HomeMy WebLinkAboutR 2014-308 Aging - Charles House Association for adult daycare respite services ORANGE COUNTY—CONTRACT CONTROL SHEET
Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7?C'Jerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specifiec.above. I I 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: Charles House Association Party/Vendor Contact Person: Paul Klever Contact Phone:—_ Party/Vendor
Address: 109 Hillcrest Ave City Carrboro 48tate:NC Zip:27510 Department:AeiU Amount: $5,000.00 Purpose:R_ espite C dire
Budget Code(s): 10432020-630100 Vendor# 19446 (N/A if new vendor) Vendor is a BOCC consultant? Yes El NoZ 1_'ontract
Type: (Check one)New❑ Renewal ® Amendment ❑ Effective Date 7/01/14 Approved by Board Yes❑ No❑ A enda Date:
Title of Contract:Caregiver Respite
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:
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 and information technology specifications:
IT Director's Signature: Date:
Risk Management
Include the following coverages: VCGL; [Auto; WC; Professional; ❑ Property; OR No Insurance Reauit'ed D. Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions ai-sh
{� c 7.11..a oved
by the Risk Manager:
U ) ,
Risk Manager's Signature: Date: U 2.'3 2
L.V1 z4
Financial Services _
This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No[d E �ent*� sary
before approval Yes[]NoM. 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: �wL�1i►.�, .✓• AA-4— Date:� I
County Attorney
Approval by Board ❑ (Contracts $90,0001- 0 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approva by anager (Most other contracts$1,000 and above). Department Director approval only ❑ (Under
$1,000). This contract has bee ewed and approved by the Attorney as to legal form and sufficie cy.:r'
Attorney's Signature Date:
County Manager
This contract has been reviewed and is approved by the County Manager YesE No❑.
This contract has been reviewed and is for signature by the Chair Yes❑No❑.
Manager's Signature: '� Date: ?
r
i
Clerk to the Board
Approved by BOCC on the_day of ,20 . Submitted for Chair signature on the_day o f 20
Clerk's Signature: Date:
Revised March 2012