HomeMy WebLinkAboutC2018-714 - 9/25/2018 - Approved DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT No.2017-049800-001
AMENDMENT NO.2
The HEALTH AND HUMAN SERVICES COMMISSION("HHSC"or"System Agency")and CORPUS
CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT(CITY)("Grantee"),who are collectively
referred to herein as the "Parties" to that certain Women, Infant and Children's Nutrition Local
Agency grant contract effective October 1, 2016 and denominated HHSC Contract No. 2017-
049800-001 ("Contract"), as amended, now desire to further amend the Contract.
RECITALS
WHEREAS, the Department of State Health Services ("DSHS") was an original party to the
Contract;
WHEREAS, all functions associated with the Contract were transferred from DSHS to HHSC by
operation of law in accordance with Senate Bill 200, 84th Legislature (requiring consolidation of
the Health and Human Services System) and Texas Government Code Chapter 531;
WHEREAS,the Contract provides that DSHS may assign,pledge or transfer the Contract to another
State agency(see Attachment B,Uniform Terms and Conditions, Section 9.06, Assignments);
WHEREAS, System Agency has elected to extend the Contract through Fiscal Year ("FY") 2019
(October 1, 2018 through September 30, 2019) in accordance with Section III of the Contract.
WHEREAS, the Parties desire to revise the Budget for FY 2018 (October 1, 2017 through
September 30, 2018) and FY 2019;
WHEREAS; the Parties desire to revise the Statement of Work; and
WHEREAS, these revisions will result in a decrease in funding of ONE HUNDRED FORTY-TWO
THOUSAND FOUR HUNDRED EIGHTEEN DOLLARS($142,418.00) for FY 2018 and an addition of
EIGHT HUNDRED FIFTY-SEVEN THOUSAND NINE HUNDRED THIRTY-FOUR DOLLARS
($857,934.00)in federal grant funds for FY 2019.
Now,THEREFORE,the Parties hereby amend and modify the Contract as follows:
1. References in the Contract to"DSHS"are hereby changed to "HHSC".
2. SECTION III of the Contract, DURATION, is hereby amended to reflect a new termination
date of September 30, 2019.
3. SECTION IV of the Contract, BUDGET, is deleted and replaced in its entirety with the
following:
C2018-714 Nm Agency Contract No.2017-049800-001 Page 1 of 6
9/25/18
Ord. 031560
TX Dept of State Health Services
SCANNED
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
IV. BUDGET
The total amount of this Contract will not exceed Two MILLION SEVEN HUNDRED FORTY
THOUSAND SEVEN HUNDRED SEVENTY-EIGHT DOLLARS ($2,740,778.00), of which
$1,012,631.00 is allocated to FY 2017 (October 1, 2016 through September 30, 2017),
$870,213.00 is allocated to FY 2018 (October 1, 2017 through September 30, 2018) and
$857,934.00 is allocated to FY 2019 (October 1, 2018 through September 30, 2019). All
expenditures under the Contract will be in accordance with Attachment A, Statement of
Work.
4. SECTION I(H) of ATTACHMENT A,STATEMENT OF WORK, is deleted and replaced in its
entirety with the following:
H. Conduct outreach to potential participants and implement strategies to retain existing
participants.
5. SECTION I(M) of ATTACHMENT A,STATEMENT OF WORK, is deleted and replaced in its
entirety with the following:
M. Allow System Agency or its agent to configure all desktop, laptops, and tablets purchase
with WIC funds for access to the Texas Integrated Network ("TXIN") Management
Information System ("MIS") at all Grantee WIC clinics and administrative offices.
Grantee will notify System Agency in writing not less than forty-five (45) days prior to
the relocation of a site, and the deployment of a new site. Grantee is responsible for all
desktop, laptops, and tablet maintenance and hardware support.
