HomeMy WebLinkAboutR 2014-376 DSS - Orange Public Transportation for Medicaid Transportation 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: Peter Murphv Contact Phone:919-245-2002
Party/Vendor Address: 600 Public Works Dr City Hillsborough State:NC Zip:27278 Department:DSS Amount: $12.75 per one-way
bip Purpose:Medicaid Transportation Budget Code(s): Vendor#_ (N/A if new vendor) Vendor is a BOCC consultant?
Yes❑No❑ Contract Type: (Check one)New❑ Renewal 0 Amendment ❑ Effective Date 7/1/2014 Approved by Board Yes
F-1 No❑ Agenda Date: Title of Contract:Medicaid 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:6� Date: C7 t
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: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Ins aMice Recluired El. Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shoi It�nflcpsFq!,_eA
by the Risk Manager:
Risk Manager's Signature: Date: 7 JUL 16 2
A"/ W
L-117 N
Financial Services By
This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑No❑. A budget amendment is necessary
before approval Yes❑No❑. If budget amendment is necessary,please attach to this form. This I nt hE.,s bqen pre-audited in the
manner required by the Local Govermne B get and Fiscal Contr,olikct:
Financial Services Director's Signat ae:, ate•
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County Attorney V Oro
ir,s rume
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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 anager❑ (Most other contracts$1,000 and above). Department Director approval on (Under
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$1,000). This contract has been e * ed and approved by the Attorney as to legal form and sufficie cy: lyl�
Attorney's Signature M Date:
County Manager
This contract has been reviewed and is approved by the County Manager YesV-1No❑.
This contract has been reviewed and is, r signature by the Chair Yes❑No❑.
Manager's Signature: Date: 7/
Clerk to` Board
Approved by BOCC on the—day of 20 . Submitted for Chair signature on the_day of
Clerk's Signature: Date:
Revised March 2012