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HomeMy WebLinkAboutUnited Diagnostic Services, LLC/CFD/$51,300.00/Ultrasound Screening PackageCzTfshfzHsfdivlijobu:;56bn-Gfc19-3134 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 United Diagnostic Services, LLC Fire Department - 2023 Appropriation # 1120 101 43-407.01 Fund; P.O. #108505 Contract Not To Exceed $51,300.00 6. DISCLOSURE AND WARNINGS: If requested by City, Vendor shall promptly furnish to City, in such form and detail as City may direct, a list of all chemicals, materials, substances and items used in or during the provision of the Goods and Services provided hereunder, including the quantity, quality and concentration thereof and any other information relating thereto. At the time of the delivery of the Goods and Services provided hereunder, Vendor agrees to furnish to City sufficient written warning and notice (including appropriate labels on containers and packing) of any hazardous material utilized in or that is a part of the Goods and Services. 7. LIENS: Vendor shall not cause or permit the filing of any lien on any of City’s property. In the event any such lien is filed and Vendor fails to remove such lien within ten (10) days after the filing thereof, by payment or bonding, City shall have the right to pay such lien or obtain such bond, all at Vendor’s sole cost and expense. 8. DEFAULT: In the event Vendor: (a) repudiates, breaches or defaults under any of the terms or conditions of this Agreement, including Vendor’s warranties; (b) fails to provide the Goods and Services as specified herein; (c) fails to make progress so as to endanger timely and proper provision of the Goods and Services and does not correct such failure or breach within five (5) business days (or such shorter period of time as is commercially reasonable under the circumstances) after receipt of notice from City specifying such failure or breach; or (d) becomes insolvent, is placed into receivership, makes a general assignment for the benefit of creditors or dissolves, each such event constituting an event of default hereunder, City shall have the right to (1) terminate all or any parts of this Agreement, without liability to Vendor; and (2) exercise all other rights and remedies available to City at law and/or in equity. 9. INSURANCE AND INDEMNIFICATION: Vendor shall procure and maintain in full force and effect during the term of this Agreement, with an insurer licensed to do business in the State of Indiana, such insurance as is necessary for the protection of City and Vendor from all claims for damages under any workers’ compensation, occupational disease and/or unemployment compensation act; for bodily injuries including, but not limited to, personal injury, sickness, disease or death of or to any of Vendor’s agents, officers, employees, contractors and subcontractors; and, for any injury to or destruction of property, including, but not limited to, any loss of use resulting therefrom. The coverage amounts shall be no less than those amounts set forth in attached Exhibit C. Vendor shall cause its insurers to name City as an additional insured on all such insurance policies, shall promptly provide City, upon request, with copies of all such policies, and shall provide that such insurance policies shall not be canceled without thirty (30) days prior notice to City. Vendor shall indemnify and hold harmless City from and against any and all liabilities, claims, demands or expenses (including, but not limited to, reasonable attorney fees) for injury, death and/or damages to any person or property arising from or in connection with Vendor’s provision of Goods and Services pursuant to or under this Agreement or Vendor’s use of City property. Vendor further agrees to indemnify, defend and hold harmless City and its officers, officials, agents and employees from all claims and suits of whatever type, including, but not limited to, all court costs, attorney fees, and other expenses, caused by any act or omission of Vendor and/or of any of Vendor’s agents, officers, employees, contractors or subcontractors in the performance of this Agreement. These indemnification obligations shall survive the termination of this Agreement. S:\\Contracts\\Departments\\CFD\\2023\\United Diagnostic Services, LLC Goods and Services.docx:2/7/2023 11:12 AM\] 2 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 United Diagnostic Services, LLC Fire Department - 2023 Appropriation # 1120 101 43-407.01 Fund; P.O. #108505 Contract Not To Exceed $51,300.00 10. GOVERNMENT COMPLIANCE: Vendor agrees to comply with all federal, state and local laws, executive orders, rules, regulations and codes which may be applicable to Vendor’s performance of its obligations under this Agreement, and all relevant provisions thereof are incorporated herein by this reference. Vendor agrees to indemnify and hold harmless City from any loss, damage and/or liability resulting from any such violation of such laws, orders, rules, regulations and codes. This indemnification obligation shall survive the termination of this Agreement. 