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2023-11-29 Final PacketNO-I-K.T OF MEETING—11/29/2023 November 29, 2023 MEETING MINUTES OF CALHOUN COUNTY COMMISSIONERS' COURT MET IN A REGULAR MEETING 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. THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Joel Behrens Gary Reese (ABSENT) Anna Goodman By: Kaddie Smith The subject matter of such meeting is as follows: 1. Call meeting to order. CountyJudge Commissioner Pct 1 Commissioner Pct 2 Commissioner Pct 3 Commissioner Pct 4 County Clerk Deputy Clerk Meeting was called to order at 10:00am 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. Candice Villarreal announced Erica Perez as the first assistant auditor. 5. Hear report from Memorial Medical Center. Roshanda Thomas gave the report for October, and announced Dr. Bunnell's retirement. Page 1 of 3 NO110E OF MEETING- 1.1/29%2023 6. Hear report from Calhoun County E911 regarding the Emergency Communications District's 2024 budget. Rachel Morales with E911 gave the report and explained that the population has decreased according to the Texas Demographic , Center's data. 7. Consider and take necessary action regarding the negotiated Customer Service Agreement with Republic Services for servicing Calhoun County Waste Management. (VLL) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese 8. Consider and take necessary action to authorize the Port O'Connor Community Center Board of Directors to enter into an agreement with Lauger Companies, Inc. for the Pavilion improvements. (GDR) Jim Copley with the Port O'Connor Community Center Board of Directors spoke on behalf of the board. Commissioners approved authorization upon the receipt of insurance. 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 lease agreement with Great American Financial Services for a Toshiba e-STUDI07518A copier and authorize the District Clerk to sign the agreement. (RHM) pass 10. Consider and take necessary action to declare the attached list of equipment from the District Clerk's Office as Waste. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 2 of 3 NOTICE OF MEETING— .11/29/2023 11. Consider and take necessary action to declare a 2011 GMC pickup VIN # 2GTP2WE29BG275578 from Precinct #1 R & B as Surplus/Salvage. (DEH) 12. 13. 14. Approve the minutes of the November 15, 2023 meeting. RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER:' Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner,,Hall, Lyssy, Behrens, Reese Consider and take necessary action on any necessary budget adjustments. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy; Behrens, Reese Approval of bills and payroll. (RHM) MMC Bills RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pet 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese County Bills RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Adjourned 10:40am Page 3 of 3 Rich2rd H. Meyer County judge David Hall, Commissioner, Precinct 1 Vern Lyssy, Commissioner, Precinct 2 Joel Behrens, Commissioner, Precinct 3 Gary Reese, Commissioner, Precinct 4 PACKET RECEIPT On r 2023 the i packet for the -� 2023 Commissioners' Court Regular Session was submitted from the Calhoun County Judge's office to the Calhoun County Clerk's Office. Calhoun County Clerk Deputy Page 1 of 1 CA LlH[®UN COUNTY C®MMISSIONS LDS' C®URT PACKET COMPLETION SHEET All Agenda Items Properly Numbered ✓ Contracts Completed and Signed All 1295's Flagged for Acceptance (number of 1295's —�—) All Documents for Clerk Signature Flagged (All documents needing to be attested to need to be signed day of Commissioner's Court.) On this Zg4k/ day of 7 � 2023, the packet for the Zq'Co day of 2023 Commissioners Court Regular Session was submitted from the Calhoun County Judge's office to the Calhoun County Clerk's Office. — &M�/ Calhoun County Judge/Assistant AGENDA Richard H. ReyeT County Judge David Hall, Commissioner, Precinct l Vern Lyssy, Commissioner, Precinct 2 ,Joel Behrens, Commissioner, Precinct 3 Crary Reese, Commmissioner, Precinct 4 NOTICE OF MEETING The Coammissioners' Court of Calhoun County, Texas will meet on Wednesday, Novenaher 29, 2023 at 1+0:00 a,m. in the Comumissiomers' Courtroom in the County CColarthouse at211 S. Ann Street, Suite 104, Port Lavaca, Calhoun County, Texas AGENDA The subject matter of such meeting is as follows; v� t-__PCtOr,K_ __di 'i, Ca'li meeting to order. �`4'nvocation. �. Fledges of Allegiance. NOV 2 2 2023 fiY;_ t 1 WOOL F, K General Discussion of Public Matters and Public Participation, 3, Hear report From Memorial Medical Center. 'S Hear report from Calhoun County E911 regarding the Emergency Communications District's 2024 budget. Consider and take necessary action regarding the negotiated Customer Service Agreement with Republic Services for servicing Calhoun County Waste Management. Consider and take necessary action to authorize the Port O'Connor Community Center Board of Directors to enter into an agreement with Lauger Companies, Inc. for the o�Pavilion improvements. (GDR) P"9. Consider and take necessary action to approve a lease agreement with Great American V Einancial Services for a Toshiba e-STUDI07518A copier and authorize the District Clerk to sign the agreement. (RHM) Page I of 2 lho. Consider and take necessary action to declare the attached list of equipment from the District Clerk's Office as Waste. (RHM) li. Consider and take necessary action to declare a 2011 GMC pickup ViN # �2GTP2WE29BG275578 from Precinct #1 R & B as Surplus/Salvage. (DEH) I2—. Approve the minutes of the November 15, 2023 meeting. 33, Consider and take necessary action on any necessary budget adjustments. (RHM) f4. Approval of bills and payroll. (RHM) a Richard H. Meyer, County J ge 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, Part iLavaca, Texas, which is readily accessible to the general public at all times. This 'Notices hall remain posted continuously for at least .32 hours preceding the scheduled meeting time. For your convenience, you mayvisit the county's website at wnv�+xr.¢ahltvwumr_mex.ana', under "Commissioners' Court Agenda" for any official court postings, Page 2 of 2 # 04 ' NOTICE.. OF MEETING — 11/29/2023 November 29, 2023 MEETING MINUTES OF CALHOUN COUNTY COMMISSIONERS' COURT MET IN A REGULAR MEETING 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. THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall Vern Lyssy Joel Behrens Gary Reese (ABSENT) Anna Goodman By: Kaddie Smith The subject matter of such meeting is as follows: 1. Call meeting to order. Countyludge Commissioner Pct 1 Commissioner Pct 2 Commissioner Pct 3 Commissioner Pct 4 County Clerk Deputy Clerk Meeting was called to order at 10:00am 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. Candice Villarreal announced Erica Perez as the first assistant auditor. Page 1 of 11 # 05 NOTICE OF MEETING— 11/29/2023 5. Hear report from Memorial Medical Center. Roshanda Thomas gave the report for October, and announced Dr. Bunnell's retirement. Page 2 of 11 wc NOTICE OF MEETING — 1.1/29/202:3 6. Hear report from Calhoun County E911 regarding the Emergency Communications District's 2024 budget. Rachel Morales with E911;gave the report and explained that the population has decreased according to the Texas Demographic Center's data. Page 3 of 11 /$ - ) (§} \ o;p ! /)§ � nE$ § } E �! (§ \ \ tv ( 000 \ �; \\\ §§§ \ \ `�■ \\2 ( \\\ 9 �,.. \$ � / § 000 000 W w w O a w� # 07 NOTICE OF MEETING-11/29/2023 7. Consider and take necessary action regarding the negotiated Customer Service Agreement with Republic Services for servicing Calhoun County Waste Management. (VLL) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy,, Behrens, Reese Page 4 of 11 Vern L Calhoun County Commissioner, Precinct #2 5812 FM 1090 Port Lavaca, TX 77979 November 16, 2023 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 next Commissioners' Court Agenda (361) 552-9656 Fax (361) 553-6664 • Consider and take necessary action regarding negotiated Customer Service Agreement with Republic Services for servicing the Calhoun County Waste Management. Sincerely, Vern Lyssy Commissioner, Pct. 2 VL/Ij OpaA ➢ 3 So 40.40 C 1 B Y S19LRp Y 6 VO 00 y/➢Y/Yb S i Y ppgCOWUNBP b ... V➢AY 9((pp➢0.Ub A AG 090.9 aaAa➢ 8{Sd:aQ 'a08VYCye A 81ag0.0. YaM1 Sib. S-31100 < IS 30:00 S B Y I19Hp1 I Y V aY 01 3f]]/18 7 Y ILY ax U)' ld, AYABa pL YYP. .0 t ].aa ➢9PYIC8 $C]}:90 BEAYSCB A'ylylPa _ _.;'Solo Sxsaa xawhaH y CMfAIpY& RBbbGTION $]<A.SO SW f0.00 Y P 9 I19LKp aX q Y b YO Vb ]/OS/]9 p ; LY 80XIA D➢➢ib➢NY pS➢ n MS_ CWYA09 3S�.6S NAe� gmm=TIaa 8 59.