6. SECTION I(N) of ATTACHMENT A, STATEMENT OF WORK, is deleted and replaced in its
entirety with the following:
N. Grantee is required to immediately address, or facilitate internal access to all its clinics
to the System Agency or its agent to facilitate the resolution of any issues restricting
valid food benefit issuance to eligible WIC participants. Grantee is required to notify
the System Agency of any issues resulting in the interruption of services for a period
of four(4) hours or more.
7. SECTION I(R) of ATTACHMENT A, STATEMENT OF WORK, is amended by deleting it in
its entirety and replacing it with the following:
R. Omitted.
8. SECTION I(S) of ATTACHMENT A,STATEMENT OF WORK, is deleted and replaced in its
entirety with the following:
S. Implement special projects according to System Agency-approved plan related to
nutrition education, outreach or breastfeeding and submit any required deliverables in
a format approved by System Agency. Funding for special projects is contingent upon
availability and approval in writing by System Agency of the Grantee's plan for the
special project.
System Agency Contract No.2017-049800-001 Page 2 of 6
DocuSign Envelope ID 8E56170E-2106-480E-A10E-A710555F4DE2
9. SECTION I(BB)of ATTACHMENT A,STATEMENT OF WORK,is deleted and replaced in its
entirety with the following:
BB. Submit to System Agency or maintain the following deliverables in a format
designated by System Agency.
1. Monthly WIC Local Agency Performance Measure Report submitted by the 15th
calendar day of the following month; and
2. Monthly Extended Hours Summary Report submitted by the 15th calendar day
of the following month.
10. SECTION II(A) of ATTACHMENT A,STATEMENT OF WORK, is deleted and replaced in its
entirety with the following:
A. Grantee shall ensure:
1. An average of 95% of families each quarter who participate in the WIC Program
by receiving food benefits also receive nutrition education classes or individual
counseling;
2. Each quarter an average of 20% or greater of all pregnant women who enter the
WIC Program are certified as eligible;
3. Each quarter an average of 80% of clients who are enrolled in the WIC Program,
excluding dual participants and transfer locked and/or migrant clients, participate
as food benefit recipients each month (breast-feeding infants are also included in
the client count); and
4. 100% of participants who indicate during the enrollment process for the WIC
Program that they have no source of health care are referred to at least one (1)
source of health care at certification of eligibility.
11.SECTION III(A)of ATTACHMENT A,STATEMENT OF WORK,is deleted and replaced in its
entirety with the following:
A. Grantee will request monthly payments using the State of Texas Purchase Voucher
(Form 4116) at https://hhs.texas.gov/laws-regulations/forms/4000-4999/form-4116-
state-texas-purchase-voucher and submit with any supporting documentation by
electronic mail to System Agency at WicVouchers@hhsc.state.tx.us. Grantee shall
indicate separately on the face of the State of Texas Purchase Voucher, the costs
associated with nutrition education,breast-feeding,and other administrative costs.
12. SECTION III(B) of ATTACHMENT A, STATEMENT OF WORK, is amended by modifying
and replacing it with the following:
B. Grantee will submit Financial Status Reports("FSR")by electronic mail to the System
Agency at WicVouchers@hhsc.state.tx.us by the last business day of the month
following the end of each quarter of the Contract term for review and financial
assessment.
System Agency Contract No.2017-049800-001 Page 3 of 6
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
13. SECTION III(D)(3)of ATTACHMENT A,STATEMENT OF WORK, is deleted and replaced in
its entirety with the following:
3. Administrative costs will be reimbursed based on actual costs,but not to exceed the
"maximum reimbursement" based upon the sum of the participants who were
issued WIC EBT cards each month plus infants who do not receive any WIC EBT
cards whose breastfeeding mothers were participants to the extent that the total so
derived does not exceed Grantee's total assigned caseload within any given month.
Surplus funds (the amount by which maximum reimbursements exceed actual
costs) can be accumulated and carried forward within the same fiscal year.
