HomeMy WebLinkAboutR 2016-665-E HR - Selerix Systems, Inc. for ACA filing terms and conditions DocuSign Envelope ID:9786A36A-88C6-45C6-8299-B927DCBC8AFC
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: Selerix Systems,Inc Party/Vendor Contact Person: Michelle DeShong Contact Phone:214-856-
4211 Party/Vendor Address: 2851 Craig Drive, Suite 300 City McKinney State: TX Zip: 75070 Department:
Amount: $12,792.00 Purpose: ACA Filing Terms and Conditions Amendment Budget Code(s): 10250020/630000
Vendor# 63369 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)
New ❑ Renewal❑ Amendment ® Effective Date 11/1/16 Approved by Board Yes❑No® Agenda Date:
This agreement is approved as to to ���€mrnrl end content:
Department Director's Signature Date: 11/11/2016
- 9Fes4ef...
I'
Information Technologies i
(Applicable only to hardware/softivare purchases or related services)This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer Date:
Risk Management
This agreement is approved for sufficienc /ok bv& standards,specifications,and requirements:
QUSA r,Orv�c 116 11/14/2016
Office of the Risk Management Officer �er�,��see4 Date:
Financial Services
This instrument has been pre-audited in yw-g§iuired by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer Date: 11/18/2016
7D4E5181ACC1409...
Legal Services
This agreement is approved as to 1 DfVfmdvsufficiency:
Office of the County Attorney Date: 11/18/2016
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd a oran ecountync.gov
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