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(New Destinations) <br />Orange County Cardinal Managed CareFund Performance AgreementPage10of 9 <br />Rev. 8/18 <br />ATTACHMENT “A” <br />Orange County Certifications –FY 2018-19 <br />Cardinal Managed Care FundPerformance Agreement <br />Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer <br />I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief <br />financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. <br />The list should be in writing with the name, title, residential address; phone and email address and if <br />possible, fax number. <br />Officers and Board of Directors <br />I certify that I have provided a current list of the Officers and Boardof Directors with this Agreement and <br />that we will continue to update the list as changes occur. The list should be in writing, with the name, <br />physical address, mailing address and if possible, phone, fax and email address. <br />Budget Submission <br />I certify that I have provided a budget for the period to be covered by funding Orange County, and that any <br />substantive changes made to this budget have been in advance authorized in writing by Orange County. <br />Annual Financial Review <br />I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget <br />adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a <br />separate sheet of paper. <br />Alignment with Organization’s Mission <br />I certify that the programs and services for which this funding is requested align with the mission of the <br />organization. <br />Intended Purpose <br />I certify that the funds provided to the agency under the terms of this Agreement will be used for a public <br />purpose and shall only be used for the purposes intended and any money not used for those purposes will be <br />promptly returned to Orange County. <br />Certified by: _______________________ Title: __________________________ Date: ___________ <br />(Provider’s Signature) <br />DocuSign Envelope ID: 45F8D9E2-21AC-4868-9A00-7CEFD1517F11 <br /><br />