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DocuSign Envelope ID:73A1D68B-6490-4299-A2E7-F696C988DD75 <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Family Centered Healthcare,PA Party/Vendor Contact Person: Anissa Vines Contact Phone: <br /> 919-245-3247 Party/Vendor Address: 400 Millstone Drive, Suite 100 City Hillsborough State: NC Zip: 27278 <br /> Department: Health Amount: $3,000 Purpose: Provide Primary Care for uninsured males of Orange County_ <br /> Budget Code(s): 10414020-630000-71422 Vendor#63536 (N/A if new vendor) Vendor is a BOCC consultant? <br /> Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7-1-2019 <br /> Approved by Board Yes❑No❑ Agenda Date: <br /> This agreement is approved as to technical form and content and I as Department Director affirmatively state work <br /> on this project has not been initiated prior to execution of the agreement: <br /> Docusigned by: <br /> tAInG� S&Wof 7/5/2019 <br /> Department Director's Signature[aC1sF2oosEsa45F. Date: <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 <br /> was 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 Docusigned by: rds, specifications,and requirements: <br /> allSa. C6V'I�.&6 7/5/2019 <br /> Office of the Risk Management Officer 7FDCF0176800408. Date: <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: �o 1ACC1409. <br /> cuSigned by: <br /> Office of the Chief Financial Officer � C 7/5/2019 <br /> Date: <br /> 704E51S <br /> Legal Services <br /> This agreement is approved as t OocuSigned by: <br /> §WAk �t, �S(b 7/8/2019 <br /> Office of the County Attorney 079A4D525C0F4FB. Date: <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 6/19 <br /> 9 <br />