14. The Parties agree to revise the supplemental condition for Section 2.03, Financial Status
Reports (FSRs) in ATTACHMENT D, SUPPLEMENTAL AND SPECIAL CONDITIONS to
provide as follows:
Except as otherwise provided in these Uniform Terms and Conditions or in the terms of
any Attachment(s) that is incorporated into the Contract, Grantee shall submit quarterly
FSRs to System Agency by the last business day of the month following the end of each
quarter of the Program Attachment term for System Agency review and financial
assessment. Grantee shall submit the final FSR no later than forty-five(45) calendar days
following the end of the applicable Fiscal Year.
15. The Parties agree to add the following supplemental condition to ATTACHMENT D,
SUPPLEMENTAL AND SPECIAL CONDITIONS:
Section 4.03, Submission of Audit, of the Health and Human Services Commission
Uniform Terms and Conditions—Grant,Version 2.13 is deleted and replaced in its entirety
with the following:
4.03 Submission of Audit
Due the earlier of 30 days after receipt of the independent certified public
accountant's report or nine months after the end of the fiscal year, Grantee shall
submit electronically, one copy of the Single Audit or Program-Specific Audit to
the System Agency as directed in this Contract and another copy to:
single_audit_report@hhsc.state.tx.us.
16. SECTION 1.16, Child Abuse Reporting Requirement of ATTACHMENT D,
SUPPLEMENTAL AND SPECIAL CONDITIONS,is deleted and replaced in its entirety with the
following:
Section 1.16 Child Abuse Reporting Requirement
a. Grantees shall comply with child abuse and neglect reporting requirements in Texas
Family Code Chapter 261. This section is in addition to and does not supersede any
other legal obligation of the Grantee to report child abuse.
b. Grantee shall comply with System Agency WIC Program Child Abuse policy.
17. This Amendment No.2 shall be effective as of May 1, 2018 or upon the date this
Amendment is signed by both Parties, whichever occurs later.
System Agency Contract No.2017-049800-001 Page 4 of 6
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
18. Except as amended and modified by this Amendment No. 2 all terms and conditions of the
Contract, as amended, shall remain in full force and effect.
19. Any further revisions to the Contract shall be by written agreement of the Parties.
SIGNATURE PAGE FOLLOWS
System Agency Contract No.2017-049800-001 Page 5 of 6
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
SIGNATURE PAGE FOR AMENDMENT No.2
HHSC CONTRACT No.2017-049800-001
HEALTH AND HUMAN SERVICES CORPUS CHRISTI-NUECES COUNTY
COMMISSION PUBLIC HEALTH DISTRICT(CITY)
�
DocuSigned by: —DocuSigned by:By: Q t, P6tri ti
C80071 B769504E9_. `—4FC9D92742CE414_.
Name: Annette Rodriquez
Cecile Young
Acting Executive Commissioner
Title: Health Di rector
Date of Execution: September 27, 2018 Date of Execution: September 26, 2018
THE FOLLOWING ATTACHMENTS ARE ATTACHED AND INCORPORATED AS PART OF THE
CONTRACT:
ATTACHMENT A-1 FFATA
System Agency Contract No.2017-049800-001 Page 6 of 6
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
SIGNATURE PAGE FOR AMENDMENT No.2
HHSC CONTRACT No.2017-049800-001
HEALTH AND HUMAN SERVICES CORPUS CHRISTI-NUECES COUNTY
COMMISSION PUBLIC HEALTH DISTRICT(CITY)
pow v\ ak
By: -'
4.
Name:
Title:
Date of Execution: Date of Execution:
THE FOLLOWING ATTACHMENTS ARE ATTACHED AND INCORPORATED AS PART OF THE
CONTRACT:
ATTACHMENT A-1 FFATA
Approved as to form:1/y/p
ssistant City Attorney
For City Attorney
ATTEST: & '
REBECCA HUERTA
fITY SECRETARY
DLL: tiu
0' COUNCIL
,
SECRETARY
System Agency Contract No.2017-049800-001 Page 6 of 6
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
The certifications enumerated below represent material facts upon which DSHS relies when reporting
information to the federal government required under federal law. If the Department later determines
that the Contractor knowingly rendered an erroneous certification, DSHS may pursue all available
remedies in accordance with Texas and U.S. law. Signor further agrees that it will provide immediate
written notice to DSHS if at any time Signor learns that any of the certifications provided for below were
erroneous when submitted or have since become erroneous by reason of changed circumstances. If the
Signor cannot certify all of the statements contained in this section, Signor must provide written
notice to DSHS detailing which of the below statements it cannot certify and why.
