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2022-06-22 Final PacketC✓ II Agenda Items Properly Numbered ontracts Completed and Signed All 1295's Flagged for Acceptance (number of 1295's -:3 _) All Documents for Clerk Signature Flagged On this 2.iday of 2022 a complete and accurate packet for 22Kk of �-�/ 2022 Commissioners Court Regular Session Day V Month was delivered from the Calhoun County Judge's office to the Calhoun County Clerk's Office. (1-"04 Z/ Calhoun County Judge/Assistant COMMISSI ONERSCOURTCHECKLIST/FORMS AGENDA Af_ . 2 � F� ELOGL,_,& �M JUN i. 7 2022 Richard H. Meyer g La � W - NTr, TE s C0..ty jnudge David Hall, Commissioner, Precinct 1 Vern Lyssy, Commissioner, Precinct 2 Joel Behrens, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 NOTICE OF MEETING The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, June 22, 2022 at 10:00 a.m. in the Commissioners' Courtroom in the County Courthouse at 211 S. Ann Street, Suite 104, Port Lavaca, Calhoun County, Texas. AGENDA The subject matter of such meeting is as follows: TCall meeting to order. / ''2. Invocation. '3. Pledges of Allegiance. 4r General Discussion of Public Matters and Public Participation. Aq rwt. g oCon ider a f Cnd take necessary action to lift or retain the county burn ban. (RHM) 5. Consider and take necessary action to approve an application to the Texas Department of Emergency Management for the Hazard Mitigation Grant Program Funding related to FEMA-DR-4485 (COVID 19 Pandemic) for a generator for the Magnolia Beach Fire AStation which is due June 30, 2022. (DEH) i. Consider and take necessary action to approve the amended plat for the J. M. Turner Subdivision. (DEH) Consider and take necessary action to approve the Final Plat of Pelicans Landing Resubdivision No. 1. (GDR) / Consider and take necessary action to approve a request from Maeghen Strahan to use the Port O'Connor Community Center property for a benefit Clay Shoot on October 8, 2022 to raise funds for the Port O'Connor Community Center upgrades. (GDR) f0 Consider and take necessary action to accept the Matagorda Bay Mitigation Trust Contract No. 031 for the Green Lake Park Development Phase 1 Engineering Services and authorize Judge Meyer to sign all documentation. (GDR) Page 1 of 2 i1 Consider and take necessary action to approve the Texas Association of Counties (TAC) Property Insurance renewal for the period 7/1/22 — 7/1/23 as recommended by Gray & Company, LLC. (RHM) 12. Consider and take necessary action to approve the FEMA-4332-DR-TX Project Completion and Certification Report for Project Worksheet #3548 Six Mile Park and the Duplication of Benefits form and authorize the County Judge to sign. (RHM) i3. Consider and take necessary action to authorize Anna Kabela, District Clerk, to sign Kofile's proposal for the preservation and imaging of historical records. (RHM) pp P4�nsider and take necessary action to authorize Anna Goodman, County Clerk, to sign a ��Data Use Agreement with the Texas HHS System. (RHM) 15. Consider and take necessary action to authorize Dustin Jenkins, EMS Director, to sign a credit application with the Goodyear Tire and Rubber Company. (RHM) r6. Consider and take necessary action to accept a second insurance proceeds payment from TAC in the amount of $3,566.47 for damages to a Sheriff Office vehicle on 3/30/22. (RHM) r/. Consider and take necessary action to approve the attached Calhoun County Library Electronic Device Lending Agreement and Hotspot Rental Agreement. (RHM) 18. Accept Monthly Reports from the following County Offices: i. Justice of the Peace, Precinct 5 - May 2022 ii. Tax Assessor -Collector — June 2021, Revised iii. Tax Assessor -Collector — July 2021, Revised iv. Tax Assessor -Collector — December 2021, Revised v. Tax Assessor -Collector — March 2022 vi. Tax Assessor -Collector — April 2022 �onsider and take necessary action on any necessary budget adjustments. (RHM) 20. Approval of bills and payroll. (RHM) / Richard H. Meyer, County 7 dg Calhoun County, Texas A copy of this Notice has been placed on the outside bulletin board of the Calhoun County Courthouse, 211 South Ann Street, Port Lavaca, Texas, which is readily accessible to the general public at all times. This Notice shall remain posted continuously for at least 72 hours preceding the scheduled meeting time. For your convenience, you may visit the county's website at www.calhouncotx ore under "Commissioners' Court Agenda" for any official court postings. Page 2 of 2 #5 NOTICE OF MEETING 6/22/2022 Richard H. Meyer County judge David Hail, Commissioner, Precinct I Vern ]Lyssy, Commissioner, Precinct 2 (Zoom)Joel Behrens, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 ]Kaddie Smith, Deputy Clerk Sara Rodriguez, County Attorney The Commissioners' Court of Calhoun County, Texas will meet on Wednesday, June 22, 2022 at 10:00 a.m. in the Commissioners' Courtroom in the County Courthouse at 211 S. Ann Street, Suite 104, Port ]Lavaca, Calhoun County, Texas. AGENDA The subject matter of such meeting is as follows: 1. Call meeting to order. Meeting was called to order at 9:59 a.m. by Judge Richard Meyer 2. Invocation. Commissioner David Hall 3. Pledges of Allegiance. US Flag- Commissioner Gary Reese Texas Flag -Commissioner Vern Lyssy 4. General Discussion of Public Matters and Public Participation. N/A 5. Consider and take necessary action to lift or retain the county burn ban. (RHM) Burn ban retained per Judge Richard Meyer. Page 1 of 5 ' NO I -ICE OF MEE FINC — 6/22/2022 6. Consider and take necessary action to approve an application to the Texas Department of Emergency Management for the Hazard Mitigation Grant Program Funding related to FEMA-DR-4485 (COVID 19 Pandemic) for a generator for the Magnolia Beach Fire Station which is due June 30, 2022. (DEH) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct i SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 7. Consider and take necessary action to approve the amended plat for the J. M. Turner Subdivision. (DEH) Jake Helfer with Elite Surveying explained the amended plat. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 8. Consider and take necessary action to approve the Final Plat of Pelicans Landing Resubdivision No. 1. (GDR) Terry Ruddick with Urban Surveying explained the final plat. RESULT: APPROVED [UNANIMOUS] MOVER: "Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 9. Consider and take necessary action to approve a request from Maeghen Strahan to use the Port O'Connor Community Center property for a benefit Clay Shoot on October 8, 2022 to raise funds for the Port O'Connor Community Center upgrades. (GDR) Jim Cooley spoke on behalf of Meaghen Strahan. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Vern Lyssy, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 2 of 5 NOTICE OF MEETING — 6/22/2022 10. Consider and take necessary action to accept the Matagorda Bay Mitigation Trust Contract No. 031 for the Green Lake Park Development Phase 1 Engineering Services and authorize Judge Meyer to sign all documentation. (GDR) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens; Reese 11. Consider and take necessary action to approve the Texas Association of Counties (TAC) Property Insurance renewal for the period 7/1/22 — 7/1/23 as recommended by Gray & Company, LLC. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 12. Consider and take necessary action to approve the FEMA-4332-DR-TX Project Completion and Certification Report for Project Worksheet #3548 Six Mile Park and the Duplication of Benefits form and authorize the County Judge to sign. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER' David Hall, Commissioner Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 13. Consider and take necessary action to authorize Anna Kabela, District Clerk, to sign Kofile's proposal for the preservation and imaging of historical records. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 14. Consider and take necessary action to authorize Anna Goodman, County Clerk, to sign a Data Use Agreement with the Texas HHS System. (RHM) PASS Page 3 of 5 I NOTICE OF MEETING— 6/22/2022 15. Consider and take necessary action to authorize Dustin Jenkins, EMS Director, to sign a credit application with the Goodyear Tire and Rubber Company. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese` 16. Consider and take necessary action to accept a second insurance proceeds payment from TAC in the amount of $3,566.47 for damages to a Sheriff Office vehicle on 3/30/22. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 17. Consider and take necessary action to approve the attached Calhoun County Library Electronic Device Lending Agreement and Hotspot Rental Agreement. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 18. Accept Monthly Reports from the following County Offices: i. Justice of the Peace, Precinct 5 — May 2022 ii. Tax Assessor -Collector — June 2021, Revised iii. Tax Assessor -Collector — July 2021, Revised iv. Tax Assessor -Collector — December 2021, Revised v. Tax Assessor -Collector — March 2022 vi. Tax Assessor -Collector — April 2022 RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy,Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 19. Consider and take necessary action on any necessary budget adjustments. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Vern Lyssy, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 4 of 5 NOTICE OF MEETING — 6%22%2022 20. Approval of bills and payroll. (RHM) MMC RESULT: APPROVED [UNANIMOUS] MOVER: David Hall,.' Commissioner Pct 1 SECONDER:' Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens; Reese COUNTY BILLS 2022: RESULT: APPROVED [UNANIMOUS] MOVER: David Hall,Commissioner Pct 1 SECONDER:: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Adjourned: 10:20 a.m. Page 5 of 5 #6 NO-IICF.0FMFFTIN(3—(r/22/2022 6. Consider and take necessary action to approve an application to the Texas Department of Emergency Management for the Hazard Mitigation Grant Program Funding related to FEMA-DR-4485 (COVID 19 Pandemic) for a generator for the Magnolia Beach Fire Station which is due June 30, 2022. (DEH) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese'` Page 2 of 16 Mae Belle Cassel From: David.Hall@calhouncotx.org (David Hall) <David.Hall@calhouncotx.org> Sent: Wednesday, June 15, 2022 5:34 PM To: Mae Belle Cassel; Katy Sellers Subject: Fwd: Agenda item Can you please place the following on the next available agenda please? Thanks! Sent from David's iPhone David Hall Commissioner Precinct 1 Calhoun County Office 361-552-9242 Cell 361-220-1751 Begin forwarded message: From: katy@ksbr-Ilc.com Date: June 15, 2022 at 5:18:23 PM CDT To: David Hall <david.hall@calhouncotx.org> Cc: Ladonna Thigpen <ladonna.thigpen@calhouncotx.org> Subject: Agenda item CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. David — I meant to get you an agenda item so we can submit the Hazard Mitigation generator application. Ladonna mentioned she had put in a generic item awhile back, but I figured it might be good to do a specific one. I wrote up the below item for submission. Request approval to submit an application to the Texas Department of Emergency Management for the Hazard Mitigation Grant Program Funding related to FEMA- DR-4485 (COVID 19 Pandemic). The County will submit an application for a generator for the Magnolia Beach Fire Station. Applications are due by June 30, 2022. Thanks, Katy Katy Sellers Managing Principal (903)243-0481 cell katy@ksbr-llc.com Calhoun County Texas NO I1CF OF MFFTING — 6/22%2022 7. Consider and take necessary action to approve the amended plat for the J. M. Turner Subdivision. (DEH) Jake Helfer with Elite Surveying explained the amended plat. RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 3 of 16 Mae Belle Cassel From: david.hafl@calhouncotx.org (David Hall) <david.hall@calhouncotx.org> Sent: Thursday, June 9, 2022 8:32 AM To: MaeBelle.Cassel@calhouncotx.org Cc: jake@eliteengr.com Subject: FW: blueprint scans Attachments: 20220608104840961.pdf Good morning ma'am. Can you please add the attached amended plat to the agenda for June 22? Thanks! From: jake@eliteengr.com (Jake Helfer) [mailto:jake@eliteengr.com] Sent: Thursday, June 9, 2022 7:26 AM To: David Hall <david.hall@calhouncotx.org>; Mae Belle Cassel<maebelle.cassel@calhouncotx.org> Subject: Fwd: blueprint scans CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Commissioner Hall, I finally got all of the signatures on this Amending Plat. I would like to get it placed on the commissioner's court agenda. Please let me know when that can happen and I can be there to answer any questions. Thanks, Jake Helfer, P.E. Elite Engineering -Firm 15371 1501 N. De Leon Street Victoria, Texas 77901 361-433-4988 Office 361-571-3063 Mobile www.eliteenzr.com ---------- Forwarded message --------- From: South Store <south@Mrint5474.com> Date: Wed, Jun 8, 2022 at 11:47 AM Subject: blueprint scans To: <jakehelferl@gmail.com> Calhoun County Texas N 54°52'34" E 661.00' p S ° AIR, SP ohaaa a � moamk y —way— m� m --------- 4� mDn .a m m ` O fA0 \ gg Qq 8$�� gRgggb m 5 �qi to N 54.53'30" E 661.00' 0 xwemve \ y rnwam —g — rwxsxr �w�xeaemvau— _ _ m ------ o' m I/ Imo• �—� � � � € ��� a I �� 19g s� di )74 c Z Dnm y I\ m A /!� i A N D ee OZ m PR2 A' 3 i��l n Ill -Ai O r a59 fs _ eye S 5e°53'30" W 661.00' \ qE p rO 1 a 5 pElSppq^ � 5ia q 60 0€iA 1 sIR_`a T. 6 IN 4 GyTO��l4) € m 5 0 � g s s y gas a3 3k eipggy $ eg a 3aaa g?�pgFge s gmo ' [a W F U) ��BSCG IY�dg� a G MIX gill NOTICE OF MEE I ING — 6/22/2022 8. Consider and take necessary action to approve the Final Plat of Pelicans Landing Resubdivision No. 1. (GDR) Terry Ruddick with Urban Surveying explained the final plat. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 4 of 16 Gary D. Reese County Commissioner County of Calhoun Precinct 4 June 9, 2022 Honorable Richard Meyer Calhoun County Judge 211 S. Ann Port Lavaca, TX 77979 RE: AGENDA ITEM Dear Judge Meyer: Please place the following item on the Commissioners' Court Agenda for June 22, 2022. • Consider and take necessary action to approve the Final Plat of Pelicans Landing Resubdivision No. 1 Sincerely, Gary D. Reese GDR/at P.O. Box 177 — Seadrift, Texas 77983 — email: gary.reese ealhouncom.om — (361) 785-3141 — Fax (361) 785-5602 � Y � 3 £ r S § IN $E9d H. yyy a �. sse$a.e AN pIn xyy q�q a "3 5b FS N 3 G ni .gi o R21! xa us 3 �.oE 5i1p A9.. v _ E a 1 r6s °Fs s y F JQ� O� v / in'esSEw ��e;-aaox 3 aY3 e3z e Sao„n cE e„ b j 7 0 5 oo� r z z O U) 0 CO � D gcf) a W� J ry z_ 0la. V � °z Z_ '$ z 'J^ V! z J W LL Ens o 01.1 Oyu Nidol Hd r O Z Z /i W 5� s a 3A LL ' wb qgWO AM Q VJ Z U w MR w yg� `r� gE'ao 9p� ^3°ga oc eLL €� rc �Y��pw 6� x r B3° gMum NO! =fig s R t$ n7"E$sC Je`s SS S'ogyo--so p J6asoe LL 9u g`$n i6 pw E \. n o W :S w �o as w ��tl��". x'g -G �x'Al "e of zo z fee 8� r w a w � #9 NOFICF OF MEET ING - 6/22/2022 9. Consider and take necessary action to approve a request from Maeghen Strahan to use the Port O'Connor Community Center property for a benefit Clay Shoot on October 8, 2022 to raise funds for the Port O'Connor Community Center upgrades. (GDR) Jim. Cooley spoke on behalf of Meaghen Strahan. RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Vern Lyssy, Commissioner.Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 5 of 16 Gary D. Reese County Commissioner County of Calhoun Precinct 4 June 9, 2022 Honorable Richard Meyer Calhoun County Judge 211 S. Ann Port Lavaca, TX 77979 RE: AGENDA ITEM Dear Judge Meyer: Please place the following item on the Commissioners' Court Agenda for June 22, 2022. • Consider and take necessary action on request from Maeghen Strahan to use the Port O'Connor Community Center property for a benefit Clay Shoot October 8, 2022 to raise funds for Port O'Connor Community Center upgrades. Sincerely, n�) o'rL--� Gary D. Reese GDR/at P.O. Box 177 — Seadrift. Texas 77983 — email: earv.reese(a)calhouncolx ora — (361) 785-3141 — Fax (361) 785-5602 April Townsend From: rangermortgage@icloud.com (Troy Cooley) <rangermortgage@icloud.com> Sent: Wednesday, June 15, 2022 2:26 PM To: April Townsend Subject: Fwd: Insurance Attachments: Event Policy Quote_6.10.22.pdf; Untitled attachment 00082.htm CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. April, attached Maeghan's e mail with the insurance persons name and number she requested that the comity legal department attorney give her a call to make sure that lie is satisfied with the quote and answer any questions. She does the port O'Connor chamber of commerce insurance for the Fireworks. The dates arejust to aet a quote says that if she put the October date they couldn't get a quote which 1 don't really understand but stranger things happen. Thanks Jim Jim Cooley Begin forwarded message: From: Maeglten Strahm <maeghen(a)nickelrock IIc.com> Date: June 15. 2022 at 10:35:41 AM CDT To: Troy Cooley <rangermortgage(ctiicloud.coni> Subject: Re: Insurance Jim, From what I'm being told, we don't get a declaration page until we get the policy, which is no more than 30 days before the event. I am including the Quote for Coverage for the Event Policy we WILL get30 days before the event which will list Calhoun County as additional insured; and they will be indemnified on the policy. I feel we should be able to get approval for this event with the condition that we have the policy in place by event time (30 days prior) They can contact Kristina Matthijetz at Wellmann (Sieglers Insurance) as she also does the policy for the POC Chamber of Commerce and is setting this Event Policy up exactly the same as theirs. Her direct# is 979-542-3449 or email kmatthiietz@wellmanninsurance.com Thanks Jim, M NICKEL ROCK, LLC PO Box 2239 San Marcos. TX 78666 Ot(512) 216-6219 CI (512) 608-8388 06/10/2022 07:05 AM Quote Number: OT-01915725 Page 1 of 4 Commercial Insurance Quote Proposal To: Contact Name: Contact Email: �� C R id ••a �„„ ro u p Contact Phone: From: CRC Binding (Houston, TX) Wholesale test Specialty Address: 10375Ri77042dAve Ste 427Houston TX License #: Underwritten By: SCOTTSDALE INSURANCE COMPANY A.M. Best rated A+ (Superior), FSC XV Minimum Earned: 100% Minimum and Advance Premium: 100% These terms are valid for 60 days from JUNE 10,2022. Our quote may differ from the terms requested. Please review the quote carefully. If the policy is cancelled at the insured's request, including non-payment of premium, there will be a minimum earned premium retained by us. If a policy or inspection fee is applicable to this policy, the fees are fully earned. No Flat cancellations. At the close of each audit period, we will compute the earned premium for that period. If the earned premium is greater than the advance premium paid, an audit premium will be due. There will be no returned premium upon Audit if the estimated exposure is less than shown, unless the Minimum and Advance Premium is less than 100%. Applicant Name: PORT O' CONNOR COMMUNITY CENTER ____� Proposed Policy Period: - 06/10/2022 To 06/11/202_2 Quote Number: I QT-01915725 Agent Reference Number: Renewal of M NEW Premium Summary LIABILITY Sub Total Premium_:___ Policy Fee Surplus Lines Tax - _ � _ — $250 MP $250 $200.00 $21.83-� - Stamp Fee $.34 Grand Total: -------- _ $472.17 -- Terrorism: Terrorism coverage can be purchased far an additional premium of 513.00 plus applicable taxes and fees. Signed acceptance/rejection required at binding. 06/10/2022 07:05 AM Commercial Liability Coverage Page 2 of 4 Limits General Aggregate $2,000 000 Products/Completed Operations Aggregate $2,000,000 Personal and Advertising Injury Per Occurrence i I $1.000,000 $1,000,000 Damage to Premises Rented to You $100000 Medical Payments $5,000 Deductible _ _ -, $0 BI/PD/PA PER CLAIMANT Liability Rating Classifications and Premium t + PRODUCTS/COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT Commercial Liability Additional Insureds Final Liability Premium: $250 MP O6/10/2022 07:05 AM Forms and Endorsements Common Policy NOTS0065TX 01-21 IMPORTANT NOTICE -TEXAS NOTS0079TX 04-09 TEXAS REQUIRED NOTICE NOTX0178CW 03-16 CLAIM REPORTING INFORMATION NOTX0423CW 12-20 POLICYHOLDER DISCLOSURE - NOTICE OF TERRORISM INSURANCE COVERAGE UTS-COVPG 03-21 COVER PAGE OPS-D-1-0117 01-21 COMMON POLICY DECLARATIONS UTS-126L 10-93 SCHEDULE OF TAXES, SURCHARGES OR FEES UTS-SP-2 12-95 SCHEDULE OF FORMS AND ENDORSEMENTS UTS-SP-3 08-96 SCHEDULE OF LOCATIONS IL 00 17 11-98 COMMON POLICY CONDITIONS UTS-496 06-19 MINIMUM EARNED CANCELLATION PREMIUM UTS-9g 06-20 SERVICE OF SUIT CLAUSE Commercial Liability CLS-SD-1L 08.01 COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL DECLARATIONS CLS-SP-IL 10-93 COMMERCIAL GENERAL LIABILITY COVERAGE PART EXTENSION OF SUPPLEMENTAL DECLARATIONS CG 00 01 04-13 COMMERCIAL GENERAL LIABILITY COVERAGE FORM CG 20 11 12-19 ADDITIONAL INSURED -MANAGERS OR LESSORS OF PREMISES Page 3 of 4 CG 21 06 05-14 EXCLUSION -ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION AND DATA -RELATED LIABILITY -WITH LIMITED BODILY INJURY EXCEPTION CG 21 16 04-13 EXCLUSION -DESIGNATED PROFESSIONAL SERVICES CG 21 32 05-09 COMMUNICABLE DISEASE EXCLUSION CG 21 44 04-17 LIMITATION OF COVERAGE TO DESIGNATED PREMISES, PROJECT OR OPERATION CG 2147 12-07 EMPLOYMENT -RELATED PRACTICES EXCLUSION CG 21 67 12-04 FUNGI OR BACTERIA EXCLUSION CG 21 73 01-15 EXCLUSION OF CERTIFIED ACTS OF TERRORISM CG 24 04 12-19 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) CG 24 26 04-13 AMENDMENT OF INSURED CONTRACT DEFINITION CG 40 12 12-19 EXCLUSION - ALL HAZARDS IN CONNECTION WITH AN ELECTRONIC SMOKING DEVICE, ITS VAPOR, COMPONENT PARTS, EQUIPMENT AND ACCESSORIES CG 40 15 12-20 CANNABIS EXCLUSION WITH HEMP EXCEPTION GLS-106s 12.13 TOTAL LIQUOR LIABILITY EXCLUSION GLS-152s 08-16 AMENDMENT TO OTHER INSURANCE CONDITION GLS-227s 02-18 ASSAULT AND/OR BATTERY EXCLUSION GLS-289s 11-07 KNOWN INJURY OR DAMAGE EXCLUSION -PERSONAL AND ADVERTISING INJURY 06/10/2022 07:05 AM Forms and Endorsements GLS-341 s 08-12 HYDRAULIC FRACTURING EXCLUSION GLS-457s 10-14 AIRCRAFT EXCLUSION GLS-47s 10-07 MINIMUM AND ADVANCE PREMIUM ENDORSEMENT GLS-570 07-21 CONTRACTORS SPECIAL CONDITIONS Each Occurrence Limit : Personal and Advertising Injury Limit General Aggregate Limit (Other than Products/Completed Operations) Products/Completed Operations Aggregate Limit : GLS-5s 04-08 SPECIAL EVENT PARTICIPANT EXCLUSION GLS-74s 09-05 AMENDMENT OF CONDITIONS IL 00 21 09-08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT IL 01 68 03-12 TEXAS CHANGES -DUTIES UTS-230g-TX 09-94 PROMPT PAYMENT OF CLAIMS -TEXAS UTS-266g 05-98 ASBESTOS EXCLUSION UTS-267g 05-98 LEAD CONTAMINATION EXCLUSION UTS-365s 02-09 AMENDMENT OF NONPAYMENT CANCELLATION CONDITION UTS-428g 11-12 PREMIUM AUDIT UTS-74g 08-95 PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION Page 4 of 4 Freedom Specialty Insurance Company National Casualty Company Scottsdale Indemnity Company Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE TERRORISM RISK INSURANCE ACT Under the Terrorism Risk Insurance Act of 2002, as amended pursuant to the Terrorism Risk Insurance Program Reauthorization Act of 2019 (the "Act"), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act: The term "certified acts of terrorism" means any act that is certified by the Secretary of the Treasury —in consultation with the Secre- tary of Homeland Security, and the Attorney General of the United States —to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. You should know that where coverage is provided by this policy for losses resulting from "certified acts of terrorism," such losses may be partially reimbursed by the United States Government under a formula established by federal law. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear, chemical, biological or radioactive events. Under the formula, the United States Government agrees to reimburse eighty percent (80%) of covered terrorism losses that exceed the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage Is provided below and does not include any charges for the portion of loss that may be covered by the Federal Government under the Act. You should also know that the Act, as amended, contains a $100 billion cap that limits United States Gov- ernment reimbursement as well as insurers' liability for losses resulting from "certified acts of terrorism" when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate Insured losses for all insurers exceed $100 billion, your coverage may be reduced. CONDITIONAL TERRORISM COVERAGE The federal Terrorism Risk Insurance Program Reauthorization Act of 2019 is scheduled to terminate at the end of December 31, 2027, unless renewed, extended or otherwise continued by the federal govern- ment. Should you select Terrorism Coverage provided under the Act and the Act is terminated Decem- ber 31, 2027, any terrorism coverage as defined by the Act provided in the policy will also terminate. Nationwide' NOTX0423CW (12-20) Page 1 of 2 IN ACCORDANCE WITH THE ACT, YOU MUST CHOOSE TO SELECT OR REJECT COVERAGE FOR "CERTIFIED ACTS OF TERRORISM" BELOW: The Note below applies for risks in these states: California, Georgia, Hawaii, Illinois, Iowa, Maine, Missouri, New Jersey, New York, North Carolina, Oregon, Rhode Island, Washington, West Virginia, Wisconsin. NOTE: In these states, a terrorism exclusion makes an exception for (and thereby provides coverage for) fire losses resulting from an act of terrorism. Therefore, if you reject the offer of terrorism coverage, that rejection does not apply to fire losses resulting from an act of terrorism coverage for such fire losses will be provided in your policy. If you do not respond to our offer and do not return this notice to the Company, you will have no Terrorism Coverage under this policy. Please select one of the checkboxes below. I hereby elect to purchase certified terrorism coverage for a premium of $ 13.00 ❑ 1 understand that the federal Terrorism Risk Insurance Program Reauthorization Act of 2019 may terminate on December 31, 2027. Should that occur my coverage for terrorism, as defined by the Act, will also terminate. ❑ I hereby reject the purchase of certified terrorism coverage. Policyholder/Applicant's Signature Print Name Date Named Insured/ Business Name QT-01915725 Policy Number, if available Natlonvifew NOTX0423CW (12.20) Page 2 of 2 # Zo NOTIC.;E 01= MF_ETING — 6/22/2022 10. Consider and take necessary action to accept the Matagorda Bay Mitigation Trust Contract No. 031 for the Green Lake Park Development Phase 1 Engineering Services and authorize Judge Meyer to sign all documentation. (GDR) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese' Page 6 of 16 Gary D. Reese County Commissioner County of Calhoun Precinct 4 June 16, 2022 Honorable Richard Meyer Calhoun County judge 211 S. Ann Port Lavaca, TX 77979 RE: AGENDA ITEM Dear judge Meyer: Please place the following item on the Commissioners' Court Agenda for June 22, 2022. • Consider and take necessary action accept Matagorda Bay Mitigation 'I ust Contract No. 031 for the Green Lake Park Development Phase 1 engineering services and authorize Judge Meyer to sign all documentation. Sincerely, Gary. Reese GDR/at P.O. Box 177 — Seadrift. Texas 77983 — email: eam.rcese r calhouncmx.ore — (361) 785-3141 — Fax (361) 785-5602 MATAGORDA BAY MITIGATION TRUST CONTRACT COVER/SIGNATURE PAGE TITLE OF CONTRACT No. 031: Green Lake Park Development —Phase 1 This Contract is entered into by the Matagorda Bay Mitigation Trust (herein referred to as "the Trust") and the following named Recipient: THE TRUST: RECIPIENT: Matagorda Bay Mitigation Trust Calhoun County P. O. Box 1269 211 S. Ann Street Poth, Texas 78147-1269 Port Lavaca, Texas 77979 Email: Trustee@mbmtrust.com EMAIL: richard.mever(a),calhouncotx.ore Contact Person: Steven J. Raabe, Trustee 2arv.reeseAcalhouncotx.ore Contact Person: Judge Richard Meyer and Commissioner Gary Reese The Recipient ("Recipient") agrees to provide Mitigation Project Work and Services ("Mitigation Project') in compliance with this Contract ("Contract') and all applicable federal and state laws, regulations, and rules. In accordance with the General Terms & Conditions, it is understood and agreed by both parties hereto that the Trust's obligations under this Contract are contingent upon Recipient's compliance with this Contract and federal and state law regulations and rules. This Contract, which constitutes promised performances by the Recipient, consists of the following documents: Contract (Cover Sheet/Signature Page) General Terms and Conditions Statement of Mitigation Project (Attachment A) Budget (Attachment B) Invoice Format (Attachment C) The Recipient hereby acknowledges that it has read and understands this entire Contract. All oral or written agreements between the parties hereto relating to the subject matter of this Contract that were made prior to the execution of this Contract have been reduced to writing and are contained herein. The Recipient agrees to abide by all terms and conditions specified herein and certifies that the information provided to the Trust is true and correct in all respects to the best of its knowledge and belief. CONTRACT PERIOD: FROM: June 1, 2022 UNTIL: December 31, 2024 FUNDING: This Contract may not exceed $266,000.00 ("funds") APPROVED: MATAGORDA BAY MITIGATION TRUST CALHO OUNTY, TEXAS BY: �� BY: ` NAME: Steven J. Raabe NAME: Richard H. Meyer TITLE: Trustee TITLE: Calhoun County Judge DATE: June 13, 2022 DATE: _G —2,7- — ?,cam a-' GENERAL TERMS AND CONDITIONS I. PARTIES A. Trustee of the Matagorda Bay Mitigation Trust herein referred to as "Trustee" or "Trust" as applicable and "Recipient," have made and entered into this Contract herein referred to as "Contract." B. Recipient represents and guarantees that it possesses the legal authority to enter into this Contract, receive the funds authorized by this Contract, and to perform the work and services described on Attachment "A" comprising the Mitigation Project ("Mitigation Project"). The Recipient has obligated itself to perform under this Contract, including subsequent contract amendments or modifications. As may be applicable to Recipient, the Recipient shall comply with appropriate federal and state licensing or certification requirements. C. The persons signing this Contract on behalf of the parties hereto warrant that they are the duly authorized representatives authorized to execute this Contract and to validly bind their respective parties to all terms, conditions, performances and provisions herein set forth. H. PURPOSE This Contract sets forth the terms and conditions upon which the Trust agrees to provide funds ("funds") to the Recipient to perform the Mitigation Project. III. RECIPIENT AS INDEPENDENT CONTRACTOR A. It is understood and agreed by both parties that the Trust is contracting with Recipient as an independent contractor and that Recipient is and shall be liable to its own employees and is responsible for its own risk of loss. B. The Recipient agrees to repay the Trust for all disallowed cost or other claims which may be declared by the Trustee occurring in connection with the Mitigation Project to be performed or administered by the Recipient under this Contract. C. Employees of Recipient are not employees or agents of the Trust. Employees of Recipient are subject to the exclusive control and supervision of Recipient and Recipient is solely responsible for employee payroll and claims arising therefrom. IV. FUNDS A. Funds and Payment Disbursements Trust agrees to pay Recipient in accordance with the approved budget structure set forth in Attachment B and other provisions of this Contract and such payment shall not exceed the amount specified in the Contract Cover/Signature Page. 2. Recipient agrees that it shall not utilize funds for administration or overhead expenses in an amount that exceeds fifteen percent (15010) of the approved budgeted project salaries of Recipient. Recipient shall ensure salary amounts charged to the project are reasonable and solely for the project(s) identified. 3. Funds will be disbursed to Recipient as follows: a. Mitigation Project Work Plan. The work plan for the execution of the Mitigation Project is described in Attachment A and includes the following: i. Details regarding the specific work and services to be performed; ii. A schedule of estimated time to perform each stage of the Mitigation Project; iii. A budget to perform the Mitigation Project as shown in Attachment B; and iv. Such other information requested by Trustee. b. Invoicing. Upon completion of each stage of the Mitigation Project or as otherwise agreed, the Recipient shall electronically submit an invoice to the Trust with details about the work and services performed, the date(s) performed and a list of all expenditures in the format shown on Attachment C and such other information requested by the Trust. Trustee may approve payment of the invoice or upon review request additional information the Trustee deems necessary for clarification or other purposes prior to payment. Trustee may withhold payment until satisfied that the invoice represents accurately the contents therein. Prior to, during, or subsequent to approval of payment of invoices to Recipient, the Trustee shall have the right to conduct an audit or investigation regarding such invoices or other information provided by Recipient. C. Progress ss Reports. Recipient shall provide Trust with a progress report with each invoice detailing the Mitigation Project activities performed to date together with a list of all expenditures with supporting documentation such as paid invoices, copies of subcontracts, reports maintained internally by Recipient, such reports to include information regarding potential issues that affect the Mitigation Project and reports submitted to Recipient's governing body and such other information requested by Trustee. d. Final Report. Recipient shall provide Trust with a final report detailing the Mitigation Project as completed which shall include copies of all reports maintained internally by Recipient, such reports to include information regarding the resolution of issues that affected the Mitigation Project and reports submitted to Recipient's governing body reflecting the completion of the Mitigation Project and such other information requested by Trustee. e. Additional Reports. Recipient agrees to provide follow-up information and documentation to any report submitted to Trust as Trustee deems reasonable and necessary and such other information requested by Trustee from time to time. 4. Recipient agrees to return, refund, or repay to Trust any sum which Trustee determines represents an overpayment to Recipient or represents funds not used in accordance with the terms of this Contract. Trustee's determination of overpayment or funds not used in accordance with the terms of this Contract shall constitute an event of potential default more fully described in Section XIV hereinafter. Trustee may withhold funds to Recipient if Trustee determines that Recipient has not complied with the terms of this Contract. Trustee's determination to withhold funds due to Recipient's failure to comply with the terms of the Contract shall constitute an event of potential default more fully described in Section XIV hereinafter. 6. Recipient agrees that it will not receive duplicate funds from another source for any of the items included in the budget set forth in Attachment B. Following Trustee's approval of the Final Report, any portion of the funds not expended or obligated in accordance with this Contract shall be returned to the Trust by Recipient. 