HomeMy WebLinkAboutR 2014-211 Aging - Triangle J Council of Governments Area Agency on Aging for MIPPA 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: Triangle J Council of Governments Area Agency on Aging Party/Vendor Contact Person: Joan Pellettier Contact
Phone:919-558-9398 Party/Vendor Address:4307 Emperor Blfd.,Suite 110 City Durham State:NC Zip:27703 Department:Aging
Amount: $3,500 Purpose:Medicare Improvements for Patients and Providers Act(MIPPA)t Budget Code(s): 10432005-444104 Vendor
#5855 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No❑ Contract Type: (Check one)New❑ Renewal
Amendment ❑ Effective Date 11/01/2013 Approved by Board Yes[]No❑ Agenda Date: Title of Contract:Contract for
Provision of Community Based MIPPA Services
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: 0`--/-/5(
IT Director
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical content an fo tion 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 In urance ❑. With incorporation of Insurance provisions as sho
by the Risk Manager: D FrMT
Risk Manager's Signature: Date: MAY — 2 2014
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Financial Services JQ
This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No[y A bu
before approval Yes[:]No[KIf budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government BudFZZ,.,cal Control Act:
Financial Services Director's Signature: A• 14A, Date: 6 G I
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 t%(Most other contracts$1,000 and above). Department Director approval only❑(Under
$1,000). This contract has b e viewe nd approved by the Attorney as to legal form and sufficiency-
Attorney's Signature Date: 1
County Manager
This contract has been reviewed and is approv by the County Manager Yes No❑.
This contract has been reviewed and is o i u y th C s❑
Manager's Signature: Date:
Clerk to the Board
Approved by BOCC on the_day of 120 Submitted for Chair signature on the_day of ,20
Clerk's Signature: Date:
Revised March 2012