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<br /> <br /> <br />ORIGINATING DEPARTMENT <br />(THIS IS THE ONL Y SECTION TO BE COMPLETED BY ORIGINA TlNG DEPARTMENT) <br />ContractorNendor: N/A Vendor Number. <br />Purpose: Home and Community Care Block Grant ( "R~) <br /> <br />Amount: <br /> <br />$580870 <br /> <br />Account # budgeted: <br /> <br />Department Number. 5750-5760-5770 Dept. Rep.: Mike Murphy <br /> <br />TYPE OF CONTRACT (Please check one) ~ New 0 Renewal <br />Effective Date: 07/01/2004 Expiration Date: 06/30/2005 <br /> <br />This document has been reviewed and approved by the Department Head as to technical content. <br />Checklist <br /> <br />~ County Policy Review 0 Vendor W-9 <br />Distributed Copies <br /> <br />o Original/copies to Vendor 0 Other Routing Instructions <br /> <br />[gj Copies to originating Department <br /> <br />Department Head's Signature Date: 08/03/2004 <br /> <br /> <br />.,/' <br /> <br />/ <br />t.t-~...-~ <br />"' <br /> <br />}./~ <br /> <br />i <br />INFORMA TIO, TECHNOLOGY DIRECTOR <br />(Applicable only for ftara are/software purchase or related services) <br /> <br />This document has been reviewed and approved by the Information Systems Director as to <br />technical content. <br />IT Director's Signature: Date: <br /> <br />CONTRACT ADMINISTRATOR <br /> <br />Date Received: ~ --4 - DLf <br />Sufficient funds are available in the proper account to pay for (this expenditure. <br />A budget amendment is necessary before this agreement is approved. <br />A budget amendment is attached as required for approval of this agreement. <br /> <br />o Pre-audit certification completed. Purchase Order/Encumbrance No:: <br /> <br />Notes:: <br /> <br />Yes 0 No 0 <br />Yes 0 No 0 <br />Yes 0 No 0 <br /> <br />1='-5 <br />