8. This Contract shall not be construed as creating any future financial obligation or debt of or on behalf of Trust. It is understood and agreed that funds may be provided to Recipient only from funds allocated for this Mitigation Project which shall be distributed subject to compliance with this Contract and upon such timing as deemed reasonable by the Trustee. V. RECORDS MANAGEMENT A. Recipient shall maintain all books, records, documents, papers, and other evidence related to Mitigation Project implementation, including financial records, reports maintained internally by Recipient and reports submitted to Recipient's governing body, and Mitigation Project performance information, in accordance with generally accepted business and accounting practices, consistently applied. Recipient shall also maintain the financial data used in the preparation of support for any cost (direct and indirect) information or analysis for the Contract or for any negotiated subcontract. Recipient shall also maintain a copy of any negotiated subcontract. Recipient shall also maintain a copy of any cost information or analysis submitted to Trustee. Recipient agrees to the disclosure and access of Trustee, or any authorized representative of Trustee to all such books, records, documents, papers, and other evidence for the purposes of review, inspection, audit, excerpts, transcriptions and copying during normal business hours. B. Recipient understands that acceptance of funds under this Contract acts as acceptance of the authority of the Trustee or his authorized representative, to conduct an audit or investigation in connection with those funds. Recipient further agrees to fully cooperate with the Trustee, or his authorized representative in the conduct of the audit or investigation, including providing all records requested. Recipient shall ensure that this clause concerning the audit of funds accepted under this Contract is included in any subcontract it awards. C. Recipient shall maintain such records and be subject to these audit requirements during the performance under this Contract fora period of five years after Trustee provides written approval of the Final Report. However, if Recipient is aware of any litigation, claim, negotiation, audit, cost recovery or other action, including actions concerning costs of items to which an audit exception has been taken, relating to the Mitigation Project that started before the expiration of the five-year record retention period, Recipient shall maintain all records and be subject to such audit requirements until completion of the action or resolution of all issues which arise from any litigation, claim, negotiation, audit, cost recovery or other action, or until the end of the five-year record retention period, whichever is later. The Trustee will have access to records at any reasonable time for as long as the records are maintained by Recipient. Recipient agrees to transfer records in its custody to Trustee upon his request. This paragraph survives termination of this Contract. D. Failure to comply with all records management and reporting requirements of this Contract shall constitute an event of potential default more fully described in Section XIV hereinafter. VI. FINANCIAL MANAGEMENT Recipient shall have a financial management or accounting system which accounts for costs in accordance with generally accepted accounting standards and principles. Recipient shall allow Trustee's review of the adequacy of the financial management system. Failure to maintain the financial accounting requirements shall constitute an event of potential default more fully described in Section XIV hereinafter. The accounting requirements shall include: A. Provide for the identification of costs in accordance with the approved project budget (Attachment B) and segregation of Mitigation Project costs between the budget categories; B. Maintain records which adequately identify the source and application of funds provided under this Contract. Such records must contain information pertaining to awards and authorizations, obligations, unobligated balances, assets, liabilities, outlays or expenditures, and income; C. Provide internal control by maintaining effective control and accountability for all cash, real and personal property and other assets paid for under this Contract. All such property acquired with Project funds must be adequately safeguarded and used solely for authorized purposes; D. Provide budget control by comparing outlays and expenditures with budgeted amounts for the funds provided by the Trust both by category and by task as shown in Attachment C; E. Support accounting records with source documentation, including cancelled checks, paid invoices, payrolls, time and attendance records, and subcontract documents; F. Permit the tracing of funds to a level of expenditures adequate to establish that such funds have not been used in violation of this Contract or applicable statutes; and G. Permit preparation of reports required by this Contract or requested by Trustee. VII. SUBCONTRACTORS A. Recipient may subcontract all or any portion of the Mitigation Project for purposes of this Contract. B. Recipient shall be responsible for all acts and omissions of all subcontractors performing or furnishing any portion of the Mitigation Project under a direct or indirect contract with Recipient to the extent provided under applicable laws and regulations. Nothing in this Contract shall create for the benefit of any such subcontractor any contractual relationship between Trust and any such subcontractor, nor shall it create any obligation on the part of Trust to pay or to see to the payment of any money due to any such subcontractor. C. Recipient shall be solely responsible for scheduling and coordinating the work of subcontractors performing or furnishing any portion of the Project under a direct or indirect contract with Recipient. Recipient shall require all subcontractors performing or furnishing any portion of the Project who desire to communicate with Trustee to communicate through Recipient with Trustee. D. All work performed for Recipient by a subcontractor shall be pursuant to an appropriate written contract between Recipient and the subcontractor which is not inconsistent with the terms and conditions of this Contract. Each subcontractor shall be provided a copy of this Contract prior to initiating any portion of the Project. VIII. PUBLICATIONS. NEWS RELEASES, AND OTHER PUBLIC All public reports, news releases, other publicity, and other materials prepared for publication pursuant to or as a result of this Contract shall acknowledge the Matagorda Bay Mitigation Trust as the funding source. Public reports or other publications, news releases, and other publicity issued by Recipient about the Mitigation Project shall be provided to Trustee. IX. RIGHTS IN DATA AND OTHER MATERIALS A. Recipient and the Trust agree that any data collected as a result of this Contract shall be jointly owned by Recipient and the Trust. Recipient and Trust agree that each shall have complete and unlimited access and use to all data collected as a result of this Contract. Further, at the termination of the Trust, or at such other time deemed appropriate by Trustee, the Trustee has the right, but not the obligation to transfer any interest in the data to Recipient. B. Recipient shall act to ensure all subcontractors used for this Mitigation Project are advised of the rights in data and other materials described herein and that the subcontractors are prohibited from asserting any rights at common law or in equity or otherwise seeking to establish any claim to statutory copyright in any data, material or information developed under this Contract. C. Recipient and the Trust agree that in addition to the joint ownership by Recipient and the Trust of any data collected as a result of this Contract, that in the event any invention or intellectual property is created as a result of this Contract in which the Recipient retains title, Trust shall have a non-exclusive, nontransferable, irrevocable, paid -up license to practice or have practiced the subject invention throughout the world. Materials developed as a result of this Contract will be made available to the Trustee in written and electronic formats upon request under the non-exclusive, nontransferable, irrevocable, paid -up license. D. The Recipient has the responsibility to obtain from its subcontractors all data and rights therein necessary to fulfill the Recipient's obligations to the Trust under this Contract. If a subcontractor refuses to accept terms affording the Trust's such rights, the Recipient shall promptly bring such refusal to the attention of the Trustee. E. Recipient shall place a section in all subcontractor contracts that complies with Section IX. X. AGREEMENT TO HOLD HARMLESS AND INDEMNIFICATION A. TO THE EXTENT PERMITTED BY APPLICABLE LAW, RECIPIENT AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE TRUST, TRUSTEE AND AGENTS, EMPLOYEES, CONSULTANTS, ACCOUNTANTS, ATTORNEYS AND OTHER PROFESSIONALS AND REPRESENTATIVES ENGAGED OR EMPLOYED BY THE TRUST TO THE FULL EXTENT PERMITTED UNDER FEDERAL AND STATE LAW FROM AND AGAINST ANY AND ALL CLAIMS, DEMANDS, AND CAUSES OF ACTION TO THE EXTENT ARISING FROM THE MISCONDUCT, NEGLIGENCE, OMISSIONS, OR RECKLESS ACTS OF RECIPIENT OR ITS EMPLOYEES, OFFICERS, OFFICIALS OR AGENTS OR ITS SUBCONTRACTORS IN CONNECTION WITH THE PERFORMANCE OF SERVICES OR WORK BY RECIPIENT UNDER THIS CONTRACT. THE PROVISIONS OF THIS PARAGRAPH SHALL SURVIVE TERMINATION OF THIS CONTRACT. B. TO THE EXTENT PERMITTED BY APPLICABLE LAW, THE RECIPIENT AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE TRUST, TRUSTEE AND AGENTS, EMPLOYEES, CONSULTANTS, ACCOUNTANTS, ATTORNEYS AND OTHER PROFESSIONALS AND REPRESENTATIVES ENGAGED OR EMPLOYED BY THE TRUST TO THE FULL EXTENT PERMITTED UNDER FEDERAL AND STATE LAW FROM ANY AND ALL CLAIMS AND LOSSES ACCRUING OR RESULTING TO RECIPIENT AND TO ANY AND ALL SUBCONTRACTS, MATERIALS, PERSONS, LABORERS AND AN OTHER PERSONS, FIRMS OR CORPORATION, FURNISHING OR SUPPLYING WORK, SERVICES, MATERIALS, OR SUPPLIES IN CONNECTION WITH THE PERFORMANCE OF THIS CONTRACT. XI. CONFLICT OF INTEREST A. Recipient shall maintain an internal policy regarding conflicts of interest and shall adhere to said policy with respect to any potential or actual organizational or personal conflict of interest between Recipient and its employees or any 0 subcontractor with respect to this Contract. Further, such internal policy shall include a prohibition that funds received by Recipient from the Trust shall not be used to pay, reimburse or otherwise give in any manner or for any purpose to the Plaintiffs and Defendants in Cause No. 6-17-CV-00047, In San Antonio Bay Estuarine Waterkeeper and S. Diane Wilson vs. Formosa Plastics Corp., Texas, and Formosa Plastics, Corp., U.S.A., in the United States District Court for the Southern District of Texas, Victoria Division. B. Recipient shall notify Trustee regarding any potential or actual organization or personal conflict of interest involving Recipient's employees or subcontractors and shall keep the Trustee informed regarding any actions taken or decisions made in connection with such employee or subcontractor. In the event that the organizational or personal conflicts of interest does not become known until after performance on the Contract begins, Recipient shall notify Trustee of the conflict and any action taken as soon as Recipient becomes aware of the conflict. C. Trustee has sole discretion to make the final determination as to whether an organizational or personal conflict of interest exits, and if the conflict of interest requires action beyond the action taken by Recipient, whatever action that may be. Trustee may request Recipient to terminate any subcontractor in whole or in part, if Trustee deems such termination necessary to avoid an organizational or personal conflict of interest. D. If Recipient was aware of an actual organizational or personal conflict of interest prior to award or discovered an actual conflict afterward and did not disclose it or misrepresented relevant information to Trust, Trustee, at his sole discretion, may terminate this Contract for default or pursue such other remedies as may be permitted by law or this Contract. E. Recipient shall place a section in all subcontractor contracts that complies with Section XI. XII. VENUE Recipient acknowledges and agrees that this Contract is being performed in Calhoun County, Texas. Recipient agrees that any permissible cause of action involving this Contract arises solely in Calhoun County. XM. ENTIRE AGREEMENT This Contract constitutes the entire and full agreement between the Recipient and the Trust, and all previous oral or written agreements relating to the subject matter of this Contract between the Trust and Recipient have been superseded, reduced to written form, and are incorporated herein. Recipient and Trust expressly agree and understand that all future, oral agreements, representations or modifications shall not have any legal binding effect unless and until reduced to writing and executed by both Recipient and Trustee, except for amendments by operation of law as provided in Section XVII in this Contract. XIV. DEFAULT AND REMEDIES A. Recipient shall be considered in default under this Contract if any one or more of the following events occur, provided that Recipient has received written notice of such potential default from Trustee and has failed to cure the potential default within thirty days from the date of said notice. If Recipient has begun a good faith effort to cure the potential default within the thirty -day period, Recipient may be allowed additional time, if deemed reasonable by Trustee in his sole discretion, as needed to cure the potential default. B. Event of Potential Default. Trustee will, in his sole discretion, determine if an Event of Potential Default exists. Each of the following shall constitute an Event of Potential Default under this Contract: If Recipient makes an assignment for the benefit of creditors or takes any similar action for the protection or benefit of creditors. 2. If at any time Recipient knowingly, negligently, or intentionally makes any representation to Trustee which is incorrect in any material respect. If Recipient knowingly, negligently, or intentionally submits any request for payment to Trust which is incorrect in any material respect. 4. If Recipient knowingly, negligently, or intentionally submits any report or certification to Trust related to the Mitigation Project which is incorrect in any material respect. 5. If Recipient utilizes funds which Trustee determines represents an overpayment to Recipient or represents funds not used in strict accordance with the terms of this Contract. 6. If Recipient fails to perform the Mitigation Project described on Attachment A in any material aspect. If Recipient fails to comply with the reporting and invoicing requirements under this Contract. 8. If Recipient fails to maintain the records management requirements under this Contract. 9. If Recipient fails to maintain the financial accounting requirements under this Contract. 10 10. If Recipient fails to maintain the insurance requirements under this Contract. 11. If Recipient fails to comply with any term or provision contained in this Contract. C. Remedies. Upon the occurrence of any such Event of Potential Default and failure of Recipient to cure such potential default as provided above, Trustee may declare Recipient in default in writing and may, as Trustee determines appropriate, withhold payments to Recipient or require Recipient to return, refund or repay any payments received prior or subsequent to the event of default. In addition, Trustee may terminate this Contract and avail himself of any appropriate legal remedies, including recovery of attorney's fees and expenses incurred in enforcing any such legal remedies, if so awarded by a court of competent jurisdiction. D. No Waiver. A waiver of any Event of Potential Default shall not be considered a waiver of any other or subsequent Event of Potential Default, and any delay or omission in the exercise or enforcement of the rights and powers of Trust shall not be construed as a waiver of any rights or powers. XV. USE OF FUNDS AND LIMITATIONS ON EXPENDITURES Funds distributed or allocated to Recipient under this Contract, or any modification thereto, shall not be used to support other programs operated by the Recipient under a different contract. Nor can such funds be carried over to a new contract or amended contract without the written permission of the Trustee. XVI. LIMITATION ON LIABILITY The Recipient understands and agrees that the Trust shall not be liable for expenditures made in violation of terms of this Contract, any laws, regulations, rules, or policies, or any other laws or regulations applicable to the Mitigation Project performed under this Contract. The Recipient also agrees that the Trust shall not be liable for any cost incurred by Recipient which exceeds the funding amount provided hereinabove. The Recipient shall be liable for such funds and shall repay such funds even if the improper expenditure, if any, was made by a subcontractor of the Recipient. XVII. AMENDMENTS BY OPERATION OF LAW Any alterations, additions, or deletions to the terms of this Contract which are required by changes in Federal law, State law, by regulations, are automatically incorporated into this Contract as if set forth fully, without written amendment hereto, and shall become effective on the effective date designated by such law, regulation, or policy. 11 XVIII. COMPLIANCE WITH LAW. Recipient covenants and agrees to comply with all applicable Federal, State and local laws, and all applicable Federal and State regulations. Recipient shall also be responsible to ensure that its' subcontractors shall comply with applicable Federal, State and local laws, and all applicable Federal and State regulations. XIX.PATENT INDEMNITY The Recipient shall include a provision in all of its contracts with contractors and subcontractors that the contractor and subcontractor will indemnify the Trustee, the Trust and its consultants, agents, attorneys, and employees against liability, including costs, for infringement of any United States patent (except a patent issued upon an application that is now or may hereafter be withheld from issue pursuant to a Secrecy Order under 35 U.S.C. §181) arising out of the manufacture or delivery of supplies, the performance of services, or the construction, alteration, modification, or repair of real property under this Contract, or out of the use or disposal by or for the account of the Trust of such supplies or construction work. XX. DISCLOSURE OF INTEREST Recipient represents and warrants that the Trustee, the Trust or its' consultants, agents or attorneys have no ownership or beneficial interest of any kind in Recipient or Recipient's subcontractors. Further, Recipient shall ensure subcontractor's compliance with Section XX. XXL SEVERABILITY If for any reason any section, paragraph, subdivision, clause, phrase, word or provision of this Contract shall be held invalid or unconstitutional by final judgment of a court of competent jurisdiction, it shall not affect any other section, paragraph, subdivision, clause, phrase, word or provision of this Contract for it is the definite intent of the parties that every section, paragraph, subdivision, clause, phrase, word or provision hereof be given full force and effect for its purpose, so long as the invalidated matter does not substantially deprive a party of the benefit of this Contract. XXII. INSURANCE Recipient shall maintain during the term of this Contract and shall provide Trustee with proof of insurance in amounts sufficient to cover the Recipient's liability subject to applicable constitutional and statutory limitations of liability. 12 1. The Trust shall not be responsible for the payment of premiums or assessments on such policies. 2. Proof of insurance showing such coverages as required herein shall be submitted to Trustee within 20 days of contract execution. 3. In the event any insurance policy as specified herein is cancelled or in the event Recipient fails to maintain the minimum insurance limits as specified herein or in the event recipient fails to provide certificates of insurance, such event shall constitute an event of potential default more fully described in Section XIV hereinabove. XXIII. ASSIGNMENT ON This Contract shall be binding on and inure to the benefit of the Trust and Recipient and their respective successors and permitted assigns. This Contract may not be assigned by Recipient without the prior written consent of the Trustee. All notices, communications, and requests given to or made upon the Trust and Recipient hereto shall, except as otherwise specified herein, be in writing and shall be delivered or mailed to such parry at the notice addresses specified on the Contract Cover/Signature Page. The Trust and Recipient may change their notice addresses but shall provide immediate notice to the other and shall provide such notice in writing to the other party. XXV. DISPUTES In the event a Recipient has a dispute with the Trust or in the event any Recipient seeks to file a claim or lawsuit, the Recipient's sole recourse shall be by informal dispute resolution between the Recipient and the Trust and if such informal dispute resolution is not resolved, then the Recipient may seek the alternative dispute resolution as provided herein. The alternative dispute resolution process shall consist of a Mediated Settlement Conference in Calhoun County, to be conducted with the Recipient and the Trust and their legal counsel. The mediator shall be selected by agreement of the Recipient and the Trustee. Should the parties fail to agree on a mediator, an attorney mediator shall be selected by the Director of Calhoun County Dispute Resolution Services. The decision made by a Mediator shall be binding on the Recipient and the Trust, and there shall be no further appeal but the decision shall be enforced, if necessary, by the District Court of Calhoun County. The Recipient agrees to submit to such binding alternative dispute resolution as provided herein. Further, Recipient's sole remedy under the informal dispute resolution and under the binding alternative dispute resolution shall be limited to all, none or part of the remaining balance, if any, of Funds allocated to it under the terms of this Contract with the Trust; however, the Trust may recoup any Funds distributed to the Recipient through the same alternative dispute resolution procedure described herein. Any remedy under the mediation shall be sole province of the Mediator unless the Recipient and Trustee agree otherwise. In no event shall a Recipient be entitled to any other remedy; including, but not 13 limited to, actual damages, compensatory damages, punitive damages, exemplary damages, interest, costs of court, actual expenses and attorneys' fees. These procedures shall be binding on Recipients notwithstanding any conflict with any law or regulation. XXVI. PERIOD OF CONTRACT This Contract will remain in effect until the termination of the CONTRACT PERIOD as defined above, unless extended, modified, or terminated by written agreement of the Parties or terminated as provided herein with the exception of the five-year records retention provision in Section V. This provision shall survive termination of this Contract. END OF TERMS AND 14 Matagorda Bay Mitigation Trust ("Trust") ATTACHMENT A STATEMENT OF MITIGATION PROJECT Calhoun County, Texas ("Recipient") 211 S. Ann Street Port Lavaca, Texas 77979 The Green Lake Park Development Project Phase 1 shall include: Surveying Services 1. Perform a Topographic Survey, a Hydrographic Survey and an Aerial Survey of the project areas. Engineering Services 1. Review master plan. 2. Update preliminary cost estimates. 3. Develop a phasing plan for proposed improvements. 4. USACE real estate preliminary planning. S. Develop construction plans, prepare contract & bidding documents, oversee the bidding process and perform contract administration. 6. Attend meetings, as required. Environmental Services 1. Wetlands Delineation. 2. Threatened & Endangered Species Assessment. 3. Cultural Resources Pedestrian Surveys. Architectural Services 1. Design of a 40' x 40' open air pavilion, picnic table covers and possible ticket booth. Geotechnical Investigation Services 1. Perform preliminary testing services of the project areas and provide recommendations. 15 Matagorda Bay Mitigation Trust ("Trust") ATTACHMENT B BUDGET Calhoun County ("Recipient") 211 S. Ann Street Port Lavaca, Texas 77979 Contract Budget Direct Salaries Taxes and Benefits Administrative Overhead Construction Consultants/Contractual $ 260,000.00 Insurance Permits Supplies/Materials Travel -Mileage Total Contract Budget $260,000.00 RECIPIENT WILL SUBMIT INVOICES TO TRUST (mark appropriate option): M X Monthly Quarterly 16 Matagorda Bay Mitigation Trust ("Trust") ATTACHMENT C INVOICING INSTRUCTIONS Below are the instructions on how to complete and submit your invoice. All invoices must be submitted electronically. You do not need to submit a hard copy unless specifically requested to do so. Invoices that don't balance or that lack proper supporting documentation will be delayed, so please ensure that your invoice is in order prior to submission. The Recipient's Contract includes the budget and invoice form (Attachment Q. The Contract's budget is tracked in two ways: Budget by Contract Category and Budget by Task. Each invoice submitted for payment must track the project costs in compliance with the Recipient's Contract as outlined in Attachment C. Each field at the top and bottom of the Invoice form must be completed and the invoice must be signed and dated by the person authorize to certify that the invoice is true, correct and complete and in accordance with the Contract. Each invoice should have the amounts being billed for the current billing period ("This Invoice" columns) and the accumulated amount billed for this Contract to -date, including the current billing period ("Contract To -Date" columns). Please take special note that the two budgets — Budget by Contract Category and Budget by Task — must always equal. Supporting documentation must be attached to the invoice for each line item being billed in the sequence such items appear in the Budget by Contract Category section. Each supporting document must be clearly labeled and in the proper budget sequence in order allow our audit of the invoice and its approval for payment. Failure to properly label or sequence the supporting documentation will cause a rejection of the invoice, so this is very important. All invoices are to be submitted electronically (email) to: Trustee@mbmTrust.com. If a Recipient has any questions whatsoever about invoicing procedures, please feel free to contact the Trust office at 361-200-1456 or write to Administrator@mbmTrust.com. Effective Date: June 1, 2020 17 Invoice to Matagorda Bay Mitigation Trust Date of Invoice: Recipient Name: Calhoun County Contract #: 031— Green Lake Park Development - Phase 1 Contract Amount: $ 260,000.00 Payment Request No: INVOICE RECAP* Billing Period This Invoice: From To Invoice Amount: $ Is this a final payment application? BUDGET BY CONTRACT CATEGORY BUDGET BY TASK Category This Invoice Contract 'To -Date Total Budget Task This Invoice Contract To -Date Total Budget Direct Salaries/Payroll Engineering Services 260,000.00 Taxes and Benefits Construction Admin Overhead Construction Consultants/Contractual 260,000.00 Insurance Permits Professional Services Supplies/Materials Travel & Mileage Total 260,000.00 *Please see Invoicing instructions Total 260,000.00 Remittance Address: 211 S. Ann Street, Suite A, Port Lavaca, Texas 77979 Name of Payment Contact Person and contact information: Gary Reese, Calhoun County Commissioner Precinct 4 Certification: I certify that the amounts being invoiced are true, correct, and complete in every material respect. Signature and Title of Authorized Representative Print Name and Title of Authorized Representative Date Signed For Office Use Only 18 CERTIFICATE OF INTERESTED PARTIES FORM 1295 Safl Complete Nos. 1- 4 and 6 If there are Interested parties. OFFICE USE ONLY Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. CERTIFICATION OF FILING Certificate Number: 2022-898556 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Matagorda Bay Mitigation Trust Poth, TX United States Date Filed: 06/13/2022 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County Date Acknowledged: 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. Phase 1 Engineering Engineering services for design and construction administration of Green Lake Park Phase 1 improvements 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary Wood, Boykin & Wolters Corpus Christi, TX United States X Aguirre, Robert Pipe Creek, TX United States X Raabe, Steven Poth, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION 1 1 My name is 5 � C.Y� `� t !�a-�.�0 i and my date of birth is My address is (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. J 1 Executed in V � �) '� County, State of a lve, } on the l J day of 5��2. , 20 1,F-, (month) (year) Signature ofauthorized agent of contracting business entity (Declarant) uirns provided by texas Ethics Commission www.etmcs.state.tx.us Version V1.1.191b5cdc #11 NUIICE 0i= MEETING — 6/22/2022 11. Consider and take necessary action to approve the Texas Association of Counties (TAC) Property Insurance renewal for the period 7/1/22 — 7/1/23 as recommended by Gray & Company, LLC. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 7 of 16 Mae Belle Cassel From: cindy.mueller@calhouncotx.org (cindy mueller) <cindy.mueller@calhouncotx.org> Sent: Tuesday, June 14, 2022 7:18 PM To: Mae Belle Cassel Cc: Richard Meyer; Donald K. Gray, ARM; Candice Villarreal Subject: Agenda Item Request Attachments: Property renewal binder for court.pdf Please place the following item on the agenda for 6/22/22: • Consider and take necessary action to approve Texas Association of Counties (TAC) Property Insurance renewal for the period 7/1/22-7/1/23 as recommended by Gray & Company, LLC. Cindy Mueller County Auditor Calhoun County 202 S. Ann, Suite B Port Lavaca, TX 77979 V: 361.553.4610 F: 361.553.4614 Cindv.mueller@calhouncotx.ore Calhoun County Texas 6&P LLC is k, Managers tin/a June 14, 2022 Ms. Cynthia Mueller Calhoun County Auditor 202 South Ann, Suite B Port Lavaca, TX 77979 Re: 711/2022-2023 Property Insurance renewal proposal Dear Ms. Mueller: I have completed my review of TAC's property insurance renewal proposal for coverage to be effective 7/1122 and offer the comments and Recommendation presented below. Attached you will find Exhibits A and B for your review. Exhibit A provides the County's annual property insurance loss ratios for 7/1/21-22 (to date) and the prior six policy periods (losses as a percent of premium). Insurers generally consider loss ratios of less than 70% to be favorable (i.e., not having a negative impact on the policyholder's future premiums). Calhoun County's seven-year property insurance loss ratio is a favorable 72% (very close to being 70%). Of course, this loss ratio is driven by Hurricane Harvey event which resulted in loss of $1,647,685. Without the hurricane loss, Calhoun County's seven-year loss ratio would have been only 14%. Fortunately, TAC's loss from Hurricane Harvey has never affected the County's premium. While Exhibit B shows modest premium rate increases over the last five years, these rate increases were driven by market forces (namely the cost for TAC to buy reinsurance to protect the pool). Exhibit B also compares the expiring premium, premium "rates" and insured values to those proposed for the 7/1122-23 renewal period. When compared to the expiring policy, the only significant change in coverage for 7/1122-23 is an increase in the deductible that applies to building/contents losses. The 7/1/21-22 deductible of $2,500 will increase to $5,000. It is my understanding that the same increase in deductibles to $5,000 is being given to every county insured by TAC. The $1,000 deductible that applies to mobile equipment will not increase for 7/1/22-23. Exhibit B points out that: 1. The 711/22-23 premium of $619,622 has increased by $39,933 (6.89%) as compared to the expiring 7/1/21-22 premium of $579,689. PO Box 1099, Mason, Texas 76856 a phone 512.496-3583 • donaldkoray(7o amad.corn 2. The total "current replacement cost new" values of $102,453,397 for buildings, contents, site improvements, fine arts and mobile equipment that the County reported to TAC for 7/1/22-23 increased by only 0.02% as compared to the values of $102,434,310 reported last year. It is my understanding that TAC plans to conduct an appraisal of the County's buildings in the coming policy year. As per the wording of the policy, the appraised values will be the basis of following year's renewal premium. 3. Only $115 of the $39,933 premium increase is attributable to the increase in values. The balance, $39,818, is the result of the 6.87% increase in the premium rates. Recommendation After reviewing the insurance renewal proposal, I recommend that Calhoun County purchase TAC's very competitive property insurance renewal proposal to become effective 711122. Please let me know if you have any questions or comments. Sincerely, Don Gray, ARM PO Box 1099, Mason, Texas 76856 • phone 512496-3583 • donaldicaravongmail.com W N N 00 00 W OM O `u of ct 1!1 a C N M co to O N N N N O u > 0�0 O m O W C N lG .O c4 6 W N rn r M M Ln e1 N W a' VM1 O d co ct p V �••� 01 to Nin41 k M o N N OIn M In Y1 i, m 4 Ck IN M .h N M 00 00 N O1 N 00 � a in r1 O o � ti N aID O M M aO-i N 1.6 00 0) O N d O N In W N p N N 01 O O t0 d M a N n ^ 0 M m c '^ 01 N �^ •y y N Ul N d 0) E f0 N c 7 N O O u d O u ate+ O 01 a + N � �. O N C N G v q O W _ .-1 vJi '6 .O-1 Y O E c O E c E J G_ CL 2 E^ C d V! 'C C J G J J E m g E '� y n 9 o ° a\d. o v m y m v O J N G V- O O" 0 O 10 �. O J o_ F- m= ii 0 I- w m H m z a a a v > a° 0. a s w] }e \( C C j \ cn § LO ] 2 ■ m / K LO q. 3 } \ cli co CO LO m [ / n } \ \ cn \ w \ co pz E 0 / < f 0 e k0 CL k ca tm > \ [ 2 0eca 0) \ \ \ \ } R f=3 cc ca : _ D m f § { - 41) 43) \ \ \ 0 > _ 0? \ o . w \� §d § a)\ % )f\/\0 f \\}a=o � \ jco }/ a)/ k \o �� kk E {{ / ] C® ]§ R7 a; ¥§.. // 0 05 0 ) k )# )#, )| Cindv Mueller From: donaldkgray@gmail.com (Don Gray) <donaldkgray@gmail.com> Sent: Tuesday, June 14, 2022 1:11 PM To: Candice Villarreal Cc: Cindy Mueller Subject: Property insurance report from Don Gray attached Attachments: 2022_letter.doc; EXHIBITS A and B Calhoun - 2022.xlsx; 2022_property renewal proposal report.pdf; replacment cost values as described in the TAC policy.pdf Follow Up Flag: Follow up Flag Status: Flagged Categories: High Priority c,Au J IUN; i ms emart ongmatect trom outside of the organization. Do not click links or open attachments unless. you recognize the sender and know the content is safe. Candice: Hello Candice. Great to talk to you earlier today. Attached is my report and an Excel file which comaions two worksheets titled Exhibits A and B. The report is provided as a Word document as well as a signed PDF file (your choice). Lastly I have attached a file which contains two important pages from TAC's Property insurance policy which describe the values that the County is to provide to TAC for each renewal and a clause which says that "the member agrees to accept the appraised values". It's been my experience that TAC will listen if a county feels that the appraiser made a mistake in calculating square footage or something that can be proven wrong. But it is also my experience that the value per square foot that they appraiser feels is appropriate is seldom changed when a county questions the appraisal. --Best Regards... Don Gray, ARM I Gray & Company, Contact Information: PO Box 1099, Mason, TX 76856 512.496.3583 Email: doiialdkoTay@gniail.com Time Limits In addition to the time limits shown elsewhere in this Coverage Document, the following apply: Automatic Coverage 120 Day Period Automatic Coverage - Rental Mobile Equipment 120 Day Period Automatic Coverage - Mobile Equipment 30 Day Period Extended Period of Indemnity 180 Day Period Ingress/Egress 30 Day Period Interruption by Civil Authority 30 Day Period 5. MAXIMUM AMOUNT PAYABLE The limit of liability shown on the CCD or in this Coverage Document, or endorsed onto this Coverage Document, is the total limit of the Pool's liability applicable to each Occurrence. The Pool's liability will never exceed the applicable limit of liability or aggregate limit of liability regardless of the number of MEMBER PROPERTY involved. in the event of a covered loss, the Pool's liability is limited to the lesser of the following: A. The actual adjusted amount of loss, less applicable deductible; or B. The limit of liability or aggregate limit of liability shown on the CCD or in this Coverage Document or endorsed onto this Coverage Document. G. VALUE REPORTING PROVISIONS The Member is required to provide the Pool 100% replacement cost values of MEMBER PROPERTY at the beginning of the Coverage Document period unless otherwise noted. The Member is not required to report changes in value for existing MEMBER PROPERTY during the Coverage Document period. The Member must report to the Pool all changes in value annually at renewal. 7. WAITING PERIOD There is a 24-hour Waiting Period before service interruption, civil authority and ingress/egress coverage will be applicable. 8. DEDUCTIBLES For a loss covered by this Coverage Document, the Pool will be liable only if the Member sustains a loss in a single Occurrence greater than the applicable deductible specified below, and only for its share of that greater amount. The deductible amount will not reduce the limit of liability. A. Named Storm: Property consisting of Mobile Equipment shall not be subject to a minimum deductible for Named Storm in Tier One Counties. For MEMBER PROPERTY wholly or partially situated in Tier One Counties, the Member's deductible resulting from a Named Storm is 2% of the 100% replacement cost value, or 100% Reproduction Cost value if applicable, as of the date of the loss at the MEMBER PROPERTY where physical damage occurred and for which the Member Is making a claim for loss or damage. If a claim for loss or damage resulting from a Named Storm involves toss or damage at more than one MEMBER PROPERTY, the deductible amount will be calculated separately TES -AS AssOCJATID% of Cots TIES Property Coverage Document 'RISK MnsnoreEa POOL Page 5 of 73 Board Approved March 25, 2022, Elf. July 1, 2022 Any notice of claim and/or related documents should be mailed to the above immediately or by fax or email. Coverage: This CCD is to outline limits, deductibles, and contributions only. All coverage is subject to the terms, conditions, definitions, exclusions, and sub -limits described in the Coverage Documents, any endorsements, and the IPA. Claims Reporting: The Named Member shall submit claims to the Pool as set forth in each applicable Coverage Document or as otherwise required by the Pool or state law. Failure to Maintain Coverage: The Named Member's failure to maintain at least one coverage through the Pool will result in the automatic and immediate termination of the IPA. Named Member Compliance: By executing the IPA, the Named Member agrees to comply with and abide by the Pool's Bylaws, applicable Coverage Documents, and the Pool's policies, as now in effect and as amended. Payment of Annual Contribution: The Named Member shall pay contributions as outlined on Invoices and as per the terms of the IPA. Pool's Right to Audit: The Pool has the right, but no obligation, to audit and inspect the Named Member's operations and property at any time upon reasonable notice and during regular business hours, as the Pool deems necessary to protect the interest of the Pool. (the perty Appraisal: Property coverage is blanket and based on Replacement Cost. The Pool will provide a formal sical appraisal of the Member's property on a periodic basis and the Member a re to accept the v� aalurWrovided by Pool's appraisal firm. Member agrees to report all buildings and conten�iSrto ren . Pool Coordinator: The Named Member shall appoint a Pool Coordinator. The name of the Pool Coordinator and the address for which notices may be given by the Pool shall be set forth in the space provided at the end of the IPA. The Pool Coordinator shall promptly provide the Pool with any required information. The Named Member may change its Pool Coordinator and the address for notice by giving written notice to Pool of the change before the effective date of the change. Any failure or omission of the Named Member's Pool Coordinator shall be deemed a failure or omission of the Named Member. The Pool is not required to contact any other individual regarding the Named Member's business except the named Pool Coordinator unless notice or contact to another individual is required by applicable law. Any notice given by Pool or its contractor to the Pool Coordinator or such individual as is designated by law for a particular notice, shall be deemed notice to the Named Member, Submission of Information: The Named Member shall timely submit to the Pool documentation necessary for the Pool to use to determine the risk to be covered for the next renewal period and to properly underwrite the risk exposure. The Pool will provide forms identifying the information requested. Termination and Renewal: The coverage outlined in this CCD may be terminated or not renewed by either party as outlined in the IPA or applicable Coverage Document. Termination for Failure to Pay: Notwithstanding any other provision in the IPA, if any payment or contribution for coverage owed by Named Member to the Pool is not paid as required by the IPA, the Pool may cancel coverage or terminate coverage and the IPA, as the Pool deems appropriate, in accordance with the Pool's Bylaws and the applicable Coverage Document The Named Member shall remain obligated for such unpaid contribution or charge for the period preceding termination. Texas Association of Counties Calhoun County S 0290 Rlsk Management Pool Coverage Number: PR-0290-20220701-1 05/02/2022 #12 NOTICE CP MEE1 ING — 6/22/2022 12. Consider and take necessary action to approve the FEMA-4332-DR-TX Project Completion and Certification Report for Project Worksheet #3548 Six Mile Park and the Duplication of Benefits form and authorize the County Judge to sign. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner.Pct 1 SECONDER: Gary Reese, Commissioner Pct 4 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 8 of 16 Mae Belle Cassel From: cindy.mueller@calhouncotx.org (cindy mueller) <cindy.mueller@calhouncotx.org> Sent: Thursday, June 16, 2022 1:26 PM To: Mae Belle Cassel Cc: ladonna thigpen; Richard Meyer Subject: Agenda Item Request Attachments: PW 3548 Six Mile Park.pdf Please place the following item on the agenda for 6/22/22 • Consider and take necessary action on FEMA-4332-DR-TX Project Completion and Certification Report for Project Worksheet #3548 Six Mile Park and the Duplication of Benefits form and authorize County Judge to sign. Cindy Mueller County Auditor Calhoun County 202 S. Ann, Suite B Port Lavaca, TX 77979 V: 361.553.4610 F: 361.553.4614 Cindy. muellerCa)calhouncotx.ore Calhoun County Texas Page 1 of 4 Category Title G Six Mile Park Cost $ 22,845.00 Repair pavilions (3) and 1 picnic shelter $ 7,105.00 Pavilion lights, boat ramp light, meter loop Bulkhead (at boat ramp) $ 14,221.17 Parking area (4887 gals RC250) $152,000.00 Pier $152,000 bid awarded to Fowler $ (52.67) Pier Change Order No. 2 ($104.00 reduction prorated) $ 11,404.81 Engineering services (prorated) $163,352.14 Total for pier only (completed 12/12/18) k 3 ri"t „ $ 207,523 31 `0 ibMR 2,11s' ... Work complete 5/11/22 Proceeds Insurance 2,380.38 Pavilions (3) 19,684.62 Picnic Shelter 42,459.65 Bulkhead (invoices will be submitted) 153,692.12 Pier (invoices submitted) 218,216.77 Proceeds received to date Project - FEMA PW 3558 3548 Type Contract Contract Contract Materials Contract Contract Contract Deductible $ 120.00 $ 660.00 $ 3,286.62 9,660.00 Total deductible 13,726.62 FEMA gross cost: Pier $ 152,000.00 Parking area $ 10,655.55 Picnic shelter/pavilions $ 4,270.40 Bulkhead $ 2,669.04 FEMA total gross cost $ 169,594.99 Insurance reductions $ (142,340.00) FEMA net cost $ 27,254.99 7/18/2019 FEMA PW 3548 Award 90% $ 24,529.49 County cost to date after insurance proceeds to date $ (10,693.46) County net revenue (expense) to date for this PW $ 35,222.95 Invoices in drop box & capital project file; not duplicated ** in PW file. *** Invoices in capital project file; not duplicated in PW file. County Auditor Progress Notes: 10/18/18 Email bid, specs, plans to Emily Foote with 406 mitigation along with PDMG & TDEM. 11/14/18 During weekly meeting, LT advised per Comm. Lyssy: Pier work perhaps complete by end of November; no specs or bids for bulkhead; parking lot (likely force account) will be scheduled after pier complete; pavilion/ Project Cost Summary; Cat G-3558 (2) 6/16/2022, 1:15 PM Page 2 of 4 Category Title Project FEMA PW' G Six Mile Park 3558 3548 Cost Type picnic shelters are complete. 12/12/18 Pier work complete; retainage released. 12/26/18 Emailed LT 2 hazard mitigation proposals to discuss with Vern. 1/4/19 Forwarded LT's response to PDMG. 2/25/19 PDMG sent several EHP questions; forwarded to Vern (cc LaDonna) with request to help answer. 3/6/19 Vern attended weekly meeting with PDMG to provide answers. but continue to gather supporting documentation for pier. 3/29/19 per phone call form LT: No Nationwide 3 Corps of Engineers permit. Alcoa obtained permit for original construction prior to county owning the pier. G&W relied on original Alcoa plans but no changes done in water with this project. Still need to submit contractor's draws as construction sequencing for pier. 4/1/19 LT emailed PDMG google map with locations of damages as requested. 4/10/2019 TDEM extended completion date to 8/25/19. 4/10/2019 Need to scan Fowler Construction draws when able to access the file. 5/3/19 Emailed Fowler invoices and change orders to PDMG. 5/23/19 Emailed letter from G&W regarding pier permit to PDMG. 6/28/19 Pending scope & cost approval by applicant. 