➢8 coo 8➢9YIC8 AITYMYS e BICYVD 88bYiC➢ $90{.3! ASgCAL - No MM M TliwYp6IWYp]M ]MbNMOIS, wWl MbRbiABm IIMSAHbwlflbXi WN ISASaM9S1 NO mMIMAMS➢MM F 3., lY]C•]BNIIWfll�lp A� v. t "v^� u3 q'g�.i: �( ��++ nP�a Awounis Manager J J _ �.. ...� Yaatmvao aa]rownrw`wrna`am+m'rTm""" atta nn SMBAND WNDINpNB. 0a019e Not IS oaak transport end d4wo of or 49 p(haImC11d1dbe1r1a0 bRa rcNOaAauoo}r YAul) ppgs(cawo'-waeo 6 . Laws. ENT SHALLSTART ON THE DATE ON WHICH SERVICE UNDER ITNUE FOR 36 MONTHS, THEREAFTER THIS AGREEMENT :ESSIVE 38 MONTH TERMS UNLESS ETY'NEA.PARTY GIVES OTHER AT LEAST SS DAYS SEFORE THE ENO OFTHE THEN ION UNDER THISAOREEMENTSYCUSTOMER SHALLSEVOID. /RN RECEIPT REOUESTEO,: AND ACTUALLY RECENED SY U trot OVUM mry hazallolr4 maloolal4, wa4fas oraWYafanee9; IOYk PdWknw,, Wocltmw w; melAwlwasteg;ormdW; wowratao b9 applNable lWoml. arolo ar l"iawa or r0ogolall" lmgwll vory; INIF1: DEFEND AND NOW HARMLESS CMPANYPSOM AND AS SUITS, PENALTIES, PINES, REM IVIATI NN, COSTS, APSD IIRASONABLE ATTORNEYS' FEES) by OF.EXCLUDED WASU IN THE WASTE MATERIALS. AMWIs VMW ipa Sm Wded Into CompaWS Irwk. Tab IS wd I Cwtowam she ar tM ume puts to CbmPerht 0.TBY;1 ae 1 .0 i 81g 0 15 �847/fl�f9 CONTINUED ON REVERSE a. PAYMENT, Cuetonwraha11Pey CC W waasaea aPal"N ar pasesa thrwo h Appiieabta Law. Wlamt I nog Mo& Ina? 3s an bmwacis.1 fu�ft chctR or aecroaee from tiaaa >n tiR18 by MnMit %i1N1LTiR('R f.FR(i1Nn,tl,inrvenm xMrva TERMS AND CONAri70NSa (ConNnuca from aMar side) 4AMAGETe PAVEMENT Cwreany shell wt ba raspm jbo W"y damnges W CaslomRtspAvoepenb wrbiit or omwdr NNgaurlflcesrbaul6Rg}rom Caapa�ry+yprovtttirv98ervibea3 CUWcmer'a iaeaiion. SUSPENSION.3taav amount A. I— ...'..u— m.....-....._.._..-...___..,_.. -. _ cusleNME'r1T. Cusitlmar shall rof. assiSra INs Agracyapm wHhaur CbmPaRya P(ICf wdtlon rgrtaem, whkh Campnay shell iwt UnraosoA WY wiIhhWa..Ccmpany may osstgn (his Aprasmen5 wdhoW GusiemaYS C.ns9M. DATE:--L-!-.._a-11 ».!,< StYa B35 (84r}6+r8 CERTIFICATE OF INTERESTED PARTIES FORM 1295 lofl 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. 2023-1098176 Republic Services Inc. Corpus Christi, TX United States Date Filed: 11/28/2023 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. Calhoun County Solid Waste/ Recycle Center 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. 11-17-23 Environmental Waste Management 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 UNSWORN DECLARATION My name is Jonathan Smith and my date of birth is My address is (street) , COrpu$cQhristl TX 78418 USA (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in NueceS County, State of TX , on the 27 day of November , 20_23 (month) (year) L.LBI'LCLCIZCL'Y�P�'� ° Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V3.5.1.0281ab6 � �a NO1 ICE OF MUTING—11/29/2023 8. Consider and take necessary action to authorize the Port O'Connor Community Center Board of Directors to enter into an agreement with Lauger Companies, Inc. for the Pavilion improvements. (GDR) Jim Cooley with the Port O'Connor CommunityCenter Board of Directors spoke on behalf of the board. Commissioners approved authorization upon the receipt of insurance. RESULT:, APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: David Hall, Commissioner Pct 1 AYES'. Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 5 of 11 Gary D. Reese County Commissioner County of Calhoun Precinct 4 November 16, 2023 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 November 22, 2023. • Consider and take necessary action to authorize the Port O'Connor Community Center Board of Directors to enter into an agreement with Lauger Companies, Inc. for the Pavilion improvements. Sincerely, Gary D. Reese GDR/at P.O. Box 177 — Seadrift. Texas 77983 —email: earv.reesencalhouncomom — (361) 785.3141 — Par (361) 785-5602 Up e `a Companies. Inc Port O'Connor Community Center Fund Association PO Box 812 Port O'Connor, TX 77982 Proposal for Addition Board tit Dircctors, NOVLMBER 7, 2023 WC prop, Esc iu add approxirnawiv a 16 font addition to ncc existing building. This will allow Cot- 3 new n Filets tin ItIC lades side plus onc• ADA toilet:. We will change one toilet onthe men's side to oVI I urinals :mdthen add tnie more urinal, two toilets and one ADA toilet. lore propose to move the c .istin• overhead door to the bath wall i.)f the addition. All construction will match the existing in. des11"11 and tiniches. • General Conditions: includes supervision; demolition; general liability insurance; workers compensation insurance; truck; tools, and haul off. • Demolition: Remove CMU walls, doors, toilets, and toilet partitions as required • Concrete: pour new slab to match existing elevation. • Masonry: install exterior split face CMU, interior install four -and eight -inch block in restrooms to match existing. • Carpeniry: Wood framing, partitions, countertops, roll up food service door, insulation, and gypsum board ceiling • Sealed concrete: floors with epoxy paint • Painting: paint walls ceilings and flooring to match existing. • Plumbing: Commercial toilets, urinals, vanity sinks, 3 bay sink, bar sink. • Electrical: Change fluorescent fixtures to LED in bar area FOR A TOTAL SUM OF $165,456.00 plus exempt from sales tax R.esp�ctfuilc stdamitt:ril. (:raiq Lau�rr Presideni Lauer (:urup:mies Inc 1Cccptcd. Jim (a wlcr, Director iin' PUJ't ( )'(:unnor G.tmmtmitt (:enter Fund Association PO 13ox 2146 ♦ V IC1'ORLA, TX 77902 1 (361) 576-0003 ♦ (361) 578-1626 FAx afl RLI Marine RLI Marine Policy ILM0707079 for Lauger Companies Inc. Policy Number: ILM0707079 RL'® NOTICE TO OUR BROKERS AND AGENTS OF OUR CLAIM NOTIFICATION PROCEDURE As part of our continuing effort to provide you with the best service available, ALL CLAIMS, OCCURRENCES, INCIDENTS and LAWSUITS under this policy are to be reported immediately to: RLI Insurance Company Email (preferred): New.Claim(&rlicorp com Fax: (866) 692-6796 Phone: (800) 444-0406 Street Address: 9025 N. Lindbergh Drive, Peoria, IL 61615 Mailing Address: P.O. Box 3961, Peoria, IL 61612-3961 When reporting the incident, be prepared to supply a report of claim or the following information: I. Policy Number 2. Contact Person information (name, address, phone, etc.) 3. Nature of incident 4. Date of incident When reporting multiple incidents, please send each loss notice separately. RIL 2131 (08/12) RLI' IMPORTANT NOTICE TO POLICYHOLDERS TERRORISM RISK INSURANCE ACT, AS AMENDED Under the Terrorism Risk Insurance Act, as amended (the "Act"), we must make coverage for "certified acts of terrorism" available in the policies we offer. We notified you at the time of offer and purchase of the policy to which this Notice is attached that this coverage was available and we gave you the right to reject our offer of such terrorism coverage. If you elected to purchase the coverage, the premium charged for such coverage is shown on the Declarations page of the policy. If you elected to reject the coverage we have not charged your policy for terrorism coverage and have attached a terrorism exclusion to your policy. PLEASE NOTE: IF YOU REJECTED THE OFFER OF FEDERAL TERRORISM INSURANCE COVERAGE, THAT REJECTION DOES NOT APPLY TO THE LIMITED EXTENT THAT RELEVANT STATE LAW REQUIRES COVERAGE FOR FIRE LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM UNDER THE ACT. 