t3a�l Revised April 2010