7/2/19 Emailed Vern to get approval of cost. 7/3/19 Vern confirmed agreement verbally; CM signed in portal. 9/19/19 Submitted time extension request to extend PoP to 2/25/2020 after discussion with Commissioner Lyssy. 9/26/19 Notice of approval Pop extended to 2/25/2020. 2/26/20 Vern needs another 6-month extension. Does not want to begin parking lot or bulkhead repair until separate GOMESA boat ramp dredging is completed. Project Cost Summary; Cat G-3558 (2) 6/16/2022, 1:15 PM Page 3 of 4 Category ITitle Project FEMA PW G Six Mile Park 3558 3548 Cost Type 3/2/2020 Vern's plan now is to do the paving work since he already has the material. Will wait to repair bulkhead after dredging is finished. As discussed with Vern, Richard & LaDonna this date, will not mention dredging in extension request. 3/2/2020 Confirmed with Vern okay to keep status quo on request to extend Pop to 8/25/2020. Submitted in TDEM portal. 7/14/20 Replied to TDEM request for project status: 80% complete. 7/30/20 CohnReznick called to remind of PoP date. 8/6/20 Talked with Vern; dredging bid not to be considered for award until 9/23; he agreed to requesting 6-mo. time extension with same verbiage as prior request. 8/6/20 Submitted request for time extension. 8/7/20 TDEM notification Pop extended to 2/25/21. 1/25/21 TDEM request for % completion. 2/8/21 Per Vern, request another time extension. 2/22/21 Replied to TDEM status request. 2/23/21 Submitted time extension request to extend Pop to 8/25/21. 3/1/21 TDEM notification PoP extended to 8/25/21. 9/1/21 TDEM request for status. 9/2/21 Submitted time extension to extend Pop to 10/25/21 after discussion with Commissioner Lyssy. 10/20/21 FEMA notification of Pop extended to 10/25/21. 10/27/21 TDEM notification Pop extended to 10/25/21. 11/1/21 Emailed Vern with request to call on status of completion. 11/4/21 After discussion with Vern, request 6 month extension because of non -Harvey improvement contractor problems. 11/5/21 TDEM request for status. Submitted time extension request to extend Pop to 4/25/22. 11/15/21 TDEM returned time extension request for milestones for each month. Edited in GMS portal and resubmitted. 5/11/22 Vern advised paving work is done and project complete. Project Cost Summary; Cat G-3558 (2) 6/16/2022, 1:15 PM Page 4 of 4 Category Title Project FEMA PW G Six Mile Park 3558 3548 Cost Type 5/17/22 Notice of PoP 4/25/22 time extension approved. 5/18/22 Notified TDEM of completion date and attemped to request another time extension in GMS but account is locked; repeated requests to unlock unsuccessful. 5/31/22 TDEM notified time to prepare closeout documents even though no time extension request submitted. 6/16/22 Sent agenda item request with closeout docs. Project Cost Summary; Cat G-3558 (2) 6/16/2022, 1:15 PM Page 1 of 2 Generated Date: 05/31/2022 14:36 FWeral EamMeney Management Agana, Project Completion and Cerlilleadon Report (P.4) Dbastan FEMA-4332-DR-TX Applicant PIPS Wh 037-0057.00 Applleant/Snblleblan Name:CALHOUN(COUNTY) 1 Ameedmenr A Ru�tll workC m 1L Camel. Elie AeumlDate Amt. seen Claimed by Co sett k prai a1Share ,..t She Done RY Dale At Am em Comahmd not Inge. PA-06- TX- 4332- 0 $27,254.99 N PW- 03548 Told for 1 PWs: $27.254.99 gobgranlee Admin: Saw Greed Total: $27,254.99 PA-0s- TX-4332- G Pw- Contract 04-0 0 $27,254.99 05-11-22 3 27,254.99 See* below 03548 (5305) g 27,254.99 eGMS access is locked out; unable to submit time extension request to actual date of completion. Page 2 of 2 Generated Date: 05/31/2022 14:36 Federal Emergency Managam.I Ageney Project ComPleflan and CertiOption Report (PA) Dissever: FENA4332-DR-TX Applicant FIPS ID: 057-99057-00 Applicant/Sobdalsion Name: CALHOUN(COUM) Certification I hereby cmtify O,dio he bestofmy knowledge mdbcliefdl wmk and cmts claimed me eligible I omdy that ell funds were m:pended in accordmce wll: the provisions ofde in acemdmca t rifle grant Condition, ell work claimed has been completed. and all casts signed FEMA-Store Agreement and l recommend anm approved aount of clamed hav m paid la fWl Signed: Date: ALZZ,w2IF Signed: Date: Appliance Anthmised R,,41,4, Govemots Authorised Representative Richard H. Meyer, County Judge '�y''µmmsigY h" TEXAS DIVISION OF EMERGENCY MANAGEMENT m$m��NPQ��W� Applicant's Attestation for Duplication of Benefits YMP Applicant: alhoun County Disaster Number: 4332 Program: I Public Assistance Please complete the below form in accordance with Section 312(a) of the Stafford Act, which states that Federal assistance cannot duplicate the benefits provided by other sources. 1. Is FEMA the only source of funds received for the project(s)? If "NO" is selected, please report any additional funding using the table below. ❑ YES❑ NO 2. Did the Applicant take action to maximize any potential insurance proceeds available to fund the project(s)? i] YES I ❑ NO I ❑ N/A— NO COVERAGE 3. Have all insurance claims related to the project(s) been closed and/or settled? If "NO" is selected, please indicate the amount of "Anticipated Insurance Proceeds" in the table below. 0 YES ❑ NOI ❑ N/A — NO COVERAGE 4. Please use the table below to report any non-FEMA funds received or anticipated for the project(s): Insurance Anticipated Grant Contractor Disposition Other PW Total PW # Claims Insurance Funds Credits or of Salvageable Funds Non-FEMA Received: Proceeds: Received: Refunds: Equipment: Materials: Received: Funds Received: 03548 218,216.77 0.00 0.00 0.00 0.00 0.00 0.00 218,216.77 Statement of Acknowledgement: I certify that that the inform ti�n provided is true and accurate to the best of my knowledge. I understand that if this information is incorrect, i did affect the federal funding for this project(s). Signature: 1 Date: G — Z Z— -2-Q Printed Name: Richard H. Meyer Title: County Judge Organization: Calhoun County #13 NOT ICE OF MEETING - 6/22/2022 13. Consider and take necessary action to authorize Anna Kabela, District Clerk, to sign Kofile's proposal for the preservation and imaging of historical records. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner:Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 9 of 16 Mae Belle Cassel From: anna.kabela@calhouncotx.org (Anna Kabela) <anna.kabela@calhouncotx.org> Sent: Wednesday, June 15, 2022 1:55 PM To: 'Mae Belle Cassel' Subject: PROPOSAL AND FORM 1295 Attachments: PROPOSAL FOR PRESERVATION AND IMAGING OF HISTORICAL RECORDS.pdf; FORM 1295.pdf Hello, Mae Belie, Will you please place the attached proposal and form 1295 on the June 22"d, 2022, Commissioners' Court agenda so the Commissioners may consider and take the necessary action to authorize Anna Kabela, District Clerk, to sign Kofile's proposal for the preservation and imaging of historical records. Please let me know if you need any additional information from me. Thank you! ANNA KABELA District Clerk Calhoun County District Clerk's Office anna.kabela@calhouncotx.ory (361) 5534631 Phone (361) 553-0637 Fax 211 S. Ann - Courthouse, Suite 203 Port Lavaca, Texas 77979 Calhoun County Texas June i 4, 2022 Honorable Anna Kabela Calhoun County District Clerk Preservation and Imaging of Historical SUBMITTED BY: Billy Gerwick Account Executive billy.gerwick@kofile.com (832) 373-9124 6300 Cedar Springs Road, Dallas, TX 75235 I4 p:214.442.6668 1 f:214.442.6669 i y,% in ^ kof file. ( www.Kofile.corn Dear Honorable Anna Kabela, This proposal addresses Calhoun District Clerk's historical records and is presented by Kofile Technologies, Inc. (Kofile). Quoted services include conservation treatments, rehousing, and imaging. Archival rehousing includes encapsulation and loose-leaf binding into Archival Recorder Binders. Note that prices for the inventory herein are good for 90 days from the date of this assessment. Kofile Technologies, Inc. (Kofile) is uniquely qualified to complete Calhoun District Clerk's modernization goals by taking an innovative approach to this project to ensure a successful outcome. Kofile's basis for success is decades of experience, realistic solutions, and professional analysis and each project is unique and deserves special attention. Our team provides realistic solutions, professional analysis, and innovative archival products to equip records stewards with the information and resources needed to preserve collections. Kofile performs all services in accordance with the Code of Ethics & Guidelines for Practice of the American Institute for Conservation (AIC) and is an Awardee of a Library of Congress FEDLINK Preservation Services for Library & Archival Collections contract. SCOPE OF SERVICES General treatments and services are outlined in the following. Services are tailored to the needs of the specific.item. Preservation—Conservotion Treatments, Deacidify, Encapsulate., & Bind (PRV) Kofile creates a permanent log (noting condition, page order, characteristics, and'heatments) for each item upon receipt. Items are inspected and control numbered as necessary. A final quality check references this log. • Dismantle volumes by hand (if applicable). • Surface clean sheets. Tcols include a microspatula, soft dusting brush, latex sponge, powdered vinyl eraser, or soft block eraser. Surface ;leaning removes materials and deposits—e.g., dust, sect, airborne particulate, sediment from water damage, mold/mildew residue, active rnic.•ro-organic growth, insect detritus, or biological or mineral contaminants. • Remove any non -archival repairs, adhesives, residual glues, or fasteners to the extent possible without causing clamage to paper and irks. • Mend tears and guard burns or, back side of sheets with acid free and reversible mending materials. • Deacidify sheets (each lice of each sheet) after careful testing with Bookkeepersn. This Commercial solution of magnesium oxide, which neutralizes acidic inks and paper by providing on alkaline reserve (offer pH and compatibility testing). Random testing ensures an 8.5 pH with a deviation of no more than = .5. • Encapsulate each sheet in a Lay Fiat Archival Polyester PocketT". Each custom envelope is composed of Skyroll SH72SC91 Mylar and inc'udes a patented lay flat design. Dirnensions match the "book block' dimensions, with a l A" binding margin. • Ro-bind in custom -fitted and -stamped orchivai quality binder. Each binder is maru'octurecl on a per -book basis and sized to 1 /4" incremental capacities. This binder is available wi-h four hubs, c gold -fooled spine, and is roller shelf -compatible. A volume may return split clue to the ocided weight of the Nlylcx, depending on page count. • A dedication/tieatment report is included in each binder. Calhoun District Clerk Preservalion and Imaging of Historical Records June 14, 2022 ® Kofile, Inc. All rights reserved. 1 2 I. fmoge—.Archival Image Capture, Image Processing, Clean Up, &Enhonce ments IMj • Capture images at a minimum 300 dpi at 256 gray levels, ensuring the highest quality far poor contrast and L:gfaility. Gray -scale ensurers optimum resolution for each page. • Images accumulate as Group IV bi-tonal images in a stordard PDF or TIFF format. • IMAGE PERFECT, Kofile's prcprielory software, ensures the optimum imoge quality with custom imago clean up and :enhancements such as deskew, despeckle, character repair, polarity reversal, and zonal processing. • Crop excess blank space around image. This may involve manual cropping to insure best quolity image. • Images or named (tagged for the: directory file structure) at core !ovol by book, volume, and page (or other requested fields). • Images are grouped (stapled) togefher'o form documents. Cases are grouped and indexed to form documents by case number. • Page Volidcdon (automated PG. numbering for validation). • If applicable, images arc optimized and scaled for system output. • If requested, annotations c+,e supported to enable the electronic addition (either custom or Book/Volume/Page) on the digital image to assist in recording keeping. • When multiple documents (Deecs, Birth Record, etc.) exist on a single page, images are split so that each document's viewoble individually. In the case of Vitals, 'his service incurs additional charges. • STITCHING: If identified, images receive stitching where )-cessrvy, sucn as entries_ that horizontally span the length of rrore than one page. Amendments arcs stitched to the appropriate Certificate and indexed in place of the original Certificate. • Calhoun District Clerk receives a MASTER (e.g., CD. DVD, ft;o, flash drive) in a medium suitable to the project size. Koffle con hold a secuift'y copy of all images for safekeeping. PROJECT PRICING This project is presented via TXMAS Contract No. TXMAS-1 B-3602. Please reference this number on the P.O. Without a signed agreement, prices are good for 90 days. All pricing is based on estimated page counts. Final billing occurs on actuals per mutually agreed upon pricing; notto exceed the P.O. without written authorization. DISTRICT COURT MINUTES A—D,D 2,346 Sewn M PRV/IM $20,553.99 PETrTION OF NATURALIZATION 1908 190 - LL M/T PRV/IM $2,041.90 1912 NATURALIZATION RECORD 1 192 LL MIT PRV/IM $2,482.56 .. ...... PROJECTTOTAL . $25,071.45 PROPOSAL ACCEPTANCE Payment Terms: Pay 50% upon execuled agreement with the balance due upon project completion. Siguature.:Title.of Authorized Official Calhoun District Clerk Preservation and Imaging of Historical Records note June 14, 2022 ® Kofile, Inc. All rights reserved. 1 3 PURCHASING VIA TXMAS Please reference Contract No. TXMAS-18-3602 directly on the P.O.. Kofile can prepare a 'Shopping Cart' in TxSmartBuy so Calhoun District Clerk can complete this purchase. STATE OF TEXAS CO-OP MEMBER LISTING FOR Calhoun Dish id Clerk ;LINK hIIIII0/comptroller.texas.goviouto-data;purchasing co-op 00001.php !co-op # C0601 Contucf cindy.mueller@calllouncotx.org Expiration 6-AUG-2022 ACCESSIBILITY OF RECORDS Records held at Kofile are maintained as private and confidential material. Calhoun District Clerk is guaranteed access to records via email or toll -free fax at our expense. Upon receipt of a records request, Kofile will flag the requested record and verify inventory control, pull supporting paperwork, and email/fax a response to the approved requester or alternate. The turnaround time for a records request will meet or exceed requirements. Please note that all records (including volumes, documents, digital images, metadato or microfilm) serviced by Kofile shall remain the property of Calhoun District Clerk. This policy applies to any agreement, verbal or written, between Calhoun District Clerk and Kofile. The records are not used by Kofile other than in connection with providing the services pursuant to any agreement between Kofile and Calhoun District Clerk. The records are not commercially exploited by or on behalf of Kofile, its employees, officers, agents, in-vitees or assigns, in any respect. Please let me know if you have any questions. We look forward to serving Calhoun District Clerk and to working together for the preservation and access of its public and historical assets. Sincerely, BB�ippllyAqpppp�AAG�eBer/w/ick d�'14Tt�, U]P/LIY�L c: (83002) 00373-9124 e: billy.gerwick@kofile.com rac Calhoun District Clerk Preservation and Imaging of Historical Records June 74, 2022 m Kofile. Inc. All rights reserved. i 4 CERTIFICATE OF INTERESTED PARTIES FORM 1295 . lati Complete Nos. 1-4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos. 1, 2, 3, 5, and 6 if there are no Interested parties. CERTIFICATION OF FILING Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2022-899527 Kofile Technologies, Inc. Dallas, TX United States Date Filed: 06/15/2022 2 Name of govemmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County, Texas District Clerk Date Acknowledged: 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. 2022-0614 Calhoun District Clerk's historical records conservation, rehousing, and imaging. 4 Nature of interest Name of Interested Party City, State, Country (place of business) (check applicable) Controlling Intermediary Cresno, Michael Dallas, TX United States X Mohn, Jonathan Dallas, TX United States X Sloneker, Sharon Dallas, TX United States X Williams, George Dallas, TX United States X Kofile, Inc. Dallas, TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is Jonathan Mohn - , and my date of birth is My address is�_ (street) (city) (slate) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in Dallas County, state of TX , on the 15 day of June , 20 22 , (month) (year) sJnature of authorized agent of contracting business entity (Dederant) �V1,,,0 P:U.,U=u oy l exw ❑uars Commission www.etmcs.state.tx.us Version V1.1.191b5cdc M n I UI!m NOTICE OF MEETING—(r/22/)Q22 14. Consider and take necessary action to authorize Anna Goodman, County Clerk, to sign a Data Use Agreement with the Texas HHS System. (RHM) PASS Page 10 of 16 �d TEXA Texas HHS System - Data Use Agreement - Attachment 2 HealthandHuman SECURITY AND PRIVACY INQUIRY (SPI) bV Services If you are a bidder for a new procurement/contract, in order to participate in the bidding process, you must have corrected any "No" responses (except A9a) prior to the contract award date. If you are an applicant for an open enrollment, you must have corrected any "No" answers (except A9a and A11) prior to performing any work on behalf of any Texas HHS agency. For any questions answered "No" (except A9a and A11), an Action Plan forCompliance with a Timeline must be documented in the designated area below the question. The timeline for compliance with HIPAA-related requirements for safeguarding Protected Health Information is 30 calendar days from the date this form is signed. Compliance with requirements related to other types of Confidential Information must be confirmed within 90 calendar days from the date the form is signed. SECTION A: APPLICANT/BIDDER INFORMATION (To be completed by Applicant/Bidder) 1. Does the applicant/bidder access, create, disclose, receive, transmit, maintain, or store Texas Yes HHS Confidential Information in electronic systems (e.g., laptop, personal use computer, ® No mobile device, database, server, etc.)? IF NO, STOP. THE SPI FORM IS NOT REQUIRED. 2. Entity or Applicant/Bidder Legal Name Legal Name: The County of Calhoun Texas Legal Entity Tax Identification Number (TIN) (Last Four Numbers Only): 1923 Procurement/Contract#: Address: 211 South Ann Street #102 City: Port Lavaca State: Texas Zip: 77979 Telephone #: (361) 553-4411 Email Address: anna.goodman@calhouncotx.org 3. Number of Employees, at all locations, in Total Employees: 8 Applicant/Bidder's Workforce "Workforce" means all employees, volunteers, trainees, and other Persons whose conduct is underthe direct control of Applicant/Bidder, whether or notthey are paid by Applicant/ Bidder. If Applicant/Bidder is a sole proprietor, the workforce may be only one employee. 4. Number of Subcontractors Total Subcontractors: 0 (if Applicant/Bidder will not use subcontractors, enter "0") S. Name of Information Technology Security Official A. Security Official: and Name of Privacy Official for Applicant/Bidder Legal Name: Ron Reger (Privacy and Security Official may be the same person.) Address: 117 W Ash Street City: Port Lavaca State: Texas ZIP: 77979 Telephone #: (361) 553-4608 Email Address: ron.reger@calhouncotx.org B. Privacy Official: Legal Name: Ron Reger Address: 117 W Ash Street City: Port Lavaca State: Texas ZIP: 77979 Telephone #: (361) 553-4608 Email Address: ron.reger@calhouncotx.org SPI Version 2.1 (06/2018) Texas HHS System -Data Use Agreement -Attachment 2: Page 1 of 18 SECURITY AND PRIVACY INQUIRY (SPI) g 6. Type(s) of Texas HHS Confidential Information the HIPAA CJIS IRS FTI CMS SSA PII Applicant/Bidder will create, receive, maintain, use, ✓ ❑ ❑ ❑ ❑ disclose or have access to: (Check all that apply) Other (Please List) • Health Insurance Portability and Accountability Act (HIPAA) data • Criminal Justice Information Services (CJIS) data • Internal Revenue Service Federal Tax Information (IRS FTI) data • Centers for Medicare & Medicaid Services (CMS) • Social Security Administration (SSA) • Personally Identifiable Information (Pit) 7. Number of Storage Devices for Texas HHS Confidential Information (as defined in the Total # Texas HHS System Data Use Agreement (DUA)) (Sum a-d) Cloud Services involve using a network of remote servers hosted on the Internet to store, manage, and process data, ratherthan a local server or a personal computer. 9 A Data Center is a centralized repository, either physical or virtual, for the storage, management, and dissemination of data and information organized around a particular body of knowledge or pertaining to a particular business. a. Devices. Number of personal user computers, devices or drives, including mobile devices and mobile drives. b. Servers. Number of Servers that are not in a data center or using Cloud Services. 1 c. Cloud Services. Number of Cloud Services in use. d. Data Centers. Number of Data Centers in use. 0 8. Number of unduplicated individuals for whom Applicant/Bidder reasonably expects to Select Option handle Texas HHS Confidential Information during one year: (a-d) a. 499 individuals or less (F) a, b. 500 to 999 individuals C) b. c. 1,000 to 99,999 individuals ® C. d. 100,000 individuals or more ® d. 9. HIPAA Business Associate Agreement a. Will Applicant/Bidder use, disclose, create, receive, transmit or maintain protected Yes health information on behalf of a HIPAA-covered Texas HHS agency for a HIPAA- ® No covered function? b. Does Applicant/Bidder have a Privacy Notice prominently displayed on a Webpage or a ® Yes Public Office of Applicant/Bidder's business open to or that serves the public? (This is a (F) No HIPAA requirement. Answer "N/A" if not applicable, such as for agencies not covered ® N/A by HIPAA.) Action Plan for Compliance with a Timeline: Compliance Date: Check with IT about privacy disclaimer. 7131122 10. Subcontractors. If the Applicant/Bidder responded "0" to Question 4 (indicating no subcontractors), check "N/A" for both 'a.' and'b.' a. Does Applicant/Bidder require subcontractors to execute the DUA Attachment 1 ® Yes Subcontractor Agreement Form? ® No N/A Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement - Attachment 2: Page 2 of 18 SECURITY AND PRIVACY INQUIRY (SPI) b. Will Applicant/Bidder agree to require subcontractors who will access Confidential ® Yes Information to comply with the terms of the DUA, not disclose any Confidential 0 No Information to them until they have agreed in writing to the same safeguards and to IE) N/A discontinue their access to the Confidential Information if they fail to comply? Action Plan for Compliance with a Timeline: Compliance Date: 11. Does Applicant/Bidder have any Optional Insurance currently in place? Yes Optional Insurance provides coverage for: (1) Network Security and Privacy; (2) Data Breach; (3) Cyber 0 No Liability (lost data, lost use or delay/suspension in business, denial of service with e-business, the Internet, networks and informational assets, such as privacy, intellectual property, virus transmission, extortion, ® N/A sabotage or web activities); (4) Electronic Media Liability; (5) Crime/Theft; (6) Advertising Injury and Personal Injury Liability; and (7) Crisis Management and Notification Expense Coverage. SPI Version 2.1 (06/2018) Texas HHS System -Data Use Agreement -Attachment 2: Page 3 of 18 SECURITY AND PRIVACY INQUIRY (SPI) SECTION B: PRIVACY ANALYSIS AND(To completed 1• i' For any questions answered "No," an Action Plan for Compliance with a Timeline must be documented in the designated area below the question. The timeline for compliance with HIPAA-related requirements for safeguarding Protected Health Information is 30 calendar days from the date this form is signed. Compliance with requirements related to other types of Confidential Information must be confirmed within 90 calendar days from the date the form is signed. 1. Written Policies & Procedures. Does Applicant/Bidder have current written privacy and Yes or No security policies and procedures that, at a minimum: a. Does Applicant/Bidder have current written privacy and security policies and (E) Yes procedures that identify Authorized Users and Authorized Purposes (as defined in the ®No DUA) relating to creation, receipt, maintenance, use, disclosure, access or transmission of Texas HHS Confidential Information? Action Plan for Compliance with a Timeline: Compliance Date: b. Does Applicant/Bidder have current written privacy and security policies and Yes procedures that require Applicant/Bidder and its Workforce to comply with the No applicable provisions of HIPAA and other laws referenced in the DUA, relating to creation, receipt, maintenance, use, disclosure, access or transmission of Texas HHS Confidential Information on behalf of a Texas HHS agency? Action Plan for Compliance with a Timeline: Compliance Date: c. Does Applicant/Bidder have current written privacy and security policies and procedures Yes that limit use or disclosure of Texas HHS Confidential Information to the minimum that is No necessary to fulfill the Authorized Purposes? Action Plan for Compliance with a Timeline: Compliance Date: d. Does Applicant/Bidder have current written privacy and security policies and procedures Yes that respond to an actual or suspected breach of Texas HHS Confidential Information, to include at a minimum (if any responses are "No" check "No" for all three): ®No i. Immediate breach notification to the Texas HHS agency, regulatory authorities, and other required Individuals or Authorities, in accordance with Article 4 of the DUA; ii. Following a documented breach response plan, in accordance with the DUA and applicable law; & iii. Notifying Individuals and Reporting Authorities whose Texas HHS Confidential Information has been breached, as directed by the Texas HHS agency? SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement - Attachment 2: Page 4 of 18 SECURITYAND PRIVACY INQUIRY (SPI) Action Plan for Compliance with a Timeline: Compliance Date: e. Does Applicant/Bidder have current written privacy and security policies and procedures that conduct annual workforce training and monitoring for and correction of any training delinquencies? Yes ® No Action Plan for Compliance with a Timeline: Compliance Date: f. Does Applicant/Bidder have current written privacy and security policies and procedures that permit or deny individual rights of access, and amendment or correction, when appropriate? Yes No Action Plan for compliance with a Timeline: Compliance Date: g. Does Applicant/Bidder have current written privacy and security policies and procedures Yes that permit only Authorized Users with up-to-date privacy and security training, and with a reasonable and demonstrable need to use, disclose, create, receive, maintain, ® No access or transmit the Texas HHS Confidential Information, to carry out an obligation under the DUA for an Authorized Purpose, unless otherwise approved in writing by a Texas HHS agency? Action Plan for Compliance with a Timeline: Compliance Date: h. Does Applicant/Bidder have current written privacy and security policies and procedures that establish, implement and maintain proof of appropriate sanctions against any Workforce or Subcontractors who fail to comply with an Authorized Purpose or who is Yes ® No not an Authorized User, and used or disclosed Texas HHS Confidential Information in violation of the DUA, the Base Contract or applicable law? Action Plan for Compliance with a Timeline: Compliance Date: 1. Does Applicant/Bidder have current written privacy and security policies and procedures that require updates to policies, procedures and plans following major changes with use or disclosure of Texas HHS Confidential Information within 60 E) Yes ® No days of identification of a need for update? Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement -Attachment 2: Page 5 of 18 SECURITY AND PRIVACY INQUIRY (SPI) g j. Does Applicant/Bidder have current written privacy and security policies and Yes procedures that restrict permissions or attempts to re -identify or further identify No de -identified Texas HHS Confidential Information, or attempt to contact any Individuals whose records are contained in the Texas HHS Confidential Information, except for an Authorized Purpose, without express written authorization from a Texas HHS agency or as expressly permitted by the Base Contract? Action Plan for Compliance with a Timeline: Compliance Date: k. If Applicant/Bidder intends to use, disclose, create, maintain, store or transmit Texas HHS Yes Confidential Information outside of the United States, will Applicant/Bidder obtain the ®No express prior written permission from the Texas HHS agency and comply with the Texas HHS agency conditions for safeguarding offshore Texas HHS Confidential Information? Action Plan for Compliance with a Timeline: Compliance Date: I. Does Applicant/Bidder have current written privacy and security policies and procedures Yes that require cooperation with Texas HHS agencies' or federal regulatory inspections, ® No audits or investigations related to compliance with the DUA or applicable law? Action Plan for Compliance with a Timeline: Compliance Date: m. Does Applicant/Bidder have current written privacy and security policies and e) Yes procedures that require appropriate standards and methods to destroy or dispose of ®No Texas HHS Confidential Information? Action Plan for Compliance with a Timeline: Compliance Date: In. Does Applicant/Bidder have current written privacy and security policies and procedures Yes that prohibit disclosure of Applicant/Bidder's work product done on behalf of Texas HHS No pursuant to the DUA, or to publish Texas HHS Confidential Information without express prior approval of the Texas HHS agency? Action Plan for Compliance with a Timeline: Compliance Date: 2. Does Applicant/Bidder have a current Workforce training program? Yes Training of Workforce must occur at least once everyyear, and within 30 days of date of hiring a new ® No Workforce memberwho will handle Texas HHS Confidential Information. Training must include: (1) privacy and security policies, procedures, plans and applicable requirements for handling Texas HHS Confidential Information, (2) a requirement to complete training before access is given to Texas HHS Confidential Information, and (3) written proof of training and a procedure for monitoring timely completion of training. SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement - Attachment 2: Page 6 of 18 SECURITY AND PRIVACY INQUIRY (SPI) Action Plan for Compliance with a Timeline: Compliance Date: 3. Does Applicant/Bidder have Privacy Safeguards to protect Texas HHS Confidential E) Yes Information in oral, paper and/or electronic form? ®No "Privacy Safeguards" means protection of Texas HHS Confidential Information by establishing, implementing and maintaining required Administrative, Physical and Technical policies, procedures, processes and controls, required by the DUA, HIPAA (45 CFR 164.530), Social Security Administration, Medicaid and laws, rules or regulations, as applicable. Administrative safeguards include administrative protections, policies and procedures for matters such as training, provision of access, termination, and review of safeguards, incident management, disaster recovery plans, and contract provisions. Technical safeguards include technical protections, policies and procedures, such as passwords, logging, emergencies, how paper is faxed or mailed, and electronic protections such as encryption of data. Physical safeguards include physical protections, policies and procedures, such as locks, keys, physical access, physical storage and trash. Action Plan for Compliance with a Timeline: Compliance Date: 4. Does Applicant/Bidder and all subcontractors (if applicable) maintain a current list of Yes Authorized Users who have access to Texas HHS Confidential Information, whether oral, written or electronic? C) No Action Plan for Compliance with a Timeline: Compliance Date: S. Does Applicant/Bidder and all subcontractors (if applicable) monitor for and remove Yes terminated employees or those no longer authorized to handle Texas HHS Confidential Information from the list of Authorized Users? ® No Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement -Attachment 2: Page 7 of 18 SECURITY AND PRIVACY INQUIRY (SPI) SECTION C: SECURITY RISK ANALYSIS AND 1 • becompleted by1 p• Bidder) This section is about your electronic system. If your business DOES NOT store, access, or No Electronic transmit Texas HHS Confidential Information in electronic systems (e.g., laptop, personal Systems use computer, mobile device, database, server, etc. select the box to the right, and "YES" will be entered for all questions in this section. For any questions answered "No," an Action Plan for Compliance with a Timeline must be documented in the designated area below the question. The timeline for compliance with HIPAA-related items is 30 calendar days, PII-related items is 90 calendar days. 1. Does the Applicant/Bidder ensure that services which access, create, disclose, receive, Yes transmit, maintain, or store Texas HHS Confidential Information are maintained IN the ® No United States (no offshoring) unless ALL of the following requirements are met? a. The data is encrypted with FIPS 140-2 validated encryption b. The offshore provider does not have access to the encryption keys c. The Applicant/Bidder maintains the encryption key within the United States d. The Application/Bidder has obtained the express prior written permission of the Texas HHS agency For more information regarding FIPS 140-2 encryption products, please refer to: htto://csrc.nist.gov/publications/fins Action Plan for Compliance with a Timeline: Compliance Date: 2. Does Applicant/Bidder utilize an IT security -knowledgeable person or company to maintain G Yes or oversee the configurations of Applicant/Bidder's computing systems and devices? ® No Action Plan for Compliance with a Timeline: Compliance Date: 3. Does Applicant/Bidder monitor and manage access to Texas HHS Confidential Information (F) Yes (e.g., a formal process exists for granting access and validating the need for users to access ® No Texas HHS Confidential Information, and access is limited to Authorized Users)? Action Plan for Compliance with a Timeline: Compliance Date: 4. Does Applicant/Bidder a) have a system for changing default passwords, b) require user Yes password changes at least every 90 calendar days, and c) prohibit the creation of weak ®No passwords (e.g., require a minimum of 8 characters with a combination of uppercase, lowercase, special characters, and numerals, where possible) for all computer systems that access or store Texas HHS Confidential Information. If yes, upon request must provide evidence such as a screen shot or a system report. Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1 (06/2018) Texas HHS System -Data Use Agreement -Attachment 2: Page 8 of 18 SECURITY AND PRIVACY INQUIRY (SPI) S. Does each member of Applicant/Bidder's Workforce who will use, disclose, create, receive, transmit or maintain Texas HHS Confidential Information have a unique user name (account) and private password? E) Yes ® No Action Plan for Compliance with a Timeline: Compliance Date: 6. Does Applicant/Bidder lock the password after a certain number of failed attempts and Yes after 15 minutes of user inactivity in all computing devices that access or store Texas HHS Confidential Information? O No Action Plan for Compliance with a Timeline: Compliance Date: 7. Does Applicant/Bidder secure, manage and encrypt remote access (including wireless Yes access) to computer systems containing Texas HHS Confidential Information? (e.g., a formal process exists for granting access and validating the need for users to remotely access Texas ®No HHS Confidential Information, and remote access is limited to Authorized Users). Encryption is required for all Texas HHS Confidential Information. Additionally, FIPS 140-2 validated encryption is required for Health Insurance Portability and Accountability Act (HIPAA) data, Criminallustice Information Services (CIIS) data, Internal Revenue Service Federal Tax Information (IRS FTI) data, and Centers for Medicare & Medicaid Services (CMS) data. For more information regarding FIPS 140-2 encryption products, please refer to: http.,Ilcstc.nist.gov/t)ub/icotionslfips Action Plan for Compliance with a Timeline: Compliance Date: S. Does Applicant/Bidder implement computer security configurations or settings for all computers and systems that access or store Texas HHS Confidential Information? (e.g., non -essential features or services have been removed or disabled to reduce the 0 Yes ® No threat of breach and to limit exploitation opportunities for hackers or intruders, etc.) Action Plan for Compliance with a Timeline: Compliance Date: 9. Does Applicant/Bidder secure physical access to computer, paper, or other systems (D Yes containing Texas HHS Confidential Information from unauthorized personnel and theft (e.g., door locks, cable locks, laptops are stored in the trunk of the car instead of the ® No passenger area, etc.)? Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement - Attachment 2: Page 9 of 18 SECURITY AND PRIVACY INQUIRY (SPI) 10. Does Applicant/Bidder use encryption products to protect Texas HHS Confidential (F) Yes Information that is transmitted over a public network (e.g., the Internet, WiFi, etc.)? ® No If yes, upon request must provide evidence such as a screen shot or a system report. Encryption is required for all HHS Confidential Information. Additionally, FIPS 140.2 validated encryption is required for Health Insurance Portability and Accountability Act (HIPAA) data, Criminallustice Information Services (CIIS) data, Internal Revenue Service Federal Tax Information (IRS FTI) data, and Centers for Medicare & Medicaid Services (CMS) data. For more information regarding FIPS 140-2 encryption products, please refer to: http:llcsrc.nist. aoy/publications/fps Action Plan for Compliance with a Timeline: Compliance Date: 11. Does Applicant/Bidder use encryption products to protect Texas HHS Confidential Information stored on end user devices (e.g., laptops, USBs, tablets, smartphones, external hard drives, desktops, etc.)? (E) Yes ®No If yes, upon request must provide evidence such as a screen shot or a system report. Encryption is required for all Texas HHS Confidential Information. Additionally, FIPS 140-2 validated encryption is required for Health Insurance Portability and Accountability Act (HIPAA) data, Criminallustice Information Services (CIIS) data, Internal Revenue Service Federal Tax Information (IRS FTI) data, and Centers for Medicare & Medicaid Services (CMS) data. For more information regarding FIPS 140-2 encryption products, please refer to: htto://csrc.nist.00v/oublications/fps Action Plan for Compliance with a Timeline: Compliance Date: 12. Does Applicant/Bidder require Workforce members to formally acknowledge rules outlining I) Yes their responsibilities for protecting Texas HHS Confidential Information and associated systems containing HHS Confidential Information before their access is provided? ®No Action Plan for Compliance with a Timeline: Compliance Date: 13. Is Applicant/Bidder willing to perform or submit to a criminal background check on Yes Authorized Users? ®No Action Plan for Compliance with a Timeline: Compliance Date: 14. Does Applicant/Bidder prohibit the access, creation, disclosure, reception, transmission, (F) Yes maintenance, and storage of Texas HHS Confidential Information with a subcontractor (e.g., cloud services, social media, etc.) unless Texas HHS has approved the subcontractor ®No agreement which must include compliance and liability clauses with the same requirements as the Applicant/Bidder? Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1 (06/2018) Texas HHS System -Data Use Agreement -Attachment 2: Page 10 of 18 SECURITY AND PRIVACY INQUIRY (SPI) 15. Does Applicant/Bidder keep current on security updates/patches (including firmware, (2) Yes software and applications) for computing systems that use, disclose, access, create, transmit, maintain or store Texas HHS Confidential Information? ®No Action Plan for Compliance with a Timeline: Compliance Date: 16. Do Applicant/Bidder's computing systems that use, disclose, access, create, transmit, Yes maintain or store Texas HHS Confidential Information contain up-to-date anti- malware and antivirus protection? ® No Action Plan for Compliance with a Timeline: Compliance Date: 17. Does the Applicant/Bidder review system security logs on computing systems that access Yes or store Texas HHS Confidential Information for abnormal activity or security concerns on a regular basis? ® No Action Plan for Compliance with a Timeline: Compliance Date: 18. Notwithstanding records retention requirements, does Applicant/Bidder's disposal Yes processes for Texas HHS Confidential Information ensure that Texas HHS Confidential Information is destroyed so that it is unreadable or undecipherable? ® No Action Plan for Compliance with a Timeline: Compliance Date: 19. Does the Applicant/Bidder ensure that all public facing websites and mobile applications containing Texas HHS Confidential Information meet security testing standards set forth within the Texas Government Code (TGC), Section 2054.516; Yes ® No including requirements for implementing vulnerability and penetration testing and addressing identified vulnerabilities? For more information regarding TGC, Section 2054.516 DATA SECURITY PLAN FOR ONLINE AND MOBILE APPLICATIONS, please refer to: https://leaiscan.com/7-X/text/HB812017 Action Plan for Compliance with a Timeline: Compliance Date: SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement -Attachment 2: Page 11 of 18 SECURITYAND PRIVACY INQUIRY (SPI) SECTION D: SIGNATURE AND SUBMISSION (to be completed by Applicant/Bidder) Please sign the form digitally, if possible. If you can't provide a handwritten. signature. 