WITNESS THESE SIGNATURES Sample Clauses

WITNESS THESE SIGNATURES. THE COUNTY BOARD OF ARLINGTON ETHIOPIAN COMMUNITY DEVELOPMENT COUNCIL, COUNTY, VIRGINIA. INC. SIGNED SIGNED BY: BY: XXXXXXX X. XXXXXX, XX. PRINT NAME PURCHASING AGENT AND TITLE: DATE: DATE: REVISED SCOPE OF WORK – SECTION II
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WITNESS THESE SIGNATURES. THE COUNTY BOARD OF ARLINGTON ACCELA, INC. COUNTY, VIRGINIA AUTHORIZED AUTHORIZED SIGNATURE: _ SIGNATURE: _ PRINT PRINT NAME: _MICHAEL XXXXX NAME: _ TITLE: PURCHASING AGENT TITLE:
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WITNESS THESE SIGNATURES. THE COUNTY BOARD OF ARLINGTON Arlington Street People’s Assistance Network, Inc. COUNTY, VIRGINIA SIGNED: Xxxxx Xxxxxxxxx PRINT NAME: SIGNED: XXXXX XXXXXX PRINT NAME: President & CEO TITLE: Procurement Officer TITLE: 5/12/2021 DATE: 5/10/2021 DATE: ATTACHMENT 1 COVID-19 RESPONSE EXPENSES: JULY 1, 2021 THROUGH JUNE 30, 2022 Budgeted Expense Cost Detailed Explanation Weekly Estimated Cost Registered Nurse (RN) $62,400.00 $40 hour x 30 hours a week x 52 weeks $1,200 Benefits $7,176.00 11.50% $138 Covid testing $20,000.00 Rapid antigen testing if state testing stops being available/ or need rapid results $385 TB skin test $2,005.08 $9.24 tests x 217 tests for each new person coming into the shelter that should be tested $39 Flu test/strep test $3,600.00 Testing to rule out COVID vs FLU vs STREP since they can present with similar symptoms $69 PPE/supplies $1,000.00 Syringes, gloves, gowns, masks, sanitizer, alcohol wipes $19 Increased liability for Nurse Practitioner (NP) for multiple shelters $2,500.00 Base liability insurance @ $2,500 $48 Liability insurance for RN $1,000.00 Base liability insurance for new nurse under NP $19 Management & Administrative Support $10,200.00 Admin support using a rate of $20/hr for 5 hours/week x 52 weeks + raise for NP of $5,000 for management responsibilties $196 computer/email costs/ phone $2,200.00 If we are looking to provided extended medical services, need to consider electronic charting which will drive up the cost (usually there is a monthly subscription cost). In addition, nurse will need laptop, docking station, and monitor. $42 Transportation costs for travel to and from different shelters $500.00 Mileage to and from shelters $10
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WITNESS THESE SIGNATURES. THE COUNTY BOARD OF ARLINGTON BRIDGES TO INDEPENDENCE, INC. COUNTY, VIRGINIA AUTHORIZED AUTHORIZED SIGNATURE: SIGNATURE: NAME: XXXXXX X. XXXXX NAME: TITLE: PROCUREMENT OFFICER TITLE: Xxxxx X'Xxxxx Interim CEO DATE: 5/26/2022 DATE: 5/26/2022 REVISED EXHIBIT B CONTRACT PRICING Budget A – FY23 Xxxxxxxx House Budget Bridges to Independence - Xxxxxxxx House FY 2023 Budget FTE Personnel: Chief Program Officer 0.25 $27,000 Data Intake Coordinator & QA 0.25 $16,181 Shelter Facilities Manager 0.75 $49,295 Volunteer & Community Outreach 0.5 $30,000 SH House Manager-Full Time Hourly 1 $45,210 SH House Manager-Full Time Hourly 1 $45,210 SH Case Manager 1 $74,726 Clinical Employment Specialist 0.25 $15,169 SH House Managers- Midday/Weekend/Relief Staff- Varies 1.5 $67,100 Total Personnel 6.5 $369,892 Non-Personnel: Building Maintenance and Repair (Cleaning Contract Incl.) $18,540 Transportation $3,297 Client Transportation $1,000 Direct Client Assistance $3,000 Language Assistance (Language Line) $6,000 Total Non-Personnel $31,837 Admin Cap Rate 7.158% Admin Cost $30,973 Grand Total $432,701 Xxxxx Xxxxxx $432,701 Admin Cap Communication(Phone/Internet) 3,000 Insurance 14,403 Audit 3,000 Supplies 6,675 Accounting 3,895 Total 0 $30,973 Budget B – FY23 Rapid