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10 ( q � 5 <br /> / n <br /> ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name : UNC Department of Family Medicine Party/Vendor Contact Person : Sherry HaX Contact <br /> 9. <br /> Phones 984-9744892 Party/Vendor Addresse 590 Manning Drive City Chapel Hill State : NC Zip : 27599 <br /> Department : Health Amount . $ 9 469 Purpose . Community Health Grant Subcontract Budget Code (s) : J 0414020 = <br /> 630000 71424 Vendor # 49882 (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 /> Department Director ' s SignatureVo.,�Ov 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 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 sufficiency of insurance standards , specifications , and requirements : <br /> Office of the Risk Management Officerr �' Date . l <br /> Fin licial Services <br /> MENEWEE <br /> This instrument has been pre - audited in the erkuiredby the Local Government Budget a dFis al Control Act : <br /> Office of the Chief Financial Officer Date : y <br /> Legal Services <br /> This agreement is approved as to legal form and sufficiency . <br /> Office of the County Attorney (.00orku twsse& c 7i Date : Ila % I .Vi <br /> Clerk to the Board <br /> Received for record retention : <br /> All Docusign contracts must be copied to Sherri Ingersoll upon completion : smgersoll@orangecountyne . 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 7/ 19 4 <br />