11. NONDISCRIMINATION: Vendor represents and warrants that it and all of its officers, employees, agents, contractors and subcontractors shall comply with all laws of the United States, the State of Indiana and City prohibiting discrimination against any employee, applicant for employment or other person in the provision of any Goods and Services provided by this Agreement with respect to their hire, tenure, terms, conditions and privileges of employment and any other matter related to their employment or subcontracting, because of race, religion, color, sex, handicap, national origin, ancestry, age, disabled veteran status and/or Vietnam era veteran status. 12. E-VERIFY: Pursuant to I.C. § 22-5-1.7 et seq., as the same may be amended from time to time, and as is incorporated herein by this reference (the “Indiana E-Verify Law”), Vendor is required to enroll in and verify the work eligibility status of its newly-hired employees using the E-Verify program, and to execute the Affidavit attached herein as Exhibit D, affirming that it is enrolled and participating in the E-Verify program and does not knowingly employ unauthorized aliens. In support of the Affidavit, Vendor shall provide the City with documentation indicating that it has enrolled and is participating in the E-Verify program. Should Vendor subcontract for the performance of any work under and pursuant to this Agreement, it shall fully comply with the Indiana E- Verify Law as regards each such subcontractor. Should the Vendor or any subcontractor violate the Indiana E-Verify law, the City may require a cure of such violation and thereafter, if no timely cure is performed, terminate this Agreement in accordance with either the provisions hereof or those set forth in the Indiana E- Verify Law. The requirements of this paragraph shall not apply should the E-Verify program cease to exist. 13. NO IMPLIED WAIVER: The failure of either party to require performance by the other of any provision of this Agreement shall not affect the right of such party to require such performance at any time thereafter, nor shall the waiver by any party of a breach of any provision of this Agreement constitute a waiver of any succeeding breach of the same or any other provision hereof. 14. NON-ASSIGNMENT: Vendor shall not assign or pledge this Agreement, whether as collateral for a loan or otherwise, and shall not delegate its obligations under this Agreement without City’s prior written consent. 15. RELATIONSHIP OF PARTIES: The relationship of the parties hereto shall be as provided for in this Agreement, and neither Vendor nor any of its officers, employees, contractors, subcontractors and agents are employees of City. The contract price set forth herein shall be the full and maximum compensation and monies required of City to be paid to Vendor under or pursuant to this Agreement 16. GOVERNING LAW; LAWSUITS: This Agreement is to be construed in accordance with and governed by the laws of the State of Indiana, except for its conflict of laws provisions. The parties agree that, in the event a lawsuit is filed hereunder, they waive their right to a jury trial, agree to file any such lawsuit in an appropriate court in Hamilton County, Indiana only, and agree that such court is the appropriate venue for and has jurisdiction over same. S:\\Contracts\\Departments\\CFD\\2023\\United Diagnostic Services, LLC Goods and Services.docx:2/7/2023 11:12 AM\] 3 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 United Diagnostic Services, LLC Fire Department - 2023 Appropriation # 1120 101 43-407.01 Fund; P.O. #108505 Contract Not To Exceed $51,300.00 17. SEVERABILITY: If any term of this Agreement is invalid or unenforceable under any statute, regulation, ordinance, executive order or other rule of law, such term shall be deemed reformed or deleted, but only to the extent necessary to comply with same, and the remaining provisions of this Agreement shall remain in full force and effect. 18. NOTICE: Any notice provided for in this Agreement will be sufficient if itis in writing and is delivered by postage prepaid U.S. certified mail, return receipt requested, to the party to be notified at the address specified herein: If to City: City of Carmel AND City of Carmel Fire Department Office of Corporation Counsel 10701 N College Avenue, Suite A One Civic Square Carmel, Indiana 46280 Carmel, Indiana 46032 If to Vendor: United Diagnostic Services, LLC 1400 Avenue Z, Suite 301 Brooklyn, New York 11235 Notwithstanding the above, notice of termination under paragraph 19 hereinbelow shall be effective if given orally, as long as written notice is then provided as set forth hereinabove within five (5) business days from the date of such oral notice. 