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 govemment under a formula established by federal law. Under this formula, the United States government generally reimburses 85% through 2015; 84% beginning on January 1, 2016; 83% beginning on January 1, 2017; 82% beginning January 1, 2018; 81% beginning January 1, 2019 and 80% beginning January 1, 2020 of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. You should also know that the Act contains a $100 billion cap that limits U.S. Government 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. Specific coverage terms for terrorism, including limitations and exclusions, are more fully described in endorsements attached to the policy. Your policy may contain an exclusion for losses that are not eligible for federal reinsurance under the Act. Definitions: "Certified act of terrorism," as defined in Section 102(1) of the Act, means an act that is certified by the Secretary of the Treasury — in consultation with the Secretary 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; and 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. RIL 2133B (01115) Page 1 of 1 INSURED surance mpan RL'� 9025 N. Lindbe gh'Dri e - Peora,CILo61615 �309) 692-1000 A stock insurance company, herein called the Company. POLICY DECLARATIONS Policy Number: ILM0707079 Broker Reference Number: Renewal of: ILM0707079 "NAMED INSURED" AND ADDRESS: AGENT/BROKER: Lauger Companies Inc. P.O. Box 2146 18734 Amwins Insurance Brokerage LLC Victoria, TX 77902 5910 North Central Expressway Suite 500 Dallas, TX 75206 POLICY PERIOD From 02/01/2023 To 02/01/2024 at 12:01 AM Standard Time at your mailing address shown above. In consideration of the premium as outlined below and subject to all the terms of this Policy, this Company agrees to provide the insurance coverage as stated in the attached Policy. This premium may be subject to adjustment. Coverage Part Premium Builders Risk and Installation Floater $2,500.00 See attached Tax, Fee & Surcharge Schedule (OMP 900) if applicable. Taxes/Fees/Surcharges: N/A Premium payable at inception unless Payment Schedule (OMP 113) applies. Total Premium: $2,500.00 Minimum Premium: N/A ADDITIONAL FORMS AND ENDORSEMENTS — MADE PART OF THIS POLICY AT TIME OF ISSUE See Attached Schedule of Endorsements (OMP 2150) OMP 100 (07/09) INSURED Authorized Signature Policy Number: ILM0707079 RU6 RLI Insurance Company Peoria, Illinois 61615 TEXAS POLICYHOLDER NOTICE TEXAS IMPORTANT NOTICE Have a complaint or need help? If you have a problem with a claim or your premium, call your insurance company or IWO first. If you can't work out the issue, the Texas Department of Insurance may be able to help. Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal. RLI Insurance Company To get information or file a complaint with your insurance company or HMO: Call: Product Manager, Marine at 309-692-1000 Toll -free: 800-331-4929 Online: https://www.rlicorp.com/contact-rli E-mail: TexasInquiries@rlicorp.com Mail: 9025 N. Lindbergh Drive, Peoria, Illinois 61615 The Texas Department of Insurance To get help with an insurance question or file a complaint with the state: Call with a question: 800-252-3439 File a complaint: www.tdi.texas.gov Email: ConsumerProtection@tdi.texas.gov Mail: MC I I1-1A, P.O. Box 149091, Austin, TX 78714-9091 TEXAS AVISO IMPORTANTE Tiene una queja o necesita ayuda? Si tiene un problema con una reclamaci6n o con su prima de seguro, llame primero a su compania de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en ingl6s) pueda ayudar. Aun si usted presenta una queja ante el Departamento de Seguros de Texas, tambi6n debe presentar una queja a traves del proceso de quejas o de apelaciones de su compaf is de seguros o HMO. Si no to hace, podrfa perder su derecho para apelar. RLI Insurance Company Para obtener information o Para presentar una queja ante su compania de seguros o IIMO: Llamada: Gerente de product, Marino en 309-692-1000 Telefono gratufto: 800-331-4929 En linea: https://www.rlicorp.com/contact-rli Correo electr6nico: TexasInquiries@rlicorp.com Direcci6n postal: 9025 N. Lindbergh Drive, Peoria, Illinois 61615 The Texas Department of Insurance Para obtener ayuda con una pregunta relacionada con los seguros o Para presentar una queja ante el estado: Llame con sus preguntas al: 800-252-3439 Presente una queja en: www.tdi.texas.gov Correo electr6nico: ConsumerProtection@tdi.texas.gov Direcci6n postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091 UW 1042ML (05/20) INSURED Policy Number: ILM0707079 RLI Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. APPLICABLE FORMS & ENDORSEMENTS FORMS AND ENDORSEMENTS LISTED BELOW APPLY TO AND ARE MADE PART OF THIS POLICY AT TIME OF ISSUE. IF LISTED UNDER A SPECIFIC SECTION, THE FORM APPLIES ONLY TO THAT SECTION AND DOES NOT CHANGE TERMS OR CONDITIONS FOR ANY OTHER SECTION. FORMS LISTED UNDER THE GENERAL SECTION APPLY TO ALL SECTIONS OF THE POLICY. General Section CPR 2225 (01/15) ILF 0001 (04/22) Inland Marine Section CL 0100 03 99 CL 0700 10 06 IM 7058 01 12 IM 7053 10 08 IM 7073 09 08 IM 7076 09 08 IM 7070 08 12 OMIM 604 (08/06) CL 0273 07 19 CL 0454 12 00 IM 2089 03 19 Certified Terrorism Loss Exclusion Signature Page Common Policy Conditions Virus or Bacteria Exclusion Schedule of Coverages - Builders' Risk and Installation Floater Builders' Risk Coverage - Builders' Risk and Installation Floater Form Contract Penalty Endorsement Testing Endorsement Rehabilitation And Renovation Coverage Endorsement Broad Additional Insureds - Builders' Risk Amendatory Endorsement - Texas Amendatory Endorsement - Texas Amendatory Endorsement - Texas ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. OMP 2150 (02/07) Page 1 of 1 INSURED Policy Number: ILM0707079 RLI Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CERTIFIED TERRORISM LOSS EXCLUSION We will not pay for loss, damage, cost or expense caused directly or indirectly by a "certified act of terrorism," as defined below. Such loss or damage is excluded regardless of any other cause or event that contributes concurrently or in any sequence to the loss. a. "Certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security and the Attorney General of the United States: (1) To be an act of terrorism; (2) To be a violent act or an act that is dangerous to human life, property, or infrastructure; (3) To have resulted in damage: (a) Within the United States; or (b) To an air carrier (as defined in section 40102 of title 49, United States Code); to a United States flag vessel (or a vessel based principally in the United States, on which United States income tax is paid and whose insurance coverage is subject to regulation in the United States), regardless of where the loss occurs; or at the premises of any United States mission; and (4) 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. No act will be certified by the Secretary of the Treasury as an act of terrorism if the act is committed as part of the course of a war declared by the Congress, or if property and casualty insurance losses resulting from the act do not exceed $5,000,000 in the aggregate. b. "Certified terrorism loss" means loss that results from a "certified act of terrorism." 2. If aggregate insured losses attributable to terrorist acts certified under the federal 'Terrorism Risk Insurance Act' exceed $100 billion in a calendar year (January 1 through December 31) and we have met our insurer deductible under the 'Terrorism Risk Insurance Act," we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion; and in such case, insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. 3. Neither the "terms" of this endorsement nor the 'terms" of any other terrorism endorsement attached to this policy provide coverage for any loss that would otherwise be excluded by this policy under: a. Exclusions that address war, military action, or nuclear hazard; or b. Any other exclusion. 4. The absence of any other terrorism endorsement does not imply coverage for any loss that would otherwise be excluded by this policy under: a. Exclusions that address war, military action, or nuclear hazard; or b. Any other exclusion. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CPR 2225 (01/15) Page 1 of 1 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS CL 0100 03 99 Page 1 of 1 COMMON POLICY CONDITIONS 1. Assignment— This policy may not be assigned without "our" written consent. 2. Cancellation — "You" may cancel this policy by returning the policy to "us" or by giving "us" written notice and stating at what future date coverage is to stop. "We" may cancel this policy, or one or more of its parts, by written notice sent to "you" at "your" last mailing address known to "us". If notice of cancellation is mailed, proof of mailing will be sufficient proof of notice. If "we" cancel this policy for nonpayment of premium, "we" will give "you" notice at least ten days before the cancellation is effective. If "we" cancel this policy for any other reason, "we" will give "you" notice at least 30 days in advance of cancellation. The notice will state the time that the cancellation is to take effect. "Your" return premium, if any, will be calculated according to "our" rules. It will be refunded to "you" with the cancellation notice or within a reasonable time. Payment or tender of the unearned premium is not a condition of cancellation. 