HomeMy WebLinkAboutR 2016-589-E Tax - Zoll Data Systems, Inc. for custom medicaid cost report DocuSign Envelope ID:08FFF9DF-E68C-4766-AOEF-6FB69555BF48
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: Zoll Data Systems Inc Party/Vendor Contact Person: Darlene Forney Contact Phone: 303-801-
1714 Party/Vendor Address: 11802 Ridge Parkway, Ste 400 City Broomfield State: CO Zip: 80021 Department: Tax
Administration Amount: $999 Purpose: Custom Medicaid Cost Report Budget Code(s): 10335020-630000 Vendor#
57181 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No❑ Contract Type: (Check one) New
Renewal❑ Amendment ❑ Effective Date 11/06/2016 Approved by Board Yes❑No❑ Agenda Date:N/A
This agreement is approved as to technical form and content:
DocuSigned,¢by:
Department Director's Signature E5EDD78428EB34BF ula t, }5jVVUS6y u Date: 10/20/2016
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Information Technologies
(Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is
approved as to information technology content and specifications:
DocuSign d by:
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Office of the Chief Information Office Date: 10/21/2016
C11 BA91E73A64DF...
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications,and requirements:
[—DocuSigned by: 11i1
Office of the Risk Management Officer allSA. (,6ntt l b Date: 10/24/2016
7FDCF9176800498...
Financial Services
This instrument has been pre-audited in thebo njSj$quired by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer E7D4E5181ACC1409�"N Date: 10/24/2016
.
Legal Services
This agreement is approved as to legal form and sufficiency:
ocuSigned by:
Office of the County Attorney ,66, r6ufs Date: 10/25/2016
EAAMKEDM8465...
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dollod(cr�,oran eg countvnc og_v
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board Date:
Revised 6/16 5