Legal Name of Contractor: FFATA Contact#1 Name, Email and Phone Number:
corpus Christi-Nueces county Public Health Dale Atchley, county Auditor
District Dale.atchley@nuecesco.com
361-888-0556
Primary Address of Contractor: FFATA Contact#2 Name,Email and Phone Number:
1702 Horne Road Blandina Costley, Accountant
Corpus Christi , Texas 78416-1902 BlandinaC@cctexas.com
361-826-7252
ZIP Code:9-digits Required www.usps.com DUNS Number:9-digits Required www.sam.gov
7841.6-1902 - 078495025
State of Texas Comptroller Vendor Identification Number(VIN) 14 Digits
746000585016
Printed Name of Authorized Representative Signature of Authorized Representative
c DocuSigned by:
Annette Rodriquez q. .t , l.-•
�4FC0D02712gyp
CfE4411D4�
Title of Authorized Representative Date
Health Director September 26, 2018
- 1-
Department of State Health Services Form 4734—June 2013
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
As the duly authorized representative (Signor) of the Contractor, I hereby certify that
the statements made by me in this certification form are true, complete and correct to
the best of my knowledge.
Did your organization have a gross income, from all sources, of less than $300,000 in
your previous tax year? n Yes n No
If your answer is "Yes", skip questions "A", "B", and "C" and finish the certification.
If your answer is "No", answer questions "A" and "B".
A. Certification Regarding%of Annual Gross from Federal Awards.
Did your organization receive 80% or more of its annual gross revenue from federal
awards during the preceding fiscal year? n Yes x❑ No
B. Certification Regarding Amount of Annual Gross from Federal Awards.
Did your organization receive $25 million or more in annual gross revenues from federal
awards in the preceding fiscal year? n Yes n No
If your answer is "Yes"to both question "A" and "B", you must answer question "C".
If your answer is "No" to either question "A" or "B", skip question "C" and finish the
certification.
C. Certification Regarding Public Access to Compensation Information.
Does the public have access to information about the compensation of the senior
executives in your business or organization (including parent organization, all branches,
and all affiliates worldwide) through periodic reports filed under section 13(a) or 15(d)
of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the
Internal Revenue Code of 1986? n Yes n No
If your answer is "Yes"to this question,where can this information be accessed?
If your answer is "No" to this question, you must provide the names and total
compensation of the top five highly compensated officers below.
For example:
John Blum:500000;Mary Redd:50000;Eric Gant:400000;Todd Platt:300000;
Sally Tom:300000
Provide compensation information here:
-2-
Department of State Health Services Form 4734—June 2013
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
.2,- % TEXAS
`*v Health and Human
•��. Services Routing Request PCS.515
Section 1:Request Information
Contract No.: 2017-049800-001 ❑ New ® Amendment No.: 2 Emergency
❑ (See Tex.Gov Tex.Gov't Code Ch.418;
Work Order No.: ❑ New ❑ Amendment No.: 42155.137 and TAC 520.41)
Contractor Legal Business Name: Corpus Christi-Nueces County Public Health District(City)
Total Contract Value(including renewals): 2,740,778 Requesting Agency/Program: HHSC/WIC
Contract Manager Name: Cynthia Wright Buyer Name: Amy Fitzgerald
Contract Manager E-mail: cynthia.wright@hhsc.state.tx.us Buyer E-mail: amy.fitzgerald@hhsc.state.tx.us
Contract Manager Phone: 512/341-4542 Buyer Phone: 512/406-2453
Section 2:CAPPS Approvals-The individuals listed shall be program specific contract approvers as designated by the program area.