3. Change, Modification, or Waiver of Policy Terms — A waiver or change of the "terms" of this policy must be issued by "us" in writing to be valid. 4. Inspections — "We" have the right, but are not obligated, to inspect "your" property and operations at any time. This inspection may be made by "us" or may be made on "our" behalf. An inspection or its resulting advice or report does not warrant that "your" property or operations are safe, healthful, or in compliance with laws, rules, or regulations. Inspections or reports are for "our" benefit only. 5. Examination of Books and Records —"We" may examine and audit "your" books and records that relate to this policy during the policy period and within three years after the policy has expired. CL 0100 03 99 Copyright, American Association of Insurance Services, 1998 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS This endorsement changes CL 0700 10 06 the policy Page 1 of 1 — PLEASE READ THIS CAREFULLY — VIRUS OR BACTERIA EXCLUSION This exclusion applies to, but is not limited to, any DEFINITIONS loss, cost, or expense as a result of: Definitions Amended — When "fungus" is a defined "term", the definition of "fungus" is amended to delete reference to a bacterium. When "fungus or related perils" is a defined "term", the definition of "fungus or related perils" is amended to delete reference to a bacterium. PERILS EXCLUDED The additional exclusion set forth below applies to all coverages, coverage extensions, supplemental coverages, optional coverages, and endorsements that are provided by the policy to which this endorsement is attached, including, but not limited to, those that provide coverage for property, earnings, extra expense, or interruption by civil authority. 1. The following exclusion is added under Perils Excluded, item 1.: Virus or Bacteria — "We" do not pay for loss, cost, or expense caused by, resulting from, or relating to any virus, bacterium, or other microorganism that causes disease, illness, or physical distress or that is capable of causing disease, illness, or physical distress. a. any contamination by any virus, bacterium, or other microorganism; or b. any denial of access to property because of any virus, bacterium, or other microorganism. 2. Superseded Exclusions — The Virus or Bacteria exclusion set forth by this endorsement supersedes the 'terms" of any other exclusions referring to "pollutants" or to contamination with respect to any loss, cost, or expense caused by, resulting from, or relating to any virus, bacterium, or other microorganism that causes disease, illness, or physical distress or that is capable of causing disease, illness, or physical distress. OTHER CONDITIONS Other Terms Remain in Effect — The 'terms" of this endorsement, whether or not applicable to any loss, cost, or expense, cannot be construed to provide coverage for a loss, cost, or expense that would otherwise be excluded under the policy to which this endorsement is attached. CL 0700 10 06 Copyright, American Association of Insurance Services, Inc., 2006 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS IM 7058 01 12 Page 1 of 4 SCHEDULE OF COVERAGES BUILDERS' RISK AND INSTALLATION FLOATER (The entries required to complete this schedule will be shown below or on the "schedule of coverages".) BUILDERS' RISK COVERAGES "Limits" Course Of Construction Limit — The most "we" pay for loss to any one "building or structure" is: $4,000,000 Contingent Coverage Limit — The most "we" pay for loss to any one "building or structure" is: $ Not Covered Difference In Conditions Limit — The most "we" pay for loss to any one "building or structure" is: $ Not Covered INSTALLATION FLOATER COVERAGE The most "we" pay for loss to any one "installation project" is: $Not Covered CATASTROPHE LIMIT $10,000,000 COVERAGE EXTENSIONS "Limits" Additional Debris Removal Expenses $5,000 Emergency Removal 10 days Emergency Removal Expenses $10,000 Fraud And Deceit $ 50,000 Limited Fungus Coverage $15,000 Waterborne Property $10,000 Copyright, American Association of Insurance Services, Inc., 2012 INSURED AAIS IM 7058 01 12 Page 2 of 4 SUPPLEMENTAL COVERAGES Expediting Expenses Expense To Re -Erect Scaffolding Fire Department Service Charges Ordinance Or Law (Undamaged Parts Of A Building) Ordinance Or Law (Increased Cost To Repair And Cost To Demolish/Clear Site) Personal Property Pollutant Cleanup And Removal Rewards Sewer Backup Temporary Storage Locations Transit Trees, Shrubs, And Plants DEDUCTIBLE Deductible Amount "Limits" $10,000 $ 5,000 $1,000 Covered $ 50,000 $10,000 $ 25,000 $1,000 $10,000 $100,000 $100,000 $10,000 See Below Copyright, American Association of Insurance Services, Inc., 2012 INSURED AAIS IM 7058 01 12 Page 3 of 4 REPORTING CONDITIONS (check one) ❑ Reporting Conditions waived M Reporting Conditions applicable as described below: Reporting Period (check one) M Monthly ❑ Quarterly ❑ Annual Adjustment Period (check one) M Monthly ❑ Quarterly ❑ Annual Additional Premium Due After Expiration — When the premium for the coverage provided by this policy is based upon reports of value any additional premium owed to "us" is due on the due date that appears on the billing notice. Coverage/Construction Frame Joisted Masonry (ISO 2) Light Non -Combustible (ISO 3) Heavy Non -Combustible (ISO 3) Masonry Non -Combustible (ISO 4) Fire -Resistive or Semi -Fire -Resistive (ISO 5-6) or Licht Rail Installation Floater Coverage Premiums Deposit Premium Minimum Premium Rate 0.045 0.0375 0.0265 0.0265 0.135 0.025 A 11z $ 2,500.00 $ 2,500.00 Copyright, American Association of Insurance Services, Inc., 2012 INSURED AAIS IM 7058 0112 Page 4 of 4 PERMISSION TO OCCUPY, BUILDERS' RISK COVERAGES (check one) ❑ Permission to occupy is not granted. ® The occupancy and use provisions under Additional Coverage Limitations are deleted, and permission is granted to occupy covered property after the date indicated below: Month 02 Day_0l Year 2018 ADDITIONAL INFORMATION Deductible: $2,500 All Other Perils $5,000 Theft 3% for Wind, Hail or Named Windstorm with a Minimum $10,000 **Protection Class 9-10 on Referral Only **Tier 1 Projects on Referral Only IM 7058 01 12 Copyright, American Association of Insurance Services, Inc., 2012 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS IM 7053 10 08 Pagel of 21 BUILDERS' RISK COVERAGE BUILDERS' RISK AND INSTALLATION FLOATER FORM In this coverage form, the words "you" and "your" mean the persons or organizations named as the insured on the declarations and the words "we", "us", and "our" mean the company providing this coverage. Refer to the Definitions section at the end of this coverage form for additional words and phrases that have special meaning. These words and phrases are shown in quotation marks. AGREEMENT In return for "your" payment of the required premium, "we" provide the coverage described herein subject to all the "terms" of the Builders' Risk Coverage. This coverage is also subject to the "schedule of coverages" and additional policy conditions relating to assignment or transfer of rights or duties, cancellation, changes or modifications, inspections, and examination of books and records. Endorsements and schedules may also apply. They are identified on the "schedule of coverages". PROPERTY COVERED "We" cover the following property unless the property is excluded or subject to limitations. 1. Builders' Risk Coverages — a. Course Of Construction — 1) Coverage — "We" cover direct physical loss or damage caused by a covered peril to "buildings or structures" while in the course of construction, erection, or fabrication. 2) Scaffolding, Fencing, And Temporary Structures — "We" also cover direct physical loss or damage caused by a covered peril to: a) scaffolding, construction forms, or temporary fencing; and b) temporary structures. 3) Coverage Limitations — a) "We" only cover: (1) "buildings or structures" in the course of construction; and (2) scaffolding, construction forms, temporary fencing, and temporary structures at "your" "jobsite". b) The "limit" provided under this coverage cannot be combined or added to the "limit" for any other coverage described in Property Covered. b. Contingent Coverage — 1) Coverage —"We" cover direct physical loss or damage caused by a covered peril to "buildings or structures" while in the course of construction, erection, or fabrication. 