Rehousing Budget Personnel: Bridges to Independence - Rapid Rehousing FY 2023 Budget FTE Total Total Personnel $0 Non-Personnel: Rental Subsidies $88,033 Optional: Ten thousand dollars ($10,000) of the funding may be used for salaries and benefits for case management services for post program aftercare. Total Non-Personnel $88,033 Admin Cap Rate 10% Admin Cost $9,782 Grand Total $97,815 Xxxxx Xxxxxx $97,815 Admin Cap Finance Manager 0.15 $7,800 Language Assistance (Language Line) $1,982 Total 0.15 $9,782 Budget C – FY23 Compensation of People with Lived Experience of Homelessness Budget Bridges to Independence FY 2023 Compensation Budget FTE Total Personnel: Total Personnel $ - Non-Personnel: Compensation to people with lived experience of homelessness $6,250 Total Non-Personnel $6,250 Admin Cap Rate 0% Admin Cap $0
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WITNESS THESE SIGNATURES. THE COUNTY BOARD OF ARLINGTON A. XXXXXX XXXXXX AND ASSOCIATES, INC. COUNTY, VIRGINIA AUTHORIZED AUTHORIZED SIGNATURE: SIGNATURE: PRINT PRINT NAME: _IGOR SCHERBAKOV NAME: TITLE: PROCUREMENT OFFICER TITLE: DATE: DATE:
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WITNESS THESE SIGNATURES. THE COUNTY BOARD OF ARLINGTON ENVIRO-STORMWATER MANAGEMENT, LLC. COUNTY, VIRGINIA AUTHORIZED AUTHORIZED SIGNATURE: _ SIGNATURE: _ PRINT PRINT NAME: _MICHAEL XXXXX NAME: _ TITLE: PURCHASING AGENT TITLE: DATE: DATE:
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WITNESS THESE SIGNATURES. THE COUNTY BOARD OF ARLINGTON KAISER FOUNDATION HEALTH PLAN OF THE COUNTY, VIRGINIA MID-ATLANTIC STATES, INC. AUTHORIZED AUTHORIZED SIGNATURE: SIGNATURE: NAME: XX. XXXXXX X. LEWIS NAME: TITLE: PURCHASING AGENT TITLE: Xxxxxx X. Xxxxxxxx Executive Director, Strategic Accounts DATE: 5/3/2024 DATE: 5/1/2024 Agreement No. 564-14 Executive Summary Group Name: Arlington County Government Group Number(s): 2040,4126 Subgroup(s): Multiple Groups Region: Mid-Atlantic States Contract Period: 07/01/2024 - 06/30/2025 Dec21 - Nov22 Dec22 - Nov23 Average Members*: 1,697 1,658 Rates** Custom HMO 8 SIG Actives: Current Rates Change % Change $ Proposed Rates Subscriber only $633.38 5.83% $36.92 $670.30 Subscriber and Spouse 1,333.76 5.83% 77.76 1,411.52 Subscriber and 1 Child 1,175.04 5.83% 68.51 1,243.55 Subscriber and 2 or more Children 1,175.04 5.83% 68.51 1,243.55 Subscriber and Spouse and 1 or more children 1,933.06 5.83% 112.70 2,045.76 Custom HMO 8 SIG DP Cobra: Subscriber only $646.04 5.83% $37.66 $683.70 Subscriber and Spouse 1,360.44 5.83% 79.31 1,439.75 Subscriber and 1 Child 1,198.54 5.83% 69.87 1,268.41 Subscriber and 2 or more Children 1,198.54 5.83% 69.87 1,268.41 Subscriber and Spouse and 1 or more children 1,971.72 5.83% 114.95 2,086.67 Custom HMO 8 SIG Retirees: Subscriber only $633.38 5.83% $36.93 $670.31 Subscriber and Spouse 1,333.77 5.83% 77.76 1,411.53 Subscriber and 1 Child 1,175.05 5.83% 68.50 1,243.55 Subscriber and 2 or more Children 1,175.05 5.83% 68.50 1,243.55 Subscriber and Spouse and 1 or more children 1,933.08 5.83% 112.70 2,045.78 Claims Summary $PMPM* Arlington County Government: Major Service Category Dec21 - Nov22 Change Dec22 - Nov23 Inpatient $64.35 (4.6)% $61.41 Outpatient 250.74 (4.5)% 239.53 Pharmacy 60.70 4.0% 63.13 Other 85.80 1.2% 86.81 Total Claims Summary $PMPM $461.58 (2.3)% $450.87 * Includes Actives and /or pre 65 Retirees only. **Benefit plan descriptions are summarized, please see Rate and Benefit Summary for full descriptions. Created On: 1/31/2024 NPS RQR Number: 15640081 NPS RQR Name: Arlington County Government
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Related to WITNESS THESE SIGNATURES