Approver Title Approver Name Approver E-mail Address See attached proof of approval
1. HHSC budget analyst Jessica Haros Jessica.Haros@hhsc.state.tx.us ❑
2. HHSC legal Ayeola Williams ayeola.williams@hhsc.state.tx.us ❑
3. Deputy Associate Commission Lindsay Rodgers lindsay.rodgers@hhsc.state.tx.us ❑
4. HDIS Contract Coordinator Sherry Mojica sherry.mojica@hhsc.state.tx.us ❑
5. Deputy Executive Commission Lesley French lesley.french@hhsc.state.tx.us ❑
6. ❑
7. ❑
8. ❑
9. ❑
10. ❑
11. ❑
12. ❑
13. ❑
14. ❑
15.Deputy Executive Commissioner
($1 M and over only) Enrique Marquez Enrique.Marquez@hhsc.state.tx.us ❑
Revised and Effective:04/02/2018
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
�;*-4:TEXAS
Ali l i Health and Human
Services Routing Request PCS.515
Section 3:DocuSign Signatories
Signatory Name E-mail Address
Contractor Signature Authority Annette Rodriguez,Public Health Director annetter@cctexas.com
Additional Contractor Signature Authority*
Contractor Signature cc Kathrine Galvan,WIC Director KathrineG2@cctexas.com
HHS Budget(SIM and over only) Greta Rymal greta.rymal@hhsc.state.tx.us
Legal Director($1M and over only) Andy Marker ledward.marker@hhsc.state.tx.us
Office of Chief Counsel($1 M and over only) Karen Ray karen.ray@hhsc.state.tx.us
HHS Signature Authority Cecile Erwin Young cecile.young@hhsc.state.tx.us
HHS Signature Authority cc
General Inbox cc
Instructions
PURPOSE
To direct HHS contracts,work orders,amendments,renewals,and extensions through routing for the contract document's final approval
and execution process.
WHEN TO PREPARE THIS FORM
The routing request form shall be completed for any document requiring CAPPS FIN 9.2 approval routing and for all DocuSign signature
routing. Requestor shall adhere to any HHS Circular-46 requirements as well as consult with program to complete the form prior to
submission to Procurement and Contracting Services Quality Assurance ("PCS QA"). The information provided on the routing request
form will be used by PCS QA to create the document routing approval path in CAPPS FIN 9.2 as well as create the DocuSign path for
contractor signatory and HHS signatory execution.
PROCEDURES
Section 1:To be completed by Buyer and Program.This section shall contain the necessary contract information.
Section 2:To be completed by the Program area.This section shall contain all required program specific approvers.These individuals will
be inserted into the CAPPS approval process. For contracts valued at $1M and over, the program Deputy Executive Commissioner is
required.
Section 3:To be completed by the Program area.This section shall contain all required contract signatory information.These individuals
will be inserted into the DocuSign routing path. For contracts valued at $1M and over, Deputy Executive Commissioner of Financial
Services,Legal Director,and Chief Counsel are required.
**There are certain aspects of this form that do not apply to DFPS.**
*If adding second contractor signature authority,please provide instructions on which documents need to be completed by this individual.
Revised and Effective:04/02/2018
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
Document Approval Status
SetID HHSTX Contract ID 2017-049600-001
Supplier CITY OF CORPUS CHRISTI
Review:Edit Approvers
Procurement QA Approval
:Approved Qv eev-vde Ccnvne is
Procurement QA Group
Approved Approved Approved Approved Approved
teradden.Megan M6 Hares.iess,ca Mae o Rodgers Lindsay p Mgxa.Sherrr,L v French Henrleke.Lestey
Prm:ramouet 00 for DavnentOVVE Inserted Approver Inserted Appnrer Inserted Approver Inserted Approver
87^51;13-403 PM 0&^113-621 AM 1 08102015-?34 AM 4r 0813'/18-1.37 PM 88102/'18-317 PM
Comments
Legal Approval
:Approved QvuwrHede conlrterle
Legal Approval
Skipped Approved Approved
No approves found a A',14ams,AyeolaI Mcfadden.Megan
I FI1+SG Doc AM Gnat t Doc Legal Inserted Approver Enor Step
—.
