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DocuSign Envelope ID: BA2C9714-6E23-4C44-906C-9D17CC0719D6 UNC SOM#22-0715 <br /> ATTACHMENT "A" <br /> Orange County Certifications—FY 2021-22 <br /> 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 possible, <br /> 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,physical <br /> 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 separate <br /> 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 /> DoeuS;9ne„y: Dean,UNC School of Medicine <br /> acting for 12/18/2 0 21 <br /> Certified by: ALO#"SA.Wesley Burks,MD'Title:Vice Chancellor for Medical Affairs Date: <br /> 6rove 6CF93G A4er0fij.s. <br /> Signature) <br /> Orange County Managed Care Fund Performance Agreement Page 9 of 9 <br /> Rev. 912021 <br />