2) When Coverage Applies —This coverage only applies when: a) the purchaser of a "building or structure" fails to acquire or maintain the insurance coverage that is required by "your" construction agreement or contract; and b) "you" are unable to collect "your" interest in the "building or structure". Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 2 of 21 3) Coverage Limitations — a) "We" only cover "buildings or structures" in the course of construction: (1) when a "limit" is indicated on the "schedule of coverages" for Contingent Coverage; and (2) at "your" "jobsite". b) The "limit" provided under this coverage cannot be combined or added to the "limit" for any other coverage described in Property Covered. c. Difference In Conditions Coverage — 1) Coverage —"We" cover direct physical loss or damage caused by a covered peril to "buildings or structures" while in the course of construction, erection, or fabrication. 2) When Coverage Applies — This coverage only applies when under the provisions or conditions of the construction agreement or contract "you" are required to obtain Difference In Conditions Coverage for a "building or structure". Difference In Conditions Coverage means coverage for direct physical loss or damage unless the loss is caused by: a) a peril that is excluded under Perils Excluded, or b) a "specified peril". 3) Coverage Limitations — a) "We" only cover "buildings and structures" in the course of construction: (1) when a "limit" is indicated on the "schedule of coverages" for Difference In Conditions Coverage; and (2) at "your" "jobsite". b) The "limit" provided under this coverage cannot be combined or added to the "limit" for any other coverage described in Property Covered. 2. Installation Floater Coverage — a. Coverage — "We" cover direct physical loss or damage caused by a covered peril to: 1) "your" materials, supplies, machinery, fixtures, and equipment; and 2) similar property of others that is in "your" care, custody, or control that are part of "your" "installation project". b. Coverage Limitations — 1) "We" only cover materials, supplies, machinery, fixtures, and equipment: a) when a "limit" is indicated on the "schedule of coverages" for Installation Floater Coverage; and b) that will become a permanent part of "your" completed "installation project". 2) "We" only cover an "installation project" at "your" "jobsite". 3) The "limit" provided under this coverage cannot be combined or added to the "limit" for any other coverage described in Property Covered. 3. We Do Not Pay — "We" do not pay for any penalties for: a. non -completion or late completion of a "building or structure" in accordance with the provisions or conditions in the construction contract; or b. non-compliance with any provisions or conditions in the construction contract. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Paae 3 of 21 PROPERTY NOT COVERED 1. Airborne Property — "We" do not cover property while airborne except while in transit on a regularly scheduled airline flight. 2. Aircraft Or Watercraft —"We" do not cover aircraft or watercraft. 3. Buildings And Structures — Only as regards the Installation Floater Coverage, "we" do not cover "buildings or structures". However, "we" do cover property that is part of "your" "installation project" and is in connection with any "building or structure". 4. Contraband — "We" do not cover contraband or property in the course of illegal transportation or trade. 5. Land — "We" do not cover land including land on which covered property is located. 6. Money And Securities — "We" do not cover accounts, bills, currency, food stamps, or other evidences of debt, lottery tickets not held for sale, money, notes, or securities. 7. Not A Permanent Part Of Building Or Project — a. Only as regards the Builders' Risk Coverages and except as provided under Supplemental Coverages - Personal Property, "we" do not cover: 1) materials and supplies; 2) machinery, tools, and equipment; and 3) business personal property that will not become a permanent part of a covered "building or structure". b. Only as regards the Installation Floater Coverage, "we" do not cover: 1) materials and supplies; 2) machinery, tools, and equipment; and 3) business personal property that will not become a permanent part of a covered "installation project". 8. Rehabilitation Or Renovation Property — "We" do not cover any standing "building or structure" in the process of rehabilitation or renovation. Rehabilitation and renovation includes, but is not limited to, any additions, alterations, improvements, or repairs to an existing "building or structure". However, "we" do cover materials, supplies, machinery, fixtures, and equipment that "you" install, construct, or lift in connection with any "installation project". 9. Roadways And Walkways — a. Only as regards the Builders' Risk Coverages, "we" do not cover walkways, roadways, and other paved surfaces that are: 1) more than 1,000 feet from; or 2) not next to nor part of covered "buildings or structures". b. Only as regards the Installation Floater Coverage, "we" do not cover walkways, roadways, and other paved surfaces unless they are part of the specifications for "your" "installation project". 10. Trees, Shrubs, Or Plants — Except as provided under Supplemental Coverages - Trees, Shrubs, And Plants, "we" do not cover trees, shrubs, plants, or lawns. 11. Vehicles — "We" do not cover automobiles or any self-propelled vehicles that are designed for highway use. 12. Waterborne Property — Except as provided under Coverage Extensions - Waterborne Property, "we" do not cover property while waterborne except while in transit in the custody of a carrier for hire. Copyright, American Association of Insurance services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 4 of 21 COVERAGE EXTENSIONS Provisions That Apply To Coverage Extensions — The following Coverage Extensions indicate an applicable "limit". This "limit" may also be shown on the "schedule of coverages". If a different "limit" is indicated on the "schedule of coverages", that "limit" will apply instead of the "limit" shown below. However, if no "limit" is indicated for a Coverage Extension within this coverage form, coverage is provided up to the full "limit" for the applicable covered property unless a different "limit" is indicated on the "schedule of coverages". Unless otherwise indicated, the coverages provided below are part of and not in addition to the applicable "limit" for coverage described under Property Covered. The "limit" provided under a Coverage Extension cannot be combined or added to the "limit" for any other Coverage Extension or Supplemental Coverage, including a Coverage Extension, Supplemental Coverage, or other coverage that is added to this policy by endorsement. If coinsurance provisions are part of this policy, the following Coverage Extensions are not subject to and not considered in applying coinsurance conditions. 1. Debris Removal — a. Coverage — "We" pay the cost of debris removal. Debris removal means the costs for the demolition, clearing, and removal of debris of covered property if such debris results from a covered peril. b. We Do Not Cover— This coverage does not include costs to: 1) extract "pollutants" from land or water; or 2) remove, restore, or replace polluted land or c. Limit — "We" do not pay any more under this coverage than 25% of the amount "we" pay for the direct physical loss or damage exclusive of the costs for debris removal. "We" will not pay more for loss to property and debris removal combined than the "limit" for the damaged property. d. Additional Limit — "We" pay up to an additional $5,000 for debris removal expense when the debris removal expense exceeds 25% of the amount "we" pay for direct physical loss or when the loss to property and debris removal combined exceeds the "limit" for the damaged property. e. You Must Report Your Expenses — "We" do not pay any expenses unless they are reported to "us" in writing within 180 days from the date of direct physical loss to covered property. 2. Emergency Removal — a. Coverage —"We" cover any direct physical loss or damage to covered property while it is being moved or being stored to prevent a loss caused by a covered peril. b. Time Limitation —This coverage applies for up to ten days after the property is first moved. Also, this coverage does not extend past the date on which this policy expires. 