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Revised 01/24 <br />1 <br />ORANGE COUNTY—INTERNAL USE ONLY <br />______________________________________________________________________________ <br />Finance Information <br />Vendor Name: Piedmont Health Services - Carrboro Community Health Center Vendor Contact Person: Jill Baron <br />Phone: 919-933-8494 Address: 301 Lloyd St City Carrboro State: NC Zip: 27510 Department: N/A Amount: <br />N/A Purpose: MoA for EMS PORT Budget Code(s): N/A Vendor # N/A <br />Vendor Status with NCSOS: N/A Vendor is a BOCC consultant: Yes No <br /> <br />Contract Details <br />Contract Type: New Amendment (Original Contract: ) (Most Recent Amendment ) <br />Effective Date 07/09/2024 End Date N/A Notice Date (Notice Purpose ) <br /> <br />Award <br /> Approved by Board (Agenda Date: ); Made or Administered by <br /> <br />Signature Authority <br />- BOCC Express Delegation (Agenda Date: ) <br />- Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000 <br />- Budget Policy Section XV (Capital Improvement Project: ) <br /> <br />Bidding <br /> Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) <br />Department Affirmation <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 /> This agreement is approved as to technical form and content. Services related to this agreement have already <br />begun or been completed. Description of the nature of the emergency condition that was addressed: <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br /> <br />Information Technologies <br />This agreement has been reviewed and is approved as to information technology content and specifications: <br /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> Inapplicable because no hardware/software purchases or related services <br /> <br />Risk Management <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br />Financial Services <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br />Legal Services <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br />Clerk to the Board <br />All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br />Received for record retention: <br />Office of the Clerk to the Board __________________________________________Date:_________ <br />Docusign Envelope ID: DEF43F67-FA08-4F7E-81F4-FB6EF300A382 <br />7/10/2024 <br />7/11/2024 <br />7/11/2024