1. 1 certify that all of the information provided in this form is truthful and correct to the best of my knowledge. If I learn that any such information was not correct, I agree to notify Texas HHS of this immediately. 2. Signature To submit the completed, signed form: • Email the form as an attachment to the appropriate Section E: . Be. •. by Texas HHS Agency(s): HHSC: � DFPS: 1-3 3. Title . Date: Texas HHS Contract Manager(s). Agency Staff: Requesting De artment(s : DSHS: 11 Legal Entity Tax Identification Number (TIN) (Last four Only): PO/Contract(s) #: EE Contract Manager: g Contract Manager Email Address: g Contract Manager hone #: g p Contract Manager: Contract Manager Email Address: Contract Manager Telephone #: Contract Manager: Contract Manager Email Address: Contract Manager Telephone #: Contract Manager: Contract Manager Email Address: Contract Manager Telephone #: Contract Manager: Contract Manager Email Address: Contract Manager Telephone #: Contract Manager: Contract Manager Email Address: Contract Manager Telephone #: Contract Manager: Contract Manager Email Address: Contract Manager Telephone #: Contract Manager: Contract Manager Email Address: Contract Manager Telephone #: SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement - Attachment 2: Page 12 of 18 SECURITY AND PRIVACY INQUIRY (SPI) INSTRUCTIONS FOR COMPLETING THE SECURITY AND PRIVACY INQUIRY (SPI) Below are instructions for Applicants, Bidders and Contractors for Texas Health and Human Services requiring the Attachment 2, Security and Privacy Inquiry (SPI) to the Data Use Agreement (DUA). Instruction item numbers below correspond to sections on the SPI form. If you are a bidder for a new procurement/contract, in orderto participate in the bidding process, you must have corrected any "No" responses (except A9a) prior to the contract award date. If you are an applicant for an open enrollment, you must have corrected any "No" answers (except A9a and All) prior to performing any work on behalf of any Texas HHS agency. For any questions answered "No" (except A9a and All), an Action Plan for Compliance with a Timeline must be documented in the designated area below the question. The timeline for compliance with H I PAA-related requirements for safeguarding Protected Health Information is 30 calendar days from the date this form is signed. Compliance with requirements related to other types of Confidential Information must be confirmed within 90 calendar days from the date the form is signed. SECTION A. APPLICANT/BIDDER INFORMATION Item #1. Only contractors that access, transmit, store, and/or maintain Texas HHS Confidential Information will complete and email this form as an attachment to the appropriate Texas HHS Contract Manager. Item #2. Entity or Applicant/Bidder Legal Name. Provide the legal name of the business (the name used for legal purposes, like filing a federal or state tax form on behalf of the business, and is not a trade or assumed named "dba"), the legal tax identification number (lostfour numbers only) of the entity or applicant/bidder, the address of the corporate or main branch of the business, the telephone number where the business can be contacted regarding questions related to the information on this form and the website of the business, if a website exists. Item #3. Number of Employees, at all locations, in Applicant/Bidder's workforce. Provide the total number of individuals, including volunteers, subcontractors, trainees, and other persons who work for the business. If you are the only employee, please answer "i." Item #4. Number of Subcontractors. Provide the total number of subcontractors working for the business. If you have none, please answer "0"zero. Item #5. Number of unduplicated individuals for whom Applicant/Bidder reasonably expects to handle HHS Confidential Information during one year. Select the radio button that corresponds with the number of clients/consumers for whom you expect to handle Texas HHS Confidential Information during a year. Only count clients/consumers once, no matter how many direct services the client receives during a year. Item #5. Name of Information Technology Security Official and Name of Privacy Official for Applicant/Bidder. As with all other fields on the SPI, this is a required field. This may be the some person and the owner of the business if such person has the security and privacy knowledge that is required to implement the requirements of the DUA and respond to questions related to the SPI. In 4.A. provide the name, address, telephone number, and email address of the person whom you have designated to answer any security questions found in Section C and in 4.B. provide this information for the person whom you have designated as the person to answer any privacy questions found in Section B. The business may contract out for this expertise; however, designated individual(s) must have knowledge of the business's devices, systems and methods for use, disclosure, creation, receipt transmission and maintenance of Texas HHS Confidential Information and be willing to be the point of contact for privacy and security questions. Item #6. Type(s) of HHS Confidential Information the Entity or Applicant/Bidder Will Create, Receive, Maintain, Use, Disclose or Have Access to: Provide a complete listing of all Texas HHS Confidential Information that the Contractor will create, receive, maintain, use, disclose or have access to. The DUA section Article 2, Definitions, defines Texas HHS Confidential Information as: "Confidential Information" means any communication or record (whether oral, written, electronically stored or transmitted, or in any other form) provided to or made available to CONTRACTOR or that CONTRACTOR may create, receive, maintain, use, disclose or have access to on behalf of Texas HHS that consists of or includes any or all of the following: (1) Client Information; (2) Protected Health Information in anyform including without limitation, Electronic Protected Health Information or Unsecured Protected Health Information; (3) Sensitive Personal Information defined by Texas Business and Commerce Code Ch. 521; SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement - Attachment 2: Page 13 of 18 SECURITY AND PRIVACY INQUIRY (SPI) g (4) Federal Tax Information; (5) Personally Identifiable Information; (6) Social Security Administration Data, including, without limitation, Medicaid information; (7) All privileged work product; (8) All information designated as confidential under the constitution and laws of the State of Texas and of the United States, including the Texas Health & Safety Code and the Texas Public Information Act, Texas Government Code, Chapter 552. Definitions for the following types of confidential information can be found the following sites: • Health Insurance Portability and Accountability Act (HIPAA) - httg://www.hhs.aov/higaa/index html • Criminal Justice Information Services (CIIS) - https://www.fbi.aov/services/ciis/ciis-security-policy-resource center • Internal Revenue Service Federal Tax Information (IRS FTI) - https://www.irs.aov/pub/irs-pdf/p1075 pdf • Centers for Medicare & Medicaid Services (CMS) - https://www.cros aov/Reaulations-and-Guidance/Regulations and Guidance.html • Social Security Administration (SSA) - https•//www ssa aov/regulations/ •Personallyldentifiablelnformation(Pll)-htt: csrc.nist.aov/publications/nistnuhc/Rnn-ta9ic„Rnn-i",rf Item #7. Number of Storage devices for Texas HHS Confidential Information. The total number of devices is automatically calculated by exiting the fields in lines a - d. Use the <Tab> key when exiting the field to prompt calculation, if it doesn't otherwise sum correctly. • Item 7a. Devices. Provide the number of personal user computers, devices, and drives (including mobile devices, laptops, USB drives, and external drives) on which your business stores or will store Texas HHS Confidential Information. • Item 7b. Servers. Provide the number of servers not housed in a data center or "in the cloud," on which Texas HHS Confidential Information is stored or will be stored. A server is a dedicated computer that provides data or services to other computers. It may provide services or data to systems on a local area network (LAN) or a wide area network (WAN) over the Internet. If none, answer "0" (zero). • Item 7c. Cloud Services. Provide the number of cloud services to which Texas HHS Confidential Information is stored. Cloud Services involve using a network of remote servers hosted on the Internet to store, manage, and process data, rather than on a local server or a personal computer. If none, answer "0" (zero.) • Item 7d, Data Centers. Provide the number of data centers in which you store Texas HHS Confidential Information. A Data Center is a centralized repository, either physical or virtual, for the storage, management and dissemination of data and information organized around a particular body of knowledge or pertaining to a particular business. If none, answer "0" (zero). Item #8. Number of unduplicated individuals for whom the Applicant/Bidder reasonably expects to handle Texas HHS Confidential Information during one year. Select the radio button that corresponds with the number of clients/consumers for whom you expect to handle Confidential Information during a year. Only count clients/consumers once, no matter how many direct services the client receives during a year. Item #9. HIPAA Business Associate Agreement. • Item #9a. Answer "Yes "if your business will use, disclose, create, receive, transmit or store information relating to a client/consumer's healthcare on behalf of the Department of State Health Services, the Department of Disability and Aging Services, or the Health and Human Services Commission for treatment payment or operation of Medicaid or Medicaid clients. If your contract does not include HIPAA covered information, respond "no."If "no,"a compliance plan is not required. • Item #9b. Answer "Yes" if your business has a notice of privacy practices (a document that explains how you protect and use a client/consumer's healthcare information) displayed either on a website (if one exists for your business) or in your place of business (if that location is open to clients/consumers or the public). If your contract does not include HIPAA covered information, respond "N/A." Item #10, Subcontractors. If your business responded "0" to question 4 (number of subcontractors), Answer "N/A" to Items 10a and 10b to indicate not applicable. • Item #10a. Answer "Yes" if your business requires that all subcontractors sign Attachment 1 of the DUA. • Item #10b. Answer "Yes" if your business obtains Texas HHS approval before permitting subcontractors to handle Texas HHS Confidential Information on your business's behalf. Item #11. Optional Insurance. Answer "yes" if applicant has optional insurance in place to provide coverage for a Breach or any SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement -Attachment 2: SECURITY AND PRIVACY INQUIRY (SPI) Page 14 of 18 other situations listed in this question. If you are not required to have this optional coverage, answer "N/A"A compliance plan is not required. SECTION B. PRIVACY RISK ANALYSIS AND ASSESSMENT Reasonable and appropriate written Privacy and Security policies and procedures are required, even for sole proprietors who are the only employee, to demonstrate how your business will safeguard Texas HHS Confidential Information and respond in the event of a Breach of Texas HHS Confidential Information. To ensure that your business is prepared, all of the items below must be addressed in your written Privacy and Security policies and procedures. Item #1. Answer "Yes" if you have written policies in place for each of the areas (a-o). • Item #la. Answer "yes" if your business has written policies and procedures that identify everyone, including subcontractors, who are authorized to use Texas HHS Confidential Information. The policies and procedures should also identify the reason why these Authorized Users need to access the Texas HHS Confidential Information and this reason must align with the Authorized Purpose described in the Scope of Work or description of services in the Base Contract with the Texas HHS agency. • Item #1b. Answer "Yes" if your business has written policies and procedures that require your employees (including yourself), your volunteers, your trainees, and any other persons whose work you direct, to comply with the requirements of HIPAA, if applicable, and other confidentiality laws as they relate to your handling of Texas HHS Confidential Information. Refer to the laws and rules that apply, including those referenced in the DUA and Scope of Work or description of services in the Base Contract. • Item #1c. Answer "Yes" if your business has written policies and procedures that limit the Texas HHS Confidential Information you disclose to the minimum necessary for your workforce and subcontractors (if applicable) to perform the obligations described in the Scope of Work or service description in the Base Contract. (e.g., if a client/consumer's Social Security Number is not required for a workforce member to perform the obligations described in the Scope of Work or service description in the Base Contract, then the Social Security Number will not be given to them.) If you are the only employee for your business, policies and procedures must not include a request for, or use of, Texas HHS Confidential Information that is not required for performance of the services. • Item #1d. Answer "Yes" if your business has written policies and procedures that explain how your business would respond to an actual or suspected breach of Texas HHS Confidential Information. The written policies and procedures, at a minimum, must include the three items below. If any response to the three items below are no, answer "no." O Item #idi. Answer "Yes" if your business has written policies and procedures that require your business to immediately notify Texas HHS, the Texas HHS Agency, regulatory authorities, or other required Individuals or Authorities of a Breach as described in Article 4, Section 4 of the DUA. Refer to Article 4, Section 4 01• Initial Notice of Breach must be provided in accordance with Texas HHS and DUA requirements with as much information as possible about the Event/Breach and a name and contact who will serve as the single point of contact with HHS both on and off business hours. Time frames related to Initial Notice include: • within one hour of Discovery of an Event or Breach of Federal Tax Information, Social Security Administration Data, or Medicaid Client Information • within 24 hours of all other types of Texas HHS Confidential Information 48-hour Formal Notice must be provided no later than 48 hours after Discovery for protected health information, sensitive personal information or other non-public information and must include applicable information as referenced in Section 4.01 (C) 2. of the DUA. O Item #1dii. Answer "Yes" if your business has written policies and procedures require you to have and follow a written breach response plan as described in Article 4 Section 4.02 of the DUA. O Item #ldiii. Answer "Yes" if your business has written policies and procedures require you to notify Reporting Authorities and Individuals whose Texas HHS Confidential Information has been breached as described in Article 4 Section 4.03 of the DUA. • Item #1e. Answer "Yes" if your business has written policies and procedures requiring annual training of your entire workforce on matters related to confidentiality, privacy, and security, stressing the importance of promptly reporting any Event or Breach, outlines the process that you will use to require attendance and track completion for employees who failed to complete annual training. SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement -Attachment 2: SECURITY AND PRIVACY INQUIRY (SPI) Page 15 of 18 • Item #1f. Answer "Yes" if your business has written policies and procedures requiring you to allow individuals (clients/consumers) to access their individual record of Texas HHS Confidential Information, and allow them to amend or correct that information, if applicable. • Item #1g. Answer "Yes" if your business has written policies and procedures restricting access to Texas HHS Confidential Information to only persons who have been authorized and trained on how to handle Texas HHS Confidential Information • Item #1h. Answer "Yes" if your business has written policies and procedures requiring sanctioning of any subcontractor, employee, trainee, volunteer, or anyone whose work you direct when they have accessed Texas HHS Confidential Information but are not authorized to do so, and that you have a method of proving that you have sanctioned such an individuals. If you are the only employee, you must demonstrate how you will document the noncompliance, update policies and procedures if needed, and seek additional training or education to prevent future occurrences. • Item #11. Answer "Yes" if your business has written policies and procedures requiring you to update your policies within 60 days after you have made changes to how you use or disclose Texas HHS Confidential Information. • Item #1j. Answer "Yes" if your business has written policies and procedures requiring you to restrict attempts to take de -identified data and re -identify it or restrict any subcontractor, employee, trainee, volunteer, or anyone whose work you direct, from contacting any individuals for whom you have Texas HHS Confidential Information except to perform obligations under the contract, or with written permission from Texas HHS. • Item #1k. Answer "Yes" if your business has written policies and procedures prohibiting you from using, disclosing, creating, maintaining, storing or transmitting Texas HHS Confidential Information outside of the United States. • Item #11. Answer "Yes" if your business has written policies and procedures requiring your business to cooperate with HHS agencies or federal regulatory entities for inspections, audits, or investigations related to compliance with the DUA or applicable law. • Item #1m. Answer "Yes" if your business has written policies and procedures requiring your business to use appropriate standards and methods to destroy or dispose of Texas HHS Confidential Information. Policies and procedures should comply with Texas HHS requirements for retention of records and methods of disposal. • Item #1n. Answer "Yes" if your business has written policies and procedures prohibiting the publication of the work you created or performed on behalf of Texas HHS pursuant to the DUA, or other Texas HHS Confidential Information, without express prior written approval of the HHS agency. Item #2. Answer "Yes" if your business has a current training program that meets the requirements specified in the SPI for you, your employees, your subcontractors, your volunteers, your trainees, and any other persons under you direct supervision. Item #3. Answer "Yes" if your business has privacy safeguards to protect Texas HHS Confidential Information as described in the SPI. Item #4. Answer "Yes" if your business maintains current lists of persons in your workforce, including subcontractors (if applicable), who are authorized to access Texas HHS Confidential Information. If you are the only person with access to Texas HHS Confidential Information, please answer "yes." Item #5. Answer "Yes" if your business and subcontractors (if applicable) monitor for and remove from the list of Authorized Users, members of the workforce who are terminated or are no longer authorized to handle Texas HHS Confidential Information. If you are the only one with access to Texas HHS Confidential Information, please answer "Yes." SECTION C. SECURITY RISK ANALYSIS AND ASSESSMENT This section is about your electronic systems. If you DO NOT store Texas HHS Confidential Information in electronic systems (e.g., laptop, personal computer, mobile device, database, server, etc.), select the "No Electronic Systems" box and respond "Yes" for all questions in this section. Item #1. Answer "Yes" if your business does not "offshore" or use, disclose, create, receive, transmit or maintain Texas HHS Confidential Information outside of the United States. If you are not certain, contact your provider of technology services (application, cloud, data center, network, etc.) and request confirmation that they do not off- shore their data. SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement -Attachment 2: SECURITYAND PRIVACY INQUIRY (SPI) Page 16 of 18 Item #2. Answer "Yes" if your business uses a person or company who is knowledgeable in IT security to maintain or oversee the configurations of your business's computing systems and devices. You may be that person, or you may hire someone who can provide that service for you. Item #3. Answer "Yes" if your business monitors and manages access to Texas HHS Confidential Information (i.e., reviews systems to ensure that access is limited to Authorized Users; has formal processes for granting, validating, and reviews the need for remote access to Authorized Users to Texas HHS Confidential Information, etc.). If you are the only employee, answer "Yes" if you have implemented a process to periodically evaluate the need for accessing Texas HHS Confidential Information to fulfill your Authorized Purposes. Item #4. Answer "Yes" if your business has implemented a system for changing the password a system initially assigns to the user (also known as the default password), and requires users to change their passwords at least every 90 days, and prohibits the creation of weak passwords for all computer systems that access or store Texas HHS Confidential Information (e.g., a strong password has a minimum of 8 characters with a combination of uppercase, lowercase, special characters, and numbers, where possible). If your business uses a Microsoft Windows system, refer to the Microsoft website on how to do this, see example: h ttps://docs. m icrosoft. com/en-us/windo ws/security/threat-protection/security-policy-settings/pass word -policy Item #5. Answer "Yes" if your business assigns a unique user name and private password to each of your employees, your subcontractors, your volunteers, your trainees and any other persons under your direct control who will use, disclose, create, receive, transmit or maintain Texas HHS Confidential Information. Item #6. Answer "Yes" if your business locks the access after a certain number of failed attempts to login and after 15 minutes of user inactivity on all computing devices that access or store Texas H H S Confidential Information. If your business uses a Microsoft Windows system, refer to the Microsoft website on how to do this, see example: https://docs.microsoft.com/en-uslwindowslsecuritvlthreat-protection/security-policy-settingsloccount-lockout-policy Item #7. Answer "Yes" if your business secures, manages, and encrypts remote access, such as: using Virtual Private Network (VPN) software on your home computer to access Texas HHS Confidential Information that resides on a computer system at a business location or, if you use wireless, ensuring that the wireless is secured using a password code. If you do not access systems remotely or over wireless, answer "Yes." Item #8. Answer "Yes" if your business updates the computer security settings for all your computers and electronic systems that access or store Texas HHS Confidential Information to prevent hacking or breaches (e.g., non -essential features or services have been removed or disabled to reduce the threat of breach and to limit opportunities for hackers or intruders to access your system). For example, Microsoft's Windows security checklist: https://docs microsoft com/en-us/windows/security/threat-protection/security-policy-settings/how to configure security policy settings Item #9. Answer "Yes" if your business secures physical access to computer, paper, or other systems containing Texas HHS Confidential Information from unauthorized personnel and theft (e.g., door locks, cable locks, laptops are stored in the trunk of the car instead of the passenger area, etc.). If you are the only employee and use these practices for your business, answer "Yes." Item #10. Answer "Yes" if your business uses encryption products to protect Texas HHS Confidential Information that is transmitted over a public network (e.g., the Internet, WIFI, etc.) or that is stored on a computer system that is physically or electronically accessible to the public (FIPS 140-2 validated encryption is required for Health Insurance Portability and Accountability Act (HIPAA) data, Criminal Justice Information Services (CJIS) data, Internal Revenue Service Federal Tax Information (IRS FTI) data, and Centers for Medicare & Medicaid Services (CMS) data.) For more information regarding FIPS 140-2 encryption products, please refer to: http://csrc.nist.aov/publications/figs). Item #11. Answer "Yes" if your business stores Texas HHS Confidential Information on encrypted end -user electronic devices (e.g., laptops, USBs, tablets, smartphones, external hard drives, desktops, etc.) and can produce evidence of the encryption, such as, a screen shot or a system report (FIPS 140-2 encryption is required for Health Insurance Portability and Accountability Act (HIPAA) data, Criminal Justice Information Services (CJIS) data, Internal Revenue Service Federal Tax Information (IRS FTI) data, and Centers for Medicare & Medicaid Services (CMS) data). For more information regarding FIPS 140-2 validated encryption products, please refer to: http://csrc.nist.gov/publications/figs). If you do not utilize end -user electronic devices for storing Texas HHS Confidential Information, answer "Yes." SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement - Attachment 2: Page 17 of 18 SECURITY AND PRIVACY INQUIRY (SPI) Item #12. Answer "Yes" if your business requires employees, volunteers, trainees and other workforce members to sign a document that clearly outlines their responsibilities for protecting Texas HHS Confidential Information and associated systems containing Texas HHS Confidential Information before they can obtain access. If you are the only employee answer "Yes" if you have signed or are willing to sign the DUA, acknowledging your adherence to requirements and responsibilities. Item #13. Answer "Yes" if your business is willing to perform a criminal background check on employees, subcontractors, volunteers, or trainees who access Texas HHS Confidential Information. If you are the only employee, answer "Yes" if you are willing to submit to a background check. Item #14. Answer "Yes" if your business prohibits the access, creation, disclosure, reception, transmission, maintenance, and storage of Texas HHS Confidential Information on Cloud Services or social media sites if you use such services or sites, and there is a Texas HHS approved subcontractor agreement that includes compliance and liability clauses with the same requirements as the Applicant/Bidder. If you do not utilize Cloud Services or media sites for storing Texas HHS Confidential Information, answer "Yes." Item #15. Answer "Yes" if your business keeps current on security updates/patches (including firmware, software and applications) for computing systems that use, disclose, access, create, transmit, maintain or store Texas HHS Confidential Information. If you use a Microsoft Windows system, refer to the Microsoft website on how to ensure your system is automatically updating, see example: httos://portal.msrc.microsoft.com/en-us/ Item #16. Answer "Yes" if your business's computing systems that use, disclose, access, create, transmit, maintain or store Texas HHS Confidential Information contain up-to-date anti-malware and antivirus protection. If you use a Microsoft Windows system, refer to the Microsoft website on how to ensure your system is automatically updating, see example: https.11docs. microsoft. com/en-us/windows/security/threat-protection/ Item #17. Answer "Yes" if your business reviews system security logs on computing systems that access or store Texas HHS Confidential Information for abnormal activity or security concerns on a regular basis. If you use a Microsoft Windows system, refer to the Microsoft website for ensuring your system is logging security events, see example: h ttps://docs. microsoft. com/en-us/wind o ws/security/threat-pro tection/aud itina/basic-security-audit-policies Item #18. Answer "Yes" if your business disposal processes for Texas HHS Confidential Information ensures that Texas HHS Confidential Information is destroyed so that it is unreadable or undecipherable. Simply deleting data or formatting the hard drive is not enough; ensure you use products that perform a secure disk wipe. Please see NIST SP 800-88 R1, Guidelines for Media Sanitization and the applicable laws and regulations for the information type for further guidance. Item #19. Answer "Yes" if your business ensures that all public facing websites and mobile applications containing HHS Confidential Information meet security testing standards set forth within the Texas Government Code (TGC), Section 2054.516 SECTION D. SIGNATURE AND SUBMISSION Click on the signature area to digitally sign the document. Email the form as an attachment to the appropriate Texas HHS Contract Manager. SPI Version 2.1 (06/2018) Texas HHS System - Data Use Agreement -Attachment 2: Page 18 of 18 SECURITY AND PRIVACY INQUIRY (SPI) 8 #15 NOTICE OF MEETING- 612212022 15. Consider and take necessary action to authorize Dustin Jenkins, EMS Director, to sign a credit application with the Goodyear Tire and Rubber Company. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 11 of 16 Mae Belle Cassel From: Dustin.Jenkins@calhouncotx.org (Dustin Jenkins) <Dustin.Jenkins@calhouncotx.org> Sent: Wednesday, June 15, 2022 12:03 PM To: Mae Belle Cassel Cc: Donna Hall; Lori McDowell Subject: Fwd: Fw: form 1295 Attachments: doc00257420220613141831.pdf Mae Belle, I would like to put the attached credit application with The Goodyear Tire and Rubber Company on the next Commissioners Court agenda for approval to sign and apply. Attached you will find the application, 1295 and W9. Thank you, J. Dustin Jenkins, DMin, MBA, MTh, LP Director of EMS Calhoun County, TX From: "joel_stratton@goodyear.com (Joel Stratton)" <joel_stratton@goodyear.com> To: Dustin Jenkins<dustin.jenkins@calhouncotx.org> Date: Mon, 13 Jun 2022 19:15:59 +0000 Subject: Fw: form 1295 CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Joel H. Stratton Fleet Tire Sales Specialist Commercial Tire & Service Centers The Goodyear Tire & Rubber Company 9007 N US HWY 59 Victoria, TX 77905 T: 361.465.4750 C: 361.484.3966 From: ct_location_348@goodyear.com <ct_location_348@goodyear.com> Sent: Monday, June 13, 2022 2:18 PM To: Joel Stratton <joel_stratton@goodyear.com> Subject: ECOSYS M2540dw [00:17:c8:b8:43:60] 1 J. Dustin Jenkins, DMin, MBA, LP Director of Emergency Medical Services 705 Henry Barber Way Calhoun County, TX dustin.jenkins@calhouncotx.org (361)571-0014 Calhoun County Texas CERTIFICATE OF INTERESTED PARTIES FORM 1295 10( 1 Complete Nos. i • 4 and 6 If there are Interested parties. OFFICE USE ONLY Complete Nos. 1, 2, 3, 5, and 6 if there are no Interested parties. CERTIFICATION OF FILING Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2022-898549 The Goodyear Tire & Rubber Company Akron, OH United States pate Filed: 06/13/2022 2 Name of governmental entity or state agency that Is a party tot the contract for which the form Is being filed. Calhoun County Cmergency Medical Services pate Acknowledged: 3 Provide the Identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. required - requested form then and possibly service 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary BlackRock New York, NY United States x 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DrCIARATION My name is Richard Bevingion and my date of birth is 04/06/1968 My address is 200 hwovntion Way Akron OH , gA716 USA , (elrccQ (city) (stale) (zip code) (caunlry) I declare under penalty of perjury that the foregoing is true and correct. Executed in Summit County, State of OH on the 13th day of June 2022 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by I exas units commission www,ethics,state.tx.us Version V1,1.191bSedc Request for Taxpayer Give Form to the Form V (Rev, Cctobor 2010) Identification Number and Certification requester. Do not Department of the Treasury 6rlmaal nevenue service ► Go to wwwim.gov/FormW9 far Instructions and the latest Information. send to the IRS, t Name (as shown on your Income tax return). Name Is required on this line; do not leave this line blank. The Goodyear Tire & Rubber Conn an _ 2 Business name/disregarded onllly name, II different Isom above dba Goodyear Commercial The & Service Centers 3 Check appropriate box for federal lax classillcatoo of the parson whose name Is entered on line t Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain anlltio% not individuals; sea a p ❑ Individual/uolu proprlelor air 0 C Corporation ❑ S ComnudsIan ❑ PAnnorship ❑ Trumlestale Inskuolions on page 3): d n 51n01ro-mnlnbar t1.0 Exempt payee code (if any) � � ❑ Llnllud Ilahlllly company. Ender the lax classification (C=C corporation, S=5 corporation, P=Partnorsnip)► `d 2 NOW Chuck Ilia appropriate box In the line above far the tax classification of the single -member owner. Do not check Exemption from FATCA reporting c in .9 LLC if the LLC is classified as a single-momber LLC that is disrog:udud from Ihu owner unless the owner of the Lt.0 Is another LLC that is not clamorwoodfrom the owner for U.S, federal tax proLLC poses. Otherwise, a single -member that code f any) D 0 Is disregarded from the owner should check the appropriate box for the tax classification of Its owner. y ❑ Other(sou instructions)► IAmrCf la vaovi,b melnlemWuvndde mnacJ LT 0 Address (number, street, and apt, or audio no,) Soo Instructions, Requestor'a name and address (optional) r 200 Innovation Way 0 City, slate, and ZIP code Akron, OH 44316-0001 7 list account number($) here (Opliomu) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. 'rhe TIN provided must match the name given on line f to avoid (Social security number I withholding. For Individuals, this Is generally your social security number ISM). Flor other fora backup resident resident alien, sole proprietor, or disregarded chilly, sae the instructions for Part 1, later. For oilier entitles. It Is your employer Identification number (BIN). If you do not have a number. see Now to got a TIN, later. Or Note: If the account Is In more than one name, see the Instructions for line 1. Alga see What Name and I_Employer Identification number Number To Give the Requesterfor guidelines on whose number to enter, 3 4- 0 2 5 3 2 4 Under penalties of perjury, I certify that: 1. the number shown an this form is my correct taxpayer Identification number (or I am wailing for a number to be Issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) [list I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I ant no longer subject to backup withholding; and 3. 1 all) a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct Certification Instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. Sao the Instructions for Part II, later. Signature of U.S. parson ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form Wg and Its Instructions, such as legislation enacted after they were published, go to wwvvJrs.gov/FermKAJ. Purpose of Form An Individual or entity (Form W9 requesun) who Is required to file on Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), Individual taxpayer Identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an information return, Examples of Information returns include, but are not limited to, the following, • Form 1099-INT (interest earned or paid) Date ► 111 /2022 • Farm 1009-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds) • Form Io99.S (stuck or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds fear)) real estate transactions) • Form 1099•K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098•E (student loan Interest), 1098-T (tuition) • Form 1099-0 (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only it you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester Mal a TIN, you might be subject to backup withholding. See What is backup withholding, later. Col. No. 1D23Ix Form W-9 (Rev. 10-2018) CREDIT APPLICATION THE GOODYEAR TIRE & RUBBER COMPANY COMMERCIAL TIRE & SERVICE CENTERS Meese Prinl LEGAL NAME AND ADDRESS OF APPLICANT Pmpriolor PannoraldP _ S Coglaravou C Ooptomllnn _ LLC Noma Sndnl Canlpnny nr QL 'n r`� / O�^m' G_�^^ ` FudSec Security Inllivinual ..�r .l I'TL.(V.. L- ^r17 C•/L''J BPCVdtyq //'.� y-� � Phyaicol AN N, a. or y,05 y ,� ty e % �' "''''j�J` ODA V\A- �'(�6fi �A,/` PC 6 0�J57 /.COO /' y __.%✓ `�/ 11 T_._Slntu _ l L,/t �S Zip Code / • / 7 _ nu, ��J / Pltune ll 7b���iZ �T���� Fox If , Finall Address n 7 / A—ontrHe , PaYGU1G CwArl '✓.1/1"N�T l LL An.JuRn PnynNn PhonicW — Z 1od1Vb10e1 pe, sPnaily puaronleeinp O.N. It applicable Personal Ouarnnto,'s SSN appllcnetc are requested to supply the followina credit Infoneallon ea IUlly and at... N.1y se poselble. Additional Information or details may be requested by The IAII Goadyenr Tiro 6 Rubber Company. H the eiEcerfs, the APpliannt will alas bP porsouelly Suaaroulnolno Iho dohl, addlllonal Inloramtlon may be requested. Pleats, see the attpcbod dlacl.. uro. Trade References: �--��_-- Cnnlacl Nmm� Phone Fa%II REQUIRED INFORMATION _— t'� �_.. _..,....... p//jam (� �q� I -1;..• ._..._.__, Year basinees nludad type of Hustnesa Huyu y di uyur eiorl bankruptcy? Yna I Na (%j­ It yes: Chapter _ Dole Curren Gtolus I Will ncnmml hn law esortI Yos (I No ( I If yes, cAniflow" "muuC bn'dI.dlmtl. / Pemhnen Grder NumM1nr NnpWrodY Yas ( ) IVO IPX II yes, sµ:aial b)11iNv luyuimmunlu NGe CAREFULLY BEFORE SIONINGI I cn In IV 1.lte r.eni,q Irt101I mINn lmi aeon sunnikN 11.1AIul'v. agvrulelY And yolunANIN and then lmo aWbonzG this LLwrlya At Tho A Ruh hof Can1may 0 A,y .1%la my o.Atw ormn... ..cull hA.A ry And nnanOol rffpcnl,nAli I�rnM]AaM<IaJIIL,Aeaael by aMNbo„nvrnu, Yuinlnq nunvl w,IN anal A. nrelnm unannrx Il Am, ✓P011., pe!gyty9 NP ➢GIJ.IJta1(WIitI LN(ill WVAYWUVIIe APINP11UlY.s,ggr�I V Anlwn.1,,;gn ny�ST l,nd,lt9 ,It w,,A,by I hp hu, wnlarvinvl last tuy,nn.J Wnnv ern NJ I fit A..— ullNrn 1e.'.10 an,mN.al nq I anroo 1. may0.,.Rom pNIM1I:,I/ In a:{a•luniu will, A., 1111.11, w1nr1-141 All nnr"..— WlvnMtealM,nail-'M0AJta, tlamom. pr enln•4A"AV":'e,W.IIn,W.G--'IA., lbn, ul nuyr„nnlm.,.'..ynn111, V1.o WrIMN MCfe. TgtRQN..Afro. talc% kdk.wd IWIV nmaoI1.NyaYi.emm. or fiumA:G Numat hnl Io u=nW a454t u.n'A't xe Aleid,nd callaImrJrn,ba spxA"11,Aprneda.l AkUalod Gal II IIA marvel aoM:niq At vgaN aneonnvel W Am AM Arcnled l.emal ,Jun IA, 1 It pinxnn A bin rd' d' A, nn tv.,J yA,,any Gtw Gary V"Aww' Nuounll fu . pc1sAA. o, bAnu.pl1.V4,rr,Inn,111VI4. hill,.. 11, Any,,, Anrl aX,ea W Wble lees, a,IGIMft N., aM at 1001 Ja AFAY be.w.,d.d III aNIII'nI In VF art,•: All JAM HJuue! Jun 11IIr41•I,In,:l uAu^liar nl enw,gnl n1 vxal—Iola fM i,nHnr:In At THE EQUAL CREDIT OP PORTUNITY ACT (ECOA) PROHIBUS CREDIT GRANTORS FROM OISCRIMINATING AOAINST CREDIT APPLICANTS ON THE BASIS OF RACE, COLOR, RE LIMON, NATIONAL ORIGIN, SEX, MARITAL STATUS, OR AGE PROVIDED THE APPLICANT HAS THE CAPACITY TO CONTRACT. THE FEDERAL TRADE COMMISSION AND TI IE CONSUMER FINANCIAL PROTECTION BUREAU ADMINISTERS COMPLIANCE WITH THE ECOA 7e—DuSfrl,j7-4�Nxtas) eMS APplluu tt, PrInIUJ Naha •d Tili.