3. Emergency Removal Expenses — a. Coverage —"We" pay for "your" expenses to move or store covered property to prevent a loss caused by a covered peril. b. Time Limitation —This coverage applies for up to ten days after the property is first moved. Also, this coverage does not extend past the date on which this policy expires. c. Limit —The most "we" pay in anyone occurrence for expenses to move or store covered property to prevent a loss is $10,000. water. d. This Is A Separate Limit —The "limit" for Emergency Removal Expenses is separate from, and not part of, the applicable "limit" for coverage described under Property Covered. Copyright, American Association of Insurance services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 5 of 21 4. FraudAndDeceit— a. Coverage — "We" cover theft of covered property when "you", "your" agents, customers, or consignees are fraudulently induced to part with the covered property: 1) to persons who falsely represent themselves as the proper persons to receive the property; 2) by the acceptance of fraudulent bills of lading or shipping receipts; or 3) as a result of or directly related to the use of any electronic data processing hardware or software. Limit — The most "we" pay in any one occurrence for theft of covered property under this Coverage Extension is $50,000. 5. Limited Fungus Coverage — a. Coverage — "We" pay for: 1) costs and expenses arising out of the presence of "fungus" on covered property caused by or resulting from a covered peril; and 2) direct physical loss or damage to covered property caused by or relating to the existence of or any activity of "fungus". b. Coverage Limitation — "We" only provide the coverage described in item 5.a. above: 1) when the "fungus" is the result of: a) a "specified peril' other than fire or lightning; or b) "flood" (if the Flood Coverage is provided under this policy); that occurs during the policy period; and 2) if all reasonable steps were taken to protect the property from additional damage at and after the time of the occurrence. c. Limited Fungus Coverage Limit —The most "we" pay for all loss or damage covered by this Coverage Extension at all "buildings or structures" is $15,000, unless another "limit" is indicated on the "schedule of coverages". The Limited Fungus Coverage Limit applies regardless of the number of claims made. The Limited Fungus Coverage Limit applies regardless of the number of locations or "buildings or structures" insured under this policy. The Limited Fungus Coverage Limit is the most that "we" pay for the total of all loss or damage arising out of all occurrences of "specified perils", other than fire or lightning, or "flood" (if applicable) during each separate 12-month period beginning with the inception date of this policy. d. If The Policy Period Is Extended — If the policy period is extended for an additional period of less than 12 months, this additional period will be considered part of the preceding period for the purpose of determining the Limited Fungus Coverage Limit. e. Recurrence And Continuation Of Fungus — The Limited Fungus Coverage Limit is the most that "we" pay with respect to a specific occurrence of a loss which results in "fungus" even if such "fungus" recurs or continues to exist during this or any future policy period. f. Limited Fungus Coverage Limit Applies To Other Costs Or Expenses — The Limited Fungus Coverage Limit also applies to any cost or expense to: 1) clean up, contain, treat, detoxify, or neutralize "fungus" on covered property or remove "fungus" from covered property; 2) remove and replace those parts of covered property necessary to gain access to "fungus"; and 3) test for the existence or level of "fungus" following the repair, replacement, restoration, or removal of damaged property if it is reasonable to believe that "fungus" is present. Copyright, American Association of Insurance Services, Inc., 2004 INSURED AAIS IM 7053 10 08 Paae 6 of 21 g. Loss Not Caused By Fungus — If there is a covered loss or damage to covered property not caused by "fungus", loss payment will not be limited by the "terms" of this Coverage Extension. However, to the extent that "fungus" causes an increase in the loss, that increase is subject to the "terms" of this Coverage Extension. 6. Waterborne Property — a. Coverage — "We" cover direct physical loss or damage caused by a covered peril to covered property while waterborne. b. Limit — The most "we" pay in any one occurrence for loss to waterborne property is $10,000. SUPPLEMENTAL COVERAGES Provisions That Apply To Supplemental Coverages — The following Supplemental Coverages indicate an applicable "limit". This "limit" may also be shown on the "schedule of coverages". If a different "limit" is indicated on the "schedule of coverages", that "limit" will apply instead of the "limit" shown below. However, if no "limit" is indicated for a Supplemental Coverage within this coverage form, coverage is provided up to the full "limit" for the applicable covered property unless a different "limit" is indicated on the "schedule of coverages". Unless otherwise indicated, a "limit" for a Supplemental Coverage provided below is separate from, and not part of, the applicable "limit" for coverage described under Property Covered. The "limit" available for coverage described under a Supplemental Coverage: a. is the only "limit" available for the described coverage; and b. is not the sum of the "limit" indicated for a Supplemental Coverage and the "limit" for coverage described under Property Covered. The "limit" provided under a Supplemental Coverage cannot be combined or added to the "limit" for any other Supplemental Coverage or Coverage Extension, including a Supplemental Coverage, Coverage Extension, or other coverage that is added to this policy by endorsement. If coinsurance provisions are part of this policy, the following Supplemental Coverages are not subject to and not considered in applying coinsurance conditions. 1. Expediting Expenses — a. Coverage — When a covered peril occurs to a covered "building or structure" or "installation project", "we" pay for reasonable expediting expenses necessary to complete construction or installation within the time frame specified in the construction or installation contract. Expediting expenses include, but are not limited to, additional: 1) labor or overtime; 2) transportation costs and storage expense; 3) expense to rent additional equipment; and 4) similar construction or installation expenses. b. Limit —The most "we" pay in anyone occurrence for all expediting expenses is $10,000. 2. Expense To Re -Erect Scaffolding — a. Coverage —"We" pay "your" expense to re -erect scaffolding after a covered loss to a covered "building or structure". b. Limit — The most "we" pay for expense to re -erect scaffolding is $5,000. 3. Fire Department Service Charges — a. Coverage —"We" cover "your" liability, assumed by contract or agreement prior to the loss, for fire department service charges. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 7 of 21 b. Coverage Limitations —"We" only pay for: 1) fire department service charges that relate to covered property; and 2) charges incurred when the fire department is called to save or protect covered property from a covered peril. c. Limit —The most "we" pay in anyone occurrence for "your" liability for fire department service charges is $1,000. No deductible applies to this Supplemental Coverage. 4. Ordinance Or Law (Undamaged Parts Of A Building) — a. Coverage — When a covered peril occurs to a covered 'building or structure", "we" pay for the value of undamaged parts of a covered "building or structure" that is required to be demolished as a result of the enforcement of any ordinance, law, or decree that: 1) requires the demolition of undamaged parts of a covered "building or structure" that is damaged or destroyed by a covered peril; 2) regulates the construction or repair of a "building or structure", or establishes building, zoning, or land use requirements at a covered "jobsite"; and 3) is in force at the time of loss. b. We Do Not Cover— "We" do not cover: 1) the costs associated with the enforcement of any ordinance, law, or decree that requires "you" or anyone else to test for, monitor, clean up, remove, contain, treat, detoxify, or neutralize or in any way respond to or assess the effects of "pollutants'; 2) loss or increased cost caused by the enforcement of any ordinance, law, or decree that requires the reconstruction, repair, replacement, remodeling, remediation, or razing of property due to the existence of or any activity of "fungus"; or 2) loss or increased cost caused by the enforcement of any ordinance, law, or decree that requires the reconstruction, repair, replacement, remodeling, remediation, or razing of property due to the existence of or any activity of "fungus"; or 3) costs associated with the enforcement of any ordinance, law, or decree that requires "you" or anyone else to test for, monitor, clean up, remove, contain, treat, detoxify, neutralize, or in any way respond to or assess the effects of "fungus". c. Coverage Limitation —This coverage is part of and not in addition to the applicable "limit" for coverage described under Property Covered. 