  • Witness Signature 4. PARENT/GUARDIAN CONSENT: (for applicants under 18 years) – I hereby certify and decree that all the information contained in the declarations above is true and accurate Print Name:................................................................... Signature …………………………………………....……... Relationship to applicant ……………………………… Phone Contact ……………………................................... Address …………………………………………………………………….....................................................................

  • EMPLOYEE SIGNATURES Signature: Phone # / Personal E-mail: Signature: Phone # / Personal E-mail: Signature: Phone # / Personal E-mail:

  • Employee Signature Employee ID: Telephone No: Employee Address: Work Location:

  • AGREEMENT SIGNATURES By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signed by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signed by Person Responsible: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Signature of Person Responsible: Date: SignaĒure on behalf of FighĒing Chance: Signature of Person(s) responsible: Date: Name: Appendix 1 Key Contact Details Participant’s Name Participant’s Email Participant’s Phone Participant’s Address Person(s) responsible’s Name Person(s) responsible Relationship to Participant Person(s) responsible’s Email Person(s) responsible’s Phone Support Coordinator (where applicable) Support Coordinator’s Name Support Coordinator’s Email Support Coordinator’s Phone Shared Living/Supported Accommodation/Group Home (if applicable) House Manager’s Name House Manager’s Email House Manager’s Phone Additional Contacts (if applicable) Role Contact’s Name Contact’s Email Contact’s Phone Appendix 2 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx ☐ (Optional) Please supply me, by email, with monthly Statements of Account to: ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services once a week. Please email invoices to: Please see Appendix 3 for Self-Management Payment Options. ☐ PLAN-MANAGED Please send invoices to my plan manager: Plan management organisatio Contact Name Email Address Phone number ☐ OTHER FUNDING (eg. self-funded, iCare or other insurance funding) Please email invoices to: Appendix 3 Self-Managed Payment Options Participants who are self-managed have a number of payment options with Fighting Chance: ☐ DIRECT DEPOSIT (preferred option) Payment of Fighting Chance invoices can be made by Electronic Funds Transfer (EFT) through your bank. Fighting Chance’s bank account details are as follows: Bank: Commonwealth Bank of Australia Account Name: Fighting Chance Australia Ltd BSB: 062-438 Account Number: 00000000 To ensure all payments are correctly allocated to your account, please include the full invoice number in the reference field. ☐ CREDIT CARD Payments can be made by credit card by clicking the ‘pay by credit card’ link included on the invoice. Please note that a service fee for this option will be imposed. ☐ PAYPAL Payment of your invoices can also be made via our PayPal account. To make payment via PayPal, please access the following link: xxxxx://xxxxxx.xx/FightingChanceAus?locale.x=en_AU To ensure your payment is correctly allocated, please enter the full invoice number in the reference field. Appendix 4 Non Face to Face Time Breakdown - Jigsaw Standard Non Face-to-Face Supports Delivered to every Jigsaw Participant daily, weekly, annually Writing the Board (i.e. preparing and writing up each person’s individualised program for the following day). Reviewing Trainee records/journal notes/medical or other key information to be able to best support the person during their day. Parent/Guardian/Carer Updates, i.e. emails, phone calls. Pre- and post-shift sta briefings. Zone setup (setting up workstations, boxes, visuals and group training areas) Resource development to support each Trainee to progress towards their employment goals (adapting training resources, creating visual aids and cheat sheets, etc). Research/Coordination to implement support strategies (disability, behavioural and learning strategies). Family reviews and the development of training plans (planning, delivery and follow up). Planning social events and extra curricular training (e.g. TAFE). Standard NDIS Annual Support Review Letter. Standard Ǫuarterly Reports - Upon Request. Complex Non Face-to-Face Supports - Delivered to Jigsaw Participants with High Intensity Support Needs (in addition to supports outlined in Standard) Allied health meetings, phone calls, correspondence. Specialist/additional sta training (internal or external), i.e. BSP implementation training. Creation of additional/detailed social stories/visuals. Data collection requested by behaviour therapists. Incident follow up or crisis meetings (seperate to regular family updates or regular allied health meetings). Development/review/discussion of medication forms/transfer plans/mealtime assistance plans etc. Detailed and regular sta training on individual complex behaviour/medical/transfer/mealtime support plans. Extended daily pre-brief and debrief. Additional Non Face-to-Face Supports - billed separately upon request Detailed NDIS Review Letters One-o engagement or training with Allied Health. Detailed Ǫuarterly Reports.

  • Contract Signature If the Original Form of Contract is not returned to the Contract Officer (as identified in Section 4) duly completed, signed and dated on behalf of the Supplier within 30 days of the date of signature on behalf of DFID, DFID will be entitled, at its sole discretion, to declare this Contract void. No payment will be made to the Supplier under this Contract until a copy of the Form of Contract, signed on behalf of the Supplier, is returned to the Contract Officer.

  • Signature Signature For the participant For the institution Xxxxxx Xxxxx prof. Ing. arch. Xxxxxx Xxxxxxx, PhD. Vice-xxxxxx for International Relations and Public Relations, based on the procuration Annex I

  • Preparer’s Signature The person completing the DBE commitment form on behalf of the consultant’s firm must sign their name.

  • Student Signature By signing this contract, Resident agrees to pay the contract amount (room, board and association fees) in accordance with Addendum B: Rate and Payment Schedule. Resident may pay the full amount due prior to the due date, at the Resident’s election.

  • Witness Witness signed - - signed - (Mr. Krit Phakhakit) (Miss Sarinthon Chongchaidejwong)

  • Legal Signature This Agreement may be executed and delivered by any party herein by sending a facsimile of the signature or by a legally recognized digital or electronic signature. Such legal signature shall be binding on the party so executing it upon receipt of signature by the other party.

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