- Alas.ion h., ONLY IF DEBT WILL BE PERSONALLY GUARANTEED 4tilce.lV.a.ABIY. ClulnmarAennpnn h: __�,,,., / Limo RegUesled: Awed' Data; "d-re44y w'9 Request for Taxpayer Give Form Form (Rev. October 2018) Identification Number and Certification to the requester. Do not Depenment of the Treasury send to the IRS. Internal Revenue Service ► Go to www-irs.gov/FormW9 for instructions and the latest information. t Name (as shown on your income tax return), Name Is required on this line; do not leave this line blank. The Goodyear Tire & Rubber Company 2 Business name/disregarded entity name, if different from above dba Goodyear Commercial Tire & Service Centers 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to following seven boxes. certain entitles, not Individuals; see a o ❑ Individual/sole proprietor or El C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate Instructions on page 3): e o single -member LLC Exempt payee code (if any) 2�'B ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P-Partnership) ► `o 2 w Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC is D a another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that code (If any) is disregarded from the owner should check the appropriate box for the lax classification of its owner. y ❑ Other (see instructions) ► (AGP� to eccounte eeenbbedoUtskle the U.S,) 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) 200 Innovation Way 6 City, state, and ZIP code Akron, OH 44316-0001 7 List account number(s) here (optional) ttlentltictatlon Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later, For other entities, It is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. ©oen©©©©nn penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. oryn Signature of Here U.S. person le w 'u'a' Date ► 1 /1 /2022 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.im.gov/F`ormWg. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number(ATIN), or employer identification number (EIN),_to report on an Information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following, • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (Including a resident alien), to provide your correct TIN, If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) ;gt 01-339(Book) (RevA-1318) Texas Sales and Use Tax Exemption Certification This certificate does not require a numberto be valid. Name of purchaser, firm or agency THE COUNTY OF CALHOUN TEXAS EIN: 74-6001923 Address (Street& number, P.O. Box or Route number) Phone (Area code andnumbeo 202 S ANN ST 361553.4610 City, state, ZIP code PORT LAVACA TX 77979 I, the purchaser named above, claim an exemption from payment of sales and use taxes (for the purchase of taxable items described below or on the attached order or invoice) from: Seller: Street address: City, State, ZIP code: Description of items to be purchased or on the attached order or Invoice: SUPPLIES, MATERIALS, PRODUCTS, LEASES, VEHICLES, EQUIPMENT, AND/OR SERVICES FOR THE Purchaser claims this exemption for the following reason: EXCLUSIVE USE OF CALHOUN COUNTY, A POLITICAL SUBDIVISION OF THE STATE OF TEXAS I understand that I will be liable for payment of all state and local sales or use taxes which may become due for failure to comply with the provisions of the Tax Code and/or all applicable law. I understandthatitisa criminaloffensetogive an exemptioncertificate to thesellerfortaxableitemsthatl know, atthe dmeofpurchase, wil(be usedina mannerotherthanthat expressedin thiscertificate, anddependingontheamountoftaxevaded, theoffensemayrange from a Class C misdemeanor to a felony of the second degree. Purchaser sign he Title // dr` Date I 3 �o as CV "NOTE: This certificate cannot be issued for the purchase, lease, or rental of a motor vehicle. THIS CERTIFICATE DOES NOT REQUIRE A NUMBER TO BE VALID. Sales and Use Tax "Exemption Numbers" or "Tax Exempt' Numbers do not exist. This certificate should be furnished to the supplier. Do not send the completed certificate to the Comptroller of Public Accounts. #16 NOTICEOFMEEIING 6/22/2022 16. Consider and take necessary action to accept a second insurance proceeds payment from TAC in the amount of $3,566.47 for damages to a Sheriff Office vehicle on 3/30/22. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 12 of 16 Mae Belle Cassel From: candice.villarreal@calhouncotx.org (candice villarreal) <candice.vi I larreal @cal hou ncotx.org> Sent: Monday, June 13, 2022 4:25 PM To: maebelle.cassel@calhouncotx.org Cc: Richard H. Meyer; David Hall; vern lyssy, joel.behrens@calhouncotx.org; Gary Reese Subject: Agenda Item - Insurance Proceeds - SO Attachments: TAC Ins Proceeds -SO 033022 2.pdf MaeBelle, Please add the following agenda item for the next available Commissioners Court. • Consider and take necessary action on a second insurance proceeds payment from TAC in the amount of $ 3,566.47 for damages to a Sheriff Office vehicle on 3/30/22. Thank you, O Candice `IJiflarreal 1n AssistantAuditor Calhoun County Auditors Office 202 S. Ann Street, Suite B Port Lavaca, 4X 77979 (Phone (361)553-4612 Calhoun County Texas TEXAS ASSOCIATION OF COUNTIES I IEGK D I E I .; ( I, 'I 58305 RISK MANAGEMENT POOL CLAIMS __- 6/9/2022-_.58305 V1L)OR IO VI NO a i.JAM17 _ � , 111`II Ni""iH t Calhoun County -- -" -- 1Arh f INvrm E D.,,� MEMO EMO APD20220159-1 MVD-to Clm/Aty Supplement payment for 2019 $3566.47 - - Chevrolet Tahoe VIN 1411 of $3,566.47 6/9/2022 APD20220159-1 $0.00 •:=^=�"."`""'•,"�' �:\�'�°""== 17P1'0'ueh�311Lt�,=4Fiil1TT31TdX:iil333'RIYzr.pL1:. _ 58305 f'EXAS A,3S0GlA) J0N OF COUNTIES _ HISK IVIANAGEMFNT POCW CLAIMS [� 1210SAN ANIOM SI'HEEi k m AUSTIN-TX 78701 (512)478-8753 � noes PAY THREE THOUSAND FIVE HUNDRED SIXTY-SIX AND 47 / 100 DOLLARS TOTHE Calhoun County ORDER 202 S Ann St Ste B OF Port Lavaca, TX 77979-4204 11105830511' TEXAS ASSOCIATION OF COUNTES RISK MANAGEMENT POOL -CLAIMS Calhoun County 202 S Ann St Ste B Port Lavaca, TX 77979-4204 o FROSI uANI( ?O_9/i'4a0 NAVE 6/9/2022 VOIOAFT'EH t800Av/s i i I AMOUNT $ 3,566.47 58305 10 RFORDFR CALL 17051327-955o WidSF001C14M OJ2? #17 NOTICF OF MFFTING-6/22/2022 17. Consider and take necessary action to approve the attached Calhoun County Library Electronic Device Lending Agreement and Hotspot Rental Agreement. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: David Hall, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 13 of 16 Mae Belle Cassel From: dsanchez@cclibrary.org (Dina Sanchez) <dsanchez@cclibrary.org> Sent: Thursday, June 16, 2022 11:42 AM To: Mae Belle Cassel Subject: Commissioners Court CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Good morning, can you please add this to the agenda for the next Commissioners' Court meeting. 1) Please consider and take necessary action to accept and approve the attached Calhoun County Library Electronic device lending agreement and Hotspot rental agreement. Thank you Calhoun County Texas Calhoun County Public Library Electronic Device Agreement Lending Guidelines and Agreement must be completed once and on file before Individual forms for each device must be completed each time a device is cl Guidelines for Borrowing and Use • Borrowers must be 18 years or older and have no fines on their account to Check out Electronic Devices. • Prior to borrowing Electronic Devices, all Patrons must sign and have on file the Waiver and Indemnification Form • The Borrowers Agreement must be signed each time an Electronic Device is checked out. • A valid government issued ID with picture and current address must be presented at checkout. • Items MUST be returned to the Information Desk during operating hours. • Claims "Returned" and "Never checked out" are not allowed for Electronic Devices. Care and Operation • By checking out the item the patron is certifying that they are capable of using the item in a safe and proper manner. • Do not leave devices charging unsupervised. Do not charge devices under a pillow, on your bed, on a couch or in a location that's exposed to direct sunlight. Do not use the library charging cord to charge other electronic devices. • An Electronic Device shall not be used in a manner inconsistent with its intended design and purpose. • If any item borrowed becomes unsafe or in a state of disrepair the patron must immediately discontinue use and notify the Library as soon as possible. • The patron will not make any modifications or alterations to Electronic Devices. • Only the Patron is authorized to use Library Electronic Devices. Patrons shall not permit the use of items checked out to them by any other person. • All consumable supplies must be purchased by the borrower. • All Electronic Devices should be returned in the same or better condition as they were borrowed in, excluding normal wear. • All Electronic Devices that are unreasonably dirty must be cleaned before being returned to the Library or a cleaning fee will be charged. • The Library does not provide supervision or instruction for the use of an Electronic Device. Fines and Liability • The overdue fine on an Electronic Device is $1 per day. If an item is more than 30 days overdue, it is considered lost and you will receive a bill to cover the replacement. If a billed item is returned in good condition within 30 days of due date, the bill will be removed from your record but you will be charged overdue fines. • All Electronic Devices borrowed are to be returned to the Library by close of business on their due date. Tools and equipment may only be returned during the Library's open hours, and may not be returned in the book drop. • A $5.00 cleaning fee will be charged for items returned without being cleaned. • The Borrower is solely responsible for the Electronic Device and will be billed for the repair or replacement cost associated with damage loss of an Electronic Device and/or peripherals as a result of neglect or abuse. Damage or loss fees may be incurred up to 5 days after check in. Page 1 of 3 Patron initial here: • A list of replacement costs of Electronic Devices is maintained by the library and is available for viewing upon request. • Patrons who have paid for lost items, then find them within 30 days past the due date, may receive a refund. If customers find materials 30 or more days after the due date, no refunds will be made. • It is the borrower's responsibility to protect the Electronic Device against loss or damage. • The Calhoun County Public Library is not responsible for any injury, loss or damage that may occur from the use of an Electronic Device. • The Calhoun County Public Library is not responsible for the loss of data while using this equipment. • Texas Penal Code Title 7 Sec. 31.03. THEFT. (a) A person commits an offense if he unlawfully appropriates property with intent to deprive the owner of property. • Full payment is expected up front. Payment plans will NOT be accepted. • The Library may file theft charges if library property is not returned. • 1 shall only use the Electronic devices for lawful purposes. I understand that this device may not be used for any purpose that violates federal, state, or local laws and Library Policies. o I acknowledge that under Federal and Texas law, it is a crime to view, distribute or exhibit material that is "harmful" to minors, or to be reckless about "whether a minor is present who will be offended or alarmed by the display" of harmful material. o I acknowledge that I am prohibited from using the electronic device for illegal activity, to access illegal or obscene materials or to display material that violates Federal, State, or local laws. o I will not violate any state or federal statute including those regarding obscenity, pornography, or delivery to minors material deemed harmful to them. • 1 acknowledge that I am not allowed to engage in the following prohibited activities: o "hacking" or otherwise attempting unauthorized use of networks; o Invading the privacy of others; o Access sexually explicit images of anyone under the age of 18 or who appears to be under the age of 18 o Violating copyright laws; o Violating software license agreements; or o Sending harassing, threatening, or libelous messages or materials using the electronic device. Page 2 of 3 Patron initial here: Calhoun County Public Library 200 W. Mahan St 106 W. Main St 502 S. 0 St Port Lavaca Port O' Connor Seadrift (361)552-READ (361)983-4365 (361)785-4241 www.cclibrary.orl Liability Waiver and Informed Consent Form Electronic Devices In consideration of my use of the Electronic Equipment lent out by the Calhoun County Public Library, I hereby voluntarily release, discharge, waive, and hold harmless, on behalf of myself, my heirs, executors, administrators, and assigns, Calhoun County, the Calhoun County Public Library, the City of Port Lavaca, the City of Port 0' Connor, the City of Seadrift, the City of Point Comfort and their employees, officers, and agents, ("hereinafter referred to as "indemnified parties") from any loss, damage, or injury to persons or property arising from the Equipment. In no event shall the Indemnified Parties be liable to me for indirect, consequential or special damages, including without limitation lost use, revenue or profits. I agree to indemnify and hold the Indemnified Parties harmless from and against all liabilities, claims, actions, proceedings, damages, losses, costs and expenses, including attorneys' fees, for all injuries or death of any person, or damage to any property occurring or arising from or connected with, directly or indirectly, my possession, use, and return of the Equipment. No warranties, expressed or implied, including without limitation: suitability, durability, fitness for a particular purpose, condition, or quality have been made by the Indemnified Parties, directly or indirectly in connection with the Equipment. I am borrowing the Equipment "as is." I acknowledge that I am responsible to examine the Equipment before checking out and will not check out if its condition is unacceptable. I agree to surrender the Equipment to the Library in as good order and condition as when received, except for reasonable wear and tear resulting from proper use, and if returned unclean, I may be charged a reasonable cleaning fee. I agree to keep and maintain the Equipment in good condition, use it in a careful and proper manner and comply with all applicable laws and regulations. I understand that the Library does not provide supervision or instruction for the use of the Equipment. I understand and acknowledge that the use of some of the Equipment involves risk of serious injury, including permanent disability and death. I agree to refrain from using any Equipment in a manner inconsistent with its intended design and purpose. I have read the Lending Guidelines and Agreement and this Liability Waiver and Informed Consent Form and sign it voluntarily. I understand that I am giving up substantial rights by signing it. Print Name Signature Calhoun County Library staff sign here Patron initial here: Date Driver's License # Library Card # Page 3 of 3 Calhoun County Public Library 200 W. Mahan St 506 W. Main St 502 S. 4ch St Port Lavaca Port O' Connor Seadrift (361) 552-READ (361) 983-4365 (361) 785-4241 www.cclibrary.org Wi—Fi HOTSPOT LENDING POLICY This form must be completed each time a device is checked out. The 3-page library's Lending Guidelines an4 Agreement for Electronic Devices must be completed once and on file before any electronic devices are checked out j By checking out the hotspot, you have agreed to the following: I have read and signed the Calhoun County Library's Lending Guidelines and Agreement for Electronic Devices. I understand that the hotspot can be checked out for 14 days and may only be renewed 1 time if there is no waiting list. The hotspot must be returned to the library by the due date with all included accessories, and in original packaging. If the hotspot is not returned within 24 hours of the due date, the Wi-Fi service may be disconnected and the hotspot will no longer be usable. An overdue fine of $1 per day will be assessed. Failure to return the device will result in a replacement charge of up to $150. The library reserves the right to refuse checkout to patrons who abuse the hotspots or repeatedly return them late. I understand that the hotspot runs on the T-Mobile network and that the speed and availability of the Wi-Fi connection will be dependent on the service area of T-Mobile's towers. Service connection is not guaranteed in all areas. I understand that the hotspot may NOT be returned in the book drop; it must be returned to the circulation desk during library operating hours. If I do not return the hotspot to the library in good working condition with all included accessories and packaging, I may be charged a replacement cost of up to $150. 1 understand that the library is not responsible for any files, data, or personal information accessed, transmitted, lost or damaged while accessing the internet via the hotspot. By signing this agreement, I accept the above checkout agreement and am stating that I am responsible for returning this equipment to the library in good working condition and free of damage. Patron Name Patron Signature: Phone Email: Library Card Date: Staff Use Only Check Out: Please check to ensure that all pieces of equipment are present at the time of checkout _ Hotspot _USB Cable _Power Adapter _Carrying Case _Instruction Card Staff initials Date Check In: Please check to ensure that all pieces of equipment are present at the time of check in. _ Hotspot _USB Cable _Power Adapter _Carrying Case _Instruction Card Staff initials Date #18 NOTICE OF MEETING — 6/22/2022 18. Accept Monthly Reports from the following County Offices: i. Justice of the Peace, Precinct 5 — May 2022 ii. Tax Assessor -Collector — June 2021, Revised III. Tax Assessor -Collector — July 2021, Revised iv. Tax Assessor -Collector — December 2021, Revised v. Tax Assessor -Collector — March 2022 vi. Tax Assessor -Collector — April 2022 RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER:" Gary Reese, Commissioner Pct 4 AYES: ;Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 14 of 16 06-08-22;22:26 ;From:Calhoun County Pct. 5 To:13615534444 ;3619832461 # 1/ 8 n,vo ✓0Snee ROR A/L..., DATE: JUNE 8, 2022 FAX COVER SHEET JUDGE NANCY POMYKAL P 0 BOX 454 PORT O' CONNOR, TX.77982 (361)983-2351 -TELEPHONE (361)983-2461 - FAX COUNTY OF CALHOUN JUSTICE COURT PCT. 5 PAGES: 8 Including this cover TO: JUDGE RICHARD MEYER & COUNTY COMMISSIONERS ATT: MaeBelle FAX NUMBERS) 361-553-4444 SUBJECT: MAY 2022 — MONEY DISTRIBUTION REPORT NOTE:_MaeBelle I am faxing the above report for MAY 2022 Please give me a call if you have any questions. Thank you, el paw THE CONTENTS OF THIS FAX MESSAGE ARE INTENDED SOLELY FOR THE ADDRESSEE(S) named in this message. This communication is intended to be and to remain confidential and may be subject to applicable attorney/client and/or work product privileges. If you are not the intended recipient of this message, or If this message has been addressed to you in error, please immediately alert the sender by fax and then destroy this message and its attachments. Do not deliver, distribute or copy this message and/or any attachments and if you are not the intended recipient, do not disclose the contents or take any action in reliance upon the information contained in this communication or any attachments. 06-08-22;22:26 ;From:Calhoun County Pot. 5 To:13615534444 ;3619832461 # 2/ 8 Money Distribution Report CALHOUN IPS MAY 2022 REPORT Receipt Cadefi\AMOUnto Total 277611 2022-OID2-SC 05-02-20" WP 21.00 LCCP 23.00 54.00 M & j 14OLOXNGS GP Cashier's Check W:07: J43: 75 05 02 :2 ,00 496. op. T::.1! �1:: . .. ...... . 317613 2022-0187 6S-04.2022 CCC 62.00 PWAP 5.00 LCCC 14.00 FINE 19.66 100.00 DEAN, LOUTS Cash iOSaO92b,22 LCCC 'G210b LAP S."Ob: tCCO I GO LTFC ¢ 3410 R mo 'Ou C edit. .t 377615 2022-0133 05.10-2022 CCC 62.OD LAI' 5.00 LCCC 14l00 FINE 10.53 LTFC 0.40 1OO.00 MEJIAS, JUSTIN MILWAEL STFI 7.90 Credit Card 3,7G16 2023.0332 CCO: U.da LKr: W 50 Is MTT,.:JASGN:; BRYAN:::.:::. F. ME:.: 1D.4:. OG: CSR14:i.: % 377917 2021.0395 05-13-2022 CCC 92.00 ZAP S.00 WRNT 5D.00 LCCC 14.00 OVNR 10.00 364.00 MORGAN, MATTHAN WAYNE FINE 66.00 LTFC 3.00 STFI 50.00 CSRV 84.00 Money order,,, to .�: P� �194022:USF .4 � a 0% TFC: ..z;DQ . ... ...... .... 'CCC 49: 00 CHS 3 OV "LAY.. i�.: t: i:�GQNZALkgkMilNd kAUL.'... WRNT- 00.. '..TF... 4 00'r; WPAY:. :.:.Stoo Cudit-Card: t .;36 d , OM 09, . I : t 377010 2022-0190 05-20-2022 CCC 62.00 LAP 5.00 LCCC 14.00 LTFC 3.00 ST71 501DO 220,60 CALDWELL, ALVIN WILLIAM DFF 89.00 Cash 96 0524 --2OZ2;:. 6C.C.:: o . L 44 E.6 5 0 ALVARADO,: SALVADOX. NI)NEZ.::. Cash 377621 2020-0208 05-24-2022 CCC 34.44 LAP 2.78 LCCC 7.70 45.00 ALVARADO, SALVADOR VUNzz 377623 2022.0203 05-25-2022 TFC 3.OD CCC 62.00 LAP S.OD STY1 SO.00 LCCC 14.00 00. 144.60 BELL, SABRINA ANN DOC 10,DD Cash 377524 20:22-0113-- LAP; .... .. ...... . m . . ....... . .. 377425 2022-0194 05-26-2022 CCC 92.00 LAP S.00 LCCC 14.00 FINE 99.00 LTFC 3.00 220.00 BLANCO, MANUEL JESUS STF1 50.00 Cash 3i�d245:,: , 20;20-' Q;L" -05-2e-2022 CCot:: 62 no !LAP �WRKT:: St. ,FINE1 . . .. ... 264 Da So ....... • 317627 2022.0171 DS-26-2022 CCC 62.OD LAP 5.60 LCCC 14.00 DFF 119.00 200.00 ELLIOTTf DANA LYNN Cashier's Chock m :Cashier b:,Chddki i:. t,:: .. ..... • . ...... 377629 2022-DIGS 05-2(-2022 CCC 62.00 GAF 5.00 LCCC 14.00 OFF 110.00 200.00 ATKINSON, KYLE WEBB Cashier's Check -.2422418 115-2G12a22':CCC' "G2 1 CC L ., 4 100 'i!br d19 00 200.60, .... ........ ...... . 377631 LDOO-0392 05-31-2022 JSF 4.00 CCC 40,00 CHS 3.00 LAP: 5.00 WANT SO.Do 299.00 SANCHEZ, PATRICK RAY IF 4.OD JCSF 1.00 OPAY 6.00 SDP 2.00 MVF 0.10 Jail Credit TPDP 2,00 OMNR 10.00 FINE 97-DO C G9.00 7CMF 5.00 . 6. 1. :1 . .. :. S.776a2i;. :IX Or.0183 tdsF,: 4 DO tid C NY .3: '0 0 - . AP r. .0 .. :.5 DO �25,. 00 ';SANCHE2':DATRICK PAY WRNTI. 50 OD IF' 4 TO:, a SP 1 90 'JPAJ!: 40': 'E „ gall di - ....... t, NvF TODP, 2;0 :;40 1 FINE 2424. .. d d I 377633 2022-0187 05-31-2022 FINE 145.00 145.00 DEAN, LOUIS 06-06-2022 page 1 06-08-22;22:25 ;From:Calhoun County Pot. 5 To:13615534444 ;3619832461 # 3/ 8 Money Dietributi= Report CALHOUN TPS MAY 2022 REPORT Receipt Ceuee/Defendant Codao\Amounts _ _ Total CRah 06-09-2022 rage a 06-08-22;22:26 ;From:Calhoun County Pot. 5 To:13615534444 ;3619832461 # 4/ 8 Money Distribukion Report CALHOUN JPS MAY 2022 REPORT Type Code Dosoriptioa Count Retained Disbursed Money -Totals The following totals repreoent - Cash and Cheeks Collected COST CGG CONSOLIDATED COURT COSTS 14 78.23 704.04 762.27 COST CCC CONSOLIDATED COURT COSTS 0 0.00 0.00 9.00 COST CHS COURTHOUSE SECURITY 0 0.00 0.00 0.00 COST IOF INDIGENT DEFENSE FUND 0 0.00 0.00 0.00 COST JCSF JUSTICE COURT SECURITY FUND 0 0.00 0.00 0.00 COST SPAY JUDOS PAY RAISE FEE 0 0.00 D.00 0.00 COST JSF JUROR SERVICE FUND 0 0.00 0.DO 0.00 COST LAF SHERIFF'S FEE 13 50.09 0.00 5B.09 COST LCCC LOCAL CONSOLIDATED COURT COST 1-1-20 14 176.64 0.00 176.64 COST LCCF LOCAL CONSOLDATED CIVIL FEES 1-1.22 l 33.00 0.00 33.00 COST MVP MOVING VIOLATION FEE 0 0.00 D.00 0.00 COST OMNI OMNI REIMBURSEMENT FEE (EFF. 1.1.20) 1 10.00 0.00 10.00 COST PRAP TEXAS PARKS & WILDLIFE 1 4.00 1.00 5.00 COST STFS STATE TRF FINE 9-1-10 1 2.00 46.00 50.00 COST SUBC SUB TETGB C 0 0.00 0.00 0.00 COST TP TECHNOLOGY FUND 0 0.00 0.00 0.00 COST TFC LOCAL TRF. FINE- FORMERLY TRF. 9-1-19 1 3.00 0.00 3.OD COST TPDF TRUANCY PREVENTION & DIVERSION FUND 0 0.00 0.00 0.00 COST WRNT WARRANT FEE 2 100.00 0.00 100.00 FEES CSRV COLLECTION SERVICES FEE 2 202,50 0.00 20R.50 FEES DDC DRIVER SAFETY COURSE - 2020 1 10.00 0.00 10.DO FEES OFF DEFERRED FEE 6 628.00 0.00 628.00 FEES JCMF JUVENILE CASE MANAGER FEE 0 D.00 0.00 0.00 FEES SCCF STATE CONSOLIDATED CIVIL FEE 1 0.00 22.00 21.00 FINE FINE FINE 6 839.00 0.00 839.00 FINE LTFC LOCAL TRAPF:C FIND (EFF. 9.1.191 4 12.00 0.00 12.00 FINE STFS STATE TRAFFIC FINE (EFF. 9.1.19) 4 8.00 192.90 20D.00 OPMT OPMT OVERPAYMENT 1 496.00 0.00 496.00 Money Totals 17 2,660.46 96G.D4 3,62G.50 The following totals represent - Transfers Collected COST CCC CONSOLIDATED COURT COSTS 0 0.00 0.00 0.00 COST CCC CONSOLIDATED COURT COSTS 0 - 0.00 0.00 0.00 COST CHS COURTHOUSE SECURITY 0 0.00 0.00 0.00 COST IDF INDIGENT DEFENSE FUND 0 0.00 0.00 0.00 COST JCSF JUSTICE COURT SECURITY FUND 0 0.00 0.00 0.00 COST JPAY JUDGE PAY RAISE FEE 0 0.00 0.00 0.00 COST JSF JUROR SERVICE FUND 0 0.00 0.00 9.99 COST LAP SHERIFF'S FEE 0 0.00 0.00 0.00 COST LCCC LOCAL CONSOLIDATED COURT COST 1-1-20 0 0.00 0.00 0.00 COST LCCP LOCAL CONSOLDATED CIVIL FEES 1.1.22 0 0.00 0.00 0.00 COST MVF MOVING VIOLATION FEE 0 0.00 0.00 0.00 COST OMNR OMNI REIMBURSEMFAITT FEE (EFF. 1.1.20) 0 0.00 0.00 0.00 COST PWAF TEXAS PARKS & WILDLIFE 0 0.00 0.00 0.00 COST STF1 STATE TRF FINE 9.1-19 0 0.00 0.00 0.00 COST SUBC SUB TITLE C 0 0.00 0.00 0.00 COST TF TECHNOLOGY FUND 0 0.00 0.00 0.00 COST TFC LOCAL TRF. FINE- FORMERLY TRF. 9-1-19 0 0.00 0.00 D.00 COST TPDP TRUANCY PREVENTION & DIVERSION FUND 0 0.00 0.00 0.00 COST WENT WARRANT FEE 0 0.00 0.00 0.DO FEES CSRV COLLECTION SERVICES PEE 0 0.00 D.00 0.00 FEES DDC DRIVER SAFETY COURSE - 2020 D D.00 0.00 0.00 FEES OFF DEFERRED FEE 0 0.00 0.00 0.00 FEES JCMF JUVENILE CASE MANAGER FEE D 0.00 0.00 0.00 PEES SCCF STATE CONSOLIDATED CIVIL FEE 0 0.00 0.00 0.00 FINE FINE FINE 0 0.60 0.00 0.00 FINE LTFC LOCAL TRAFFIC FINE (EFF. 9.1.19) 0 0.00 0.00 0.00 FINE STP1 STATE TRAFFIC FINE, (EFF. 9.1.19) 0 0.00 0.00 0.00 OPMT OPMT OVERPAYMENT 0 0.00 0.00 0.00 Transfer Totals 0 0.00 0.00 0.00 The following totals represent - Jail Credit and Community Satvi!b COST CCC CONSOLIDATED COURT COSTS 0 0.00 0.00 0.00 COST CCO CONSOLIDATED COURT COSTS 2 8.00 72.00 80.00 06-08.2022 Page 3 06-08-22;22:26 ;From:Calhoun County Pot, 5 To:13615534444 ;3619832461 # 5/ 8 Money Dietributlod Report CALHOUN JPS MAY 2022 REPORT Type Code Description Count Retained Diaburoed Money-Totalo COST CHS COURTHOUSE SECURITY 2 6.00 0.00 6.00 COST IDF INDIGENT DEFENSE FUND 2 0.40 3.GO 4.00 COST JCSP JUSTICE COURT SECURITY FUND 2 2.00 0.00 2.00 COST JFAY 99DOE PAY RAISE FPS 2 1.20 10.00 12.00 COST Jsr JUROR SERVICE FUND 2 0.80 7.20 0,00 COST LAP SHERIFF'S PEE 2 10.DD 0.00 10.00 COST LCCC LOCAL CONSOLIDATED COURT COST 1-1-20 0 D.00 0.00 0.00 COST LCCF LOCAL CONSOLDATED CIVIL FEES 1-1-22 0 0.00 9.00 0.00 COST MVF MOVING VIOLATION FEE 2 0.02 0.10 0.20 CCST OMNR OMNI REIMBURSEMENT FEE (EFF. 1.1.20) 2 20.00 0.00 20.00 COST VWAF TEXAS PARKS & WILDLIFE 0 0,00 0.00 0.00 COST STF1 STATE TRF FINE 9-1-19 0 0.00 0.00 6.06 COST SUBC SUB TITLE C 1 1.50 20.50 30.00 COST TP TFC14NOMGY FOND 2 0.00 0.00 B.00 COST TFC LOCAL TRF. FINE- FORMRRLY TRF. 9-1.19 1 3.00 0.09 3.00 COST TPDF TRUANCY PREVENTION & DIVERSION FUND 2 0,00 4.00 4.00 COST WRNT WARRANT PEE 2 100.00 0.00 100.00 FEES C$RV COLLECTION SERVICES FEE 2 144.00 0.00 144.00 FEES DDC DRIVER SAFETY COURSE - 2020 0 0.00 D.66 6.66 FEES DFF DEFERRED FEE 0 0.00 0.00 0.00 FEES JCMF JUVENILE CASE MANAGER FEE 2. 20.00 0.00 10.00 FEES SCCF STATE CONSOLIDATED CIVIL FEE 0 9.00 9,00 0.00 FINE FINE FINE 2 182.80 0.00 102.80 FINE LTFC LOCAL TRAFFIC FINE (EFF. S.1.19) 0 0.00 O.DO D.00 F;NE SIPS STATE TRAFFIC FINE (EFF. 9.1.19) 0 0.00 0.00 0.00 OPMT OPMT OVERPAYMENT 0 0.00 6.66 0.66 Credit Totals 2 497,72 126.28 624,0D The following totals represent - Credit Card Payments COST CDC CONSOLIDATED COURT COSTS 3 14.20 127.83 142.03 COST CCC CONSOLIDATED COURT COSTS 1 4.00 39.00 40.00 COST CHS COURTHOUSE SECURITY 1 3.00 0.00 3.06 COST IDF INDIGENT DEFENSE FUND 1 0.20 1.80 2.00 COST JCSP JUSTICE COURT SECURITY FUND 1 1.00 0.00 1.00 COST JFAY JUDGE PAY RAISE FEE 1 0.60 5,40 6.00 COST JSF JUROR SERVICE FUND 2 0.40 3.60 4.00 COST LAP SHERIFF'S PER 4 16.45 0.00 16.45 COST LCCC LOCAL CONSOLIDATED COURT COST 1-1-20 3 i2.O4 0.00 32.07 COST LCCF LOCAL CONSOLDATED CIVIL FEES 1.1.2.2 0 0.00 0.00 0.00 COST MVP MOVING VIOLATION FEE 1 0.01 0.09 0.10 COST OMNR OMNI REIMBURSEMENT FEE (EFF. 1.1.20) 2 12.91 0.00 22.91 COST PWAV TEXAS PARRS & WILDLIFE 0 0.00 0.00 0.00 COST STP1 STATE TRF FINE 9.2.19 0 0.00 0.00 0.00 COST SUBC SUE TITLE C 1 1.50 28.50 30.00 COST IF TECHNOLOGY FUND 1 4.00 0.00 4.DO COST TFC LOCAL TRF. FINE- FORMERLY TRF. 9.1-19 1 3.00 0.00 3.00 COST TPDF TRUANCY PREVENTION & DIVERSION FUND 1 0.00 2.00 2.00 COST WRNT WARRANT FEE 2 64.54 0.00 54.54 FEES CSRV COLLECTION SERVICES FEE 2 148.50 0.00 148.50 FEES DDC DRIVER SAFETY COURSE - 202D 1 10.00 0.00 10.00 FEES DPP DEFERRED FEE 0 0.00 alga 0.00 PEES JCMF JUVENILE CASE MANAGER FEE 1 S.00 0.00 5.00 PEES SCCF STATE CONSOLIDATED CIVIL FEE 0 0.00 0.00 0.00 PINE FINE FINE 3 199.43 0.00 199.43 FINE LTFC LOCAL TRAFFIC FINE (EFF, P, 1.19) 2 3.46 0.00 3.48 FINE STF1 STATE TRAFFIC FINE (EPP. 9.1. 19) 2 2.32 55.67 57.99 OPMT OPMT OVERPAYMENT 0 0.00 0.00 0.00 Credit Card Totals 4 526.61 260.89 787.50 The followiag totals rapreaeat - Combined Money COST CCC CONSOLIDATED COURT COSTS 17 92.43 831.87 524.30 COST CCC CONSOLIDATED COURT COSTS 1 4.00 36.00 40.00 COST CHS COURTHOUSE SECURITY 1 3.00 0.00 3.DD COST IDr• YNDId= DEFENSE FUND 1 0.20 1.80 2.00 COST JCSF JUSTICE COURT SECURITY FUND 1 1.00 0.00 1.00 COST JPAY JUDGE PAY RAISE FEE 1 0.60 5.40 6.00 COST JSF JUROR SERVICE FUND 1 0.40 3.90 4.00 06-00.2022 Page 4 06-08-22;22:26 ;From;Calhoun County Pct. 5 To:13615534444 ;3619832461 # 6/ 8 Money Didtributian Report CALHOUN JP5 MAY 2022 REPORT Type Code DooCription Count Retained D144uraed Markey-Tatals COST LAP SHERIFF'S FEE 17 74.54 0.00 74.54 COST LCCC LOCAL CONSOLIDATED COURT COST 1-1-20 17 208.71 0.00 208.71 COST LCCF LOCAL CONSOLDATRD CIVIL PEES 1.1-22 1 33.00 0.00 33.00 COST MVF MOVING VIOLATION FEE 1 0.01 0.09 0.10 COST OMNR OMVI RETMSURSBMENT FEE (EPP. 1.1.20) 3 22.91 0.00 22.91 COST PWAF TEXAS PARES & WILDLIFE 1 4.00 1.00 9.00 COST STF1 STATE TRF FINE 9-1-ID 1 2.00 49.DD 50.00 COST SUBC SUB TITLE C 1 1,50 28.50 30,90 COST IF TECHNOLOGY FUND 1 4.00 0.00 4.00 COST TFC LOCAL TRP. PINE- FORMERLY TRF. 9.1-19 2 6.00 0.00 6.00 COST TFOF TRUANCY PREVENTION & DIVERSION FUND 1 0.00 2.00 2.00 COST WANT WARRANT FEE 4 164.S4 0.00 Id4.54 FEES CSRV COLLECTION SERVICES FEE 4 351.OD 0.00 351.00 FEES Doc DRIVER SAFETY COURSE - 2020 2 20.00 0.00 20.00 FEES OFF DEFERRED FEE 6 628.00 0.09 699.90 FEES JCMP JUVENILE CASE MANAGER FEE 1 5.00 0.00 5.00 PEES SCCF STATE CONSOLIDATED CIVIL PEE 1 0.00 22.00 21.00 FINE FINE. FINE 9 1,038.43 0.00 1,038.43 FINE LTFC LOCAL TRAFFIC FINE (EFF. 9.1.19) 6 15.48 0.00 i5.4E FINE STF1 STATE TRAFFIC FINE (EPP. 9.1.19) 6 30.32 247.67 257.99 OPMT OPMT OVERPAYMENT I d96.00 0.00 496.00 Money Totals 21 3,IB7-07 1,226.91 4,41d,00 TAo Rpllowing totalo represent - Combined Money and Credits COST CCC CONSOLIDATED COURT COSTS 17 92.43 831.37 924.30 COST CCC CONSOLIDATED COURT COSTS 3 12.00 108.00 120.00 COST CIIS COURTHOUSE SECURITY 3 9,00 9.99 9.00 COST IDF INDIGENT DEFENSE FUND 3 0.60 $.do 6,00 COST JCSF JUSTICE COURT SECURITY FUND 3 3.00 0.00 3.00 COST JPAY JUDGE PAY RAISE PEE 3 I.BD 16.20 10.09 COST JSF JUROR SERVICE FUND 3 1.20 10.86 12.00 COST LAP SHERIFF'S FEE 19 84.54 0.00 84.54 COST LCCC LOCAL CONSOLIDATED COURT COST 1-1-20 17 208.71 D.00 208.71 COST LCCF LOCAL CONSOLDATED CIVIL FEES 1.1.22 1 33.00 0.00 33.00 COST MVP MOVING VIOLATION FEE 3 0.03 0.27 0.30 COST OMNR OMNI REIMBURSEMENT FEE (EFF. 1. 1.20) S 42.91 0.00 42.91 COST PWAF TEXAS PARNS & WILDLIFE 1 4.00 1.00 5.00 COST STF1 STATE TRF FINE 9-1-IR 1 2.66 49.06 50.00 COST S98C SUB TITLE C 2 3.00 57.00 60.00 COST TP TECHNOLOGY FUND 3 12.00 0.00 12.oO COST TFC LOCAL TRF. FINE- FORMERLY TRY. 9-1-19 3 9.0D 0.00 9.00 COST TPDF TRUANCY PREVENTION & DIVERSION FUND 3 0.00 6.00 6.00 COST WRNT WARRANT FEE 6 264.94 0.00 264.54 FEES CSRV COLLECTION SERVICES FEE 6 495.00 0.00 495.DO PEES DDC DRIVER SAFETY COURSE - 2020 2 20.00 O.DO 20.00 FEES DFP DEFERRED FEE 6 628.OD 0.00 628.00 FEES JCMF JUVENILE CASE MANAGER FEE 3 15.OD 0.00 15.00 FEES SCCF STATE CONSOLIDATED CIVIL FEE 1 0.00 21.00 21.00 FINE FINE FINE 11 1,221.23 0.09 1,221.23 FINE LTFC LOCAL TRAFFIC FINE (EPP, 9.1.29) 6 15.48 0,00 15.48 FINE STF1 STATE TRAFFIC FINE (EPP. 9.1.19) 6 10.32 247,67 257.99 OPMT OPMT OVERPAYMENT 1 496.00 0.00 496.00 Report Totals 23 3,684.79 1,353.21 $1038.00 2022 Page 06-08-22;22:26 ;From:Calhoun County Pot. 5 To:13615534444 ;3619832461 # 7/ 8 Money Distribution Report CALROON JP5 MAT 2022 REPORT Date Payment Type Pines Court Coate Fees Fonda Restitution Other _ Total 00-06.0000 Cash & Checks Collected 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Jail Credits & Comm Service 0.00 0.00 D.00 0.00 0.00 0.00 0.00 Credit Cards & Transfers 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Total Of all CDllectiOnJ 9.99 0.00 0.00 0.00 0.00 0.00 0.00 0941.1991 Cash & Checks Collected 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Jail Credits & Comm Service 0.00 0.00 0.00 0.00 0.00 0.60 0.00 Credit Cards & Transfers 0.00 0.00 0.00 0.00 0.00 D100 0.00 Total of all Collections 0.00 0.00 0.00 Clad 0.00 0.00 0.00 01.01.2004 Cash & Checks Collected 0,00 0.00 0.00 0.00 0.00 499.00 496.00 Jail Credi L•s & Comm Service 162.80 287.20 154.00 0.00 0.00 0.90 624.00 Credit Cards & TranOfeve 94.90 160.10 80.00 O.DO O.OD 0.00 325.00 Total of all Collections 297.70 447.30 234.00 0.00 0.00 099.00 1.445.00 01-01-2020 Cash & Checks Collected 1,051.00 1,218.00 861.50 0.00 0.00 0.00 3,130.90 Jail Credits & Comm Service 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Credit Cards & TT9n0ders 176.00 203.00 83.50 0.00 0.00 0.D0 462.50 Total of all Collections 1,227.DO 1,421.00 945.06 0.00 0.00 0.00 3, 593.60 TOTALS Cash & Checks Collected 1,051.00 1,210.00 861.50 0.00 0.00 4%, 00 3,626.50 Jail Credits & Comm Service 182.80 287.20 15d.00 0.00 0.00 0100 024,00 Credit Cards & Transfers 260.90 363.10 163.50 0.00 0.00 0.00 787.50 Total of all Collections 1,494.70 1,86B.30 1,179.00 0.00 0.00 496.00 5,039.00 Paso 06-08-22;22:26 ;From:Calhoun County Pot. 5 To;13615534444 ;3619832461 # 8/ 8 Money Distribubion Report CALHOUN JPS MAY 2022 REPORT Dascription Count Collected Retained Disbursed State of TaXAS Ouartarly Reporting Totals State Comptroller Coat and Foes Report Section I: Report for Offenses Committed 01.01-20 Forward 17 924.30 92.43 831.87 01-01-04 - 12-31-19 2 70.00 5.50 64.50 09-01.91 22.31.03 0 0.00 0.00 0.00 Bail Bond Fee 0 0.00 0.00 0100 DNA Testing Fee - Juvenile 0 0.00 0.00 0.00 EMS Trauma Fund (EMS) 0 0.00 0.00 0.00 Juvenile Probation Diversion Fees 0 0.00 0.00 O.Do State Traffic Fine (eft. 09-01-29) 6 257,99 10.32 247.67 State Traffic Fine (prior 09.01.19) 1 50.00 2.00 18.00 Intoxicated Driver Fine 0 0.00 0.00 0.00 Prior Mandatory Coate (JRF,IDP,JS) 3 12.00 1.20 10.80 Moving violation Foos 1 0.10 0.01 0.00 DNA Testing Fee - Convictions C 0.00 0.00 0.00 DNA Testing Fee Comm Supw 0 0.00 0.00 0.00 Truancy Prevention and Diversion Fund 0 clog 0.00 clog Failure to Appear/Pay Fees C 0.00 0.00 0.00 Time Payment Face 0 0.00 0.00 0.00 Judicial Fund Const County Court 0 0.00 0.00 0.00 Judicial Fund - Statutory County Court 0 0.00 0.00 0.00 Section II: As Applicable Peace Officer Face 1 5.00 4,00 1.00 Motor Carrier Weight Violations 0 0.00 0.00 0.00 Driving Record Fee 0 clog else 0.00 Report Sub Total 31 11319.39 115.46 1,203,S3 State Comptroller Civil Peas Report CF: Birth Certificate Feat 0 0.00 O.CO 0.00 CF: Marriage License Fees 0 0.00 0.00 0.00 CF: Declaration D1 Informal Marriage 0 0.00 0,00 0.00 CF: Nendisolosure Fees 0 0.00 O.og 0.00 CF: Juror Donations 0 also 0.00 0100 CF: Justice Court Indig riling Fees 0 0.00 0.00 else CF: Stat Prob Court Indig Filing Fees 0 0.00 0.00 0.00 CF, Stat Prob Court Judie Filing Fees D else 0.00 0.00 Cr: Stat Cnty Court Indig Filing Fees 0 0.00 0.00 0.00 CFi Scat Cnty Cgura Judie Filing Foes 0 9.00 0.00 O,og CP: Cast Cnty Court Indig Piling Fees 0 0.00 0.00 0.00 CF: Cost Doty Court Judie Filing Pees C 0.00 0.00 0.0D CF: Dist Court Divorce & Family Law 0 0.00 0.00 also tr: Diet Court Other Divorce/ramily Law 0 0.00 0.00 0.00 CF: Dist Court Indig Legal Services 0 0.00 0.00 0,00 CF: Judicial Support Fee 0 0.00 O.og 0.00 CF: Judicial & Court Para. Training Fee 0 0.00 O.DO 0.00 Report Sub Total 0 0.00 0.00 0.00 Total Due For Thin Period 31 11310.39 115.46 1,203.93 THE STATE OF TEXAS before me, the undersigned authority, this day County of Calhoun County personally appeared Nancy Pomykal, Justice of the Peace, Precinct NO 5, Calhoun County, Texas, who being duly sworn, deposes and says that the above a fOtegoing pOtt 15 true And correct, MiCDCOs my nand this �, y 0 A.D. >//AV'✓7U`� in CC NM5 Dun uTexte•-Ce ' Peace, SUMMARY 'TAX ASSESSOR-COLLECTORSMONTHLY REPORT COLLECTIONS DISBURSEMENTS - Title Certificate Fees 669 $ 8,892.00 - .Title Fees Paid TXDOT - - - $ 5,647.00 _ .Title Fees Paid County Treasurer Salary Fund $ 3,30.00 Motor Vehicle Registration Collections $ 203,236.31 Disabled Person. Fees.. - $ 'd50.00 '. .Postage - - $ - Global Atlditonal Collections - $ Paid TXDOT -,$ 166,617.76 Paid TXDOT SP $ 27,135.50 Paid County Treasurer - $ - Paid .County Treasurer Salary. Fund - $ 6,966.26 - DMVCCARDTRNSFEE $ _21566.81 - .$ GLAdditonal Collections $ — - $. GLOBAL (IBC) Credit/Debit Card Fee's - $ 1,745:36 - GLOBAL -Fees In Excess of Collections - - $ 821.45 MERCH SERVICES STATEMENT Additional Postage .-Vehicle .Registration . $ - -. Paid County Treasurer -.Additional Postage $ Motor Vehicle Sales& Use Tax Collections - $ -622,445.65 Paid State Treasurer - - $ 622,446.66 . Special Road/Bridge Fees Collected - $ 28,150.00 - PaidCountyTreasurer'- RIB Fees - - $ 28,150.00 Texas Parks & Wildlife Collections - $ 6,663.00 - TPW GLOBAL CC TRANSACTION FEES - $ GLOBAL ADDITIONAL COLLECTIONS - ' $ Paid Texas Parks & Wildlife . ' . $ 6,096.70. Paid CountyTreasurer. Salary Fund - - - - $ -, 666.30- - P&W CCARDTRNSFEE $ 78.93 - GLOBAL Additonal'Collections - '$ - - GLO13AL.(IBC) Credit/Debit Card Fees $ 94.82 GLOBAL In Excess/Shortage of Collections $, (15.89) Boat/Motor Sales-& Use Tax Collections . $ ,34,376.41 - Paid State Treasurer - $. 32,667.59' Paid,CountyTreasurer, Salary Fund - $ '` 1,718.82 TABG5%CO COMMS FOR MONTH OF TABC 5% CO COMMS FOR MONTH. OF MAY 2021 $ ,53.00 " Paid County Treasurer, Salary fund - $< 53.00 Business Personal Property - Misc. Fees Paid County Treasurer Excess Funds Paid County Treasurer Overpayments Current Tax Collections Penalty and Interest.- Current Roll Discount for early payment of taxes Delinquent Tax Collections Penalty & Interest - Delinquent Roll Collections for Delinquent Tax Attorney Advance FM & L Taxes Advance - County AdValorem Taxes Paid County Treasurer - Nev. East Paid County Treasurer - all other Districts Paid County Treasurer - Delinq Tax Atty. Fee Payment in Lieu of Taxes Paid County Treasurer- Navig. East Paid County Treasurer - Ail other Districts Special Farmers Fees Collected Paid State Treasurer, Farmers Fees $ 53.14 $ 53.14 $ 2.94 $ 80,838.92 $ 11,608.46 $ 6,066.28 $ 2,237.04 $ 3,136.49 $ 97,987.15 $ 69.12 $ 2,687.37 $ 3,135.49 $ $ $ 45.00 Hot Check Collection Charges $ _ Paid County Treasurers, Hot Check Charge $ Overage on Collection/Assessing Fees $ _ Paid County Treasurer, overage refunded $ Escheats $ _ Paid County Treasurer -escheats $ TOTAL COLLECTIONS $ 1,007,504.96 TOTAL DISBURSEMENTS TOTAL OF ABOVE RECEIPTS PAID TO STATE AND COUNTY C KERRIBON Tax Assessor-rollartnr 45.00 $ 1,007,504.96 $ 1,007,504.96 ., SUMMARY - TAX ASSESSOR -COLLECTORS MONTHLY:REPORT - - COLLECTIONS DISBURSEMENTS - Title Certificate Fees 483 . $. 6,409.00 -. Title Fees.Paid TXDOT $< 3,994.00. - - Title. Fees PaidCounty Treasurer Salary Fund - $ 2,415.00 Motor Vehicle Registration Collections $ - 133,102.12 Disabled Person Fees: -.$ 40.00 .Postage .. $ - Global Additonal Collections _ $. 6.04 Paid TXDOT - - - - - $ 108,967.99 - Paid TXDOT SP - ,_ -.$. 17,831.56 Paid County Treasurer- - $ Paid County Treasurer Salary. Fund $- - 4,783.70 - DMVCCARDTRNSFEE. -$ 1,566.88 $- GLAdditonalCollections $ 6.02 $. GLOBAL (IBC) Card Fee's - $ 1,756.95 GLOBAL Fees In shortage of. Collections - $ (154.03) MERCH SERVICES STATEMENT Additional Postage -Vehicle Registration $ 33.85 Paid County Treasurer- Additional Postage. $.' 33.85 Motor Vehicle Sales & Use Tax Collections $ 576,058:88 - Paid State Treasurer- - $ 676,058.88 .Special Road/Bridge Fees Collected $ 18,440.00 Paid County Treasurer -.RIB Fees $ - -18,440.00 - - Texas Parks & Wildlife Collections $- - 3,368.00 - TPW GLOBAL CC TRANSACTION' FEES $. - 73.60 - GLOBAL ADDITIONAL COLLECTIONS - _ _ $ - - Paid.Texas Parks & Wildlife - $ -3,031.20 - Paid County Treasurer Salary Fund - - - $- 336.80 - P&W CCARDTRNSFEE $ 73.60. GLOBAL AdditonalCollections $ . GLOBAL .(IBC)"Credit/Debit Card Feels $ 102:47 GLOBAL In Excess/Shortage of Collections - - $ (28,87) - - Boat/Motor Sales $ Use Tax Collections , . $ 45,$25.87 . Paid State Treasurer - $.. 43,249.58 Paid County Treasurer; Salary Fund $- ` 2,276.29. TABC 5% CO COMMS FOR MONTH OF TABC 5%CO COMMS FOR MONTH OF DECEMBER 2020 $.. 50.00 - Paid County Treasurer; Salary Fund - $. 50.00 P'n,.n0.i G..ew ➢. NIi..