2021-245-E-Health-Ibraheem G. Ackall, DDS contract amendment

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DocuSign Envelope ID:7612C085-C654-45EE-8C46-CB6A802CCEE7 ORANGE COUNTY—DEPARTMENT USE ONLY Party/Vendor Name: Ibraheem G.Ackall,DDS Party/Vendor Contact Person: L George Ackall,DDS Contact Phone: 719-691-1162 Party/Vendor Address: 405 Perry Creek Dr. City Chapel Hill State:NC Zip: 27514 Department: Health Amount: 4000 Purpose: Dental Services Budget Code(s): 10410120-630000 Vendor#65708 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New❑ Renewal ❑ Amendment ® Effective Date 5-15-21 Approved by Board Yes❑No ❑ Agenda Date: This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: DDocuSigned by �/� : ''�"" (XIMIn.1A.�l.A. SIw akf 5/4/2021 Department Director's Signature ,,,rF9000F3445P7 Date: Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Information Technologies (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficienc ioa�aa�:standards, specifications,and requirements: aura. Cbvvu ttb 5/4/2021 Office of the Risk Management Office 00498 Date: Financial Services This instrument has been pre-audited i mMmot acquired by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer Date:5/6/2021 s4�5rsr�CCU Legal Services This agreement is approved as t ItP46ftff1h%d sufficiency: aI kuI M.arit, TbSCb 5/6/2021 e52 Office of the County Attorney 5eor �� Date: Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: Revised 07/20