HomeMy WebLinkAbout2012-296 S DSS - Orange Public Transportation for Medicaid Transportation $12.75 per way per client ORANGE COUNTY—CONTRACT CONTROL SHEET
Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager
determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for
BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should
be completed through the legal review process prior to being routed for signature.
Department
Party/Vendor Name: Orange Public Transportation- Party/Vendor Contact Person: At Terry Contact Phone:919-245-2002
Party/Vendor Address: 600 Public Works Dr City Hillsborough State:NC Zip: 27278 Department:DSS Amount: $12.75 per way per
client Purpose: Medicaid Transportation Budget Code(s): Vendor# (N/A if new vendor) Vendor is a BOCC
consultant? Yes❑No❑ Contract Type: (Check one)NewEj Renewal E Amendment ❑ Effective Date 07/01/12 Approved by
Board Yes❑No❑ Agenda Date:06/15/12 Title of Contract:Mediciad Transportation Memorandum of Understanding
If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for bid were
bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's Signature: Date:
*� rccor
(Applicable only to hardware/software ppurchas s or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical content and information technology specifications:
IT Director's Signature: Date:
Risk Management
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; El Professional; ❑ Property; OR No Insurance Required & Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager:
Risk Manager's Signature: Date:
Financial Services
This Contract is conditioned j4pon appropriation by the Board of Commissioners Yes❑NoEd A budget amendment is necessary
before approval YesE]Nou�. If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Budget and Fiscal Control Act:
Financial Services Director's Signature: h•- /vx, Date:
County Attorney
Approval by Board ❑ (Contracts $90,000.00 gy more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval Manager (Most other contracts$1,000 and above). Department Director approval only El (Under
K
$1,000). This contrac t has be vie d approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date:
County Manager
This contract has been reviewed and is approved by the County Manager YeRffNo❑.
This contract has been reviewed and is for signature y the Chai Yes❑No2.-
Manager's Signature: Date;!. ,-
Clerk to the Board
Approved by BOCC on the—day of 0 Submitted for Chair signature on the day of 20_.
Clerk's Signature: Date:
Revised March 2012