5. Ordinance Or Law (Increased Cost To Repair And Cost To Demolish/Clear Site) — a. Increased Cost To Repair — 1) Coverage — When a covered peril occurs to a covered 'building or structure", "we" cover the increased cost to repair, rebuild, or reconstruct: a) damaged portions of a covered 'building or structure"; and b) undamaged portions of a covered "building or structure" whether or not those undamaged portions need to be demolished; as a result of the enforcement of building, zoning, or land use ordinance, law, or decree and is in force at the time when a covered peril occurs to a covered "building or structure". 2) If The Building Is Repaired Or Rebuilt — If a covered 'building or structure" is repaired or rebuilt, it must be intended for similar occupancy as the current property, unless otherwise required by building, zoning, or land use ordinance, law, or decree. Copyright, American Association of Insurance services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 8 of 21 3) Coverage Limitation — "We" do not cover the increased cost of construction until the covered 'building or structure" is actually repaired or replaced, whether at the same or another location, and unless the repairs or replacement are made as soon as reasonably possible after the loss, not to exceed two years. The period for repair or replacement may be extended by "us" in writing during the two year period. b. Cost To Demolish And Clear Site — "We" cover the cost to demolish and clear the site of undamaged parts of the covered 'building or structure" that is damaged or destroyed by a covered peril. The demolition must be a result of the enforcement of a building, zoning, or land use ordinance, law, or decree that is in force at the time when a covered peril occurs to a covered "building or structure". c. We Do Not Cover— "We" do not cover: 1) the costs associated with the enforcement of any ordinance, law, or decree: a) that requires "you" or anyone else to test for, monitor, clean up, remove, contain, treat, detoxify, or neutralize or in any way respond to or assess the effects of "pollutants'; b) that requires "you" or anyone else to test for, monitor, clean up, remove, contain, treat, detoxify, neutralize, or in any way respond to or assess the effects of "fungus"; or c) "you" were required to comply with before the covered peril occurred to a covered "building or structure", even if the "building or structure" was undamaged and 'you" failed to comply with the ordinance, law, or decree; or 2) loss or increased cost caused by the enforcement of any ordinance, law, or decree that requires the reconstruction, repair, replacement, remodeling, remediation, or razing of property due to the existence of or any activity of "fungus". d. What We Pay — 1) If The Building Is Repaired Or Replaced At Same Site Or Opt To Build At Another Location — If the covered 'building or structure" is repaired or replaced at the same location or "you" opt to build at another location, "we" pay the lesser of: a) the amount "you" actually spend to demolish and clear the site of undamaged parts of the covered "building or structure", plus the actual increased cost to repair, rebuild, or construct the property but not for more than a 'building or structure" of the same height, floor area, and style at the same location; or b) $50,000. 2) If The Building Is Repaired Or Replaced And Required By Ordinance Or Law To Relocate — If the covered 'building or structure" is rebuilt at a new location due to an ordinance or law requirement, "we" pay the lesser of: a) the amount "you" actually spend to demolish and clear the site of undamaged parts of the covered "building or structure", plus the actual increased cost to construct a 'building or structure" of the same height, floor area, and style at a new location; or b) $50,000. 3) If The Building Is Not Repaired Or Replaced — If the covered "building or structure" is not repaired or replaced, "we" pay the lesser of: a) the amount "you" actually spend to demolish and clear the site of undamaged parts of the covered "building or structure"; or b) $50,000. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 9 of 21 6. Personal Property — a. Coverage — "We" cover direct physical loss or damage caused by a covered peril to business personal property that will not become a permanent part of a covered "building or structure" or "installation project". b. Coverage Limitation — "We" only cover business personal property while being installed or stored in a covered "building or structure" or "installation project". c. Limit —The most "we" pay in anyone occurrence for loss to personal property is $10,000. 7. Pollutant Cleanup And Removal — a. Coverage — "We" pay "your" expense to extract "pollutants" from land or water if the discharge, dispersal, seepage, migration, release, or escape of the "pollutants" is caused by a covered peril that occurs during the policy period. b. Time Limitation — The expenses to extract "pollutants" are paid only if they are reported to "us" in writing within 180 days from the date the covered peril occurs. c. We Do Not Cover — "We" do not pay the cost of testing, evaluating, observing, or recording the existence, level, or effects of "pollutants". However, "we" pay the cost of testing which is necessary for the extraction of "pollutants" from land or water. d. Limit —The most "we" pay for each location is $25,000 for the sum of all such expenses arising out of a covered peril occurring during each separate 12-month period of this policy. 8. Rewards — 2) "We" pay a reward to an eligible person for the return of stolen covered property, when the loss is caused by theft. b. Eligible Person Means —An eligible person under this Supplemental Coverage means the first person to voluntarily provide the applicable law enforcement agency the necessary information or return the stolen covered property. An eligible person cannot be: 1) "you" or any family member; 2) "your" employee or any of his or her family members; 3) an employee of the applicable law enforcement agency; 4) any person who had custody of the covered property at the time the property was stolen; or 5) any person involved in the crime. c. Coverage Limitation — There will be no reward payment unless and until the person(s) committing the crime is (are) convicted or the covered property is returned. Limit — The most "we" pay in any one occurrence under this Supplemental Coverage is $1,000. The amount "we" pay is not increased by the number of persons involved in providing the information. 9. Sewer Backup — a. Coverage — "We" cover direct physical loss or damage to a covered "building or structure" or "installation project" caused by or resulting from: a. Coverage — 1 ) water or waterborne material that backs up, 1) "We" pay a reward to an eligible person for overflows or is otherwise discharged through information leading to the arrest and a sewer or drain, sump or septic tank; or conviction of any person or persons committing arson, theft, or vandalism. The 2) water or waterborne material below the conviction must involve a covered loss, under surface of the ground, including but not this policy, caused by arson, theft, or limited to water or waterborne material that vandalism. exerts pressure on or flows, seeps, or leaks Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Paae 10 of 21 through or into a covered 'building or structure" or "installation project', sidewalk, driveway, foundation, swimming pool, or other structure. b. Coverage Limitations —"We" do not cover loss or damage resulting from: 1) escape of water or waterborne material from a sump pit not equipped with a sump pump; 2) failure to perform routine maintenance and repair of all sump pumps and related equipment; and 3) failure to perform routine maintenance of sewers and drains including keeping sewers and drains free from obstructions. This limitation does not apply if "you" are not responsible for the maintenance of sewers or drains that results in loss or damage. c. Limit —The most "we" pay in anyone occurrence under this Supplemental Coverage is $10,000. 