� f�11....N....w. S OII, I,A Business Personal Property - Misc. Fees Paid County Treasurer Excess Funds Paid County Treasurer Overpayments Current Tax Collections Penalty and Interest - Current Roll Discount for early payment of taxes Delinquent Tax Collections Penalty & Interest - Delinquent Roll Collections for Delinquent Tax Attorney Advance - FM & L Taxes Advance - County Ad Valorem Taxes Paid County Treasurer - Nev. East Paid County Treasurer - all other Districts Paid County Treasurer - Delinq Tax Atty. Fee Payment in Lieu of Taxes Paid County Treasurer- Navig. East Paid County Treasurer - All other Districts Special Farmers Fees Collected Paid State Treasurer, Farmers Fees $ 222.08 $ 222.08 $ 2.33 $ 68,838.88 $ 6,428.58 $ 12,724.74 $ 6,776.10 $ 9,581.90 $ 82,297.72 $ 62.34 $ 1,410.57 $ 9,681.90 $ 105.00 $ 105.00 Hot Check Collection Charges $ - Paid County Treasurers, Hot Check Charge $ Overage on CollectionlAssessing Fees $ - Paid County Treasurer, overage refunded $ Escheats $ - Paid County Treasurer -escheats $ TOTAL COLLECTIONS $ 877,216.72 TOTAL DISBURSEMENTS TOTAL OF ABOVE RECEIPTS PAID TO STATE AND COUNTY L /- nl KERRI-BOYD Tax Acsa_aenr-rnIIPrfnr $ 877,216.72 $, 877,216.72 SUMMARY TAX ASSESSOR -COLLECTORS -MONTHLY REPORT °REV'1§11YDECJffM04R20 q COLLECTIONS DISBURSEMENTS Title Certificate Fees 535 $ 7,085.00 Title Fees Paid TXDOT $ 4,410.00 Title Fees Paid County Treasurer Salary Fund $ 2,675.00 Motor Vehicle Registration Collections $ 152,260.09 Disabled Person Fees $ 75.00 Postage $ Global Additonal Collections $ - Paid TXDOT $ 124,460.57 Paid TXDOT SP - $ 20,603.98 Paid County Treasurer $ - PaidCountyTreasurerSalaryFund $ 6,422.10 DMV CCARDTRNSFEE $ 1,948.44 $ - GLAdditonalCollections $ - $ - GLOBAL (BC) CrediNDebit Card Fee's $ 1,462.77 GLOBAL Fees In Excess of Collections $ 485.67 MERCH SERVICES STATEMENT $ - Additional .Postage -Vehicle Registration - $ - PaidCountyTreasurer- Additional Postage $ - Motor Vehicle Sales &.Use Tax Collections $ 560,202.66 Paid State Treasurer $ 660,202.66 Special Road/Bridge Fees Collected $ 20,390.00 Paid County Treasurer -RB Fees $ 20,390.00 Texas Parks & Wildlife Collections $ 2,725.00 TPW GLOBAL CC TRANSACTION FEES $ 31.64 GLOBAL ADDITIONAL COLLECTIONS $ - Paid Texas Parks & Wildlife $ 2,462.50 Paid County Treasurer Salary Fund $ 272.50 P&W CCARDTRNSFEE $ 31.64 GLOBAL Additonal Collections $ GLOBAL (IBC) Credit/Debit Card Fee's $ 87.81 GLOBAL In Excess/Shortage of Collections $ (66.17) Boat/Motor Sales & Use Tax Collections $ 33,496.24 Paid State Treasurer $ 31,821.43 Paid County Treasurer, Salary Fund $ 1,674.81 TABC 6%CO COMMS FOR MONTH OF $ - TABC 5% CO COMMS FOR MONTH OF $ _ Paid County Treasurer, Salary Fund $ Business Personal Property - Misc. Fees $ 6,920.75 Paid County Treasurer $ 6,920.76 Excess Funds $ - Paid County Treasurer $ - Overpayments $ 118.31 Current Tax Collections $ 1,803,876.16 Penalty and Interest - Current Roll $ - Discount for early payment of taxes $ 19,020.72 Delinquent Tax Collections $ 27,599.52 Penalty & Interest - Delinquent Roll $ 10,992.17 Collections for Delinquent Tax Attorney $ 8,188.71 Advance - FM & L Taxes $ - Advance - County AdValorem Taxes $ 1,786,987.63 Paid County Treasurer -Nev. East $ 1,276.18 Paid County Treasurer- all other Districts $ 36,300.73 Paid County Treasurer - Delinq Tax Atty. Fee $ 8,188.71 Payment in Lieu of Taxes $ - Paid County Treasurer - Navig. East $ - PaidCountyTreasurer- All other Districts $ - Special Farmers Fees Collected $ 66.00 Paid State Treasurer, Farmers Fees $ 66.00 Hot Check Collection Charges $ 16.00 Paid County Treasurers, Hot Check Charge $ 15.00 Overage on Collection/Assessing Fees - $ - Paid County Treasurer, overage refunded $ - Escheats $ - Paid County Treasurer -escheats $ TOTAL COLLECTIONS $ 2,634,636.49 TOTAL DISBURSEMENTS TOTAL OF ABOVE RECEIPTS PAID TO STATE AND COUNTY KERR[BOY Tax Assessor-Collertnr $ 2,634,636.49 $ 2,634,636.49 SUMMARY TAX ASSESSOR -COLLECTORS MONTHLY REPORT MARCH 2022 Title Certificate Fees Title Fees Paid TXDMV Title Fees Paid County Treasurer Salary Fund Motor Vehicle Registration Collections Disabled Person Fees Global Additonal Collections Paid TXDMV Paid TXDMV SP Paid County Treasurer Paid County Treasurer Salary Fund DMV CCARDTRNSFEE GL Additional Collections GLOBAL (IBC) CrediUDebil Card Fee's GLOBAL Fees In Excess of Collections MERCH SERVICES STATEMENT Additional Postage -Vehicle Registration Paid County Treasurer - Additional Postage Motor Vehicle Sales & Use Tax Collections Paid State Treasurer Special Road/Bridge Fees Collected Special Road/Bridge Fees Collected out of County Coll. Paid County Treasurer- RIB Fees Texas Parks & Wildlife Collections TPW GLOBAL CC TRANSACTION FEES GLOBAL ADDITIONAL COLLECTIONS Paid Texas Parks & Wildlife Paid County Treasurer Salary Fund P&W CCARDTRNSFEE GLOBAL Additonal Collections GLOBAL (IBC) Credimeblt Card Fee's GLOBAL In Excess/Shortage of Collections Boat/Motor Sales & Use Tax Collections Paid State Treasurer Paid County Treasurer, Salary Fund TABC 6% CO COMMS FOR MONTH OF TABC 5 % CO COMMS FOR MONTH OF Feb 2022 Paid County Treasurer, Salary Fund County Beer & Wine Collections Paid County Treasurer, County Beer & Wine Paid County Treasurer, Salary Fund INTEREST EARNED ON OFFICE ACCOUNT Paid County Treasurer, Nay. East Paid County Treasurer, all other diwiets COLLECTIONS DISBURSEMENTS 646 $ 7,228.00 . $ 4,498.00 $ 2,730.00 $ 196,061.11 $ 40.00 $ 13.61 $ 83,412.93 $ 23,980.19 $ 78,470.18 $ 6,737.18 $ 2,614.27 $ - $ 1,770.58 $ 743.69 $ 17.90 $ 17.90 $ 437,621.82 $ 437,521.82 $ 25,460.00 $ 220.00 $ 25,680.00 $ 3,697.00 $ 83.49 $ 3,237.30 $ 83.49 $ 359.70 $ 111.76 $ (28.27) $ 44,203.51 $ 41,993.33 $ 2,210.18 $ 55.00 $ 1,070.00 $ 26.13 $ 1,016.50 $ 53.50 $ 26.13 Business Personal Property - Mist. Fees Paid County Treasurer Excess Funds Paid County Treasurer Overpayments Current Tax Collections Penalty and Interest- Current Roll Discount for early payment of taxes Delinquent Tax Collections Penalty & Interest- Delinquent Roll Collections for Delinquent Tax Attorney Advance - FM & L Taxes Advance - County AdValmem Taxes Paid County Treasurer- Nev. East Paid County Treasurer - all other Districts Paid County Treasurer - Delinq Tau Ally. Fee Payment In Lieu of Taxes Paid County Treasurer - Navig. East Paid County Treasurer' -All other Districts Special Farmers Fees Collected Paid State Treasurer, Farmers Fees Hot Check Collection Charges Paid County Treasurers, Hot Check Charge Overage on Collection/Assessing Fees Paid County Treasurer, overage refunded Escheats Paid County Treasurer -escheats $ 346.63 $ 346.63 $ 2.48 $ 246,642.97 $ 21,134.09 $ 41.78 $ 6,192.33 $ 3,880.03 $ 2,943.58 $ 267,145.68 $ 218.72 $ 9,445.82 $ 2,943.58 $ 70.00 $ 70.00 $ 45.00 $ 45.00 TOTAL COLLECTIONS $ 994,857.65 TOTAL DISBURSEMENTS $ 994,857.56 TOTAL OF ABOVE RECEIPTS PAID TO STATE AND COUNTY $ 994,857.56 KERRIBOY Tax Assessor -Collector RI HARD H f1 Y�R County J SUMMARY TAX ASSESSOR -COLLECTORS MONTHLY REPORT APRIL 2022 COLLECTIONS DISBURSEMENTS Title Certificate Fees 461 $ 6,188.00 Title Fees Paid TXDMV $ 3,883.00 Title Fees Paid County Treasurer Salary Fund $ 2,305.00 Motor Vehicle Registration Collections $ 150,133.04 Disabled Person Fees $ 25.00 Rd & Bridge OUT OF COUNTY COLLS, Global Additonal,Collections $ - Paid TXDMV $ 11 . Paid TXDMV SP 7, 12971 Paid County Treasurer $ 12,834.25 Paid County Treasurer Salary Fund $ 6,093.20 DMV CCARDTRNSFEE $ 1,718.64 $ GL Additonal Collections $ $ - GLOBAL (IBC) Credit(Debit Card Fee's $ 1,615.46 GLOBAL Fees In Excess of Collections $ 203.18 MERCH SERVICES STATEMENT $ Additional Postage -Vehicle Registration $ - PaidCountyTreasurer- Additional Postage $ - Motor Vehicle Sales & Use Tax Collections $ 540,398.43 Paid State Treasurer $ 540i398.43 Special Road/Bridge Fees Collected $ 19,000.00 Special Road/Bridge Fees Collected out of County Coll. $ 280.00 Paid County Treasurer -R/B Fees $ 19,280.00 Texas Parks & Wildlife Collections $ 4,425.00 TPW GLOBAL CC TRANSACTION FEES $ 265.20 GLOBAL ADDITIONAL COLLECTIONS $ - Paid Texas Parks & Wildlife $ 3,982.50 Paid County Treasurer Salary Fund $ 442.50 P&W CCARDTRNSFEE $ 265.20 GLOBAL Additional Collections $ - GLOBAL(IBC) Credit/Debit Card Fee's $ 137.71 GLOBAL In Excess/Shortage of Collections $ 127.49 Boat/Motor Sales& Use Tax Collections $ 69,548.32 Paid State Treasurer $ 66,070.90 Paid County Treasurer, Salary Fund $ 3,477.42 TABC 5% CO COMMS FOR MONTH OF $ - TABC 50A CO COMMS FOR MONTH Of $ - Paid County Treasurer, Salary Fund $ County Beer& Wine Collections $ 120.00 Paid County Treasurer, County Beer & Wine $ Paid County Treasurer, Salary Fund 114.00 $ 6.00 Business Personal Property - Misc. Fees $ 188.85 Paid County Treasurer $ 188.85 Excess Funds $ - Paid County Treasurer $ - Overpayments $ 0.93 Current Tax Collections $ 105,387.55 Penalty and Interest - Current Roll $ 10,906.08 Discount for early payment of taxes $ - Delinquent TaxCollections $ 9,316.62 Penalty&Interest - Delinquent Roll $ 3,811.70 Collections for Delinquent Tax Attorney $ 4,794.06 Advance - FM & L Taxes $ 1.54 Advance- County AdValorem Taxes $ 127,904.54 Paid County Treasurer-Nev, East $ 117.85 Paid County Treasurer- all other. Districts $ 1,398.95 Paid County Treasurer- Delinq Tax Atty. Fee $ 4,794:06 Payment in Lieu of Taxes $ Paid County Treasurer - Navig. East $ _ Paid County Treasurer- All other Districts $ Special Farmers Fees Collected $ 35.00 Paid State Treasurer, Fanners Fees $ 35.00 Hot Check Collection Charges $ Paid County Treasurers, Hot Check Charge $ _ Overage on Collection/Assessing Fees $ Paid County Treasurer, overage refunded $ - Escheats $ - PaidCountyTreasurer-escheats $ . TOTAL COLLECTIONS $ 924,850.47 TOTAL DISBURSEMENTS $ 924,850.47 TOTAL OF ABOVE RECEIPTS PAID TO STATE AND COUNTY $ 924,850,47 KERRI BO D Tax Assessor -Collector - I RICH -RD H E ER County) e SUMMARY TAX ASSESSOR -COLLECTORS MONTHLY REPORT APRIL 2022 Title Certificate Fees Title Fees Paid TXDMV Title Fees Paid County Treasurer Salary Fund Motor Vehicle Registration Collections Disabled Person Fees Rd & Bridge OUT OF COUNTY COLLS. Global Additional Collections Paid TXDMV Paid TXDMV SP Paid County Treasurer Paid County Treasurer Salary Fund DMV CCARDTRNSFEE GL Additonai Collections GLOBAL (IBC) Credit/Debit Card Fee's GLOBAL Fees In Excess of Collections MERCH SERVICES STATEMENT Additional Postage Vehicle Registration Paid County Treasurer - Additional Postage Motor Vehicle Sales & Use Tax Collections Paid State Treasurer Special Road/Bridge Fees Collected Special Road/Bridge. Fees Collected out of County Coll. Paid County Treasurer - RIB Fees Texas Parks & Wildlife Collections TPW GLOBAL CC TRANSACTION FEES GLOBAL ADDITIONAL COLLECTIONS Paid Texas Parks & Wildlife Paid County Treasurer Salary Fund P&W CCARDTRNSFEE GLOBAL Additonal Collections GLOBAL (IBC) Credit/Debit Card Fee's GLOBAL In Excess/Shortage of Collections Boat/Nlotor Sales & Use Tax Collections Paid State Treasurer Paid County Treasurer, Salary Fund TABC 5% CO COMMS FOR MONTH OF TABC 5%CO COMMS FOR MONTH Of Paid County Treasurer, Salary Fund County Beer& Wine Collections Paid County Treasurer, County Beer & Wine Paid County Treasurer, Salary Fund COLLECTIONS DISBURSEMENTS 461 $ 6,188.00 $ 3,883.00 $ 2,305.00 $ 160,133.04 $ 25.00 $ 113,382.24 $ 17,129.71 $ 12,834.26 $ 6,093.20 $ 1,718.64 $ $ $ $ 1,515.46 $ 203.18 $ $ 265.20 8 - $ 540;398.43 $ 19,000.00 $ 280.00 $ 4,426.00 $ 265.20 $ 69,548.32 120.00 $ 540,398.43 $ 19,280.00 $ 3,982.50 $ 442.50 $ 137.71 $ 127.49 $ 66,070.90 $ 3,477.42 $ 114.00 $ 6.00 Business Personal Property - Mist. Fees Paid County Treasurer Excess Funds Paid County Treasurer Overpayments Current Tax Collections Penalty and Interest - Current Roll Discount for early payment of taxes Delinquent Tax Collections Penalty & Interest- Delinquent Roll Collections for Delinquent Tax Attorney Advance - FM & L Texas Advance - County AdValorem Taxes Paid County Treasurer- Nev. East Paid County Treasurer - all other Districts Paid County Treasurer - Delinq TaxAtty. Fee Payment In Lieu of Taxes Paid County Treasurer- Navig. East Paid County Treasurer -All other Districts Special Farmers Fees Collected Paid State Treasurer, Fanners Fees Hot Check Collection Charges Paid County Treasurers, Hot Check Charge Overage on Collection/Assessing Fees Paid County Treasurer, overage refunded Escheats Paid County Treasurer -escheats $ 188.85 $ 188.85 $ $ 0.93 $ 105,387.55 $ 10,906.08 $ 9,316.62 $ 3,811.70 $ 4,794.06 $ 1.54 $ 127,904.54 $ 117.85 $ 1,398.95 $ 4,794.06 $ 35.00 $ 36.00 TOTAL COLLECTIONS $ 924,850.47 TOTAL DISBURSEMENTS $ 924,850.47 TOTAL OF ABOVE RECEIPTS PAID TO STATE AND COUNTY $ 924,850.47 A�� KERRI Tax Assessor -Collector 1 CH RD FJ I YER County ge SUMMARY TAX ASSESSOR -COLLECTORS MONTHLY REPORT APRIL 2022 COLLECTIONS DISBURSEMENTS Title Certificate Fees 461. $ 6,188.00 Title Fees Paid TXDMV $ 3,883.00 Title Fees Paid County Treasurer Salary Fund $ 2,306.00 Motor Vehicle Registration Collections $ 150,133.04 Disabled Person Fees $ 25.00 Rd & Bridge OUT OF COUNTY COLLS. Global Additonal,Collections $ Paid TXDMV $ 24 717,129. Paid TXDMV SP $ 171 Paid County Treasurer $ 1 2,,834..25 PaidCounty Treasurer Salary Fund $ 5 DMV CCARDTRNSFEE $ 1,718.64 $ ,093093.20 GL Additonai Collections $ - $ _ GLOBAL(IBC) Credit/Debit Card Fee's $ 1,515.46 GLOBAL Fees In Excess of Collections $ 203.18 MERCH SERVICES STATEMENT $ Additional Postage -Vehicle Registration $ Paid County Treasurer - Additional Postage $ Motor Vehicle Sales & Use Tax Collections $ 540,398.43 Paid State Treasurer $ 540,398.43 Special Road/Bridge Fees Collected $ 19,000.00 Special Road/Bridge Fees Collectetl out of County Coll. $ 280.00 Paid County Treasurer -R/S Fees $ 19,280.00 Texas Parks & Wildlife Collections $ 4,425.00 TPW GLOBAL CC TRANSACTION FEES $ 265.20 GLOBAL ADDITIONAL COLLECTIONS $ - Paid Texas Parks & Wildlife $ Paid County Treasurer Salary Fund 3,982.50 982.50 P&W CCARDTRNSFEE $ 265.20 $ GLOBAL Additonal Collections $ - GLOBAL (IBC) Credit/Debit Card Fee's GLOBAL In Excess/Shortage of Collections $ 137.71 71 $ 127.49 Boat/Motor Sales& Use Tax Collections $ Paid State Treasurer 69,548.32 Paid County Treasurer, Salary Fund $ 66,070.90 $ 3,477.42 TABC 5% CO COMMS FOR MONTH OF $ TABC 6% CO COMMS FOR MONTH Of $ - Paid County Treasurer, Salary Fund $ County Beer & Wine Collections $ Paid County Treasurer, County Beer&Wine. 120.00 Paid County Treasurer, Salary Fund $ 114.00 $ 6.00 Business Personal Property -Misc. Fees $ 188.86 Paid County Treasurer $ 188.86 Excess Funds $ - PaidCountyTreasurer $ - Overpayments $ 0.93 Current Tax Collections $ 105,387.65 Penalty and Interest - Current Roll $ 10,906.08 Discount for early payment of taxes $ Delinquent Tax Collections $ 9,316.62 Penalty&Interest - Delinquent Roll $ 3,811.70 Collections for Delinquent Tax Attorney $ 4,794.06 Advance - FM & L Taxes $ 1.54 Advance- County AdValorem Taxes $ 127,904.64 Paid County Treasurer -Nev. East $ 117.85 Paid County Treasurer - all other Districts $ 1,398.95 Paid County Treasurer- Delinq Tar Atty. Fee $ 4,794.06 Payment in Lieu of Taxes $ Paid County Treasurer - Nevig. East $ Paid County Treasurer -All other Districts $ Special Farmers Fees Collected $ 35.00 Paid State Treasurer, Farmers Fees $ 36.00 Hot Check Collection Charges $ - Paid County Treasurers, Hot Check Charge $ Overage on Collection/Assessing Fees $ Paid County Treasurer, overage refunded $ Escheats $ Paid County Treasurer -escheats $ TOTAL COLLECTIONS $ 924,860.47 - TOTAL DISBURSEMENTS $ 924,850.47 TOTAL OF ABOVE RECEIPTS PAID TO STATE AND COUNTY $ 924,850.47 KERRIBOYD Tax Assessor -Collector \ RIC iARD 8 EYER Coun dge #19 NOTICE 01= MEE I ING — 6/22/2022 19. Consider and take necessary action on any necessary budget adjustments. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Vern Lyssy, Commissioner Pct 1 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 15 of 16 a ;N .z �0 O O e =i Wg yJ O fA O O �N Igy 4yu.1 fAO p{ y p O O O p y O CB S N H =z ® fA 000 0 = W 00 {y fA fA 1A M = C � W EH fA ElL a F =N _Z Q O d zz� w _W zz 2 (D0Q w =W �� Z z z W G = �i Z z z W K W e F sr rn rn¢ O ��' H ra rn rn 7 Q Q E z Q a =a a F ea H 0lu w 'o Z =� Z gaw A CO a z 'of =c e�aNw Z s ¢a U N w _Z y O K W zz =Z W mW oo BW oa W m co=� W z N W �i �(D =Lu W �e �O1 O N M z c� O z a 6 W U) w aW J � U a a eta < h s ¢ w a O O_ L W m z� M O rn a 0 w 0 0 w 0 O N 0 w 0 w J 0 0 U. U. lz W 2 tlJ W D 0 2 z 5aa a�U u w C a� fn G m r 6 0 a lu W N W 0 N 00000 ��wwrnww N F H H F. ¢�Z¢a C7�U' C 0 0 0 c z z z 2 e a rn 0 °o 6 w 0 0 0 fn w J a > a }LL w a wzz� U = O u J LL Q 0 2 m c m o 0 o c `��mcdc J' 0 z W f W U' z f w :k ;a :z :z :§ AL �§ §§a! ■ ■§� §§ § ■ ■ee § zz z . U) , � § 2 � I- ; E» j\\ § § §LU \ @ �w § \§ kk / e B LU z k \ ■ # 20 NOTICE OF MEETING— 6/22/2022 20. Approval of bills and payroll. (RHM) MMC RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct1 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Budge Meyer, Commissioner Hall,`Lyssy, Behrens, Reese COUNTY BILLS 2022: RESULT: APPROVED [UNANIMOUS], MOVER: David Hall, Commissioner Pct'1 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Adjourned: 10:20 a.m. Page 16 of 16 ( \ kH ( ; p q§|` Pd { \ \ _ ( � �§ j 0 \ k §§ PO \ ) va k ) t ) bi § ` § � \ Ea / po 7 \bd \ \ b m « ) ; §m ; \ \ / §B/B * §§ c § \ to \ � •• � ¢ . § � \ \ � } 0 } ! E § i k § J �� w PUPO § 7 § MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---June 22, 2022 TOTALS TO BE APPROVED -TRANSFERRED FROM ATTACHED PAGES TOTAL PAYABLES, PAYROLL AND ELECTRONIC BANK PAYMENTS $', 1,059,175,66 TOTAL TRANSFERS BETWEEN FUNDS $ 27D,208;31_ TOTAL NURSING HOME UPL EXPENSES $ 1,080,354.39: V TOTAL INTER40VERNMENT TRANSFERS _ $ 533,060.69 GRAND TOTAL pISBURSEMENTS APPROVED:June 22, 2022. $i :2A.32,799.05, ✓ MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---June 22 2022 PAYABLES AND PAYROLL 6/16/2022 Weekly Payables 535,378,18 8/16/2022 Citibank Credit Card -see attached 5,102.50 6120/2022 McKesson340B Prescription Expense 7,232.73 612012022 McKesson-340B.Prescription Expense 2,833.14 6120/2022 Amerisource Bergen-340B Prescription Expense 885.43 6120/2022. Amerisource Bergen-340B Prescription Expense 2,895.04 6120/2022 Payroll Liabilities -Payroll Taxes 126,818.55 6120/2022 Payroll 379,078.22 Prosperity Electronic Bank Payments 6110.6/15/22 Credit Card & Lease Fees 6,745.52 6/10/2022 Cleargage-Patient Financing Service 78.02 6110-6117/22 Pay Plus-Pattent Claims Processing Fee 321.36 6/10/2022 ExpertPay- child support 1.826.97 TOTAL PAYABLESt PAYROLL AND ELECTRONIC BANK PAYMENTS $ '1,069,9'75.66 TRANSFER BETWEEN FUNDS FROM MMC TO NURSING HOMES 6116/2022 MMC Operating to Crescent -correction of NH insurance payment deposited 5,346.00 into MMCOperating In error 6/16/2022 MMC Operating to Golden Creek-carrection of NH Insurance and medicare 29.958.86 payment deposited Into MMC Operating in error 6/16/2022 MMC Operating to Gulf Pointe Plaza -correction of NH insurance and 8,479.89 payment deposited into MMC Operating all 6/2022 MMC Operating to Tuscany Village -correction of NH insurance and medicare 27.015,36 payment deposited. into MMC Operating 6116/2022 MMC Operating to Bethany -correction of NH insurance payment deposited 199,408.20 into MMC Operating in error TOTAL TRANSFERS BETWEEN FU,NG$ $', 270,208;31, y NURSING HOME UPL EXPENSES 6/20/2022 Nursing Home UPL-Cantex Transfer 467,081.07 6/20/2022 Nursing Home UPL-Nexion Transfer 129,652.40 8/20/2022 Nursing Home UPL-HMG Transfer 78,953.25 6/20/2022 Nursing Home UPL Tuscany Transfer 183,436.34 6/20/2022 Nursing Home UPL-HSL Transfer 201,231.33 TOTAL NURSING WOME UPL EXPENSES, $ 7,04354.39 INTER -GOVERNMENT TRANSFERS 6/2012022 IGT DSH 2O22 Pass 1 and Pass 2 to be paid July 1, 2022 98,092.00 6/20/2022 IGT DSRIP OYI1 to be paid July 6, 2022 434,968,69 TOTALINTE0,GOVERNNeNTTRANSFERS _ $ 633,06049 GRAND TOTALDISBURSEMENTS'APPROVED June 22,1022 $7;3,032,7RAS"' Page 1 of 16 RECEIVED BY THE COUN YAUDITORON JUN s 2022 MEMORIAL MEDICAL CENTER 06/16/2022 p AP Open Invoice List CALHNU6AGOUNTY, TF-kA6 ap_open_Inveice.lamplate Due Dates Through: 07107/2022. Vendor# Vendor Name Class Pay Code T2900 3MCOMPANY✓ M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net SC00049449 ✓ 06/14/2006/01/2006/26/20 16,175.71 0.00 0.00 16,175.71 ✓ SOFTWARE Vendor TotaNNumber Name Gross Discount No -Pay Net T2900 3M COMPANY 16,175.71 0.00 0.00 16.175.71 Vendor# Vendor Name Glass Pay Code A11DO ABBOTT LABORATORIES,/. M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 615403214 05/31/20 06/02/2O 07/02/20 11.58 0.00 0.00 11.58 SUPPLIES Vendor Total; Number fame Gross Discount No•Pay Net A1100 ABBOTT LABORATORIES 11,58 0.00 O.00 11.58 Vendor# Vendor Name Class Pay Code 10995 ABILITV NETN1pRK.yBHIFTHOUND) Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 22MOO82842 ✓ 06/07/20 06/06/20 07106/20 647.28 0.00 0.00 647.28 SCHEDULING SERVICES Vendor Total$ Number Name Gross Discount No -Pay Net 10995 ABILITY NETWORK (SHIFTHOUND) 647.28 0.00 0.00 647,28 Ventlor# Vendor Name Class Pay Code A1600 AIRGAS USA, LLC- CENTRAL DIV ✓ M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 9988952246 ✓ 06114/20 05/31/20 06/25/20 545.72 0.00 Q00 545.72 ✓ RENTAL 91263621641✓ 06114/2005131/2006/25/20 2,385.72 0.00 0.00 2,386.72 RENTAL 9988962247 / 06/14/20 05/31/20 06/25/20 903.08 0.00 0.00 903,08 RENTAL 9988954908 ✓ 06/14/20 05/31/20 06/25/20 192.09 0.00 0.00 192.09 ✓ OXYGEN Vendor Totale Number Name Gross Discount No -Pay Net A1680 AIRGAS USA, LLC -CENTRAL DIV 4,026.61 0.00 0.00 4.026.61 Vendor# Vendor Name Class Pay Code A2218 AQUA BEVERAGE COMPANY M Invoice# Comment Tran Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net 202677 06/14/20 06/31/20 06/26/20 45.96 0.00 0.00 45.96 WATER Vendor Totals Number Name Gross Discount No -Pay Net A2218 AQUA BEVERAGE COMPANY 45.96 0.00 0.00 45.96 Vendor# Vendor Name Class Pay Code 12800 AUTHORITYRX Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 1402 ✓ 06116/2006/02/2006103/20. 10,264.00 0.00 0.00 10,264.00 sf 340E Vendor Totals Number Name Gross Discount No -Pay Net 12800 AUTHORITYRX 10,264.00 0.00 0.00 10,264.00 file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.com/u88125/data 51tmp_cw5report4ll719.,. 6/16/2022 Page 2 of 16 Vendor# Vendor Name Class Pay Cade A2600 AUTO PARTS & MACHINE CO. ,�� IN Invoice# Comment Tran Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net -059q22- 06/16/20 05/09/20 05/24/20 39.49 0.00 0.00 39.49 ^ jQ -X SUPPLIES D54222- 06/16/20 05/09/20 05124/20 16.99 0.00 0.00 16.99��'' 964311 SUPPLIES Vendor Total: Number Name Gross Discount No -Pay Net A2600 AUTO PARTS & MACHINE CO. 56.48 0.00 0.00 56,48 Vendor#Vendor Name Class Pay Code 61150 BAXTER HEALTHCARE ✓ W Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 75186808 ✓ 06/14/20 05/23/20 06/17/20 2,367.50 0.00 0.00 2,367.50 ✓ 75186999 ✓ 06/14/20 05/23/20 06/17/20 629.50 0.00 0.00 629.50 ✓ LEASE 75152288✓ 06115/20 05/19/20 06/13/20 55.45 0100 0.00 55.45 ,✓ SUPPLIES 75184957 ✓ 06/16/20 05/23/20 06/17/20 63,24 0.00 0.00 63,24 _SUPPLIES , 75364999 ✓ 06/15/20 05/27/20 06/21 /20 507.47 0.00 O.OD 507.47 �! SUPPLIES 75247745 ✓ 06/15/20 05/27/20 06/21/20 42.67 0.00 0.00 42.67 ✓� SUPPLIES 75267545 ✓ 06/15/20 05/31/20 06/26/20 110.91 0.00 0.00 110.91✓� SUPPLIES Vendor Totals Number Name Gross Dlscaunt No -Pay Net B1150 BAXTER HEALTHCARE 3,776.74 0.00 0.00 3,776.74 Vendor#Vendor Name Class Pay Code B1220 BECKMAN COULTER INC �/ M Invoice# Comment Tran Dt Inv Dt Due DI Check O Pay Grass Discount No -Pay Net 731862D % 06/14/20 06/03/20 06128/20 6,990.69 0.00 0.00 6,990.69 y^� SUPPLIES 109930335 ✓ 06/14/20 06/03/20 06/28/20 2,661.79 0.00 0.00 2,661.79 f SUPPLIES 5458619 ✓ 06/14/20 06/05/20 06/30/20 6,249.42 0.00 0.00 6,249AP ✓ CONTRACT 109931393 ✓ 06/14/20 06/05/20 06/30/20 2,621.27 0.00 0.00 2,621.27 ✓ SUPPLIES 1099344181S 06/14120 06/06/20 07/01/20 $2.48 0.00 0.00 . 82.48 SUPPLIES , 109935267 f 06114/20 06/06/20 07/01120 11,812.94 0.00 0.00 11,812.944� Vendor Totals Number Name Gross Discount No -Pay Net B1220 BECKMAN COULTER INC 30,418.59 D.00 0.00 30,418.69 Vendor# Vendor Name Class Pay Code 14753 BIOMERIEUX, INC w/ Invoice# Comment Tran Dt Inv Dt Due Ot Check 0, Pay Gross Discount No -Pay Net 1212777185 V/� 06/15/2004/1 PJ200511 PJ20 2D,616.07 0.00 0.00 20,616,07 SUPPLIES 1212782546 t/ 06115120 04/20/20 05/20120 20,585.81 0,00 0.00 20,685.61 r% file:!(/C:/Users/ltrevino/cpsi/memmed.epsinet.com/u88125/data_5/tmp_cw5report4l l719... 6/16/2022 Page 3 of 16 SUPPLIES 1212783375 / 06/1512004/2112005121/20. 11,863.12 0.00 0.00 11,863.12 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 14753 BIOMERIEUX, INC 53,065.00 0,00 0.00 53.065.00 Vendor# Vendor Name Class Pay Code 51650 BOSART LOCK & KEY INC M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross DlscoUnt No -Pay Net 124315 X/ 06/14/2006/01/2007101/20 31,76 0.00 0.00 31.75 SUPPLIES i Vendor Totals Number Name Gross Discount No -Pay Net B1650 BOSART LOCK & KEY INC 31.75 0.00 0.00 31.75 Vendor# Vendor Name Class Pay Code 12740 BUILDING KID STEPS I/ f Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net MAY2022A 06116/20 05131/20 06/15120 974.00 0.00 0.00 974.00 ! SPEECH THERAPY v . MAY2022 06116/2005/31/2006/15/20 1,174.00 0.00 0100 1,174.00 SPEECH THERAPY . MAY2022B 06/16/20 05/31/20 06/15/20 1,261.00 D.00 0.00 1,261.00 SPEECH THERAPY, Vendor Totals Number Name Gross Discount No•Pay Net 12740 BUILDING KID STEPS 3,409.00 0.00 0.00 3,409.00 Vendor* Vendor Name Class Pay Code C1325 CARDINAL HEALTH 414, INC. %� W Invoice# Comment Tran Dt Inv Dt Due of Check D Pay Gross Discount No -Pay Net 8002858449 06/16/20 05/21/20 06/25/20 253.20 0.00 0.00 253.20 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net C1326 CARDINAL HEALTH.414, INC. 253.20 0100 0.00 253.20 Vendor# Vendor Name Class Pay Code C1992 COW GOVERNMENT, INC. r'� M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net W035850 yrr. 06114/2004/16/2005/1 W20 62,54 0.00 0.00 62.54 PHONECORD W077189 V % 06/14/20 04/18/20 05/18/20 -30.60 0.00 0.00 •30.60 CREDIT v' X116112 ,/"% 06114/20 05/11/20 06/10/20 300,46 0.00 0.00 300.46 RAM UPGRADE Vendor TotaIFNUmber Name Gross Discount No -Pay Net 01992 CDW GOVERNMENT, INC. 332.40 0.00 0.00 332,40 Vendor# Vendor Name Class Pay Code L1629 CHRISTINA ZAPATA-ARROYO ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 061322 06/16/20 06/13/20 06/30/20 330.00 0.00 0.00 330.00 L/ SLP SERVICES Vendor Totals Number Name Gross Discount No -Pay Net L1629 CHRISTINA ZAPATA-ARROYO 330.00 0.00 0.00 330.00 Vendor# Vendor Name I Class Pay Code 14400 CULINARY CONCESSIONS LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net file:///C:/Users/ltrevino/cpsi/memmed.cpsinet,com/u88125/data 5/tmp_cw5report411719... 6/16/2022 Page 4 of 16 INV00005784 06/14120 05131120 06/30/20 29,655.72 0.00 0.00 29,655.72 SUPPLIES ✓: Vendor Total. Number Name Gross Discount No -Pay Net 14400 CULINARY CONCESSIONS LLC 29,655.72 0.00 0.00 29,055,72 Vendor# Vendor Name Class Pay Code 11368 CYRACOM LLC v'r,. Invoice# Comment Tran Dt Inv Dt Due Dt Check DPay Gross Discount No -Pay Net 2022020219 / 06/14/20 05/31/20 06/30/20 402.68 0.00 0.00 402.66 INTERPRETATION SERVICES ✓r r Vendor Totals Number Name Gross Discount No -Pay Net 11368 CYRACOM LLC 402.68 0.00 0.00 402.68 Vendor# Vendor Name Class Pay Code D1145 DEPT OF STATE HEALTH SERVICES Lj W Invoice# Comment Tran Dt Inv Dt Due Dt Check D- Pay Gross Discount No -Pay Net 4500005385 t,/ 06/16/20 0501120 06/25/20 664.66 0.00 0.00 664.66 uj MAMMO INSPECTION . Vendor Totals Number Name Gross Discount No -Pay Net D1145 DEPT OF STATE HEALTH SERVICES 664.66 0.00 0,00 664.66 Vendor# Vendor Name Class Pay Code 10060 DETAR HOSPITAL ,i ICP invoice* Comment Tran Dt Inv Dt Due Dt Check D' Pay Gross Discount No -Pay Net DTR2205021 ,/' 06/14/20 06/07/20 06/30/20 188A8 0.00 0.00 188.48 f- LAB SERVICES , Vendor Totals Number Name Gross Discount No -Pay Net 10060 DETAR HOSPITAL 188.48 0.00 0.00 188.48 Vendor# Vendor Name Class Pay Code 10368 DEWITT POTH & SON ✓'. Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 6841170 „/ 06/15/20 06/08/20 07/01120 76,00 0.00 0.00 76.00 SUPPLIES 6840960 06/15/20 06/06/20 07/01/20 338.43 0.00 0.00 338.43 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 10368 DEWITT POTH 3 SON 414.43 0100 0.00 414.43 Vendor# Vendor Name Class Pay Coda 11011 DIAMOND HEALTHCARE CORP j' Invoice# Comment Tran Dt Inv Ot Due of Check D Pay Gross Discount No -Pay Net IN20055252V 06/14/20 04/01120 04/26120 19,166.67 0.00 0.00 19,166.67 CPR SERV IN20055251 „% 06/14/20 04/01120 04/26/20 31,144.58 0.00 0.00 31,144.58 BEHAV HEALTH SERV IN20055291 ✓- 06114/20 05/01/20 05/26120 19,166.67 0.00 0.00 19,166.67 CPRSERV f IN20055290 „j� 06/14/2005101/2005/26/20 31,144.58 0.00 0.00 31.144.58 ✓F BEHAV HEALTH SERV . Vendor Totals Number Name Gross Discount No -Pay Net 11011 DIAMOND HEALTHCARE CORP 100,622.50 0.00 0.00 100,622.50 Vendor# Vendor Name Class Pay Code 11291 DOWELL PEST CONTROL ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Not 10035 r/ 06/14120 00/11/20 07/06/20 260.00 0.00 000 260.00 j file:///C:/Userslltrevino/cpsi/memmed,cpsinet,com/u88125/data_5/tmp_cw5report411719... 6/ 16/2022 Page 5 of 16 PEST CONTROL , 10043 r% 06/14/20 06/11/20 07YOKO 505.00 0.00 0.00 505.00 1/ PESTCONTROL . Vendor Totals Number Name Gross Discount No -Pay Net 11291 DOWELL PEST CONTROL 765.00 0,00 0.00 765.00 Vendor# Vendor Name Class Pay Code 12788 DUDE SOLUTIONS, INC/ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net INV116098 v1 06/07120 06/01120 07/01/20 5,057.62 0.00 0.00 5,057.52 f' WORXHUB Vendor Totals Number Name Gross Discount No -Pay Net 12788 DUDE SOLUTIONS, INC 6,057.62 0.00 0.00 5,057.52 Vendor# Vendor Name Class Pay Code W1167 ELITECH GROUP INC (WESCOR) ,:' W Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 787224 ✓ 06/15/20 06/08/20 06/15/20 282.24 0.00 0.00 282,24 SUPPLIES Vendor Totale Number Name Gross Discount No -Pay Net W1167 ELITECH GROUP INC (WESCOR) 28224 0.00 0.00 282.24 Vendor# Vendor Name Class Pay Cade 11284 EMERGENCY STAFFING SOLUTIONS Invoice# Comment Tran Dt Inv DI Due Dt Check DPay Gross Discount No -Pay Net 41266 , 0611412005/31/2006/10/20 2,220.00 0.00 0,00 2.220.00 ✓ ER PHYSICIAN STAFFING . 41284 06/14/2006115/2006/25/20. 40,062.50 0,00 0.00 40,062,50` / ER PHYSICIAN STAFFING 1I-I9+L) Vendor Totale Number Name Gross Discount No -Pay Net 11284 EMERGENCY STAFFING SOLUTIONS 42,282.50 0.00 0.00 42,282.50 Vendor# Vendor Name Class Pay Code 12808 ESUTURES.COM r/ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 450690 �' 06/14/2005/31/2006/30120 10.50 0,00 0.00 10.50 ✓ f SUPPLIES Vendor Totale Number Name Gross Discount No -Pay Net 12808 ESUTURES.COM 10.50 0.00 0.00 10.50 Vendor# Vendor Name Class Pay Code F1400 FISHER HEALTHCARE �% M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 2803255 f� 06/01/2005/17/2000/11/20. 16623 0.00 0100 160.23 SUPPLIES 3027503 „/' 06/01/20 05/20/20 06/14/20 122.48 0.00 0.00 122.48 f' SUPPLIES . 3027604 r/'� 06/01 /20 05/20/20 06/14/20 81.28 0.00 0.00 8128 % SUPPLIES ✓, 3157672 4% 06114120. 05/25/20 06/19/20 150.10 0.00 0.00 160.10 ✓'' SUPPLIES 3202417 06/14/20 05126120 06/20/20 1,371.11 0.00 0.00 1,371.11 V,/ SUPPLIES ✓% 3284527 ,�� 06/14/20 05/31/20 06/25/20 35.88 0.00 0.00 35,88 ✓ ,SUPPLIES 3328583 y% 06/15/20 06/01/20 06/26/20 758.16 0,00 0.00 758.16 file:///C:/Users/Itrevino/cpsi/memmed.epsinet.com/u88125/data_5/tmp_cw5report411719... 6/ 16/2022 Page 6 of 16 SUPPLIES 3373913 06/15/20 06/02/20 06/27120. 341.10 0.00 0,00 341.10 „/ �•' .SUPPLIES 3507460 ✓" 06/15120 06/07/20 07/02/20 121.37 0.00 0.00 SUPPLIES 3507458 f 06/15/20 06/07/20 07/02/20 116.08 0.00 0.00 116.08 ✓ SUPPLIES 3552464 �'l 06/15/20 06/08/20 07/03/20 557.33 0.00 0.00 557.33 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net F1400 FISHER HEALTHCARE 3,821.12 0100 0.00 3,821.12 Vendor* Vendor Name Class Pay Code 13960 G & SMANAGEMENT GROUP LLC .% Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 340385299 1 06/14/20 06/08/20 06/18/20 1,651.50 0.00 0.00 1,651.50 DISPOSAL , 340385301 ✓ 06/14/20 06/08/20 06/18/20 377.13 0.00 0.00 377.13 V WASTE DISPOSAL , 340385300 �� 06114/2006108/2006/18/20 260.55 0,00 0.00 260.55 WASTE MAY 22 Vendor Totals Number Name Gross Discount No -Pay Net 13980 G & S MANAGEMENT GROUP LLC 2,289.18 0.00 0.00 21289,18 Vendor# Vendor Name Class Pay Cade 12404 GE PRECISION HEALTHCARE, LLC 1 Invoice# Comment Tran Dt Inv Dt Due Dt Check O Pay Gross Discount No -Pay Net 6002138788 t j 06/16/20 06/01/20 07/01 /20 3,588.68 0.00 0.00 3.588.58 CONTRACT 6002138746 ,//06116/2006/01/2007/01f20 680.00 0100 0.00 680.00 CONTRACT � , 8002138810 06116/2008/0112007/01/20 5,665.83 0.00 0.00 5;865.83 ✓ CONTRACT 6002138970 Vj 06116/20 06101/20 07/01/20 868.16 0.00 0.00 868.16 i/z CONTRACT 6002138789 ,/ 061IW20 06/01/20 07101/20 86.67 0.00 0.00 86.67 ✓'� CONTRACT 6002152622 � // 06/16/20 06/08/20 07/07/20 2,422.50 0,00 0.00 2,422.50 j CONTRACT 6002162623 / 06/16/2006/0812007107/20 1,816.88 0.00 0.00 1,816.88 CONTRACT 6002152619 ,/ 08116/20 06/00/20 07/07120 2,422.50 0.00 0,00 2.422.50 CONTRACT 6002162620 ✓' 06116/20 06/08/20 07/07/2D 2,422.50 0.00 0.00 2,422.50 CONTRACT 6002152621 �% 06/16/20 06/08/20 07/07120. 2,422.50 0.00 0.00 2,422.60 ✓ CONTRACT Vendor Totals Number Name Gross Discount No -Pay Net 12404 GE PRECISION HEALTHCARE, LLC 22,396.12 0.00 0.00 22,398.12 ' Vendor# Vendor Name Class Pay Code W1300 GRAINGER M Invoice# Comment Tran DI Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net 9335963139 1//06/15/20 06/07/20 07/02/20 532.92 0.00 0.00 532.92 ✓`� file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.com/u88125/data_5/tmp_cw5report411719.., 6/16/2022 Page 7 of 16 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net W1300 GRAINGER 532.92 0,00 0.00 532.92 Vendor# Vendor Name Class Pay Code G1210 GULF COAST PAPER COMPANY �' M Invoice# Comment Tran Dt Inv of Due Ot Check D- Pay Gross Discount No -Pay Net 2242255 v. 06/15/20 05/31/20 06/30/20. 88.26 0.00 0,00 88.26 Vr. SUPPLIES 2242078 j / 06/15/20 05/31/20 06/30/20. 717.32 0.00 0.00 717.32 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net G1210 GULF COAST PAPER COMPANY 805.58 0.00 0.00 805,58 Vendor# Vendor Name Class Pay Code 11095 GULF COAST SCIENTIFIC Invoice# Comment Tran Dt Inv or Due Dt Check D Pay Gross Discount No -Pay Net 74833 ,/ 06/15/20 05110/20 06/15/20 299.86 0.00 0.00 299.86 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 11096 GULF COAST SCIENTIFIC 299.86 0.00 0.00 299,86 Vendor# Vendor Name ;Class Pay Code 11552 HEALTHCARE FINANCIAL SERVICES Invoice# Comment Tran or Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 100525294 V1 06/16120 06/07/20 07101120 4,919.41 0.00 0.00 4,919.41 LEASE JULY 22 , 100625296 f 06116/20,06/07/2007101120 7,447.86 0.00 0.00 7,447.86r✓ LEASE JULY 22 i00625297 06/16/20 06/07120 07/01/20 1,797.44 0.00 0.00 1,797.44 L./ LEASE JULY 22 100619828 06/16120 06/07/20 07/01/20 4,610.62 0.00 0.00 4,610.62 " LEASE JULY 22 , Vendor Totals Number Name Gross Discount No -Pay Net 11552 HEALTHCARE FINANCIAL SERVICES 18,775.23 0.00 0.00 18,775.23 Vendor# Vendor Name Class Pay Code H1399 HILL -ROM COMPANY, INC ✓ M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gmss Discount No -Pay Net 1492194 ✓ 06/16/20 05/07/20 06/16/20 73.07 0.00 0.00 73.97 ✓� SUPPLIES 1492193 1/ 06/15/20 06/07/20 06/15/20 76,57 0.00 0.00 76.57 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net H1399 HILL -ROM COMPANY, INC 150,54 0.00 0.00 150.54 Vendor# Vendor Name Class Pay Code 10922 HUNTER PHARMACY SERVICES r' v; Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 4941 ✓ 06/16/200513112006/20/20 14,890.40 0.00 0.00 14,890.40 ,. PHARM SRVS- ADOLPH Vendor Totals Number Name Gross Discount No -Pay Net 10922 HUNTER PHARMACY SERVICES 14,890.40 0.00 0.00 14,890,40 Vendor# Vendor Name Class Pay Code 12228 INNOVATIVE STERILIZATION v' Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net file:///C:/Users/ltrevino/cpsi/memmed.cpsinet,com/u881251data_51tmp_cw5report411719... 6/16/2022 Page 8 of 16 25293 V ° 06/15/20 06/Ot/2006/15/20 847.32 0.00 0.00 847.32 SUPPLIES j Vendor Totals Number Name Grass Discount No -Pay Net 12228 INNOVATIVE STERILIZATION 847.32 0.00 0.00 847.32 Vendor# Vendor Name Class Pay Code 11264 ITA RESOURCES, INC ✓ W Invoice# Comment Tran Dt Inv Dt Due Dt Check 0-Pay Gross Discount No -Pay Net MMC062022 / 06/14/20 06/13/20 06/20/20 25,894.07 0.00 0.00 25,894.07 My" RESPIRATORY SVCS Vendor Totals Number Name Gross Discount No -Pay Net 11264 ITA RESOURCES, INC 25,894.07 0.00 0.00 25,894.07 Vendor# Vendor Name Class Pay Code 11108 ITERSOURCE CORPORATION r„i Invoice# Comment Tran Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net INV429941✓ 06/14/200610112006/16/20 1,194.79 0.00 0.00 1,194.79 �J SUPPORT SERVICES Vendor Totals Number Name Gross Discount No -Pay Net 11108 ITERSOURCE CORPORATION 1.194.79 0.00 0.00 1,194.79 Vendor# Vendor Name Class Pay Code L0700 LABCORP OF AMERICA HOLDINGS ✓ M Invoice# Comment Tran Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net 73127534 ✓J06/14/20 05/28/20 06/22/20 26.29 0100 0.00 26.29 LAB SERVICES , Vendor Totals Number Name Gross Discount No -Pay Net L0700 LABCORP OF AMERICA HOLDINGS 26.29 0.00 0.00 26.29 Vendor# Vendor Name Class Pay Cade L1001 LANDAUER INC W Invoice# Comment Tran Ot Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 101010875 06/16/20 05/20/20 06/20/20 954.18 0.00 0.00 954.18 DOSEBADGES Vendor Total: Number Name Gross Discount No -Pay Net L1001 LANDAUER INC 954.18 0.00 0.00 954.18 Vendor#Vendor Name Class Pay Code L1640 LOWE'S BUSINESS ACCTISYNCB W Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Grass Discount No -Pay Net 060222 00/16120 06/02/20 06/28/20 465.29 0.00 0.00 465,29 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net L1640 LOWE'S BUSINESS ACCT/SYNCB 465.29 0.00 0.00 465.29 Vendor# Vendor Name Class Pay Code M2178 MCKESSON MEDICAL SURGICAL INC ,j Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 19461686 ✓ 06/07/20 06/06/20 06/21/20 170.23 0,00 0.00 170.23 SUPPLIES 19451217 r/ 06/14/20 06/03/20 06/18/20 2,111.37 0.00 0.00 2.111.37 ✓ SUPPLIES 19478690 ✓ 06/15/2006/1012006/25120 49.13 0.00 0,00 49.13 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net M2178 MCKESSON MEDICAL SURGICAL INC 2,330.73 0.00 0.00 2,330.73 Vendor# Vendor Name Class Pay Code file:///C:JUsers/ltrevino/cpsi/memmed.cpsinet.com/u88125/data 5/tmp_ew5report411719... 6/16/2022 Page 9 of 16 10613 MEDIMPACT HEALTHCARE SYS, INC. A/P ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check DPay Gross Discount No -Pay Net 30450799 (1611612006/01/2006/30/20. 36.54 0.00 0.00 36.54 ✓ INDIGENT Vendor Totals Number Name Gross Discount No -Pay Net 10613 MEDIMPACT HEALTHCARE SYS, INC. 36.54. 0.00 0.00 36.54 Vendor# Vendor Name Class Pay Code M2470 MEDLINE INDUSTRIES INC ✓ M Invoice# Comment Tran DI Inv Ot Due Dt Check D' Pay Gross Discount No -Pay Net 2208854612 06/0120 04/27/20 05/22/20 5,304.32 0.00 0.00 5,304.32 SUPPLIES 2210839879 .% 06/01/20 05/11/20 06/05/20 1,945.32 0.00 0,00 1,945,32 v " SUPPLIES 2211779101 06/01/20 05/18/20 06/12/20 144.94 0.00 0.00 144.94 1/ SUPPLIES 2211779104v% 06/01/2005/18/2006/12/20. 22.82 0.00 0.00 M82 SUPPLIES 2211779103 t/ 06/012005/18/2006/12/20. 93.84 0.00 0100 93.84 ✓� SUPPLIES 2212609163 ✓ 06/09/20 05/25/20 06/19/20 4.19 0.00 0100 4.19 SUPPLIES 2212671144 V% 06/14/20 05/25/20 06/19/20 541.36 0.00 0.00 541.36 SUPPLIES 2213359100 , f 06/15/20 05/03/20 05/28/20 388.48 0.00 0.00 388.48 1z SUPPLIES 2211955567 ✓ 06/15/20 05119120 06/13/20 443.82 0.00 0.00 443.82y� SUPPLIES 2212496607 �% 06/15/20 05/24/20 06/18/20 113.60. 0.00 0.00 113,60 SUPPLIES 2212496609 r/ 06/15/20 05/24/20 06118/20 1,685.21 0.00 0.00 1,685.21 SUPPLIES 2212498606 6/r 06/15/20 05/24/20 06/18/20 113.50 0.00 0.00 113.60 SUPPLIES 2212671145 rf 06115/200512512006/19/20 297.60 0.00 0.00 297.60 ✓i SUPPLIES 2212986186 ,% 06/1 MO 0626/20 06/20/20 137.77 0.00 0.00 137.77 SUPPLIES 2213358499 :' 06/15/20 05/30/20 05/24/20 827.32 0.00 0.00 827.32 SUPPLIES 2213329757 ,i 06/15/20 05/30/20 OW24/20 433.22 0.00 0.00 433.22 SUPPLIES 2213468649 rj� 06115/20 06/01/20 06126/20 4.19 0.00 0.01) 4.19 r% SUPPLIES 2213468647✓ 06/1520. 06/01/2006126/20 205.46 0.00 0100 205.46 ✓, SUPPLIES 2213503833 / 06/15/20 06/01/20 06/26/20 757.33 0.00 0.00 757.33 ✓ SUPPLIES 2213468648r/ 06/15/20 06/01/20 00/26/20 93.84 0.00 0,00 93.84 SUPPLIES 2213468646 V/ 06115/20 06/01/20 06126120 2,086.79 0.00 0.00 2,085.79 SUPPLIES file:///C:/Users/Itrevino/epsi/memmed.epsinet.com/u88125/data_5/tmp_cw5report411719.,. 6/16/2022 Page 10 of 16 2213664940 ✓ 06/15/20 06/02/20 06/27/20 89.71 0.00 0,00 $9.71 SUPPLIES v'` Vendor Totals Number Name Gross Discount No -Pay Net M2470 MEDLINE INDUSTRIES INC 15,734.73 0.00 0.00 16,734.73 Vendor# Vendor Name Class Pay Code M2499 MEDTRONIC USA, INC. ✓ w Invoice# Cment Tran Dt Inv or Due Dt Check D Pay Gross Discount No -Pay Net 5866232551 06/14/20 05/31120 06/30/20 5,424.00 0.00 0.00 5,424.00 ✓ SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 1 M2499 MEOTRONIC USA, INC. 5,424.00 0.00 0.00 5AP4.00 Vendor# Vendor Name Class Pay Code 10536 MORRIS & DICKSON CO, LLC / Invoice# Comment Tran Dt Inv Dt Due or Check Or Pay Gross Discount No -Pay Net 8268858 ✓ 06/14/2006/01/2006111/20 1,080.78 0.00 0.00 1,080.78 ✓'' INVENTORY .. 8271686 J 00114/2006/01/2005/11/20 11233.39 0.00 0.00 1,203.39 ✓" { INVENTORY / 8PG8863 ,/ 06/14/20 06/01/20 06/11/20 40.75 0.00 0.00 40.75 i INVENTORY 8268862 ✓ 06/14/20 06/01/20 06/11/20 95.73 0.00 0.00 95.73 ✓ INVENTORY �. 