wavi8-4_3 PM T 08/02/18-434 PM
Comments
Return to Docurnee Ma:agement
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
TEXAS
Health and Human
REQUEST DOCUMENT Services Commission
CAPPS Contract Change Request
Requestor 00000155626-Alvarado,Elizabeth
Requisition ID 0000029477
Document ID ADH0000000000000000029128
Document Owner 00000155626-Alvarado,Elizabeth
Contract change request header
Agency lead contact for contract 00000106057-Wright,Cynthia
changes
Desired amendment effective date May 01,2018
Amendment contract number 2017-049800-001
Request amendment description Amendment to Medical and Social Services Division WIC Local Agency
contract No.2017-049800-001 (PO#106400)to change contract language,
update the budget,and change the contract term.
Contract change request details
Does the amount change Yes
New requested changed amount $ 2,740,778.000
Does the date change Yes
New request contract end date September 30,2019
Does the scope change Yes
New change in scope Signature Page change to update budget and change
contract language to the Scope of Work.
Supplemental information and comments
DocuSign Envelope ID:8E56170E-2106-480E-A10E-A710555F4DE2
HHS PurchasingPage: 1 of 1
Run Date: 512212018
Requisition Run Time: 08:14:56 AM
Report ID: TXCP0002X
Business Unit HHSTX Origin CE3 Requestor ELIZABETH BCM Status Valid
ALVARADO
Requisition ID 0000029477 Status Approved Requestor 512/341-4801 Req Approval 05/17/2018
Phone Date
Requisition 05/10/2018 Description FY18/19 WIC LA38 Contract Amen
Date
HEADER COMMENTS:
CORPUS CHRISTI-NUECES COUNTY PUBLIC HEALTH DISTRICT(CITY)
WIC Local Agency Amendment to amend contract language in the Statement of Work and Special Conditions attachments,decrease funding for
FY2018,and add funding for FY2019 renewal.
Total Contract Amount(FY17-FY19):$2,740,778.00
FY18 funding decrease amt:$142,418.00
FY19 funding amount:$857,934.00
Line Description UOM Qty Price Amount Line Status
1 Medical&Social Services Division EA 1 0.00 0.00 Approved
FY18 zero-dollar amendment to
change Contract Language for
Contract#2017-049800-001.
Vendor ID Vendor Loc Vendor Name Class Item Buyer
1746000574 948 48 AMY FITZGERALD
Schedule 1 Schedule Amount 0.00
Dist Account Fund Dept ID Program PCA Appn. Agy CFI Agy CF2 Amount Location
Ln Yr.
1 761100 0001 GWICSUB 70257 03257 2018 0.00 Austin:4616 W Howard
Ln
Line Nbr Comments
1 Supporting Documentation for Contract No.2017-049800-001 FY18 Amendment and FY19 Renewal. Medical and Social Services
Division.
Line Description UOM Qty Price Amount Line Status
2 FY19 Renewal for Contract 2017- EA 1 0.00 0.00 Approved
049800-001 to change contract
term.
Vendor ID Vendor Loc Vendor Name Class Item Buyer
1746000574 948 48 AMY FITZGERALD
Schedule 1 Schedule Amount 0.00
Dist Account Fund Dept ID Program PCA Appn. Agy CF1 Agy CF2 Amount Location
Ln Yr.