19. TERMINATION: 19.1 Notwithstanding anything to the contrary contained in this Agreement, City may, upon notice to Vendor, immediately terminate this Agreement for cause, in the event of a default hereunder by Vendor and/or if sufficient funds are not appropriated or encumbered to pay for the Goods and Services to be provided hereunder. In the event of such termination, Vendor shall be entitled to receive only payment for the undisputed invoice amount representing conforming Goods and Services delivered as of the date of termination, except that such payment amount shall not exceed the Estimate amount in effect at the time of termination, unless the parties have previously agreed in writing to a greater amount. 19.2 City may terminate this Agreement at any time upon thirty (30) days prior notice to Vendor. In the event of such termination, Vendor shall be entitled to receive only payment for the undisputed invoice amount of conforming Goods and Services delivered as of the date of termination, except that such payment amount shall not exceed the Estimate amount in effect at the time of termination, unless the parties have previously agreed in writing to a greater amount. 19.3 The City may terminate this Agreement pursuant to Paragraph 11 hereof, as appropriate. 20. REPRESENTATIONS AND WARRANTIES The parties represent and warrant that they are authorized to enter into this Agreement and that the persons executing this Agreement have the authority to bind the party which they represent. S:\\Contracts\\Departments\\CFD\\2023\\United Diagnostic Services, LLC Goods and Services.docx:2/7/2023 11:12 AM\] 4 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 United Diagnostic Services, LLC Fire Department - 2023 Appropriation # 1120 101 43-407.01 Fund; P.O. #108505 Contract Not To Exceed $51,300.00 21. ADDITIONAL GOODS AND SERVICES Vendor understands and agrees that City may, from time to time, request Vendor to provide additional goods and services to City. When City desires additional goods and services from Vendor, the City shall notify Vendor of such additional goods and services desired, as well as the time frame in which same are to be provided. Only after City has approved Vendor’s time and cost estimate for the provision of such additional goods and services, has encumbered sufficient monies to pay for same, and has authorized Vendor, in writing, to provide such additional goods and services, shall such goods and services be provided by Vendor to City. A copy of the City’s authorization documents for the purchase of additional goods and services shall be numbered and attached hereto in the order in which they are approved by City. 22. TERM Unless otherwise terminated in accordance with the termination provisions set forth in Paragraph 19 hereinabove, this Agreement shall be in effect from the Effective Date through December 31, 2023 and shall, on the first day of each January thereafter, automatically renew for a period of one (1) calendar year, unless otherwise agreed by the parties hereto. 23. HEADINGS All heading and sections of this Agreement are inserted for convenience only and do not form a part of this Agreement nor limit, expand or otherwise alter the meaning of any provision hereof. 24. BINDING EFFECT The parties, and their respective officers, officials, agents, partners, successors, assigns and legal representatives, are bound to the other with respect to all of the covenants, terms, warranties and obligations set forth in Agreement. 25. NO THIRD PARTY BENEFICIARIES This Agreement gives no rights or benefits to anyone other than City and Vendor. 26. DEBARMENT AND SUSPENSION 26.1 The Vendor certifies by entering into this Agreement that neither it nor its principals nor any of its subcontractors are presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from entering into this Agreement by any federal agency or by any department, agency or political subdivision of the State of Indiana. The term “principal” for purposes of this Agreement means an officer, director, owner, partner, key employee or other person with primary management or supervisory responsibilities, or a person who has a critical influence on or substantive control over the operations of the Vendor. 26.2 The Vendor certifies that it has verified the state and federal suspension and debarment status for all subcontractors receiving funds under this Agreement and shall be solely responsible for any recoupment, penalties or costs that might arise from use of a suspended or debarred subcontractor. The Vendor shall immediately notify the City if any subcontractor becomes debarred or suspended, and shall, at the City’s request, take all steps required by the City to terminate its contractual relationship with the subcontractor for work to be performed under this Agreement. 