Orange County NC Website
Browse       Search
DocuSign Envelope ID: 1D078E61-3408-4B43-8758-39AO9lBlBE00 <br /> ATTACHMENT "A" <br /> Orange County Certifications—FY 2021 <br /> Cardinal Managed Care Fund Performance 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 Board of 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 /> (((Agencys_Name>)) <br /> Orange County Cardinal Managed Care Fund Pei formance Agreement Page 9 of 9 <br /> Rev. 112021 <br />