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DocuSign Envelope ID:A18808EO-5F70-4494-BCOC-49B95D82162D <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: LifeLine Mobile,Inc. Party/Vendor Contact Person: Karyn Prater Contact Phone: 614-497- <br /> 8300 x104 Party/Vendor Address: 2050 McGaw Rd. City Columbus State: OH Zip: 43207 Department: Health <br /> Amount: $445,748 Purpose: Provide Mobile Dental Clinic per specificiations Budget Code(s): 61370035-802000- <br /> 30012 Vendor# 65761 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: <br /> (Check one)New ® Renewal ❑ Amendment ❑ Effective Date 10-17-19 Approved by Board Yes®No❑ <br /> Agenda Date: 10-15-19 <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 /> S�_Wof 10/17/2019 <br /> Department Director's Signature[3C16F2n09E3445F. 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 and related services)This agreement has been reviewed and is <br /> approved as to information technology coi h Decusigned by: ins: <br /> 1t� 44yvf 10/17/2019 <br /> Office of the Chief Information Officer c1aa91E73Ae4DF.. Date: <br /> Risk Management <br /> This agreement is approved for sufficiency Docu5igned_by: <br /> . Is,specifications,and requirements: <br /> aUsa CbVln.t,{�6 10/18/2019 <br /> Office of the Risk Management Officer 7F❑CF9170800498. 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: Docu5igned by: <br /> ('1) '�' � 10/21/2019 <br /> Office of the Chief Financial Office 7NE518,Acc,400. Date: <br /> Legal Services <br /> This agreement is approved as t DocuSigned by: iciency: <br /> , 6t Pklvf5 10/21/2019 <br /> Office of the County Attorney EAAM33EMA@405.. 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 12/18 9 <br />