27. IRAN CERTIFICATION Pursuant to I.C. § 5-22-16.5, the Vendor shall certify that, in signing this Agreement, it does not engage in investment activities within the Country of Iran. S:\\Contracts\\Departments\\CFD\\2023\\United Diagnostic Services, LLC Goods and Services.docx:2/7/2023 11:12 AM\] 5 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 Ray Lankin CEO 474240849 2/7/2023 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 2/15/2023 2/15/2023 2/15/2023 2/15/2023 Exhibit A Service Agreement For Carmel Fire Department (‘Host’) stThisAgreement (“Agreement”) is made this February 1, 2023 (“Effective Date”) between Carmel Fire Department, whose address is 2 Civic Square, Carmel, IN 46032 (“Host”), United Diagnostic Services, LLC, (collectively referred to as “UDS”), whose address is 1400 Ave Z, Suite 301, Brooklyn, NY, 11325 SERVICES TO BE PROVIDED BY UDS: 1. Ultrasound Screening Services UDS will provide onsite screening services to specified Host locations on as needed basis and pre-arranged dates to conduct the screening tests and services identified in Schedule 1. Individual results will be sent directly to the homes of participants; HIPAA compliant Aggregate Reports will be provided to Host, if applicable. Participant approval isrequired to forward results to managing physician. Services that are the practice of medicine will be provided by applicably licensed professionals employed and/or engaged by UDS. In the event that a participant desires to obtain professional items and services from aprovider, the same shall be arranged through separate arrangements directly between the provider and the participant. All services shall be provided subject to the terms and conditions set forth inthe Terms and Conditions attached to this Agreement. 2. Promotion. UDS will support the success ofHost’s wellness program by designing and supplying announcements, invitations, letters, signs, brochures and posters inboth electronic and hard copy form. These will be customized to detail the coordination of any existing Wellness efforts and Benefit Plans of Host organization. 3. Registration. Advance registration ensures prompt, timely administration of the screenings, minimizing the disruption ofthe employee’s time. UDS will publish a toll free number for employees, provide web based scheduling portal and coordinate any other required registration requirements with Host. 4. Hold Harmless. UDS and/or the professional entity with which it contracts to provide the services of licensed professionals assumes all liability for all services conducted and the accuracy and privacy of individual results. As between UDS and Host, UDS shall indemnify and hold Host harmless from any liability arising from the services provided pursuant to this Agreement. 5. Confidentiality. UDS agrees to hold all screening information and/or Host benefits information confidential and will not sell or disclose any Individually Identifiable Health rdInformationtoany3 party. 6106.100/1122 1 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 6. Education sessions. Section omitted. 7. Payment for services. Specific professional, delivery, and educational services, including, but not limited to, ultrasound screening, annual wellness visits with physicians provided at the request ofparticipants shall be billed and collected through Host and/or Host’sthird party administrator of self-insured health plan. To the extent that payment made by third party administrator is less than the contractual amounts set forth in this Agreement, Host shall pay the difference to UDS. UDS has arranged for itscontracted professional entity and its providers to provide services according to the fee schedule set forth on Schedule 1 ifdesired and selected to do soby Host’s health and wellness plan beneficiaries. Host acknowledges and agrees that such charges are not subject to third party payer or plan audit and/orrepayment demand and that Host shall indemnify, defend, and hold UDS and its professional entity contractors harmless from and against any and all claims or demands for repayment by Host’s third-party administrator. 8. Remittance of Fees. Remittance of the fees will be made to UDS at the following address, within thirty (30) days of invoicing: United Diagnostic Services, LLC 1400 Ave Z, Brooklyn, NY, 11235. RESPONSIBILITIES OF HOST 1. Executive Sponsorship. Host shall identify key managers or executives who shall assist through the sponsorship and endorsement of any health and wellness promotion. 