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DocuSign Envelope ID:081C06CA-1640-444A-8371-6 FEB B2DO11DF <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Party/Vendor Name: Chatham County Public Health Department Party/Vendor Contact Person: Tara Gregory <br /> Contact Phone: 919-742-5641 x 8266 Party/Vendor Address: 1000 S. 1 Oth Ave. City Siler Ci State:NC Zip: 27344 <br /> Department: Health Amount: $2,250 Purpose: Replication of CHG voucher program Budget Code(s): 10414020- <br /> 680007-71424 Vendor#51966 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: <br /> (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7-1-19 Approved by Board Yes❑ No❑ <br /> Agenda Date: <br /> This agreement is approved as to technical form and content and I as Department Director affirmatively state work on <br /> this project has not been initiated prior to execution of the agreement: <br /> DocuSigned by: <br /> Department Director's Signature Sb�wakf Date: 7/3/2019 <br /> 3C16F2D09E344IF. <br /> Agreements for emergency services or repair are not subject to the above affirmation. If services related to this <br /> agreement have already begun or been completed please briefly describe the nature of the emergency condition that was <br /> addressed: <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 /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> This agreement is approved for sufficient oocuSiggned by: rds,specifications,and requirements: <br /> Qusa. (h4 6 7/3/2019 <br /> Office of the Risk Management Office 7FDCF9176800498 Date: <br /> Financial Services <br /> This instrument has been pre-audited it Docusigned by: the Local Government Budget and Fiscal Control Act: <br /> Office of the Chief Financial Officer rq � � Date: 7/4/2019 <br /> 7NE5181ACC1409. — - <br /> Legal Services <br /> This agreement is approved as tc11079A4D525C0F4FB <br /> Docusigned by: <br /> S� <br /> Office of the County AttorneyKAZ AAkYt, Date: 7/8/2019 <br /> . <br /> Clerk to the Board <br /> Received for record retention: <br /> All Docusign contracts must be copied to Sherri Ingersoll upon completion: singersoll@orangecountync.gov <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 12/18 4 <br />