HomeMy WebLinkAboutR 2013-488 Aging - NC Dept of Ins for Senior Health Insurance Information Program (SHIP) $1,739 1__�f LISS
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: NC Dept of Insurance Party/Vendor Contact Person: R Van Braxton Contact Phone:919-807-6900 Party/Vendor
Address: 11 S Boylan Ave. City Raleigh State:NC Zip:27603 Department: Aging Amount: $1,739.00 Purpose: Senior Health
Insurance Information Program(SHIIP Budget Code(s): 10432005-444104 Vendor# (N/A if new vendor) Vendor is a BOCC
consultant? Yes❑No❑ Contract Type: (Check one)New❑ Renewal® Amendment ❑ Effective Date: 10/17/13 Approved by
Board Yes❑No❑ Agenda Date: Title of Contract: RQ 17272304
If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No[j. 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:
IT Director
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and apf roved 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; ❑ 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: L Z Z L3
Financial Services
This Contract is conditioned u n appropriation by the Board of Commissioners Yes❑ .No A bud,-,et amendment is necessary
before approval Yes❑No�f budget amendment is necessary,please attach to this form. This instrumem:has been pre-audited in the
manner required by the Local Government BudgeOft-il d Fiscal Control Act:
Financial Services Director's Signature: f---�-' J✓�1; late:
County Attorney
Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval by Manager&Most other contracts$1,000 and above). Department Director approval only❑(Under
$1,000). This contract has evie d and approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date:
County Manager
This contract has been reviewed and is a r d by the Co ; ty Manager Yes No❑.
This contract has been reviewed is ig ature th hair. Yes❑No❑.
Manager's Signature. Date:
Clerk to the Board
Approved by BOCC on the`day of 20 . Submitted for Chair signature on the_day of ,20
Clerk's Signature: Date:
Revised March 2012