2. Communication. Host will grant UDS access to normal communication channels with employees/members; including home mail, e-mail, payroll stuffers, newsletters, public postings orany method of employee communication normally utilized. All promotional materials will be approved by Host in atimely manner. 3. Benefits Information. Host shall provide specific details of wellness efforts or other benefits as appropriate to UDS for inclusion in education or promotion efforts. 4. Confidentiality. Host will not disclose the terms or pricing of the UDS screening event rdwithany3 party. 6106.100/1122 2 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 ACCEPTANCE: HOST: Carmel Fire Department Signature: ______________________________ Title: _____________________________ Print Name: ______________________________ Date: _____________________________ United Diagnostic Services, LLC Signature: ______________________________ Title: _____________________________ Print Name: ______________________________ Date: _____________________________ 6106.100/1122 3 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 UDS - TERMS AND CONDITIONS 1. Representations and Warranties. UDS warrants that ithasthe necessary resources, including technology, equipment, software, programs and trained personnel toproperly perform the screening services described herein consistent with standard practices; that itwill perform the screening services described herein inaprofessional manner; that it isaduly formed organization in good standing under the laws of the state inwhich the screening will occur; that itmaintains professional and general liability insurance coverage inasufficient amount forcoverage against risks reasonably anticipated inproviding the screening services; that ithas the authority toenter into and perform obligations set forth inthis Agreement; and that this Agreement does not violate any law orregulation towhich UDS issubject. 2. ERISA Disclaimer. The parties acknowledge and agree that UDS will provide population health management services to Host under this Agreement. Inproviding such service, the parties agree that UDS will not exercise any discretionary authority over the management ordisposition ofassets ofany welfare benefit plan (as such term isdefined in the Employee Retirement Income Security Act of1974 ("ERISA"). UDS’sduties will belimited to providing certain contractually agreed upon services as herein set forth. Therefore, the parties agree that UDS isnot a fiduciary (assuch term isdefined by ERISA Section 3(21)) with regard to Host'shealth benefits plan orany health and welfare benefit plan. 3. UDS Indemnification. As between UDS and Host, UDS agrees that itwill hold harmless and indemnify the Host for any third party claims arising out ofany negligent act oromission or intentional misconduct by UDS and/orits contracted provider(s) inthe performance ofscreening services under this Agreement. UDS shall be obligated tohold harmless andindemnify the Host inconnection with such claim only if, and tothe extent, ajudicial determination ismade of UDS’snegligence orintentional misconduct. 4. Promotion Support. To the extent that UDS provides theHost with any electronic or printed materials (the “Promotion Materials”), itprovides these materials subject toalimited license tothe Host to use the Promotion Materials for the Host’sown use. UDS may revoke this license at its discretion atany time. The license shall expire upon completion ofthe wellness event orthe agreement between Host and UDS. The Host may not copy ordistribute the Promotion Materials in any manner except as may be agreed toinadvance by UDS. 5. Excuse of Performance. UDS shall not be responsible ifits performance of this Agreement is interrupted ordelayed by contingencies beyond its control, including, without limitation, acts ofGod, war, lockouts orother labor orindustrial disturbances, fires, accidents toequipment, injunctions orcompliance with laws, regulations ororders ofany governmental body (whether now existing orhereafter created). In such event, UDS shall use best efforts toprovide reasonably alternative services. 6. Independent Contractor. UDS’s relationship with theHost pursuant hereto isthat ofan independent contractor, and nothing inthis Agreement shall be construed todesignate UDS asan employee, agent or partner ofor ajoint venture with Host. 7. Entire Agreement. This Agreement constitutes the entire understanding and agreement of the parties and cancels and supersedes allprior negotiations, representations, understandings oragreements, whether written ororal, with respect tothis Agreement. This Agreement shall bebinding upon and shall inure to the benefit ofthe successors, assigns legal representatives and heirs ofthe parties hereto; provided, 6106.100/1122 4 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 however, that the Host may not assign itsrights ordelegate its obligations under this Agreement without the prior written consent of UDS, which consent shall not beunreasonably withheld. UDS - TERMS AND CONDITIONS CON’T 8. Governing Law. This Agreement shall be governed by and construed inaccordance with the laws ofthe State of New York without regard tothe conflicts oflaws or rules ofany jurisdiction. 