1 761100 0001 GWICSUB 70257 03257 2018 0.00 Austin:4616 W Howard
Ln
Line Nbr Comments
Total Requisition: $0.00
DOCU ;
SECURED
Certificate Of Completion
Envelope Id:8E56170F2106480FA10FA710555F4DE2 Status:Completed
Subject:Amending$2,740,778;2017-049800-001;Corpus Christi-Nueces County A-2;HHSC/WIC
Source Envelope:
Document Pages: 13 Signatures:3 Envelope Originator:
Certificate Pages:2 Initials:0 Texas Health and Human Services Commission
AutoNav:Enabled 1100 W.49th St.
Envelopeld Stamping:Enabled Austin,TX 78756
Time Zone:(UTC-06:00)Central Time(US&Canada) PCS_DocuSign@hhsc.state.tx.us
IP Address:167.137.1.14
Record Tracking
Status:Original Holder:Texas Health and Human Services Location:DocuSign
8/6/2018 12:17:35 PM Commission
PCS_DocuSign@hhsc.state.tx.us
Signer Events Signature Timestamp
Greta Rymal Completed Sent:8/6/2018 12:46:28 PM
Greta.Rymal@hhsc.state.tx.us Viewed:8/6/2018 3:05:12 PM
Texas Health and Human Services Commission Signed:8/6/2018 3:05:41 PM
Security Level:Email,Account Authentication Using IP Address: 107.77.210.37
(None) Signed using mobile
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Annette Rodriquez ,—oocuSlgneaby: I_ Sent:8/6/2018 3:05:43 PM
annetter@cctexas.com QIf �j0 �J Viewed:8/16/2018 12:50:04 PM
°FC90927d2CE°'°
Health Director Signed:9/26/2018 12:12:05 PM
City of Corpus Christi
Security Level:Email,Account Authentication
Signature Adoption:Pre-selected Style
(None) Using IP Address:64.201.138.47
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Andy Marker Completed Sent:9/26/2018 12:12:08 PM
Edward.Marker@hhsc.state.tx.us Viewed:9/26/2018 2:56:14 PM
Texas Health and Human Services Commission Signed:9/26/2018 2:56:16 PM
Security Level:Email,Account Authentication Using IP Address:167.137.1.17
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Karen Ray Completed Sent:9/26/2018 2:56:19 PM
Karen.Ray@hhsc.state.tx.us Viewed:9/27/2018 6:21:39 AM
Chief Counsel Signed:9/27/2018 6:21:43 AM
HHSC Using IP Address:70.112.121.87
Security Level:Email,Account Authentication Signed using mobile
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Signer Events Signature Timestamp
Cecile Young ,--DocuSI9nedby Sent:9/27/2018 6:21:45 AM
cecile.young@hhsc.state.tx.us d,,;,_ Viewed:9/27/2018 12:43:13 PM
Acting Executive Commissioner S.—ceoo;,e sesoae9 Signed:9/27/2018 12:43:38 PM
HHSC
Signature Adoption:Uploaded Signature Image
Security Level:Email,Account Authentication
(None) Using IP Address: 167.137.1.17
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Amy FitzGerald COPIED Sent:8/6/2018 12:46:28 PM
amy.fitzgerald@hhsc.state.tx.us Viewed:8/29/2018 12:27:06 PM
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Cynthia Wright Sent:8/6/2018 12:46:28 PM
cynthia.wright@hhsc.state.tx.us COPIED Viewed:8/6/2018 1:29:15 PM
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Kathrine Galvan COPIED Sent:8/6/2018 3:05:43 PM
KathrineG2@cctexas.com Viewed:8/6/2018 3:31:56 PM
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Pam Wells O PI E D Sent:9/27/2018 6:21:46 AM
pam.wells@hhsc.state.tx.us
Texas Health and Human Services Commission
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 9/27/2018 6:21:46 AM
Certified Delivered Security Checked 9/27/2018 12:43:13 PM
Signing Complete Security Checked 9/27/2018 12:43:38 PM
Completed Security Checked 9/27/2018 12:43:38 PM
Payment Events Status Timestamps