8268884 ✓ 06/14/20 06/01/20 06111/20 27.21 0.00 0,00 27.21 INVENTORY , $271687 f 06/14/20 06/01/20 001120 143.40 0.00 0.00 143.40 ,INVENTORY % 8268860 06/14/20 06/01/20 06111120 4.67 0.00 0.00 4,67 INVENTORY 8268859yj� 06/1412006/01/2006/11/20 11.52 0.00 0.00 11.52 INVENTORY 8271397✓,/ 0611412006/01/2006111/20 15,89 0100 0.00 16.89 INVENTORY 8271396 ✓/ 0611412006/01/2006/11/20 16.14 0.00 0.00 18.14 INVENTORY 8268398✓ 06114120 06101120 06/11/20 1,418.11 0.00 0.00 1,418.11 INVENTORY 8268861 06/14/20 06/01/20 06/11/20 138,29 0.00 0.00 138.29 INVENTORY 8273995 „% 06/14/20 06/02/20 06/12/20 138.29 0.00 0.00 138.29 INVENTORY 7388 ,y' 06/14/20-06/02/20 06/12/20 -15.27 0.00 0.00 •15.27 CREDIT CM43866 ✓, 06/14120 06/02/20 06112/20 •0.79 0.00 0.00 -0.79 CREDIT 8273994 .r 06114120 06102/20 06/12/20 5,621.51 0.00 D.00 5,021.51 ,INVENTORY 8283994 f 06/14/20 06/05/20 06/15/20 198.44 0.00 0.00 198.44 INWENTORY 8281840 ✓ 05/14/20 06/05/20 06/15/20 666.82 0.00 0.00 666.82 of /INVENTORY $283996 r/ 06/14/20 06/05120 06/15/20 1,187.74 0.00 0.00 1,187.74,-' file:///C:(Users/ltrevino/cpsi/memmed.cpsinet,com/u88125/data_5/tmp_cw5report411719... 6/16/2022 Page 11 of 16 INVENTORY 8281842 ✓/ 06/14/20 06/05/20 06/15/20 164.26 0.00 0.00 164.26 ' ✓ INVENTORY , 8285372 06/14/20 06/06/20 06/16/20 122.86 0.00 0.00 122.86 ✓ll INVENTORY . 8285371 /' 06/14/20 06/06/20 06/16/20 102.01 0.00 0.00 102.01 ✓� INVENTORY 8287339 06/14120 O6/06/20 06/16/20 87.35 0.00 0.00 87.35 f� INVENTORY , 8293979 06/14/20 06/07/20 06/17/20 460.86 0.00 0.00 460.86 INVENTORY , 8290560 ✓ 06/14/2006107/2006/17/20 1,616.80 0.00 0.00 1.615.80 INVENTORY , i B290561 ✓ 06/14/20 06/07/20 06/17MO 4,472.78 0.00 0.00 4,472.78 �; r INVENTORY 8290559 ✓ 06/14/20 06/07/20 06/17/20 102.01 0.00 0.00 102.01 INVENTORY 8293141 06/14/20 06/07/20 06/17/20 3,589.59 0.00 0.00 3,589.59 y( INVENTORY 8293977 .1/ 06/14/20 06/07/20 06/17/20 349.76 0.00 0.00 349.76 INVENTORY CM44967 ./ 06114/20 06107120 06/17/20 -9.13 0.00 0.00 •9.13 CREDIT 8290027 06/14/20. 06/0712006117/20 3,997,18 0.00 0.00 INVENTORY , 8295843 / 06/14/20 06/08/20 06/18/20 1.30 0.00 0.00 1.30 .INVENTORY 8298347,/ 06/14120. 06/08/2006/18/20 24125 0.00 0.00 241.25 ✓f INVENTORY 8297052 v! 06/14120 06108120 06/18/20 24.90 0.00 0.00 24.90 INVENTORY 8298348 f 06/14/20 06/08/20 06/18/20 835.90 0.00 0,00 835.90 .INVENTORY . 8297051✓! 06/14/2006/08/2006/18/20 49,79 0.00 0.00 49.791,,,/ INVENTORY , CM45261 ✓ 06/14/20 06/08/20 06/18120. -41.18 0.00 0.00 -41.18 CREDIT CM45622 06/14/2006/09/2006/19/20 -276.58 0.00 0.00 -276.58 y` CREDIT CM45624 06/14/20 05/09/20 06/19/20 -283.67 0.00 0.00 -283.67 % CREDIT 8300958 / 06114/2006/09/2006/19/20 49.70 0.00 0.00 49,70 INVENTORY CM45623 1✓ 06/14/20 06/00/20 06/19/20 -46.08 0.00 0.00 -46.08 CREDIT / 8308347 ✓ 0611412006/12/2006/22120 3,106.27 0.00 0.00 3,106.27 ✓J ,INVENTORY 8308349 06114120 06/12/20 06/22/20 640.84 0.00 0.00 , 640.841/ ,INVENTORY , 8310459 f 06/14/2006/12/2006/22/20 1,796.24 0,00 0.00 1,796.24 -,� INVENTORY . file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.com/u88125/data_5/tmp_cw5report411719... 6/16/2022 Page 12 of 16 8310458 06/14/20 06/12/20 06/22/20 1,223.55 0.00 0,00 1,223.55 �/ INVENTORY 8308348 / 06114120 06112120 06/22120 29.14 0.00 0,00 29.14 f' INVENTORY 8308350 �/ 06/14/20 06/12/20 06/22/20 74.69 0.00 0.00 74.69 ''� INVENTORY ✓ . 8314731 y! 06/14/20 06113/20 06/23/20 3,144.35 0.00 0.00 3.144.35 y/! INVENTORY 8314732 4,j 06/14/20 06/13/20 06/23/20 476.77 0.00 0.00 476,77 , f' INVENTORY 8318828 � 06116/20 06/14/20 06/24/20 877.67 0.00 0.00 877.67 INVENTORY 8318827 ✓1 06/16/20 06/14/20 06/24/20 91.27 0.00 0.00 91.27 INVENTORY Vendor Totals Number Name Gross Discount No -Pay Net 10536 MORRIS & DICKSON GO, LLC 39,097.07 0.00 0.00 39,097.07 Vendor# Vendor Name Class Pay Code 13548 NACOGDOCHES TRANSCRIPTION Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Not /j 7715 .f 06/14/20 05/19/20 05/29/20 322.00 0.00 0.00 322.00 .� TRANSCRIPTION SERVICES 7731 ✓ 06/14/20 06/13/20 06/23/20 310,40 0.00 0.00 316.40 TRANSCRIP SERV Vendor Totals Number Name Gross Discount No -Pay Net 13548 NACOGDOCHES TRANSCRIPTION 638.40 0.00 0.00 638.40 Vendor# Vendor Name Class Pay Code 12388 NATIONAL FARM LIFE INSURANCE Invoice# Comment Tran Ot Inv Dt Due Dt Check D Pay Grass Discount No•Pay Net / 3692910 1 06/14/2006/0112006/01/20 3.874.25 0.00 0.00 3,874.25 PAYROLL DEDUCT Vendor Totals Number Name Gross Discount No -Pay Net 12388 NATIONAL FARM LIFE INSURANCE 3,874.25 0.00 0.00 3,87425 Vendor# Vendor Name Class Pay Code 12096 NEOGENOMICS LABORATORIES vF Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 5413438 / 06/14/20 06/31/20 06/30/20 540.00 0:00 0.00 v' 60.0.00 LAB SERVICES . Vendor Totals Number Name Gross Discount No -Pay Net 12096 NEOGENOMICS LABORATORIES 540.00 0.00 0.00 540.00 Vendor# Vendor Name Class Pay Code 13624 NEXION HEALTH AT NAVASOTA INC // Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net TELEME020220602 06/1412006/01/2006/15/20 1,000.00 0.00 D.00 1,000.00 TELEMED REIMBURSEMENT ✓r Vendor Totals Number Name Gross Discount No -Pay Net 13624 NEXION HEALTH AT NAVASOTA INC 1,000.00 0.00 0.00 1,000.00 Vendor# Vendor Name Class Pay Code 01600 OLYMPUS AMERICA INC ,;� M Invoice# Comment Trw or Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 32770808 06/15/20 06/07/20 07/02/20 194.03 0.00 0.00 194.03 1 / %/' SUPPLIES file;///C:/Userslltrevino/cpsi/memmed.cpsinet.com/ti88125/data_5/tmp_cw5 report411719... 6/ 16/2022 Page 13 of 16 32770807 ,;' 06/15/20 06/07/20 07/02/20 447.03 0.00 0.00 447.03 SPPLIES , 32776838 06/16120 (16107/20 07102/20 1,137.51 0,00 0.00 1,137.51 SERVICE CONTRACT Vendor Totals Number Name Grass Discount No -Pay Net 01500 OLYMPUS AMERICA INC 1,778.57 0.00 0.00 1,778.57 Vendor# Vendor Name Class Pay Code 11155 PARA / Invoice# Comment Tran Ot Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 11254 f 06/07/20 06/01/20 07/01/20 3,084.00 0.00 0.00 3.084.00 1 REV INTEGRITY PROGRAM 11332 06107/20 06/01/20 07/01/20 950= 0.00 0.00 950.00 e% tee= TRANS OTR PROCESSING Vendor Totals Number Name Gross Discount No -Pay Net 11155 PARA 4,034.00 0100 0100 4,034.00 Vendor# Vendor Name ,Class Pay Code 10570 PROFESSIONAL MEDIA RESOURCES �../ Invoice# Comment Tran Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net 2206005 U/ 06/14/20 06/03/20 06/30/20 118.60 0100 0.00 / 118.60 S,f TX ADVANCE BOOK Vendor Totals Number Name Gross Discount No -Pay Net 10570 PROFESSIONAL MEDIA RESOURCES 118.60 0.00 0.00 118.60 Vendor# Vendor Name Class Pay Code / 11080 RADSOURCE ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net. SC32090722 i/ 0611612006/1212007/01/20 1,791.67 0.00 0.00 1.791.67 v= SAMSUNG GC80 Vendor Totals Number Name Gross Discount No -Pay Net 11080 RADSOURCE 1,791.67 0.00 0.00 1,791.67 Vendor# Vendor Name - Class Pay Cade 11251 RAPID PRINTING LLC Invoice# Comment Tran Dt Inv Ot Due Ot Check D Pay Gross Discount No -Pay Net 14015 ✓ 06/14/2006107/2006/17120 1,48925 0.00 0.00 1,489.25 T SHIRTS 13719 06/16/20 05/09/20 05/19/20 22.00 0.00 0.00 22.00 FOAM BOARD Vendor Tatale Number Name Gross Discount No -Pay Net 11251 RAPID PRINTING LLC 1,511,25 0.0D 0.00 1.511.25 Vendor# Vendor Name Class Pay Code 11764 ROBERT RODRIQUEZ ,// Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 061522 06/16/20 06/15/20 06/25/20 20.00 0100 0.00 20.00 v' FOOD HANDLER PERMIT REIN Vendor Totals Number Name Gross Discount No -Pay Net 11764 ROBERT RODRIQUEZ 20.00 0.00 0.00 20.00 Vendor# Vendor Name Class Pay Code 11252 FIX WASTE SYSTEMS LLC Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 3704 06/16/20 06/01/20 06/26/20 60.00 0.00 0.00 60.00 V WASTE Vendor Totals Number Name Gross Discount No -Pay Net file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.com/u88125/data_5/tmp_cw5report411719.,. 6/16/2022 Page 14 of 16 11252 RX WASTE SYSTEMS LLC 60.00 0.00 0.00 60.00 Vendor# Vendor Name Class Pay Code 10936 SIEMENS FINANCIAL SERVICES ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 56382200040573 "' 06/1612006/02/2006/22120 4,038.24 0.00 0.00 4,038.24 ✓✓� LEASE Vendor Totals Number Name Gross Discount No -Pay Nei 10936 SIEMENS FINANCIAL SERVICES 4,038.24 0.00 0.00 4,038.24 Vendor# Vendor Name Class Pay Code T2204 TEXAS MUTUAL INSURANCE CO r / W Invoice# Comment Tran Dt Inv Ot Due Dt Check D Pay Gross Discount No -Pay Net IOD3734701 �1 06/14/20 06102/20 06/22120 4,310,00 0.00 0.00 4,310.00 �Z PAYROLL DED Vendor Totals Number Name Gross Discount No -Pay Net T2204 TEXAS MUTUAL INSURANCE CO 4,310.00 0.00 0.00 4,310.00 Vendor# Vendor Name Class Pay Code 11908 TMS SOUTH ✓` Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net INV49443 i,i 06/14/20 06/03/20 07/03/20 284.58 0.00 0.00 284.58 V/ SUPPLIES Vendor TotalENumber Name Gross Discount No -Pay Net 11908 TMS SOUTH 284.58 0.00 O.OD 284.58 Ventlor# Vendor Name Class Pay Code T3130 TRI-ANIM HEALTH SERVICES INC/ M Invoice# Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 1 /Comment 65061567 06/01/20 06/25l20 06/19/20 i 304.70 0.00 0.00 304.70.f SUPPLIES Vendor Totals Number Name Gross Discount No -Pay, Net T3130 TRI-ANIM HEALTH SERVICES INC 304.70 0.00 0.00 304.70 Vendor# Vendor Name Class Pay Code / 14372 TRIAGE, LLC „/ Invoice# Comment Tran Dt Inv of Due Dt Check D Pay Gross Discount No -Pay Net INV1796469799/ 06116/2004/01/2005/01/20 4.674.00 0.00 0.00 4,674.00 RADIOLOGY STAFFING INV1796508594 ,f 06/1612005120V2006/19120 4.239.00 0.00 0.00 4,239,00 RADIOLOGY STAFFING Vendor Totals Number Name Gross Discount No -Pay Net 14372 TRIAGE, LLC 8,913.00 0.00 0.00 8,913.00 Vendor#Vendor Name Class Pay Code /' 13616 TRIOSE, INC Invoice# Comment Tran Dt Inv Dt Due Dt Check or Pay Gross Discount No -Pay Net TRI105108 06/14/20 06/03/20 06/18/20 487.13 0.00 0.00 487.13 FREIGHT r Vendor Total:Number Name Gross Discount No -Pay Net 13616 TRIOSE, INC 487.13 0.00 0.00 467.13 Vendor# Vendor Name Class Pay Code 11067 TRIZETTO PROVIDER SOLUTIONS V1 Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net / 35FK062200/ 06/16120 06/01/20 06/26/20 1,108.40 0.00 0.00 1,108.40, PATIENT STATMENTS Vendor Totals Number Name Gross Discount No -Pay Net file:/I/C:/Userslltrevinolcpsi/memmed.cpsinet.comlu88125/data_5/tmp_cw5report4l l719... 6/ 16/2022 Page 15 of 16 11067 TRI2ETTO PROVIDER SOLUTIONS 1,108.40 0.00 0A0 1,108.AO Vendor# Vendor Name Class Pay Code 14208 TRUSTED HEALTH, INC u! Invoice# Comment Tran Dt Inv Dt Due Dt Check D• Pay Gross Discount No -Pay Net INVIO276 �% 06114/20 05128/20 06/27120 5.618.75 0.00 0100 5,618.75 ✓ TRAVEL NURSE STAFFING INV10424 06/14/2006/04/2006/24/20 5,580.00 0,00 0.00 5,580.00 , / TRAVEL NURSE STAFFING L 5'11 " U lt*vvf i✓" Vendor Totals Number Name Gross Discount No -Pay Net 14208 TRUSTED HEALTH, INC 11,198.76 0.00 0.00 11,198.75 Vendor# Vendor Name Class Pay Code 11001 ULINE ✓' Invoice# Comment Tran Dt Inv or Due Dt Check D Pay Gross Discount No -Pay Net 149640862 ✓ 06/15/2006/01/2007101120 5,40132 0.00 0100 5,401.321 /,'._ SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 11001 ULINE 5,401.32 0.00 0100 5,401.32 Vendor# Vendor Name Class Pay Code U1064 UNIFIRST HOLDINGS INC ✓/ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 8400396728 ✓ 06114/20 06/09/20 07104120 2,151.44 0.00 0.00 2,151.44v''1- INVENTORY 8400396703 V 06/14/20 06/09/20 07/04/20 3438 0.00 0.00 34.78 ✓ / LANDRY /tf 8400396706 ✓ 06/114/20 06/09/20 07/04/20 188.56 0,00 O.00 188.56 ✓F, LAUNDRY 8400396707 ✓f 06/14/20 06/09/20 07/04/20 211.12 0.00 0.00 211.12 LAUNDRY 8400396720 06/14/20 06/09/20 07/04/20 85.11 0.00 0.00 85.11 t/ LAUNDRY 8400396704 �7 06/14/20 06109120 07/04/20 201.59 0,00 0.00 201.59 - LAUNDRY Vendor Totals Number Name Gross Discount No -Pay Net U1084 UNIFIRST HOLDINGS INC 2,872.60 0.00 0.00 2,872.60 Vendor# Vendor Name Class Pay Code 11110 WERFEN USA LLCv Invoice# Comment Tran Dt Inv Dt Due Dt Check DPay Grass Discount No -Pay Net 9111108526./f 06/09/20. 02/02/2007/01/20 506.00 0.00 0.00 506.00 y . SUPPLIES 9111113231 ,% 06/09/20 02/12/20 07/01/20 434.50 D,00 0.00 434,50 SUPPLIES 9111119848,Z 06/09120 02123/20 07/01120 1,309.08 0.00 0.00 1,309.08 SUPPLIES .`� 911112502706109/2003/07/2007/01/20 V 83.87 0.00 0.00 83.87 fJ SUPPLIES 9111169191 ✓ 08115/20 06/07/20 07/02/20 1,027.78 0.00 0.00 19027.78 f SUPPLIES 9111169921 06/15/20 06/08/20 07103/20 9,900,00 0.00 0.00 9,900,00 �= SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net 11110 WERFEN USA LLC 13,261.23 0.00 0.00 13,261.23 file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.corn/u881251data_5/tmp_cw5report4I 1719... 6/16/2022 Page 16 of 16 Vendor# Vendor Name Class Pay Code 10556 WOUND CARE SPECIALISTS Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay WCS00005281 ✓ 06/16/20. 06/0112006/30/20 8,675.00 0.00 0.00 WOUND CARE SERV Vendor Totals Number Name Gross 10556 WOUND CARE SPECIALISTS 8,676.00 Report Summary Grand Totals: Gross Discount 535,378.18 0.00 JUN 16 ZRZ BY COUNTY AUDITOii CALHOUN COUNTY, TEXAS Discount No -Pay 0.00 0.00 No -Pay 0.00 Net 8,675.00 Net 8,675.00 Net 535,378,18 file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.com/u88125/data 5/tmp_cw5report411719... 6/16/2022 DFOEIVED BY THE (IOUNTY AUDITOR ON f- AN 16 202E Account Statement (onuser41M(4NAcc9anl ROSNAImAS1 OMAS Account Inquiries: Toll Free: 1-(800)-248-4553 International: 1-(804)-954.7314 Account Number XX)(X-XXXX-XXYJ TDDrr Y: 1-(877)-505-7276 Send Notice of Billing Errors and Cuslomer Seevtce Inquiries to: CITIBANK, N.A., PO BOX 6125, SIOUX FALLS SD 571178125 Transactions 08710 05M 5999 7533700213030000 OMW4 05/13 05112 4899 5541734213228132662al32 05113 05112 7379 76455572132DMIS007921 05116 05113 $599 02305372134M650099608 05MB OW16 8052 554573721372MS73800079 05120 05119 7399 55125032139700481A19607 OSa3 05n0 9399 05134372141SOM749M 05M 06120 9399 05134372141S00037439D70 05/30 05127 8398 5542950214789436203S297 05130 05r27 8699 8271116214TOM14592331 OSGO 05127 8299 054366421473W270564734 05131 05130 8299 054368421S0300248070153 06/01 06/01 7399 554328621522OD396045731 06103 06/03 5964 55432862154200113057090 rce. Foryour records only. _ $10,000 anm umn $0 Statement Closing Date 0810312022 Days 1n BII6ng Period 31 NOTICE MEMOITEM(S) LISTED BELOW --^^-•-•----^.•. 1 Wings Euanls And Tents 3616737230 TX 77901 USA [ �49so t SM4PT1 1 2 SPARKLIGHT 877869M53 AZ M12 USA f317S4 '✓ 281326B2718 3 CPSI 251.6624156 AL 36595 USA \;' Deposi for TSHA OBerrec ,,500,00 4 TRACTOR SUPPLY blads PORT IAVACA TX 77979 USA , Jf19,96 5 TEXAS HOSPITALASSOC 6124951000 TX 78701 USA t;4511,00 6 DIGICERT INC 8017010634 UT 84043 USA �AM00 ✓ 7 NPOB NPDBMRSA.GOV 800-767873E VA 22033 USA v Na401178S v4so S NPDBNPDB,HRSA,GOV 900.7678732 VA 22033 USA �'/50 1r NUO11987 9 APIC 2074542MI VA 22202 USA 0741p01,'� 3620352E 10 TSICP.ORG SLANCO iO��1..W TX 76605 USA V , ,-25,0000 11 FSP•EMRSAFETYBHEALT 972.2358330TX 75243 USA ✓5,00 12 FSP•EMR SAFETY B HEALT g72.2354MO TX 75243 USA 2.50 13 NNASERVICESLLC BW-8768827 CA 91311 USA 408.85 V 14 NNA SERVICES LLC 000876-OD27 CA 91311 USA ass OR NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION wt CITIBANK, N.A. Ba5OUX FALLS 81157117.6125 ROSHANDA S THOMAS 202 S ANN ST PORT LAVACA TX 77979-4204 Page 1 at 2 tct (.ivz-- Account Number XXXX-XXXX-XXXX Statement Closing Date June 03, 2022 JUN 1 U 202E BY COUMt ! AUOITOH CALHOUN COUNTY, 'tFXA,� 00007905040 Not an invoice. For your records only. --.... ...... •Fapona'sea1okn Cadlmmm�araly:Ow lelephonelinaaarc op9n ewrytlay,+Paymank; YYumay mWWnpaymentmywrYlaNkually OilaJaN aOCWlrtonlNc _I hoursY tlay. Call me CYgomer5ety<alekpM1onenum0orapaAletl an tM hantol Ysng C2iManogw. Plmao tom matmma arganmgonsde mt4ave Ne CtlNAamgv ,be sglamenl la revert a Inter Stolen Cm Cuban"CId. online paymanl flown, Imbued IOr endhowere. ll paying b/ may, place OWN sNfidant matlhg One. Plmaem0eyouwRWmnumber on Me homel dd chmN. + Cad4aldar CrtM/rum: EacM1 CarWokalrym on WOWWAClnt Led c, .net Imrall Cadhomdertlbalmances Rl1'.. 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Plnse badlyua no later Man M days,her too dma tome bra on "I, tld nmore Ifgmollen Page 2 of 2 MEMORIAL MEDICAL CENTER PURCHASE ORDER 'Bill To: 815 N. VIRGINIA ST. Ship To: 815 N. VIRGINIA ST, PORT LAVACA, TX 77979 PORT LAVACA, TX 77979 PHONE: (361) 552-6713 PHONE: (361) 552-6713 FAX: (361) 552-0312 FAX: (361) 552-0312 Vendor Name: Date: —(all L4 190a 9-- Vendor Address: Vendor Phone #: Vendor Fax #: P.O. # Account # Initiated By: ®® ®� ` IMAMS ©EME � ME WE MEANS MM_ r' � 9 0, A -� i' %,%irr' Est. Freight �4 'Est TotalCost'1') tY gdeby TQTAI COST NOTES: Di. iCcr{ _ 5Sl C¢ l u ¢rxa $wc. lIm-W ✓ Contact: Date: Dept. Director Quoted By: Die Nutsing Buyer: B.T.A. Dir. Clinical Services CFO Administrator MEMORIAL MEDICAL CENTER PURCHASE ORDER Bill To: 815 N. VIRGINIA ST. PORT LAVACA, TX 77979 PHONE: (361) 552-6713 FAX: (361)552-0312 Vendor Name: UVI bdd,4 Vendor Address: Vendor Phone #: Vendor Fax #: Ship To: 815 N. VIRGINIA ST. PORT LAVACA, TX 77979 PHONE: (361) 552-6713 FAX: (361)5522-0�312 Date: /d6r/ C PO.# Account# Initiated By: Data Required Expense # Form # 9401 Department Deliver To Line ^�•• ^ ' " ur No. It 9•..1 i i r Description Unit Cost Unit Mess. Extended Cost — C1� AJ�O NhL�b; d �.5�0 z 0.. �r.�; ; -21; 11,E 4s �t5,f,., .fA �S 5 6 PAL 11p•,r: 9 n I �V�.10G7 Yp 9 ��ppt'(UYY�IIC.. 1 �/f 6 f �l�Cldl,(�t C �.lo✓ Est. Freight p wn o, -" rr -i I I V • );at• Total COSY r , ' , l l -I • -t y NOTES: PM L — (_6 ffjt ihS-A — MLw�Lr✓sL T4T� SST 3'7 • -Lit) Ste- +'D Ids- I N1G I Oyt Y0I -Tb4q ', $1'11 o a .51) Caatact: Quoted By: Bayer: Date: E.T.A. Dept. Directar Dir. Nursing __ Dir. Clinical Services MSKESSON STATEMENT A. of: 06110/2022 Page: 002 To enure proper wordat to yaw attaurt, detach and retum this �*wro: eaoo and, with your ramhuance Oct 8115 As of: 00/10/2022 Igoe; 002 MEMORIAL MEDICAL CENTER Mall to: Camp: 8000 AP AMT DUE R@AITTID VIA ACH DEBIT Territory; N VIRGINIA 3TREIT Statement for Information onlyANT DUE REMITTED VIA ACH DEBIT815 Statement for information only PORT LAVACA TX 77979 Customen 632536 Oale: 061il,2022 Cue: 632536 PIEIISE CHECK ANY Date: 06111=22 fTEMS NOT PAID (r) Mal :g Due Reoehab;Pdional °ocean f9laa5p6 Data Oats Number RMeronea Cash Daxdptbn Dlaeoum AmaurB P (9mao) F AmountP ReeNvabb (Mt) F Numhor PF column legend: P 2 Peel Due Item, F e Rdum Due Item, blank = Current Due hem TOTAL• NNlonal pcct 89233fi MFMOPoAL MEDICAL CENTFA Fulum Due: Pend Due: Lett Payment 08/07/2017 24�L't 6^lzbr.Il 3q /•bt. 4. pig , APPROVED ON JUN 2 0 2022 BY COUNTY AUDITOR CALHOUN COUNTY. TEXAS Sublot.hn 0.00 If Pald By 0611412022, 0.00 Pay This Amount: 2.451.97 11 Peld After 0611412022, any this Ammon: 7,380.35 LED 7.232.73 USD 7.380.35 LED For AR Inquiries please contact 800-867-0333 Due If Pcld On new USD 7,232.731 Oleo not 8 old We: 147.62 Due N Wld We: LED 7.380.35 MWESSON STATEMENT As of: D6/10/2022 Page: 001 To answer prop, Oren„ to ywr accoum, aatach ,st mum this ccmwnv: aoso stub w„h yaw erm„tarts DC: 8115 A. of: 00/10MO22 Page: DOI H® PHCY 0434/MB4 MB1 PHS Mall to: Comp: BODO pMT DUE HBAITT® VIA ACH OMIT Tenitery: ]]90 MC" AL MEDICAL CBOTFA Statement for inlmmation onlyAMT DUE REMITTED VIA ACH DEBIT 816 N VIRGINI( 816 N IA ST Customer. 190813 Statement for Information only AVAC Data: 06/11/2022 PORT LAVgCA TX ]]9T9 Cast: 190813 PLEASE CHECK ANY Date: 06/11/2022 rrEMS NOT PAID (+) t� BNn9 D. AewNabl6 stlanel Aseount Wipe Cash Dele Data Number Releernee Dawtl Ibn Discount p Amotnt P (9-11 F q Ores; P Receivable nary F Number Customer Numb, 190013 HIM PNCY 0434IMM MEO PHS 08/08/2022 06/14/2022 7346843431 2017063421 1151nv01ce 0.48 23.77 23.29✓ 7146843431 06/10/2022 06/14/2022 7347338501 2017053639 115lovolce 0.03 1.59 1.56 ✓ 7347338601 PF.eolumn Angara: P = Past ew Item, F = Flags Door Item, bank = Carol Due Item TOTAL• Cunamer Numbr 190879 H® PHCY 0194/MBA M® PHs Subtotals: 25.36 USO Futuer Dom 0.00 Dw, It Paid On Time: If Reid By O6/1412022, USD 24.86 Peal Dow. 0.00 Pry This AmwM: 24.85 USD Disc Ion If pald at, bst Payment 8,388.94 11 Peitl Alter 08/14/2022, Coo 11 Paid We. 0.51 06/06/2022 Pay this Amours25.38 USD Us: USD 25.38 APPROVED ON JUN 2 0 2022 BY COUNTY AUDITOR CALHOUN COUNTY, T€XAD For AR Inquiries please contact 800-867-0333 MSKESSON STATEMENT As of: 06/10/2022 Page: 001 To anwm Proper oneX to your account, &tech and return this Gmn.oy: eoo4 slab with Your rom„lance Be: 6115 As of: 06/10/2022 Page: 001 WALMART 1098/MEN MED pHB Mall to: Comp: 0000 pMT DUE i1BAITTm VIA ACM DEBIT MEKD18AL MEDICAL CENTER Territory: 400VIC KALISIX Statement for information only AMT DUE REMITTED VIA ACH DEBIT 15 815 N 1A 5T Customer, 256342 Statement for Inlmmallan only PoRT LAVACVgCp T% 77979 Deib: 06/11/2022 Curt: 256342 PLEASE CHECK ANY Oele: Oe/11/2022 ITEMS NOT PAID (s) pMM Due Reoeembb'etlonel Account I96 0Me Number Reference Description Cash Dimmed(grob) Amount P F Amount P Set) F RaeaNebb Number Customer Number, 258342 WALMART 1098IMEM MEB WE 06/06/2022 06/14/2022 7346282978 35814815 1151nvmce 6.80 289.91 284.1l✓ 7346282978 06/06/2022 06/14/2022 7346282980 35948042 1151nvolce 6.92 346,13 339.21✓ 7346202900 06/0W2022 D011412022 7346282982 35940042 1151nvolce 0.01 0.32 0.31✓ 7346282982 00/06/2022 06/14/2022 7346448035 0603221006 1151nvolee 0.24 0.241/ 7346448835 OWW2022 06/14/2022 7346606782 36992073 1151nvoico 0.03 1.27 1.24 ✓ 7346606782 06/07/2022 06/14/2022 7346606784 3605100E 11 Moraine 8.44 422.08 413.64✓ 7346606764 D6/07/2022 06/14/2022 7346732195 06062209112 1151nv4ice 32.89 1.644.31 1,611.42✓ 7346732195 06/08/2022 06/14/2022 7346868947 36187045 1151nvoice 31.26 1,563.09 1,531.83 ✓ 7346868947 05/08/2022 06114MO22 7347009982 0607220730 1951mmice 7.92 395.77 387.85✓ 7347009982 00/09/2022 06/14/2022 7347117422 36251991 1151nvaica 5.80 200.00 284.20✓ 73471/7422 05/09/2022 06/14/2022 7347117426 36312683 1151mmice 20.21 1,010.32 990.11 / 7347117425 UB/09/2022 06114MO22 7347247479 0608221044 11 Slovaks 0.02 0.95 0.93 ✓ 7341247479 06/10/2022 06114MO22 7347354610 36372434 1151nvaice 0.16 0A6✓ 7347354610 06/10/2022 08/14/2022 7347354612 36372434 1151mmIcs 8.46 422,89 414.43 ✓ 73Q354612 06/10/2022 06/14/2022 7347354613 36432938 11 simmIce /1.54 577.21 565.67 1/ 7347354613 06/10/2022 05/14/2022 7347516232 0609220905 1951nvolce 0.02 0.95 0.93 ✓ 734]518232 PF column bgene: P = Post Due item, F Future Due Item, blank = Current Due Item TDTAL Customer Number Rfi8342 WAIMARi 1098/MQ1 M® PHS SuMmale; 6,965.80 USD Fmum Due; 0.00 Duo If Pate On Time: Peal Due! It Pales 2022, USD 6,828.29 0.00 Pay This Amount; 8,028.28 USD Dix teal N peM ble: Last Payment 8,386.99 It Alter 08/14/2022, 39.32 Uue 11 Poltl late: 06/06/2022 th PaY this is Amount: 6.985.80 USD U50 6,985.80 APPAOVOOO JUPI 2 0 2022 BY COUNTY AUDiTOA For AR Inquiries please contact 800-867-0333 CALHOUN COUNTY. TEXAS MWESSON comw�. eopp HIE PHY FC 490/MEM MC PHS MEMORIAL MEDICAL METER VICKY KALISEK 815 N VIMINIA ST FORP UVACA Of 77979 STATEMENT As me 06/10/2022 Page: 001 To aneure pmper cmtlh to your accoum, coach and mien this stub with your nmftWn. DC: 0115 A. of: 08/10M022 Pope: 001 AMT DUE RDAITTm VIA AGH DEBIT TeMlory: 400 Mall to: Comp: $000 statement for Information only AMT DUE FDh1DT® VIA DEBIT Customer: 464450 Statement for Information only my Data 06/11/2022 Cum: 464450 PLEASE CHECK ANY Data: 06/11/2022 IT@aS NOT PAID (1) San Ow Reemvablt'"Ums l Account 53AIl96 Cash Amount P AmouguP gecaNabb Data Data Number iiefararree paaetlpllpn Discount (Bross) IF(rmt) F Number Customer Number 464450 H® MY FC 490/MEAI MC MS 00/07/2022 06/14/2022 7346559866 56XB38540 /151nvolce 6.68 333.88 327.20✓ 7346659866 Ofi/09/2022 06/14/9022 7347078337 5SX543967 IIshuolco 0.13 6.47 6.34' - 7347078337 06/10/2022 06/14/2022 7347334237 55x546377 I151nvmca 0.29 14.35 14.06 7347334237 PF column letal P = Past Due Jim, F = Futuna Due Item, blank = Current Duo Item TOTAL CugOmer Number 4844B0 H� PHY FC 4pplMl9d MC PH9 Subtotalm 354.70 USD Future a": 0.00 If If Pala By 06/1412022. Due If Peitl On Time: pup; Pay This Amoum: USD 347.60 USD plat log H cost late: 347.60 1/Peg Led P2Yment 6.366.94 It Paid After 06/14/2022, Due 11 saw isle: 7.10 06/06/2022 Pay this Amount: Am 954.70 USD USD 354.70 APPDOVEDON JUN 20 2022 6Y COUNTY AUDITOR CALHOUN COUNTY, TEXAS For AR Inquiries Illease contact 800-867-0333 MSKESSON STATEMENT As of: 06/10/2022 Page: 001 TO amlre proper Cmdlt to your .4eount, Mao and M. this oaroam: eva4 pub with your rxnKtatme DC: 8115 A. d% 06/10/2022 Pegg: 001 CVS PHCY ]475IMFM MC PHS pMT DUE REMITT® VIA pCH 0®R TSMIory: 400 Mall to: Comp: 000D MEMORIAL MEDICAL CFTITFA Statement for information only AMT DUE REMITTED VIA ACH DEBIT KAUSIX Custamer: 835438 Statement lot Information only 816 N MIR N AVACViFtGIIA ST Date: 06/11/2022 POHI IAVACp T% ]]BT9 Coat: 835438 PLEASE CHECK ANY Date: 08/11/2022 ITEMS NOT PAID (s) BBin9 Due NemAredretional Acccunl MIPS Cash Data Data Amount P Am M P gqaawWebb Number Reference Description Discount (91=0 F (net F Numbm Copom a Number B35438 CVS PHCY ]4]6/MEM MC PHS 06/08/2022 06/14/2022 7347020579 1728106 1161nvolce 0.69 34.69 34.DO ,� 7347020579 O PF Wumn legend: P = Part am no, F = Forest Dun Ilem, blank = Comm Due Nam TOTAL Cuatamer Number 835438 CVS PNCY ]4]6/M6M MC PNS Summat3: 34.69 LED Forum Due: 0.00 Dee If Paid On Time: If Pam By 0611412022, USD 34.00 Pam Due: 0.00 Poy This Amount: 34.01) LED Via Iom 8 paid tare: P2M 0,306.84 If Alter 06/1412022, 0.69 Due It PoId W. 06 B108/2022022 Frayy this Thin Amount: 94.64 USD UBD 34.89 APPHOVEO ON JUN 20 2022 SY CMMAUorcop CALHOUN coUlM. i€xAs For AR Inquiries please Contact 800-867-0333 MWESSONSTATEMENT An lab 0611 T/2022 page' 002 To aaure super `resit to year account, detach and nature this ca,M.or eeos stub Nbh your morgame OC: 6115 As W: 06/17/2022 Page: 002 MEMORIAL MEDICAL CENTER Mall to: Camp: ao00 AP ANT DUE NFDAITTm VIA AC11 OMIT Territory: 915 N VIRGINIA STREET Slalemenl Ier information only ANT DUE FIEMITTED VIA ACH DEBIT PORE IAVACA TX 77979 Customer. 632536 Slatement for inlormallon only Date: 06118/2022 Coat: 632536 PLEASE CHECK ANY Dale: 06/18/2022 R9aS NOT PAID (✓) 9 D'_._�—... Want Data Date `—_ atbml Aceom�d5r l 3s mber Number Reference Cash DexMpten Dlsmum -- Amount P harm¢) F lf rrI Amount P Receivable _I Bar) F Number PF oaame lateen: P = Post Due Item, F = FNum Due Item. beak = Current 0. Item TOTAL NWk l Amt 632636 MMONAL MEOICAL CBITPR Sublomis: 2.901.06 USD RAuna Due: 0.00 Pact Om: If PaM By D6121/2022, 493,64- Pay This Amount: 2,833.14 USD Lam Poyrneg 2,451.97 If Paid After 0612112022, 09/0712017 Pry this Amount: 21901,06 USD AMOVEIU r1N. JUN �gCoulty"aJg7df9 For AR Inquiries please contact 800-867-0333 c7 c UN Ounm iyT A5 Dun II Pau On Ting- USD 2.833.14(' Dla lost 0 paid late: 67.92 our. D Pala lac: USD 2.901.06 MSKESSON STATEMENT As of: 06/17/2022 Page: 001 To ensure proper amfth to your account, detach soft mt. INA �m,a1•anv row stub wNh your remiltance DC: 8115 As of: 06/17/2022 Pegs: 001 HIM PHCY 0434/MEM MW PHS AMT DUE NEv11T7111) VIA ACH DEBIT Territory: 7790VIC Nell to: G.P: 9000 MEMORIAL MEDICAL CENTER Slatamenl for information Only qMT DUE REHITTfD VIA ACH O®R KIRGINI Customer. 190813 Stalemenl for information only 815 N 915 N IA ST Date: 06/18/2022 AVAC PO(n LAVACA TX %%9]9 Cust: 190513 PLEASE CHECK ANY Date: 06/18/2022 IrBAS NOT PAID (+l Billing Due N�4atiwwl Aaounl �9 25y% Cash Date Mt. Nummbert,mr Polemnn OoxMplbn Dieooum Amwnl P (gores) F Amount P Nenivebl0 (oul) F NumM Castro- Numbr 190813 HIM PHCY 04341MB4 M® MS 06/1512022 06/21/2022 7348240659 2017053953 1151nuoice 0.23 11.42 11.19 ,% 7348240659 f PF solamn H9r1tl: P a f et nude Item, F = Mum 0. Item, blank = Currant Duo Item TOTAL• Cugamr Number 190813 H® PHCY 0434IMF3N Mf20 MS sumatm.: 11.42 USD Fubn Due: 0.00 0. It Pale On TIm.: If lose By 06/21/2022, USD 11.19 ✓ Pest Doe: 0.00 Pay We Amount: I1.19 USD Dix bat 8 pelO late: 0.23 Taal Payment 7.232.73 If Palo Aster 08121M022. D. It Palft UK.: 06/13/2022 Pay this Amoam: 11.4E U50 US0 11.42 APPROVED OM JUN 20 2022 DY COUNTY AUDITOR CAALHOUN COUNTY, TO(AG For AR Inquiries please contact 800-807-0333 MSKESSON STATEMENT As of: 0611712022 Pap: 001 To eneum Preper aside to your aecoOM, Ueiaeh and relum into cnnnmr esua dub w0b your ro itta" DC: 8115 As of: 06117/2022 Page: 001 WAINART 1099/MB4 Mm PHS Mall to: Comp: 8000 MEMORIAL MEDICAL CO4iOi AMT DUE REMITT® VIA ACH OMIT Territory: 400 Statement for Information only ANT DUE REMITTED VIA ACH OMIT KAUSFI( Statement I09 information only 015VICIN 615 N IA BT Customer. 256342 AVACVIRGI PORT IAVACA T% ]79)9 Dale: 06/18/2022 Ceer: 256342 PLEASE CHECK ANY Data: 06/IW2022 RQ1S NOT PLAID (s) Siting Date Data Date allmrul Number l� Number Account 3fi Weer RNerence DeacapHon Caen Diewunl Amount P (gtwe) F (nd) P (men F Receivable Number Customer Number 256342 WALMART 10981161 M® PHS 06113MG22 06/21/2022 7347658411 36489552 lisim01co 7.89 39450 386,61✓ 1347658411 _ 06/IW2022 00/21/2022 7347658412 36523350 1151nvoico 0.16 0.16.✓ 7347658412 06/13/2022 06/21/2022 7347658413 36591704 1151nvoice 0.02 0.02✓ 7347658413 _ 00/13/2022 00/21/2022 7347658414 36661201 /151nvolce 4.62 230.76 226. 14 ✓ 7347658414 06/1112022 00/21/2022 7347641052 0610220733 t951nvoic0 0.04 1.90 1.86✓ 7347041052 _ 06/14/2022 06/21/2022 73480,6062 36772766 1151nvalcm 5.80 289.92 284.12✓ 7340016062 06/14/2022 06/21/2022 1348156347 0613220948 1151ms1cu 2.53 126.72 124.19 ✓` 7348156347 06/15/2022 06121/2022 7348260967 36900043 1151nvoim 5.80 289.92 294.@✓ 7348260967 0(Y15/2022 06(21/2022 7348396483 061422DB43 1951nv0ico 0.02 0.77 a.75✓ 7348396483 _ 06/15/2022 06/21/2022 7348396484 0614220953 1151nvotco 0.02 0.95 0.93`/ 7340396484 06,46/2022 06/21/2022 7348546914 36968750 1151nvoica 0,03 1.27 1.241/ 1348545914 06/16/2022 0612112022 7348700187 0615221042 115lnvoice 0.03 1.27 1.24'✓ 7348708187 06/11/2022 06/21/2022 7348842074 37072238 11 Slnvoico 5.80 289.91 284.11 ✓ 7348842074 06YI712022 06121/2022 7348842075 3701223H 1is Inyalcc 28.30 1.415.08 1.386.78 7348542075 _ 06/17/2022 0612172022 7348842076 37134136 1151nvaice 0.02 0.02 7340842076 06/17/2022 06/21/2022 7349010698 0616220805 1151h7mi. 0.02 0.95 0.93 ✓ 734DO10698 06/17/2022 06/17/2022 7349079547 MFC PR CORR CR PUcing Co, 370.38. P 370.38. P✓ 7349079547 06/17/2022 06121/21122 7349079648 MFC PR CORR IN Rnin9 Cor 3.32 165.95 102.63 7349079548 PF edumn legend: P = Pad am hem, F = Future One Item, blank = Current Due Item TOTAL Customer Number 256342 WALMARr 1098IMEN M® PHS Sublalab: 2.639.69 USD Felum Due: 0.00 OUP II Mid On TMe: N Paid @7 06121/2022, USE) / 2.775.47 / Peat Due: 370.38- Pay This Amount 2,775A7 USD Disc tort 0 pale ble: 64.22 Led Payment 7,232.73 It Paid After D6R112022, Due If Paid late 06/13MO22 APPAOVM ON Pay this Anmum: 2,839.69 USD USD 2.839.69 JUN 20 2022 BY COUNTY AUDITOR For AR Inquiries please Contact: 800-967-0333 CALHOUN COUNTY, TEM9 MSKESSON STATEMENT A. of: 06/17/2022 N,: 001 To areum proper eretlh to your solvent, de teh and alt. file c„�i..r a4w slab with Your mmKlanea DC: ails AS of: 06(1]/2022 Page: 001 HIM R4Y FC 490IMW MC MS Mail lm Come: 8000 MEMORIAL MEDICAL CENTER ANT DUE REMITTED VIA ACH DEBIT Tetmoly: 400 VICKY KALEEK Statement for infonnauon only IA ACH DEBIT T DUE R ITTED 815 N VIRGINIA 51 Caldwell 464450 Statement O only PDHT LAVACA TX 77979 Date: 06/18/2022 Cush 464450 PLEASE CHECK ANY Dale: 06/18/2022 Al NOT PAID (11 Me Due Me Oate hcelvabbNatlPlMl AccouQIAii nt j�^196 Numeer 1lefemtme Caen _— Deeelptbn Discount Amount P (arose) F Amount P ReCaNl9e (tlet) F Number Cuslwnm Number 464450 HIM MY FC 490/ME]4 MC Wit 06/14/2022 06/21/2022 7347976900 55.551349 1151nvolee 0.53 26.56 26.03✓ 7347978960 I11 06/14/2022 05/2112022 7347970961 55x551428 II61moice 0.18 0.06 7347978961 8.88✓ I 06/14/2022 06121/2022 7347978962 55x651506 I151nvaice 0.32 15.92 15.60 ✓ 7347978962 _ 06/1612022 06/21/2022 7348538029 5505]3]5 1151nvoice 0.12 6.15 6.03 ✓/ 734863802e 0611]12022 06/21/2022 7348816190 55XB59699 115myabo 1.20 59.]] 58.57 ✓ 7348816190 IJ PF Widid legend: P = Past Due Item, F = Fmure Due Item, blank = Cunant Due Item TOTAL CUlAMWNumber 464450 HM MY FC 490IMM MC PHS Buldwals: 117.46 USD Ful. Due: 0.00 Due 11 Paltl On Time: 11 Paid By 0612112022, USD t 15.11 Pact Duo: 0.00 Pay This Amount: 115.11 USD Oleo laid H paid HIS: LAW Payment ],232.]3 If Pant Altar 2022, 2.35 Due If Paid We: 06/13/2022 Pawml:y this Am Amount: 117.413 USD USD 117.46 APPROVED OM JUN 2 0 2022 BY COUNTY AUDITOR CALHOUN COUNTY, TEXAS For AR Inquiries please contact 800-867-0333 MSKESSON STATEMENT v,,,.,evry eo0o CVS PHCY ]4]51MEM MC PHS ANT DUE REMITTED VIA ACH OMIT MFMORIAI. MEDICAL CENTER Statement for inlannation only VICKY KALISEI( 815 N VIH6INIA ST PORT IAVACA TX 7]9]9 As of: 06/17/2022 Page: 001 To enoe, proper omdN to your account, detach am ratom this atub with your mmBtanee DC: 0115 As of: 06117MO22 Page: 001 Mon Io: Comte 8000 Territory: 400 AMT DUE REMITTED VIA Atli DOW Customer- 835438 Statement for inlormation only Date: 06/18/2D22 CuM: 835438 PLEASE CHECK ANY Date: OW18/2022 RBMS NOT PAID (�) DRirg Due Reasisalijlalimal Accoum SUPHO Cash Amount P AmouM P iMceHeMe Dale Data Number Relemnce Deacripgon Dlxount (grwa) F (eat) F Number Customer Number 835438 CVS PHCY 7475/MEM MC PHIS 06/15/2022 O6/21/2022 7348414222 1738110 1151molce 06/17/2022 06117/2022 73490]]574 MFC PR CORR CR Rsing Cor 08/17/2022 OW21/2022 73490]]575 MFC PR CORR IN Rising Cor PF caiumn Infook P = Rose Due Item, F = FNure Due Item, blank = Current Due Item TOTAL Customer Number 835438 CVS PNCY 747SIM FM MC PHS Subtatak: RAmo Duo: 0.00 I/ Paid Sy 0612112022, Pass Due: 123.46. Pay This Amoum: Lest Payment 7.232.73 H Pald Alter 06/21/2022• 06/13/2022 Pay this Amount: APPrimm ON JUN 2 0 2022 13Y COUNW AUDITOR cALHOUN COUNTY, TENAS 0.01 63 0.62 ✓ 34641422 123.7 96- P 123.46• P ✓ 34907757 4 1.11 55.32 54.21 ]3490]]5]5 67.51- USD Due 11 PaW On TMo: USO 68.63- 68.63- USD Dix lost K peW late: t.12 Due N Palo late 67.51- USD USD 67.51. For AR Inquiries please contact 800-867-0333 STATEMENT Statement Number: 63176384 AmensourceBergen Date: 06-10-2022 1 Of 1 AMERISOURCEBERGEN DRUG CORP WALGREENS S12494 340E 1001352841037028186 12727 W. AIRPORT BLVD, MEMORIAL MEDICAL CENTER - SUGAR LAND TX 7747&6101 1302 N VIRGINIA ST PORT LAVACA TX 77979.2609 DEA: RA0289276 Sal -Frl Due in 7 days 866451.9655 AMERISOURCEBERGEN P.O. Box W6223 Not Yet Due: 0.00 CHARLOTTE NC 28290.6223 Current: 865.43 Past Due: 0.00 Total Due: 865:43 Account Balance: 866.43 Account Activity Document Due Reference Purchase Order Document Original Last Receipt Amount Received Balance Date Date Number Number Type Amount 06-06-2022 00-17-2022 3095130011 106174 Imcice 80.16 0.00 89.18 ' 06-06.2022 08.17-2022 3096130012 166176 Invoice 2.34 0.00 2.N W-07-2022 08474022 309529709D 166232 Invoice 178.19 0.00 W3.19 0&09-2022 0&174MID 3095610309 166250 Involce 321.05 0.00 32L05 08-0&2022 0&17-2022 30957,t4351 16W59 Involce 273.17 0.00 273,17 0S-10.2022 06.17-2022 3095744352 166261 Invoice 0.09 0,00 0.09 011-10.2022 08-17-2022 309574430 I66260 Involce 1.43 0.00 1.43 Current 145 Days 16.30 Days 31.60 Days 61-90 Days 91-120 Days Over 120 D ay!no 885.43 I 0.00 D.00 0.00 0.00 0.00 Thank You for Your Payment Reminders Date Amount Due Date Amount 06.10.2 2 (319.58) 05-17.2022 02 885.43 Total Due: 865,43 APPR04EDON JUN 2 U 2022 8Y COUNtYAUDITOR CALHOUN COUNW, TEXAS % STATEMENT Statement Number: 63221107 AmerlsourceBergen, Date: 06-17-2022 l aft AMERISOURCEBERGEN DRUG CORP WALGREENS#124" 340B IN1352M I037028186 12727 W. AIRPORT BLVD. MEMORIAL MEDICAL CENTER SUGARLANDTX 774784101 1302 N VIRGINIA ST PORT LAVACA TX 77979-2509 DFA: RA0289276 Sal - Fri Due in 7 days 866451-9655 AMERISOURCEBERGEN P.O. Box WIC23 Nor Val Due: MW CHARLOTTENC 28290-5223 Cunenl: 2.895.04 Past Duc: 0.00 Tonal Due: 2.895.04 Ace..M Balance, 2,895.04 Account Activity Document Due Reference Purchase Order Document Original Last Receipt Amount Received Balance [late Date Number Number Type Amount 06.13-2022 06-24-20n 3WSOO1406 IW289 Invoice 43.66 0.00 43,86 06-13-2022 06.24-2022 3095891407 168270 Invoice 102.18 0.66 102.18 / 06.13.2022 06�24-2022 3095939789 106317 Invoice 1.03 am 1.63 / 06-14-2022 Ofi-24.2022 3096082178 106325 Invoice 45.27 0.00 45.27 06.14-2022 06.24.2022 309MU179 166326 Meow 0.29 0.00 019 136-15.2022 05-24-2022 3096231518 1663M Invoice 108.26 0.00 106.20 WA&2022 06-24-2m2 3090391NS 160345 Invoke 1e39 0.00 15.39 OG-17.2622 W-24-2022 30WSW62 166355 hr dee 2.580.16 0.00 2.580.16 __ Current 1.15 Days16J0 Days 37-60 Oays 61.90 Days�1-172tOy. Over - - 120 Days 2.B95.o4 _�'j 0.00 _0.6� _o.00 6.66 Thank You for Your Payment Reminders Date IAunt Due Date Amount 06-07-20225.43) 0424.2022 2,895.04 - Total Due: 2,895.04 APPROVEDON JUN 20 2022 ` SYCOUNTYAUDtfOR CALROUN COUNTY, TEXAS TOLL FEE PHONE NUMBER: 1-800-SSS-3453 (EFTPS TUTORIAL SYSTEM: 1-800-572-8683) "ENTER 9-DIGIT TAXPAYER IDENTIFICATION NUMBER" "ENTER YOUR 4-DIGIT PIN" "MAKE A PAYMENT, PRESS 1" "ENTER THE TAX TYPE NUMBER FOLLOWED BY THE # SIGN" E71F FEDERAL TAX DEPOSIT ENTER 1" "ENTER 2-DIGIT TAX FILING YEAR" "ENTER 2-DIGIT TAX FILING ENDING MONTH" 1ST QTR - 03 (MARCH) -Jan, Feb, Mar 2ND QTR - 06 (JUNE) - Apr, May, June 3RD QTR - 09 (SEPTEMBER) - July, Aug, Sept 4TH QTR -12 (DECEMBER) - Oct, Nov, Dec "ENTER AMOUNT OF TAX DEPOSIT - FOLLOWED BY # SIGN" "1 TO CONFIRM" "ENTER W/CENTS AMOUNT OF SOCIAL SECURITY" "ENTER W/CENTS AMOUNT OF MEDICARE" "ENTER W/CENTS AMOUNT OF FEDERAL WITHHOLDING" "6-DIGIT SETTLEMENT DATE" "1 TO CONFIRM" ACKNOWLEDGEMENT NUMBER #### ENTER: 0 0 $ 126;818.SS _1 . $ 63,622.40 $ 14,879.36 $ 48,316.79 CHECK $ CALLED IN BY: CALLED IN DATE: CALLED IN TIME: FAAP•Paymll FileslPaymll Taxes12 UW13 R1 MMC TAX DEPOSIT WORKSHEET 6.16.22 Ri.xis 611812022 Run Cate: OVIII/22 MIOEIAL MEDICAL CENTER Plus 204 Tire: 15:C! Payroll Register : 9--Weakly i P2EEr, Pay Perioi 06/03/22 - 06/16/22 h.m4 1 Final Sumry I-- P a y C o d e S u m m a r y ----------------------------------------- -•• D e d u c t i o n s S u m m a x y-----------•-` I Payed Description Hrs 10TISRI IROIGI Gross I Code Atoll --------------- __--------- .---------- .-------------- .------ ......................... ............................................ 1 REGULAR PAY-S1 9472.00 N 11, 11 204976.74 AIR 435.94 A/R2 AIR3 I REGULAR PAY-S1 1643.50 N N II N 82392.62 AOVANC AWARDS BCBSVI 989.8E 1 REGULAR PAY-SI 521.00 Y N N 16247.R3 BOOTS CAFE N CAFE-1 2 REGULAR PAY-S2 2532.75 N I1 N 53209.4C CAFE-2 CAFE-3 CAPS-1 2 REGULAR PAY-52 247.75 Y N N 9523.5! CAFE-5 CAFE-C CAE-D 1559.75 3 REGULAR PAY-S3 1380.00 N N N -11216.65 CAFr-.F CAFE-E 22205.15 CAFS-I 3 REGULAR PAY-S3 130.25 Y N 14 6073.12 CAFE-L CkFR--F CANCER C GALL PAY 2463.00 N 1 N N e926.0, CHI'LD 22E1.01 CLINIC 155.00 CONSIN 106.09 D DOUBLE TIRE 4.73 N 1 N I1 115.89 CRFDUN CD AD'1 GESTALT D DOUBLE TIME 4.75 N 2 N 11 129.39 DR?-LF DIS-LF FAT 0 DOUBLE TIME 7.00 N 3 N N 194.18 EATCSR FEDTAE 48316.79 FICA-M 7419.68 0 DOUBLE TIE 3.75 Y 1 N II 141.90 FICA-0 31811.2C FIF.STC ?,ffi S 3382,90 E BEiRA WAGES N N H N 7510.00 FLY. FE FORT D "rlA E SKIER WAGES N 1 N N N 59528.25 GIFT S 215.23 GRAVT GRP-IN F FUNBRAL LEAVE 8.00 N 1 N N 336.00 GTL ROSP-I ID TFT 3 INSEViCE 10.75 N 1 N N 346.51 LEAF LEGAL 205.98 MASH. 767.4E K EXTENDED -ILLNESS -BANK 236.00 N I N U m3.00 HE UT 303.10 NEVIS MLSC P PAID-T2.ME-OFF 139.63 S N N N 2303.58 MISC( MMCSBR. WltX 1354.02 P PAID -TILL -OFF 1447.00 N 1 N N 37163.01 OTHER PHI PBI•** Y CALL PAY 2 232.00 N 1 5 11 464.00 PR FIN RELAY REPAY Y Y.HCA/CUF.VES N N It :4 75.00 S;XC SCRUBS S.MCI; 2 CALL PAY 3 144.0 N 1 N 11 432.00 ST-i.4 STONDF 640.8E STONE v COVID-FFCRA 44.00 N 1 N N 1219.84 STONE2 SIDDEN SUNACC 760.28 SURILL 949.63 SUIIND $37.74 SU77LIF 951.71 S?71STD 1261.68 SUSVIS SOFCHG 363.00 TS.i-1 TSA-2 TSA-C TSA-P TSA-R 38131.42 TUTIDN UNIFOR UWINOS Grand Totals: 20e71.85 l Gross: 544733.70 Deducticrs: 165355.4E Net: 373070.12.1 Checks Count:- FT 194 PT 9 Other 51 Famle 229 Hale 23 Credit OverAnt 24 2eroNet Tem Total: 252 ------------------------------------------------------------------------____._.___---------- -------------.. . Pay Enid //mom: r, z _ a Na, :CHECK _ :m » »; »: ,m a: m�Al 2, m 60652 _a.=» m= _mom m m; o, a: z m aeKINS _ _e __ ma = « •a aYTID= ce saw : > » a, _ m 00152 em,e ma = a ' . __" , -DE « _ . m T ma , m 1 z m c, _ m iP ® All c I %\ \ 2 _u e m* _1 m D %\ _ \ \ ;. 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L sa = m ,725 : ate. e* _ c a. ca =0 m z es = mw: e, s wz = c . m »a M1 m 02927 :: GkINES ma -D m e=Mrmll ;mom . a am D: _ JACQUELINE ._s «m =0 w 1.1 � � � � JAJ�7- !mm _ m . ate: as = o maT . , a:A a» 12 s» 05757 _ems, az = m ' m=, s= _ »2o :w _ ; as Mama ;. . wm = m m Al aw M m zee :mc az = m :ate ;m « as = m ze _m._ wa OD_ «__= a= DO .: = se =ems : . , » = m;u : KYLE _L «z = u !n a .. «e = spa m . : : : *0!24,22 m , mz =Diem =:e 3 moms _ m . YULYLA ,K RIGLEZ a: \J \ \ . m., ca =0 < =mom :+I w HAIJIL mz = m : ^11RIEZ as = m \^ d \ N % 1 ! me = w RUM Date: 136;1at22 ➢6s:JRLAL BSDZCAL CS!8ER 3I•REERLI' Page Lce: 16:3i ..� Crec.. ' :ti ... P:CIST? p3...::A- iyaedlET :0000001^7?ER'vT[!Y2 • PRDSPERISY %l. Nre ;aomt =:EC9. M ]ATE 20757 EE-HVN P. Dios L320. 54 CC 20616 JOIE L PE11A 9:2.16 DD 637 .A:sY XLK"ei DD 29a5: JALYN:1 GREE` 231.i3 DD �:6i24/22 206.5 DAKCELn CAMCr:D 55.E9 D7 76/N/22 2i3 CHER'.,' L d:!i;lci 11450 DIANA E LEA!, 2204.52 DD 06/24/22 .1 M. JAC"•EY 2 6=.8FCR: 2565A9 51733 AJ.I = 7: CCL?'31 537, 23 'i h. 2261E REAMER L SKIT:i 2321.74 DD 0v(24!22 26735 '3R;P.:E V GARZA 2519] .'CeLG'i A SCEDIT 133D. L9 DD E6i i4!22 30451 A?1EER JVPD 211.42 3:C$4 LGRA [. Lh+30F\ 344.15 GD 'Js i 1i/E2 3 LC5A :RACKY Z C?cr*A 2Z4i. iL C", •,c i24!:i 5:311 :1,411.SRIIIE LYNX JIF:ENU Ia25.37 DD 'Ce/2,/22 e:A.Y - FAMER 171E ..ti DD ':. K•./22 3:46i 'nAi: Z. 9dT:..A 2353.37 DD 31503 RAC, -:EL . N??R"EF 3097.2E DD 06/24!i2 31032 S511R D KRTSTA i249.33 DD i22 31945 CCDY L JRIK 163.03 DD DEi.,V:2 39413 DEIMI DATA I'll -Al OD 06/24/22 3a702 AA:iA VkIEScA ?E!D!EL! 112;.95 DD '?612{121 A3v.STAi:A L PEAEZ E4i... _. :5i24!2: i.:112 LL7] TGN_MP. M. ^.F.EVIt1G 537.50 DD C6/2s'/22 41205 JER1EiTE AVX.A:D 940.32 CD Chi 2;l72 ._225 __..] A CF-1152l 1343,ii D: C6/24/l: 4:236 ?AttELA R VMXCY 1252.37 DD s6/24/:: 4:274 'X-M; CAhti 1nC:. 