9. Notices. Allrequired notices or those which the parties may desire togive under this Agreement shall be inwriting and communicated inadvance. 10. Originals. Acopy orfacsimile ofthis Agreement shall beas effective asan original. 6106.100/1122 5 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 SCHEDULE 1 HEALTH FAIR DETAILS ACCOUNT Account name. – Carmel Fire Department DETAILS Estimated Employee Participation TBD ththDateofEvent(s): March 13-17, 2023 Event(s) Duration: TBD Event(s) Location: TBD APPOINTMENT PROCEDURES & PRICING Ultrasound Screening Packages to include the following: 1. Echocardiogram (Valve function, Heart Pumping Ejection Fraction), Carotid Doppler, Aortic Aneurysm (AAA), Thyroid, Complete Abdomen (Liver, Spleen, Gall Bladder, Kidney), Bladder Ultrasound, Pelvic (External Women only), Testicular (Men only): 300.00 – 30 minutes 2. Onsite program delivery fee outside of New York Included 3. Nurse Practitioner Positive Result Consultation Included nd4. 2 Outreach for abnormal results With coordination of care recommendations Included Bill To: Carmel Fire Department ADDRESS 2 Civic Square, Carmel, IN 46032 Host Initial: United Diagnostic Services Initial: 6106.100/1122 6 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 EXHIBIT B Invoice Date: Name of Company: Address & Zip: Telephone No.: Fax No.: Project Name: Invoice No. Purchase Order No: Goods Services Person Providing Goods/Services Date Goods/ Service Provided Goods/Services Provided Describe each good/service separately and in detail) Cost Per Item Hourly Rate/ Hours Worked Total GRAND TOTAL Signature Printed Name DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 EXHIBIT C INSURANCE COVERAGES Worker’s Compensation & Disability Statutory Limits Employer’s Liability: Bodily Injury by Accident/Disease: $100,000 each employee Bodily Injury by Accident/Disease: $250,000 each accident Bodily Injury by Accident/Disease: $500,000 policy limit Property damage, contractual liability, products-completed operations: General Aggregate Limit (other than Products/Completed Operations): $500,000 Products/Completed Operations: $500,000 Personal & Advertising Injury Policy Limit: $500,000 Each Occurrence Limit: $250,000 Fire Damage (any one fire): $250,000 Medical Expense Limit (any one person): $ 50,000 Comprehensive Auto Liability (owned, hired and non-owned) Bodily Single Limit: $500,000 each accident Injury and property damage: $500,000 each accident Policy Limit: $500,000 Umbrella Excess Liability Each occurrence and aggregate: $500,000 Maximum deductible: $ 10,000 DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 Ray Lankin United Diagnostic Services, LLC CEO 7th February 23 Ray Lankin DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5 INDIANA RETAIL TAX EXEMPT City ®f Carmel CERTIFICATE NO. 003120155 002 0 FEDERAL EXCISE TAX EXEMPT ONE CIVIC SQUARE 35-6000972 CARMEL, INDIANA 46032-2584 ORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL - 1997 IASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. 2/6/2023 377027 Page 1 of 1 PURCHASE ORDER NUMBER 108505 THIS NUMBER MUST APPEAR ON INVOICES, A/P VOUCHER, DELIVERY MEMO, PACKING SLIPS, SHIPPING LABELS AND ANY CORRESPONDENCE DESCRIPTION FF Ultrasound Screening UNITED DIAGNOSTIC SERVICES LLC Carmel Fire Department VENDOR 1400 AVENUE Z SHIP 10701 N. College Avenue, Ste A SUITE 301 TO Carmel, IN 46280- BROOKLYN, NY 11235 - PURCHASEID BLANKET CONTRACT PAYMENTTERMS FREIGHT 73941 QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION Department: 1120 Fund: 101 General Fund Account: 43-407.01 171 Each Ultrasound Screening Package per Quote - Health Fair $300.00 $51,300.00 Details Sub Total $51,300.00 CAA Send Invoice To: Carmel Fire Department 2 Civic Square `' /, Carmel, IN 46032- PLEASE INVOICE IN DUPLICATE DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT PAYMENT $51,300.00 SHIPPING INSTRUCTIONS * A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN SHIP PREPAID. AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN C.O.D. SHIPMENT CANNOT BE ACCEPTED. THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER. PURCHASE ORDER NUMBER MUST APPEAR ON ALL SHIPPING LABEL - THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. ORDERED BY Denise Snyder James Crider TITLE Accreditation/Budget Administrator Director of Administration CONTROL NO. 108505 CONTROLLER DocuSign Envelope ID: 8D63D231-D271-4365-B924-DB82D2E1A5E5