35 4:275 PAM: P. FA.UZ "3.34 D: J6Ra22 1:347 AD2IPVl,'A D OJOS 766.30 PO :6124 /22 4:366 .C'RKTA A LSAL r'1F1E AFCEL 1( CASSEL 1146.62 DD 4307 DLCA I 3ETASE"N7..7 ?46.65 EC 1.6, 24!22 4:612 SGG:A A. DGAJA.A:C ]]l. li :D :5;: ;36L7 JACQUELINE h FARTMIZ 967.?4 CD 06/24/22 4L7.; ELSEY d "..3:CR 34a S3 CC :6I24/22 4135E .MI"AE NICM LE E$a'i E33.i1 CC Oai 24/:: 4:397 ROYAVAA WTIKEZ 779.32 OD 06i2;/12 .SCS TJA;iITA.3 :iL:LE?. 2=... .•; 24.._ -52; SR:.NBY V STR2CRL16 775.32 DD :6, C6 CRRISTY S:Ws 9EE.59 CD 96i 24!Ci :E: ANA C3iAVASA i527A", DD 05Ri123 4212; 7JC' MZACA 7;5.'7 DD C61`24/22 42354 EL1': 42320 N.ICRAL A HEIL 3004.3; DD D6l2; l22 7n1. . IN ... '.:2 L ]4: .._2DIi _ t _ {1!IE..� :L 14.•.'] Eli .];2.1:( icr: 2i:3i •• ..._...=t313ta: ,••• 9EDISE-r •• -ray i?ri.d 051C2 r22-- E/:ilk Rar.: 1 .. c moss Elam •' NEW x ANT :01:; _OrJ1r. Vr_-':2 E94.4E CG SG+,: PENMG_rJUEN, 9C53.So OD aii2d/22 ia151 _.._:::i5'E'AICH-ULE 2%f0?r 1;::.3i D: SON F:C'KEW V:LL5GLC 605.51 OD 150721122 Milk ^2 AM-, M10 i.S.?CSa GRIGSBY 702.1.2 OD iw 2ilk i HIE .=1API3 is 5D573 DEA6A 2 DAVIS 155i.:. CD .. .. 50556 EEC:. Sc DAIS iPE.45 DD e^:AT ME DEEU a WKME: 22211E SC :1 Ali 5O52c ADII)A RODRIGUEZ (41.32 DO C6124l22 i5G25 LEA+. iESE.l'DEZ 547.95 OD Dil[;/22 5510E CRYSYAL M CILWIEZ 694. i. OD ail2;122 i5127 A?S:L T 3:CS= 2914. 6: c5392 SHAMIO!i.:ACI' C L09.93 DD IPZ4122 5i .i _L'U1I 'A:L'f_ 7t E.?2 _D: ..... _ 565IC RIIA L eO1EY537 904.57 DO 06i24122 :. - 60M SORA OVALLS L.?C CD Cyr 24 2i 60L': Xic, A:IA. DUKE CD 5a165 :EEESA A EE"iiED MAT DD :c 24T 60211 EESEi:A9 GrpY:{ E5E.97 DO oii 2; /22 i06ii DESCRY A LOECASIA 69o.70 DE 05/2;122 iG91; COFSPELO WMA i6;.35 DO ,W4/22 i312; SA2s 4S R vi::A MEN :. :12; 22 i32?9 JAEN .R'JS:0 i40.40 ID 36i21P.1:2 ES1D0 EEL:C:?A EXTD2 Wli . i5:21 ' MANA.. A.I:IA ?75.02 . CER4... 95:117 ELiIICAEOSA PILURREEAL 559.74 DO 65i5: EL:A T_i:3IA SE50 DD Will, 65213 LEE SIRERLY M2. iS DD 06lAM i5366 CYNMA. GAFM 6G2X OC Oi hni i5353 %E L; A . EEEC ... i _ ... 24W 65455 AN- L °LO. S 5;6.Si OC ".S::;122 :54E? 9P.i:A : 17402 Ei9.K Gs24!:: 65-4!: RCSA E0D'_G'22 ..:.42 On .. IA: 65512 RA.RIA fYJR;LS 9?5.60 DO 2v'/2;1i2 55705 EOMMU HERBER; 952.2i DO GEr24/22 :SiE5 X:R:A i L-MUA 676.:3 OD :6 24/22 Si.,E? :SYS.A.: Av:iisnz MA D2 MCI i8?i: D:Y.::I:;; GAR... r.7.75 DD WWI ii563 C3 ciO2EEe 4UC4S?EOR) 914.E4 DD a6l20.12 537 i2 NAZWI2 D:.: .._9`U`SE iE AE CC ....... 7a129 sAA N ELEDSD: 2113.62 ON o6i24' 2 ... ......d !: g--' 2557.7: .. .E12; l:: Eon My TIES ~ HN — � :' m j!. . e . m _— . » _ :: ». — « _ «m = « \/ S : / } m _e . s c! = m — � : s wz = m w, _ , URCIA e: ; m m «_� e! , « w:: . « _ _ m _ _F , se = a w.w= az =gym= -S , , » m se Doa — a_; a; _ m _.mm mm s « a=. : a ea = « • 3�IE / APE jESSIM_ EWER ca = 6qata a6 MELESS4.GEE c: _ « MELne: au =0 u — », az =,! WI ~~ = / \ 2 ~ EM : U25AT / \ o:XMINH c az = m 82217 XM_A MENGIR m* s a _ _._. 749.74 _. q . mr e a« _ m . e. me . = wa = m MMIUMNEZ , s :sue P. \M � / /% \ \ ME AMMx , ae M 02454 : a 941 RECITAX DEPOSIT FOR MIMIC PAYROLL "F PAY PERIOD: BEGIN 613/2022 y2 PAY PERIOD: END 571612022 PAY DATE: 6124120t2 GROSS PAY: $ 544,733.70 DEDUCTIONS: AIR S 435.94 ADVANC BOOTS SUNLIFE CRITICAL ILLNESS S 849.63 SUNLIFE ACCIDENT $ 760.28 SUNLIFE VISION SUNLIFE SHORT TERM DIS S 1,261.68 BCBS VISION 5 989.86 CAFE-D S 1.659.76 CAFE-H S 22,206.15 S • S CAFE.P CANCER CHILD S 2,281.01 CLINIC S 1SS.00 COMBIN $ 306,09 CREDUN S DENTAL S DEP.LF SUNLIFE TERM LIFE S 861.71 SUNLIFE HOSP INDEM S 537.74 FED TAX $ 48,316.79 FICA-M S 7,439.68 FICAO S 31.811.20 FIRST C S - FLEX S S 3,382.90 FLX-FE S GIFT S $ 219.23 GRP-IN GTL HOSP-I LEGAL $ 977.44 OTHER S 303.10 NATIONAL FARM LIFE S 1,864.02 MED SURCHARGE $ 385.00 PR FIN S - RELAY REPAY STONEOF $ 940.85. STONE STONE 2 STUDEN TSAR 5 38,131.42 UWIHOS S TOTAL DEDUCTIONS: S 166,65$.48 S -wlowerM*reRe'ant NET PAY: i 379078.22 S -PpWn MATtlteaoer" TOTAL CAFE 125 PLAN: $ 31,650.11 S - S e.laaewlcBRrra6r-S 5 S AXABLE PAY: $ 513,083.69 S 913.083. 99 "CALCULATED" From Mac Reoon Difference ICA- MED(ER) ,nsw S 7.439.71 ICA- MED(EE) tsu S 7.439.71 S 7,439.68 S 0.0: ICA -SOC SEC (ER) em. S 31,811.18 ICA - SOC SEC (EE) e2a. S 31.811.18 S 31.811.20 $ (0.0: ED WITHHOLDING $ 48.316.79 S 48.316.79 S TAX OEPCBIT: S 126,818.55 126.818.67 6 FICA -MEDICARE 2. S 14,879.42 S14,879.36 FICA • SOCIAL SECURITY lzu% S 63,622.36 $63.622.40 PREPARED BY: FED WITHHOLDING $ 48,316.79 $48,316.79 PREPARED DATE: TOTAL TAX: S 126,618.57 $126,818.56 $ 0.02 S REVISED NI&7014 TOTALS $ 644.733.70 $ 436.94 S $ 849.63 5 760.28 5 1.261.60 S $99.86 S 1,669.76 S 22,205.15 S S - 5 - S $ 2,281.01 S 1SS.00 S 306.09 857.71 637.74 48,316.79 7,439.68 31.811.20 3,382.90 219.23 977.44 303.10 IA54.02 385.00 640.86 S 38,131.42 S - S 166,655.4E $ 379,078.22 Exempt Amt-. EmPloyeas over FICA -SS Cap: S - Payeode S - Employee Ralm6.: TOTAL: $ Caitlin Clevenger 6/182022 413 Rt MMC TAX 05POSIT WORKSHEET 616.22 R1 mn. TAX ,.1- �U 4 vL i CL. LLl n T d J� G CO O'm fl N Nj ON o uv w r j v .� 'IS CO r q r �. IN ++ N N N m N^ m C w N Qa N gP H dom^Glnomoim m.-iPe A'_N �0 TR ec e'{,'N m � pp.. n � GV Nib" m � o N s a� a 8 ppa, ZR cv cc cccccc .'J '� 5°'� N poi atQ O '6LL d9999 �?D9 L 6d.R2 YC 9y V_>Lw ��� �� 1V Yl 1 T U 6 rIl ll U U ll V U U U 6 M 6 M M 6 U M 6 V V V� M M r.l C �' r C ZZ g � 0 N - W - ON „\ W m P/s-I �y OOOOOOOO� .' �0 QOg �Immuwi �n .^°lo i°uic u w'N°oon$o,^omenmmNBmn. S 1` _ -:: co co ,gmnN umla moti mnmc gm a`�o1^-. .i°.. I'°.�M1 N N :.1 J1 _ 6II IQn� n"8��^.:m�rsiP mm. � cmi�o u o ••c � m� � I- V 8�iN m mmum^3T^mN �a ggo; SmS� 99g2�8 n n^� < > > O> cc¢y OOOyO < yC�N4ac�n O �iry Q•y N2'^sa � t;{? `II H W N N /LI N m N D P j O 2 N aNil y e Id I1 6 w O O O V OV11 0 0 0r C V 2 n 2< N O 2 y� O O xQ< �� C• �< t iJ 1- 6 6 C w� 2 W 9 ���_°�ay�d^c`z<i'mjN`C✓iNCYj'OLLoo°>>° � � n �K.lu 6 � inn _ rrf n?af eui'uFiAoo `<G �I W o � u uu.Ti uum�o �o l`c 2 E 3f 3i vri Transaction Summary Transaction Complete Trace #. " Texas Health and Human Services Commission Memorial Medical Center Operating County Payment Total 1 $_ 434.968.69 Bank Routing and Account Number Settlement Date 7/6/2022 DSRIP Amount $434,968.69 Entered By Marley Moehri Page No:1 of 1 Run Date: 6l1712022 Run Time: 13:12:32 Transaction Summary Trace Number: 000000006424718 has been deleted successfully. Texas Health and Human Services Commission Memorial Medical Center Operating County 746003411 Payment Total 1$428.172.31 Bank Roulina and Account Number 113122655 '."'4357 Settlement Date 7/6/2022 DSRIP Amount $428,172.31 Entered By Marley Moehri Page No: i of 1 Run Date: 6117/2022 Run Time: 13:10:52 Marlev ODonnell From: HHSC Texas Healthcare Transformation and Quality Improvement Program c TXHea IthcareTransformation@ hhsc.state.tx.us> Sent: Friday, June 17, 2022 1:05 PM To: Jason Anglin; dmoore@mmcportlavaca.com; Roshanda S. Thomas; MarleyoDonnell; czafereo@cmcvtx.org; duane.woods@cmcvtx.org; pstrauss@cmcvtx.org; dherolt@cmcvtx.org; mike.olson@cmcvtx.org; skennedy@vcb.org; CFO - Beatriz Trejo - 102595; mariluna@ttbh.org; plopez@ttbh.org;jonny.hipp@chdcc.org Cc: HHSC PFD DSRIP Payments; HHSC Texas Healthcare Transformation and Quality Improvement Program; Jason Anglin; cbrzozowski@cmcvbe.org; pstrauss@cmcvtx.org; dherolt@cmcvtx.org; Duane.Woods@cmcvtx.org; Cynthia.Martinez2@dchstx.org; eric.hamon@dchstx.org; Michelle Ramirez; steve.king@dchstx.org; mtaylor@ttbh.org; setexasrhp@harrishealth.org; Victoria.Nikitln@harrishealth.org; Michael.Norby@harrishealth.org; Sarah_schauman@premierinc.com;jamie_marsh- wheeler@premierinc.com; Kristoffer_Hammarstrom@premierinc.com; joseph.dygert@harrishealth,org; amanda.callaway@harrishealth.org; kevin.lin@harrishealth.org; Catie Hilbelink; donna.littlefield@nchdcc.org; Belinda Chism; Linda Wertz; Jonny Hipp; eddie.olivarez@hchd.org; DAIREN SARMIENTO; Lourdes Acevedo Subject: UPDATE to DSRIP DY11 IGT Notification Attachments: Affiliation Summary 06,17.22.xlsx; IGT Summary 06.17.22.xlsx WAI I-NINIG-Remote attachments, VERIFY SENDER organization. Do not click links or open attachments unless you Good Afternoon IGT Entities Nueces County Hospital District LPPF, Calhoun County dba Memorial Medical Center, Citizens Medical Center, and Tropical Texas Behavioral Health, We identified errors in the DSRIP Category C achievement that impacted DSRIP payments and IGT. The IGT for the following were updated and included in the attached updated files. Please let us know if you have any questions and we apologize for the error, RHP IGT Entity Provider TPI Provider Name Updated IGT Due Reasons for Changes 4 Nueces County 132812205 Driscoll Children's $9,817,344.67 Provider notified HHSC that Hospital District Hospital D3-333 was incorrectly LPPF reported. D3-333 AM-50.1 was changed to NMI. Previous IGT due was $9,985,428.68 3 Calhoun County 137909111 Memorial Medical $434,968.69 CI-147 AM-10.1 was dba Memorial Center incorrectly calculated so Medical Center achievement changed from 75%to 100%. Previous IGT due was $428,172.31 4 Citizens Medical 137907508 County of Victoria $1,448,973.90 C1-147 AM-9.1 and AM-10.1 Center dba Citizens were incorrectly calculated so Medical Center both changed from 75%to 100% achievement. Previous IGT due was $1,408,203.04 5 Tropical Texas 138708601 Tropical Texas $8,287,126.21 Mi-211 AM-10.3 was Behavioral Behavioral Health incorrectly calculated so Health achievement changed from 75%to 100%. Previous IGT due was $9,261,389.79 Thank you, Linda Huynh Healthcare Transformation Waiver HHS Medicaid and CHIP Services From: HHSC PFD DSRIP Payments <PFD_DSRIP_Payments@hhs.texas.gov> Sent: Thursday, June 16, 2022 8:15 AM Subject: DSRIP DY11 IGT Notification Importance: High Anchors/Government Entities/Providers: Please carefully review this message in its entirety making note of the information provided which pertains to the DY11 Delivery System Reform Incentive Payments (DSRIP) Attached are the following files: DSRIP Notification- DY11 Round 1 July 2022 Affiliation Summary and DY11 Round 1 July 2022 IGT Summary workbooks. These workbooks include DY10 and DY9 DSRIP payments. The DY11 Round 1 July 2022 Affiliation Summary workbook has separate tabs for each Regional Healthcare Partnership (RHP) and contains the Intergovernmental Transfer (IGT) needed, by affiliation, for DY10 and DY9 Round 1 DSRIP payments. The DY11 Round 1 July 2022 IGT Summary workbook has separate tabs for each RHP and contains the total IGT needed by each IGT Entity for DY10 and DY9 Round 1 DSRIP payments, Providers can determine their estimated payment amount by dividing Column M of the DY11 Round 1 July 2022 Affiliation Summary by the state share of the current FMAR The current FMAP is 67.000/0/33.00%. The Transformation Waiver Team will email the Anchors information to share with providers regarding how much will be paid by Category and measure on Friday, June 17, 2022. Health and Human Services Commission (HHSC) Provider Finance Department is unable to answer questions regarding this information. Please send any questions regarding this information to T)(FI ealthcareTransforrnationcmhhsc.state.tx_us HHSC requires that the appropriate TexNet bucket is used for DSRIP Reporting IGTs. The DSRIP Reporting IGT should be placed in DSRIP. IGT Entities may choose to IGT less than the required amount for DSRIP Reporting payments; however, all affiliated providers and metrics will be paid proportionately. IGT may not be directed towards specific providers, Categories, or metrics. A screen shot/.pdf of the confirmation/trace sheet or email of the confirmation number if the TexNet Is submitted over the phone is required and must be emalled to PFD DSRIP Payments(dhhs.texas.00v. We are requesting that all government entities enter their IGT transactions into TexNet no later than July Sth with a Settlement Date of July 6th. No IGT's submitted after July Sth will be accepted. HHSC Accounting will request the Comptroller to issue payments according to the following estimated schedule: Tuesday, July 05, 2022 Last date for Public entities to enter TexNet and submit Trace Sheet Wednesday, July 06, 2022 TexNet Sweeps (Settlement date of funds) Wednesday, July 20, 2022 Payment issue date for Transferring Hospitals "Big 6" Friday, July 29, 2022 Payment issue date for Non -Transferring Hospitals Information regarding TexNet Connect can be found at htti3s://comptroller.texas.gov/prooramsLsyste_ms/�h=1193. od f Thank you, HHSC Provider Finance Payments Texas Health and Human Services Commission North Austin Complex P.O. Box 149030, Mail Code H•400 4601 Guadalupe St Austin, TX 78751 CP � TEXAS 4 Health and Human 41 Services Confidential: This transmission is confidential and intended safely for the use of the individual ar entity to which it is addressed. if you receive th15 transmission in arrorplease notiry sender and remove all copies from your computer. Transaction Summary Transaction r'�— -*- Texas Health and Human Services Commission Memorial Medical Center Operating County Payment Total 1 $98,092.00 7/1/2022 Bank Routing and Account Number Settlement Date DSH Amount $98,092.00 Entered By Marley Moehrf Page No:1 of 1 Run Date: er1412022 Run Time:14:58:07 To: jgulihur@rchd.care; jsmith@medicalartshospital.org; diana.strupp@tenethealth.com; scarruth@obmc.org; brichards@oceanshealthcare.com; megan@pm-hs.com Cc: Hodges,Jandi (HHSQ; Quintanilla,Sarah (HHSQ; Guzman,Kenneth (HHSQ; HHSC PFD Uncompensated Care Tools; Wolfe,Megan (HHSQ; Michalik,Ed W (HHSQ; Grady,Victoria C (HHSQ; Cantu,Rene (HHSC); Regmi,Asha (HHSQ; Heinemann,David (HHSQ; Dovalina,Jose (HHSQ; Heinemann,David (HHSC); lacques,Robert (HHSQ; Brown,Adam (HHSQ; Rios,Mariana (HHSC); HHSC PFD DSH Payments Subject: DSH 2O22 Final Payment IGT Notification 2 of 4 Attachments: 2022 Final DSH Payment Calculation,xisx ARNING-Remote attachments, 'VERIFY SENDER know DSH Providers: outside of the organization. Do not click links or open attachments unless you The Texas Health and Human Services Commission (HHSC) Provider Finance Department is adopting a new communication process. As of September 1, 2022, stakeholder announcements will be sent via GovDelivery, a free email subscription service used by HHSC. To receive future GovDelivery announcements and IGT Notifications, click the following link and subscribe to the Disproportionate Share Hospitals (DSH) topic. (Click Here to Subscribe). Attached is the finalized 2022 Final Disproportionate Share Hospital (DSH) Payment Calculation Workbook. The DSH payments and intergovernmental transfer (IGT) amounts are based on the calculations in the Model Scenario Analysis (see tabs labeled " Non -State" and "State" for non -state-owned and state-owned hospitals respectively). Payment amounts/transfer amounts for state hospitals can be found in column V of the "State" tab. Payment amounts for non -state hospitals can be found in column AZ of the "Non -State" tab and the corresponding IGT amounts in column BE of the same tab. To ensure that all government entities receive this notification, HHSC strongly encourages providers to send this information to any government entity who is IGT'ing on their behalf. Below are the pertinent dates associated with the DSH Pass 1 and Pass 2 payment: • June 30, 2022 Last date to schedule transfer in TexNet July 1, 2022 Pass 1 and Pass 2 IGT Settlement Date • July 12, 2022 State Owned Hospitals submit Journal Entry • July 29, 2022 Latest DSH Pass 1 and Pass 2 Payment Date **Late IGTs will not be accepted. Pass 3 payment amounts cannot be calculated until HHSC is in receipt of the IGT for the Pass 1 and Pass 2 Payments. Please ensure you select the DSH bucket in TexNet when you enter your IGT. It is imperative that you send a screen shot/PDF copy of the confirmation/trace sheet from TexNet or an email with the confirmation number, settlement date and IGT amount if the TexNet is submitted over the phone, to DSHPavments@hhs.texas.rov. Additional information regarding the TexNet process is available here. State owned hospitals must send a copy of their Journal Entry to DSHPavments(thhs.texas.Kov. If you have questions regarding the DSH payment process, please send an email to DSHPayinents@hhs.texas.eov Thank you, HHSC Provider Finance Payments North Austin Complex Mail Code H-400 4601 Guadalupe St Austin, TX 78751 Texas Health and Human Services Commission 091 TEX.AS t; ; Health and Human Services Proposed Method for State -Owned Hospftals 5 Non -State Owned Urban Public Hospital Class t 3 Non -State Owned Urban Public Hospital Class 2 143 Non -State Owned All Other Hospitals Texas Health and Human Services Commission April 27, 2015 Texas Health and Human Services Commission April 27, 2015 322,149 949,083 738,597 1,060,746 68,467 372.408 130,776 199,243 1,455,348 7,259,446 1,846.349 3.301,697 Texas Health and Human Services Commission April 27, 2015 1.060,746 - 225,579,101 225.579,101 2,042,991.475 979,509,706 1,230,969.552 199,243 - 42,371,163 42.371,163 264,233,136 119,949.481 214,094,433 3,374.858 - 717,700,147 717.700.147 2.263,831,292 998,607,773 1,209,645,130 Texas Health and Human Services Commission April 27, 2015 76,934,514 1,966,056,961 225.579,101 - 1.740,477,859 23,877,632 2,685,041 261,548,095 42.371,163 - 219.178,932 3,006,890 106,430,940 2.157,400,351 670,415,688 47,284,480 1,488,984,683 20,399,957 Texas Health and Human Services Commission April 27, 2015 249,456,734 122,886.749 309.222,683 681,546,166 681.546,166 - 1,284.510,794 45,378,054 22.350,385. - 67,726,438 07.728,438 - 193,819,657 690,815,625 31,029,788 - 721,845,413 718,446.067 3.399,346 1,438,954,284 Texas Health and Human Services Commission April 27, 2015 IMD CHECK $20.102,034 1,496,767 683.042,934 - 493,933 501.900 433,085,266 1.283,014,027 249,957,668 225,847 67,954,285 - 74,530 - 22,424,914 193,593,810 45,529,371 1,676,731 720,122.799 (1,121.784) 51,422 - 29,959,426 1.437,277,552 690,163.373 Texas Health and Human Services Commission April 27, 2015 (5.109710J 452,860,883 293,778,300 - 452.860,883 230,182,051 40,636.711 13,410,114 - 40,636,711 27.317,574 439,476,497 16,114,407 - 439,476,497 280,646,302 549.851,244 Texas Health and Human Services Commission April 27, 2015 Variance: Final Veddtive,!FlnaflCiT 0,005pee $15,421,371.04 Recoupments Not Collected - 18.626,624 157,933,690 60,744,356 - - 9.014,800 Available Funds 3.205,253 - 13.845,019 $18,626,623.75 $180,793,408.79 $180,926,839.36 Texas Health and Human Services Commission April 27, 2015 Page 1 of I RECEIVED BY THE COUNTY AUDITOR ON 061J0216 2922 MEMORIAL MEDICAL CENTER AP Open Invoice List 0 12:04 ep_dpen_invoice.template CALHOUN COUNTY, TEXAS Dates Through: Vendor# Vendor Name Class Pay Code 11824 THE CRESCENT Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 060722 06/15/20 06/07/20 07/08/20 5,346.00 0.00 0.00 5,346.00 TRANSFER NItIhSUY4lU- pylVli dCpO.IFj Iki1 ryWlytt- orr.n Vendor Totals Number Name Gross Discou t No -Pay Net 11824 THECRESCENT 5,346.00 0.00 0.00 5,346.00 Report Summary Grand Totals: Gross Discount No -Pay Net 5,346.00 0.00 0.00 5,346.00 APPROVEDOM JUN 16 2022 CALHOUNCUCOUNTYW. ITOR file:///C:/Users/Itrevino/cpsi/memmed,cpsinet.com/u88125/data_5/tmp_cw5report395806... 6/ 16/2022 Page I of 1 COUNj� RY AUOROR ON AMA& MEMORIAL MEDICAL CENTER 2022 0 AP Open Invoice List r 12:02 �L 40UN COUN Dates Through: ap_opan_Invoice.lemplate yFy�� Vendor# Vendor NBYrIF!' Class Pay Cade 11836 GOLDENCREEK HEALTHCARE Invoice# Comment Tran Dt Inv Dt Due or Check D Pay Gross Discount No -Pay Net 060222A 06/15/20 06/02/20 07/08/20 2,772.96 0.00 0.00 2,772.96 TRANSFER NO k(www. puid l.4064,a 144 k LL 11KK1 ' 080322 06/15/20 06/03/20 07/08/20 44.08 0.00 U 0.00 44.08 1,/ TRANSFER 11 11 060822 06/15120 06/08/20 07108/20 20,937.70 0.00 0.00 20.937.70 L� TRANSFER it. It . 061422 06/15/20 06/14/20 07/08/20 6,204.12 0.00 0.00 6,204.12 MEDICARE REPAYMENT Vendor Totals Number Name Gross Discount No -Pay Net 11836 GOLDENCREEK HEALTHCARE 29,958.86 0.00 0.00 29,958.86 Report Summary Grand Totals: Gross Discount No -Pay Net 29,958.86 0.00 0.00 29,958.86 JUN 16 2022 Sy ALHOUN COUNTY �s file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.comhi88125/data_5/tmp_cw5report303515... 6/ 16/2022 Page 1 of 1 HKONIVED BY THE 60UNW AUDMOR ON JUN 16 2022 MEMORIAL MEDICAL CENTER 06/16/2022 0 Sa318OUNCOUNTY,,TEXAS AP Open Invoice List ap_open_involce.template Dates Through: Vendor# Vendor Name Class Pay Code 12696 GULF POINTE PLAZA Invoice# Comment Tran Dt Inv Dt Due Dt Check O Pay Gross Discount No -Pay Net 060222C 06/15/20 06/02/20 07/08/20 696.47 0.00 0.00 696,47 TRANSFER NH (VSUVkht.e P^j 6gXw i h cl y, iA MNAc_ �", `X 060222A 06/15/20 06/02/20 0 08/20 5,263.42 0.00 U 0.00 5,263.42---- TRANSFER It tr . 060222E 06/15/20 06/02/20 07108/20 2,520.00 0.00 0.00 2,520,00 TRANSFER N 11 Vendor Total: Number Name Gross Discount No -Pay Net 12690 GULF POINTE PLAZA 8,479.89 0.00 0.00 8,479.89 Report Summary Grand Totals: Gross Discount No -Pay Net 8,479.89 0.00 0.00 8,479.89 APPAOV60OM JUN 16 2022 BY COUNTY AUDITOR CALHOUN COUNTY, TEXAB file:///C:/Users/Itrevino/cpsi/memmed.cpsinet.com/u8 8125/data_5/tmp_cw5report417030... 6/ 16/2022 Page 1 of 1 RECEIVED BY THE COUNTY AUDITOR ON 2022 MEMORIAL MEDICAL CENTER 04%a26 0 AP Open Invoice List 12O CAIJiDUN COUNTY, TEXAS Dates Through: ap_open_invoice.template Vendor# Vendor Name Class Pay Cade 13004 TUSCANY VILLAGE Invoice# Comment Tran Dt Inv Dt Due Dt Check DPay Gross Discount No -Pay Net 0602228 06/15/20 06/02/20 07/08/20 7,463.00 0.00 0.00 7.463.00 y TRANSFER Nftjhsijvk tr- pdkf denoSaFrd ik-6 kwL Opu"t-+vl J 060222D 06/15/20 06/02/20 07/08/20 306.29 0.00 0.00 306.29 ✓ TRANSFER it It . 060222A 06/15/20 06/02/20 07/08/20 4,668.00 0.00 0.00 4,668.00 ✓ TRANSFER It it , 060222C 06/15/20 06/02/20 07/08/20 3,961.00 0.00 0.00 3,951.00 TRANSFER tt rt 0603223 08/15/20 06/03/20 07/08/20 86.82 0.00 0.00 86,82 TRANSFER tk i1 060322 06/15/2006/03/2007/08/20 1,092.00 0.00 0.00 1,092.00 TRANSFER t` 0 060322A 06/15/20 06/03/20 07/08/20 1,839.91 0.00 0.00 1.839.01 TRANSFER p I t 060822 06/15/20 06/08/20 07/08/20 389.00 0.00 0.00 389.00 TRANSFER [t if 061422 06/15/20 06/14/20 07/08/20 7.219.34 0.00 0.00 7,219.34 ✓ MEDICARE REPAYMENT Vendor TotalE Number Name Gross Discount No -Pay Net 13004 TUSCANY VILLAGE 27,015.36 0.00 0.00 27,015.36 Report Summary Grand Totals: Gross Discount No -Pay Net 27,015.36 0.00 0.00 27.015.38 JUN 16 2022 BY COUNTY AUDROR CALHOUN COUNTY, TEXAS file:///C:/Users/Itrevino/epsi/memmed.cpsinet.com/u8 81251data_5/tmp_cw5report547669... 6/16/2022 Page 1 of 1 RECEIVED BY THE COUNTY AUDITOR ON JUN 16 2022 MEMORIAL MEDICAL CENTER 06/16/2022 0 AP Open Invoice List 0ALHdl5ftOUNTY,TERAB ap_open_invoice.template Dates Through: Vendor# Vendor Name Class Pay Code 12792 BETHANY SENIOR LIVING Invoice8 Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 060622A 06/15/20 06/06/20 07/08/20 13,837.44 0.00 0.00 13,837A4 TRANSFER N } jNUK*.LL p' Rj jq0" taa 1HN milkL GP41" 060722 06/16/2006/07/2007108/20 30,962.26 0.00 0.c0 30,962.26 rj TRASFER j1 It , 060822 06/15/20 06/08/20 07/08/20 5,736.90 0.00 0.00 5,736.90 TRANSFER It 11 061422 06115120 06/14/20 07/08/20 148,871.60 0.00 0.00 148,871.60 MEDICARE REPAYMENT Vendor Total: Number Name Gross Discount No -Pay Net 12792 BETHANY SENIOR LIVING 199,408.20 0.00 0.00 199.408.20 Report Summary Grand Totals: Gross Discount No -Pay Net 199,408.20 0.00 0.00 199.408.20 JUN 16 2022 BY COUNTY AUDITOR CALHOUN COUNTY, TEXAS file:///C:/Users/ltrevino/cpsihnemmed. cpsinet.com/u88125/data_5/tmp_cw5reportl 855 59... 6/16/2022 Memorial Medical Center Nursing Home UPL Weekly Cantex transfer Prosperity Accounts 6/20/2022 Mrinn! wnxrMP Aw wnl.M uLnnW A,n.rTMwrr.nnxr.arl x.xTl xrmnL n9T. urTwr eunr y..nn..a3 ,mml.nrn w6na. 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IIIIm SJN 6d 5.2vi.l 6111IJ01t Y W..R1,MCC I( xf(YIM."90m, 11191x W 61 9l6} b)1)/NiI HYMRVR(HA OISBn((VIAIPM1390Y)1}W WMpI E 4261, 126.W 3/Iti/tpN NxB-IGq HC(UIMIMI MI(DY4Up¢V2MR5 (3930V 6/Mrro11 ' 1502195 9,59300 6/16:2011 MA4AO NMNIGNNONfipI6 1113 ]AINnyWp;Ry}1[• 11 0.45W 11 6i1lIlV)) Vn.IMNyIrruYIMCUIUPAI))1FD]Y111}UY 61135V 6, lass 0 3332M 5,133 30 • J,3116i u1u+o+} uxc cXMMuxnr Il xuwMlMl nIWJYI eJa® VIMIW+ UnilMxYllnore nfMIMIM) Mnmytl9lWV A/MI] xVMava Ml[(v M:<41MIMI I+tWIAlRmflSbv. b/l3/+p}} NVM3Mv frY DlfB NC(IAIMIMl l9CC6}330[f61M5 fifivion I3moov rnenla N[C4i wtci WM1t MYY 6{IY+U]t gg OXJ WII[R xf4iN (nRI CCNf[M III .1symn pplll Clll/Nll xX9 � IIrM Nf[l4MIMf )KMMII MO[W}fMls 6/IIRO}I Vn[COMMUMM1 fl Xff4NrIMJ I3W1M1{11WL y10.'I0+} Mann NC olA n<CLfIMeMi 9Nlb111IIf133ttr 6/Id:011 Moon NC 01 In 11CC 41MIMl IN l3f1{USS9 UIY f/IWM)] Ir II HMANMv1ANOXfl1IIHCW 9MxlWW)TTl]141C1 C/IX/IOIl UMf COMMV XIN11MI la6O]M II f10f(Q TOTALS �!M1N Artfx tevn4<rfl6nvVunnlevC NervYrev lr\+NIVuM!Inr xvnf 6n�NOJn C61 d}l lnn h.lf ]VJ}.Irr IMes I91% f.939W M Ib Y l9] VIV1 399% 153 % 5.9250 6916 Y19) >6.i91.5a L13)61 l.l]3X1 11569. )0 11.569.la 1120.1, 1,920.1a 11619i 6119153 Lll9M i67961 M. 63960 5.17999 16.)9)s9 umm ex sm." ]91.1113M 467,1115.95 169.91066 612Df2022 Quick View Select quick View Accounts Account Number / Name Account Type Account Number Number of Accounts: 14 '4454 MEMORIAL MEDICAL I NH GOLDEN CREEK HEALTHCARE '4365 MEMORIAL MEDICAL CENTER - CLINIC SERIES 2014 '4357 MEMORIAL MEDICAL CENTER - OPERATING '4373 MEMORIAL MEDICAL CENTER - PRIVATE WAIVER CLEARING '4361 MEMORIAL MEDICAL CENTER / NH ASHFORD '4403 MEMORIAL MEDICAL CENTER/NH BROADMOOR '4411 MEMORIAL MEDICAL CENTER/NH CRESCENT '4446 MEMORIAL MEDICAL CENTER/NH FORT BEND '4438 MEMORIAL MEDICAL CENTER / SOLERA AT WEST HOUSTON 'z996 MMC-MONEY MARKET FUND 5506 MMC -NH BETHANV SENIOR LIVING '5441 MMC -NH GULF POINTE PLAZA- MEDICAREIMEDICAID '5433 MMC -NH GULF POINTE PLAZA - PRIVATE PAY '3407 MMC -NH TUSCANY VILLAGE Treasury Center Select Group Groups Add Group Current Balance Available Balance $3,501,983.88 $3,614,279.23 5129,79471 5129, 790.71 https://prosperity.albanking,comlonlineMessonger Data roponed 3S of Jun 20, 2= is Collected Balance $3,501,983.88 5129,790.71 Prior Day Balance $3,252,839.88 $124.912.14 $536 40 5536.40 5536.40 5536.40 51,530,145.21 51,618,271.33 51,530,145.21 51,367,344.67 $431.82 5431,82 5431.82 $431.82 5207,464 99 5208,218.05 5207464.99 5182450,83 581,992:08 SB2.693.93 581,992.08 578,516.89 5126,941, 19 S126,941.19 $126,941,19 $102,581.19 570490.82 $77,202,14 570,490.82 569,393.31 5101.476.79 5113.39.5.29 5101,476.79 586,175.04 5760.479,01 5760,479.01 $760.479.01 $760.479.01 5201,385.77 $205.470.27 $201,385.77 5191,225.62 $43,360,52 $43,360.52 543.360.52 543.36052 $35,818.5. $35.818.56 535818.56 53376243 5211,670.01 5211.670.01 5211,670.01 5211.670.01 ` n,li�4les ,c Page yeiaalec mi OG�29201^ al F 1 ilt Memorial Medical Center Nursing Home UPL Weekly Nexion Transfer Prosperity Accounts 6/20/2022 vrlrw„ ASPPunt Blelnnlne ft Edit Today', BQ M., Amnum m Be Tr.f ntd 1, Munlry v Nw4ne Hame nmNr Balance nnf!ln0ut ,Tmnf2ervin Oa .ntt Mi... Home F'PG3 RSMM.. - 86.638.39 e9,9BP91 119,fifi1.00 139,M0.72 / 129,652,40 Bar4 Balmy 139.]9p.]IY Vuuntt leave ln6allntt UP= SUPetlmQIPPMrII rM Nnre 0nypvlanref e{owr 56,090willpl rmm{erndl=mrnursinpname N,rel: E.M. . . pvnpaknee P{5100 malhlM[drpafllyd fo aCen vvrvunt. JUN 2 0 2022 BYCOUNIYAUDrrOR CAALHOUN COUNTY, TTEW APRllalerert 17.66 M,Ylnbrert ]B.T9 � lunelnternt �eltr Adlutt Balana/rreMerAmr ]29.652.10 Y/ itn111A umR.6. Cr0 6/10/2022 t mn wrap u.m4opm uyt r,amm wmmmllP3rv.easM1 urlrremrer s,mm,�rro.raa,a,. 6/I]/]OII TSYSRRAH311PR BRO33lRR 5016M655U691) 9� 6/D/2022 NHO [CN31HCC41MPM3316W3411 WI}OS95 611W}022 NNR l ECNONCC W MPMI N60J34I1"M212)96 b/16/}02} MNSfTREMEN153R910E{103SIMllM169)905 6/I5IM2 T5Y5/IRAHSIIRST9nCD3TIM354JWW9269129 61:11202: CR 10 b/3R03WIREOMNERIOH HEALTH AT GMUM CREEK 4/IN}02 Depa�il /10(IO2I iSYH3PGN311R5T6xCOfi1MT N36Lt5539169p9 6210/20}! NNB-CCHOtICCUIMPPR 29600J{tl MG%0}HJ90 MMCpow.m g1P1/4mp6 j3JIUlJC.gy/ TnnlImin pIIP/fsmpl glpp/4mpJ qIM/4mp fbpv gIMR XN PORf10N %Mow 1,91000 }.996.5} 1,90.5I kmn 1474n 11990 6fo 90 4,800.00 4mm 5.2%.90 5)%W Y,}13 {3 IKJX6 1 102.162.I0 n99.E0 199.61 107,1013, 691 W 299" 61.1n9D! 119.6}LN/ L9{1.$T L11U9 12LI9e.12 6120/2022 Quick View Select Quick View Accounts Account Number / Name Account Type Treasury Center Select Group Groups Aod Group as of Jun 20, 2022 8 Account Number Current Balance Available Balance Collected Balance Prior Day Balance Number of Accounts: 14 $3,501,983.98 $3,614.279.23 $3,501,983.88 53,252,839.68 '4454 MEMORIAL MEDICAL I NH GOLDEN CREEK $129,790.71 ✓' S129790,71 5129.790.71 5124,912.14 HEALTHCARE '4365 MEMORIAL MEDICAL CENTER - CLINIC SERIES $536.40 S536.40 $536.40 $536.40 2014 '4357 MEMORIAL MEDICAL 51,530,145.21 $1.018,271.33 51,530,145.21 $1,367.344.67 CENTER -OPERATING '4373 MEMORIAL MEDICAL CENTER -PRIVATE $431.82 $431.82 5431.82 5431.82 WAIVER CLEARING '4381 MEMORIAL MEDICAL 5207.464.99 $208,218.05 $207.464.99 5182,450.63 CENTER! NH ASHFORD '4403 MEMORIAL MEDICAL CENTER/NH S81 a92.08 $82.693.93 581.992.08 578,516.89 BROADMOOR '4411 MEMORIAL MEDICAL $126.941.19 5126.941.19 5126.941.19 $102,581.19 CENTER/NH CRESCENT '4446 MEMORIAL MEDICAL $70,490.82 S77 202.14 570,490.82 569,393.31 CENTER / 14H FORT BEND '4438 MEMORIAL MEDICAL CENTER /SOLERA AT 5101,476.79 5113,395.29 5101,476.79 $86,175.04 WEST HOUSTON '2998 MMC-MONEY MARKET $760.479.01 $760,479.01 $760,479.01 $760,479.01 FUND 'S506 MMC -NH BETHANY 5201,385.77 $205,470,27 $201.385.77 $191,225.62 SENIOR LIVING '5441 MMC -NH GULF POINTE PLAZA- AZA 543,36D.52 543.360.52 543,360.52 543,360.52 ME0ICARE/MEDICAID '5433 MMC -NH GULF POINTE PLAZA -PRIVATE PAY 535.818.56 $35.818.56 535,818.56 S33,762.43 '3407 NIMC -NH TUSCANY VILLAGE $211,670.01 5211,670.01 5211,670.01 $211.670.01 hllpe://prosperity.olbanking.com/online Messenger nd,,alos rr Page gene13m3 on Ofi121)2022 m F r 1/i Memorial Medical Center nursing Home LIPI. Weekly HMG Transfer Prosperity Accounts 6120/2022 Pr.rlw. Y ..,m a. Mwunl uFnro, wnGns rnnn.nmN xur 1610n t .—Rov, 41.nn r/oN rrw.m.ln iO.Cli.nd co a. rm vae In ulq[ xv .— PuK51.N91iw•elirifih/.`I ,,. 31.f61M 3}AY. n9 ).J11 54.5155. 19.71Z.66 9an4xalanee 35,M5)G ✓ lean n'blanfn low XurW�Xam. ,.,.I GdfhfiitaRW'yl/janlMi�W, fubmnr OPP A,od IW.d 1. Snhn Apollnbmt ]36✓ Mrylnbml 1.93 Iun.InNnn ♦dlwlalanaa/rnroNlMl f1>t2M V Pr.Hau. N ohmol'. Mwunl a.(Innln( / h.Nt inglelMte �"" Nbme /hrmOnnm TfaalfLrJn Dilkand Ue ul. Tm. f5e 1M 61bne X X.me J1.9413J 31J)S SV iJ,a09'I - gAWS. t9.lop.99 Ym fflanN 33,J609} Vatwff LNn m Bala... low rynN: plot W'onfn NUN1: [nNanerhoo c f.eb NwRnb.rIw.W.J hot MHC dde000lMM1 tocoon .from. JUN 2 0 2022 BY COUNTY AUDITOR CAWOUN COUNTY, T Wr, npol lnnna 'As Mrylnur..l 11.11 IurxLmn. MjwtftlwN/InnllMMnt b5.1N.f91/ ToIm.Mor.l., 11.953R4' 1/ 1PmavN' �s"C.. WIIWMLIr14[6p 2 blSolfoi} l I:N.I N'Mlr rumlenWn ml rrmNn S.mmaxl)o}}VunWM Vh}nnMnfummarym.{OR.tlr. a l`y J Gii 6/17/2022 HUMANA INS CO HCCLAIMPMT 614982830000540693 6/17/2022 HUMANA CHA OIS9 HCCIAIMPMT 5249324200001603 6/25/2022 HN9• ECHO HCCIAIMPMT 74M1411 AP00W243782 6114110ZZ HNS - ECHO HCCIAIMPMT 74WJ411 UQMZ119SS 6/14/2022 HUMANA INS CO HCCIAIMPMT 624982830p00515250 6/14/2022 HUMANA INS CO HCCLAIMPMT 624932 83WIOS14203 6/14/20ZZ HUMANA INS CO HCCIAIMPMT 624982 B90000516686 6/14/2022 HUMANA CHA DISS HCCLAIMPMT 62496242U0001324 6/23/2022 CK 108E 6/13/2022 CKZ083 6/13/2022 WIRE OUT HMO SERVICES, LLC 61131ZO22 Deposit �t �(Wta>sddiNii 6/2022 Deport 6/25/5/2013 MERCHANT BANKCO DEPOSIT 4964785188899100001 6/13/2022 WIRE OUT HMO SERVICES, LLC 6/13/2022 MERCHANT PANKCO DEPOSIT 4964795188399200001 MARC PORTION gIPP/CPmP glpP/C4mP4 Tr6ANes93P1 Tramfer,In gIPP/Camel 2 gIPP/COmP3 Sts 30 QjPPTI NNPORTION 909.72 - 909.72 1.146.41 1.1,164. 156.82 - iS6.92 919.86 91986 670.35 - 610.15 149.73 ]45.]3 2.230.W - 2122000 19.723.72 - 19.72372 1.137.81 , IU33.93 - 15,986.15 4,310A5 - 9122005 33.2SL89 35.A3,66 35.]II.66 MMC P00.TgN gIPP/COmP gIPP/CPmP4 Tr40sim-001 Trsnslu-m gIPP/CwP1 1 q]PP/COmP3 Elapse QIPPTI NN PORTION U.93019 34,930.59 4,950,00 - 4,950.00 31,935.50 L36G.d0 3,360.00 8L635.50 4334059 93„T10.S9 64A93.39 78.11SUS 78.95129 612012022 Quick View Select Quick View Accounts Account Number I Name Account Type IF Soamh All Account Number Number of Accounts: 14 '4454 MEMORIAL MEDICAL / NH GOLDEN CREEK HEALTHCARE '4365 MEMORIAL MEDICAL CENTER - CLINIC SERIES 2014 '43.57 MEMORIAL MEDICAL CENTER -OPERATING '4373 MEMORIAL MEDICAL CENTER - PRIVATE WAIVER CLEARING '4381 MEMORIAL MEDICAL CENTER/NH ASHFORD '4403 MEMORIAL MEDICAL CENTERINH BROADMOOR '4411 MEMORIAL MEDICAL CENTER I NH CRESCENT '4446 MEMORIAL MEDICAL CENTER/NH FORT BEND '4438 MEMORIAL MEDICAL CENTER / SOLERA AT WEST HOUSTON '2998 MMC -MONEY MARKET FUND '5506 MMC •NH BETHANY SENIOR LIVING '5441 MMC -NH GULF POINTE PLAZA- MEDICAREIMEDICAID '543 MMC -NH GULF POINTE PLAZA - PRIVATE PAY •3407 MMC -NH TUSCANY VILLAGE httPs:/IPTOSPatity.olbanking.com/onlinaMessenger Treasury Center Select Group Groups Aittl Grtri1p Data Current Balance Available Balance Collected Balance $3,501,983.ea $3,614,279.23 S3,501,983.88 5129,790.71 S129190.71 S129,790.71 as of Jun 20, 2022 Prior Day Balance S3,252,839.88 S124,912.14 $536.40 S536.40 S536.40 S536.40 S1830,145.21 $1.618.271.33 $1,530,145.21 S1,367,344.67 S431.82 S431.82 $431.82 S431.82 S207.464.99 S208.218.05 S207,464.99 S182.450.83 $81,992.08 S82.693.93 S81,992.08 S78,516.89 5126.941,19 $126.941.19 S126,941.19 $102,581,19 $70,490.82 $77.20214 $70490.82 S69,303.31 S101,47679 S113,39&29 $101,476.79 S86,175.04 S760A79.01 S760479.01 S760479.01 S760,479.01 S201,385.77 S205A70.27 S201,385.77 S191,225.62 $43,350.52 S43,360.52 S43360.52 S43360.52 S35818.56 $35.818.56 $35.818.56 S33,762.43 S211.670.01 $211,670.01 $211.670.01 $211,670.01 ' ndicafcv,c Page yeecratao en 06120,20, 22 at 8 V Memorial Medical Center Nursing Home UPL Weekly Tuscany Transfer Prosperity Accounts 6/20/2022 vnneur ewltn e. 4caw1 M3MIq bendiq Tr nl4mdtb NunMt Nbmr '•••W 41mt� TnmltnOul tnm4nln [yrtlu tl er aAr T 10e NN GrNmr Nun' Nbnr TtlltldyynlMe b)Aaa l6 1l.lSS II Ibi,9)41< t11.6tbG1 /193,436.34 &nl Nbnn 211.6NGIV Vanan[e Nae Q'JybAentn bJbw+$S.CPow.11 br nam/nnllotMnminp bane. Nani:farnarcbwebW a Eanbbknng400lIw MafCdevomNlaopen arcmm APPROVED ON JUN 2 0 2022 By CALHOUN COUP EMS tree lnedmn INN MWNNWPP O'S 9•e1G91 Wo MGaK QIM uIS 14sar'. tllwt4hn[eRnntlnaml i WIIWMIIt11F•OG r, MMCPORTION gIPP/Comp QIPP/Camp gIPP/Comp Tnm/ei43a1 TmnsEesr-In i gIPP/Comp2 3 46Upse QIPP TI NH PORTION 6/1612D22 Deposit 29,078.66 - 29.078.66 6/13/2022 WIRE OUT ON6AR ENTERPRISES, LLC 38.855.11 - 6/13/2022 Deposit - 143,056.84 - 143.856.84 6/13/1022 HN6•ECHO HCCUMMPMT 746003411"0000265049 - 1,525.04 - 1,525.04 6/10/2022 KS PLAN AOMINIST HCCLAIMPMT 179113000028241 - 5.155.00 - 5,155.00 6/10/2022 NOVITAS SOLUTION HCCU4IMPMT 67670142OOOOI42 - 3,820.80 - 3,820.80 / 38,1155.11 383,436.34 183,439.34 &20i2022 Quick View Select Quick View Accounts Account Number,' Name Account Type Treasury Center Select Group Groups Adtl Group Account Number Current Balance Available Balance Number of Accounts: 14 $3,501.983.86 $3,614,279,23 '4454 MEMORIAL MEDICAL 1 $129,790.71 5129.790.71 NH GOLDEN CREEK HEALTHCARE '4366 MEMORIAL MEDICAL 5536.40 S536.40 CENTER - CLINIC SERIES 2014 '4357 MEMORIAL MEDICAL $1.530,145.21 S1,618,271,33 CENTER 'OPERATING '4373 MEMORIAL MEDICAL S431.82 $431.82 CENTER - PRIVATE WAIVER CLEARING '4381 MEMORIAL MEDICAL S207.464.99 S208,218.05 CENTER I NH ASHFORD 3AU MEMORIAL MEDICAL CENTER lNH $81,992.08 S82.693.93 BROADMOOR '4411 MEMORIAL MEDICAL $126.941.19 S126.941,19 CENTER I NH CRESCENT '4446 MEMORIAL MEDICAL $70.490.82 S77,202.14 CENTER I NH FORT BEND '4438 MEMORIAL MEDICAL CENTER! SOLERA AT S101 476.79 $113.395.29 WEST HOUSTON '2998 MMC -MONEY MARKET S760,479.01 S760,479.01 FUND am MMC -NH BETHANY 5201.385,77 S205A7027 SENIOR LIVING '5441 MMC -NH GULF POINTE PLAZA- S43,360.52 543.360.52 MEDICAREJAEDICAID '5433 MMC -NH GULF POINTE $36 818.56 $35.818.56 PLAZA - PRIVATE PAY '3407 61MC -NH TUSCANY S211,670.01 $211,670.01 VILLAGE hltps a/prosperity.oibanking. com/online M essenger Collected Balance $3,501,983.68 S129.790.71 is of hm 20, 2022 a" Prior Day Balance $3.252,839.88 $124.912.14 S536.40 S536.40 S1,530,145.21 $1,367344,67 S431.82 S431.82 S207,464 99 S182,450.83 S81,992.08 S78,516.89 S126,941-19 S102.581-t9 $70A90.82 S69.393.31 S101,476.79 S86,175.04 $760.479,01 S760.479.01 S201.385.77 S191225.62 S43.360.52 S43 360.52 $35,618.56 S33762A3 S211,670.01 S211,670.01 • mdirales n page 75n2ruIG•n un t7¢20�a02: a. A W Memorial Medical Center Nursing Home UPL Weekly HSLTransfer Prosperity Accounts 6/20/2022 vr..m. u<perl usmlNnr NUNn. Nome ••. -�•• MYrx. N1fYlry}M(MIIIXk tl1 a41 e6 WNwOINf:,to NMpbrcnwttnrlohfGmua 6 bwetc,ofs1 w rhtm MtoMcenrwpwnnNeNhvn1. m open uvwm APPROVED ON JUN 2 0 2022 BY COUNTY AUDITOR CA LHOUN COUNW. TEXAS VeMll:b Metlkan I1mWn11aN vmMmdlo Brnl &nn[e vnwue U.rr m L4na rlplNtntll 11A9 ✓� Mrylnuml � pel5 NMrnnmt ael.nouneertnn IUMIg. ---T ptW�Y � / WIL YfRf.60 e/le/t011 is\NU W.Mh Irmarn\MMUII1-1m Sum munno..Wll Un no.wsvmnN m toll Jn NAIVE •" �F ^I` y LLPL'011 Tmaifflu @N/G 3 DIPP GmPl QINIGIq) @N(GM 16P1! CRIPTI NIS IORMON 6/V/301l NOVITAS -SOLUTION NCOUNAPMT 6]4D111O]W 106 @,LW IS KIND Is6(16/MSS DE mml M,2@b.I1 3,166.I1 6/16/202E DN3Nt - I1A365@ 13,I96.S6 6115(1011 AS @131MVJI50 35119 WIREMOVI OUT K'MANY SMORMP LIVING, 61111ID11 WIRE OUT B(LNANY SEMgR IIVING ITP Dl.])LSI 611111011 D1Wm I11D13.95 p 6/Ilp022 11A15 31.015.0 011)/Alt EMMA )I.%@.11 6]IO/AR DRAMA 2,25". 6110/A,MMU ]TUQLAO 17,32130 6/l0Al2 NWITDSNUM104HCCUIMPMTV609E{W5q / I0]m @L1111 mLM1@) 6/2012022 Treasury Center Quick View Select Quick View Accounts Select Group Account Number/Name Groups )1Ud Grnup Account Type Search F All DDA D8t2reported aS of Jw r 20, 2U22 8 Account Number Current Balance Available Balance Collected Balance Prior Day Balance Number of Accounts: 14 $3.501,983.88 $3.614,279.23 $3,501,983.88 $3,262,839.88 •4454 MEMORIAL MEDICAL NH GOLDEN CREEK 5129.790.71 $129.790.71 S129,790.71 $124.912.14 HEALTHCARE '4365 MEMORIAL MEDICAL 5535.40 $536,40 $536.40 $536.40 CENTER. CLINIC SERIES 2014 '4357 MEMORIAL MEDICAL $1,530,145,21 51,618271.33 $1,530,146.21 $1,367.344,67 CENTER - OPERATING '4373 MEMORIAL MEDICAL S-31.82 5431.82 5431.82 $431.82 CENTER - PRIVATE WAIVER CLEARING '4381 MEMORIAL MEDICAL 5207,464.99 5208218.05 5207.464.99 5182,450.83 CENTER/NH ASHFORD '4403 MEMORIAL MEDICAL CENTER I14H 581.992.08 582.693.93 581.992.08 578.516.89 BROADMOOR •4a 11 MEMORIAL MEDICAL 5126,941. 19 $126,941.19 $126,941.19 $102,581.19 CENTER/NH CRESCENT '4446 MEMORIAL MEDICAL 570,490.82 $77,202.14 570,490.82 S69,393.31 CENTER/NH FORT SEND '4438 MEMORIAL MEDICAL CENTER I SOLERA AT 5101 .476.79 5113.395.29 S101A76.79 586,175.04 WEST HOUSTON '2998 MMC -MONEY MARKET $760,479.01 S760A79.01 $760,479.01 5760,479.01 FUND '5506 MMC-NH BETHANY $201.385.77 S205A70.27 $201,385.77 5191225.62 SENIOR LIVING '5441 MPAC -NH GULF POINTE PLAZA. 543260.52 $43,360.52 543.360.52 $43,360.52 MEDICAREIMEDICAID '5433 MMC •NH GULF POINTE $35,81856 535,818,56 535,818.56 533.762.43 PLAZA .PRIVATE PAY '3407 MMC -NH TUSCANY 5211.670,01 5211.670.01 $211.670.01 5211,670.01 VILLAGE https://prosperity.olbanking,comronline Messenger Pai,1e germrateo on 06126202: at A 111 a O U U U V� U W to In U U U In U U U U W W W W W W W W W W W W P P P P P P P P P P P P P P P P O O O O O O O O O O O O O O O O xn xn xn n n xn xn xxn xn xn l9 y am m x x ac �c �c �c ac ac ac ac >c ac �o c mA 3 m m Ar r r Ar Ar Ar Ar ,br r ,br Ex A O x3 A A p m p m p O 0 O b O C) O") En En En En En En En En En Aw m ov z z a Doz> a� n� na Do D° rma � m" m�' D mZ [_" r r y ry ry ry ry ry ry ry ry ry 'b C o a a n n n �i n °x y w z a a a z Co J J J P w P P P P P P P P A w P P P P P P P P P P M CO U U U y U U A A A W W N Oa W O A A N O O O �D c0 J A J O ym m C9 > b>[p rom rop7 bm rom ro[9 mrom b m 07 r r yoro r r y Ar�7 �r Dr Dvry Dr ;a Or ar �r r "3n n Z yn a -Al CC)) -Aln An -Ain AO AO O O O yo rT,3 $ �3 jA ry`n3 �A� K y3 S 3 3 ya a a o co> c9a c�a q� 9a a ya cc> c�a a a Z z rL C e b z ro Z ro b Z ro z ro Z z ro z b z Z Z y y y ro r-i r-i r ry ry ry �y ry ry y y y N do J y J U �p J W N r N V U W J mrz w+�i .mm nn C r m y y x H y W A N W N W N CO J Oa W W P N P W P J D9 O P O W A p J U A �G J Oa O w b b Ey Ey < o. m m� z a � a a O O e o � 0 0 3 <CD O <CD O,m y m W m C) C) zzaz zzz ° non n�n ym0 o 'm0 ro ro .y OA °$ O AN U A.� O c tNA N N O O O ryn 0._ O O O O 00 00 jC v a -zi y3 y3 �o n y y Z Z n �n 3 y H H M c o e y 0 a w � n 0 0 y 0C yy Z y W D m m m > no r> a a p n C a a c r F O y m a m y 0 or Z w U y O C m n m m D yZy Z z N t�A N O O O V� U b O U O U A N O N tAn A A t'pi� A N O A O n p 2 n ..-m s -4 m m m m >00 m m zm a nm nr oO 0n c nM < A M m _'� z m m m m ZZ vv 'w Z n n ° n r L) n O a y a v a a e MD m m m O z m y x g Oz O O O m y n n n 'mj o Y Zii zO_ S z z R. 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