10. Temporary Storage Locations — a. Coverage — "We" cover direct physical loss or damage caused by a covered peril to: 1) materials and supplies that will become a permanent part of a covered 'building or structure" or "installation project"; 2) business personal property as described under Supplemental Coverages - Personal Property; and 3) trees, shrubs, plants, and lawns as described under Supplemental Coverages - Trees, Shrubs, And Plants (only for the perils described under Trees, Shrubs, And Plants) while temporarily in storage at a location that is not "your"'jobsite". b. We Do Not Cover— "We" do not cover property in storage if the property has not been specifically allocated to or otherwise identified with a covered "building or structure" or "installation project'. c. Limit —The most "we" pay in anyone occurrence for loss to property at a storage location is $10,000. 11. Transit — a. Coverage — "We" cover direct physical loss or damage caused by a covered peril to: 1) materials and supplies that will become a permanent part of a covered 'building or structure" or "installation project` 2) business personal property as described under Supplemental Coverages - Personal Property; and 3) trees, shrubs, plants, and lawns as described under Supplemental Coverages - Trees, Shrubs, And Plants and only for the perils described under Trees, Shrubs, And Plants while in transit. b. Limit —The most "we" pay in anyone occurrence for loss to property in transit is $10,000. 12. Trees, Shrubs, And Plants — a. Coverage —"We" cover direct physical loss or damage including debris removal expenses, to outdoor trees, shrubs, plants, and lawns. b. Coverage Limitation — "We" only cover trees, shrubs, plants, and lawns that are: 1) at a covered "jobsite"; and 2) being planted or installed as part of "your" construction project. c. Covered Perils — "We" only cover loss to trees, shrubs, plants, and lawns caused by the following perils: 1) fire; 2) lightning; 3) explosion; 4) riot or civil commotion; 5) falling objects; or 6) vandalism. d. Limit— The most "we" pay in anyone occurrence for loss to trees, shrubs, and plants is $10,000. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 11 of 21 PERILS COVERED "We" cover risks of direct physical loss or damage unless the loss is limited or caused by a peril that is excluded. PERILS EXCLUDED "We" do not pay for loss or damage caused directly or indirectly by one or more of the following excluded causes or events. Such loss or damage is excluded regardless of other causes or events that contribute to or aggravate the loss, whether such causes or events act to produce the loss before, at the same time as, or after the excluded causes or events. a. Civil Authority — Order of any civil authority, including seizure, confiscation, destruction, or quarantine of property. "We" do cover loss resulting from acts of destruction by the civil authority to prevent the spread of fire, unless the fire is caused by a peril excluded under this coverage. b. Earth Movement — Any "earth movement" However, if eruption, explosion, or effusion of a volcano results in "volcanic action", "we" will pay for the loss or damage caused by that "volcanic action". If "earth movement" results in fire, "we" will pay for the loss or damage caused by that fire. If "earth movement" (other than eruption, explosion, or effusion of a volcano) results in explosion, "we" will pay for the loss or damage caused by that explosion. This exclusion does not apply to covered property while in transit. c. Flood — "Flood". "We" also do not cover waterborne material carried or otherwise moved by "flood", whether or not driven by wind, including storm surge, or material carried or otherwise moved by mudslide or mudflow. However, if "flood" results in fire, explosion, or sprinkler leakage, "we" will pay for the loss or damage caused by that fire, explosion, or sprinkler leakage. This exclusion does not apply to covered property while in transit. d. Fungus — Except as provided under Coverage Extensions - Limited Fungus Coverage, the existence of or any activity of "fungus". But if "fungus" results in a "specified peril', "we" cover loss or damage caused by that "specified peril'. This exclusion does not apply to: 1) loss that results from fire or lightning; or 2) collapse caused by hidden decay. e. Nuclear Hazard — Nuclear reaction, nuclear radiation, or radioactive contamination (whether controlled or uncontrolled; whether caused by natural, accidental, or artificial means). Loss caused by nuclear hazard is not considered loss caused by fire, explosion, or smoke. Direct loss by fire resulting from the nuclear hazard is covered. Ordinance Or Law — Except as provided under Supplemental Coverages - Ordinance Or Law, enforcement of any code, ordinance, or law regulating the use, construction, or repair of any "building or structure"; or requiring the demolition of any "building or structure" including the cost of removing its debris. "We" do not pay for loss or increased cost regardless if the loss or increased cost is caused by or results from the: 1) enforcement of any code, ordinance, or law even if a "building or structure" has not been damaged; or 2) increased costs that "you" incur because of "your" compliance with a code, ordinance, or law during the construction, repair, rehabilitation, remodeling, or razing of a "building or structure", including the removal of debris, following direct physical loss or damage to the property. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 12 of 21 g. Sewer, Septic Tank, Sump, Or Drain Backup And Water Below The Surface — Except as provided under Supplemental Coverages - Sewer Backup: 1) water or waterborne material that backs up, overflows or is otherwise discharged through a sewer or drain, sump or septic tank, eaves trough or downspout; or 2) water or waterborne material below the surface of the ground, whether naturally or artificially occurring, including but not limited to water or waterborne material that exerts pressure on or flows, seeps, or leaks through or into a covered "building or structure" or "installation project", sidewalk, driveway, foundation, swimming pool, or other structure. But if sewer, drain, sump, septic tank, eaves trough, or downspout backup and water or waterborne material below the surface results in fire, explosion, or sprinkler leakage, "we" cover the loss or damage caused by that fire, explosion, or sprinkler leakage. This exclusion does not apply to covered property while in transit. h. War And Military Action — 1) War, including undeclared war or civil war; or 2) a warlike action by a military force, including action taken to prevent or defend against an actual or expected attack, by any government, sovereign, or other authority using military personnel or other agents; or 3) insurrection, rebellion, revolution, or unlawful seizure of power including action taken by governmental authority to prevent or defend against any of these. With regard to any action that comes within the "terms" of this exclusion and involves nuclear reaction, nuclear radiation, or radioactive contamination, this War And Military Action exclusion will apply in place of the Nuclear Hazard exclusion. 2. "We" do not pay for loss or damage that is caused by or results from one or more of the following: a. Contamination Or Deterioration — "We" do not pay for loss or damage caused by or resulting from contamination or deterioration including corrosion, decay, rust, or any quality, fault, or weakness in covered property that causes it to damage or destroy itself. But if contamination or deterioration results in a covered peril, "we" do cover the loss or damage caused by that covered peril. b. Criminal, Fraudulent, Dishonest, Or Illegal Acts— "We" do not pay for loss or damage caused by or resulting from criminal, fraudulent, dishonest, or illegal acts committed alone or in collusion with another by: 1) "you", 2) others who have an interest in the property; 3) others to whom "you" entrust the property; 4) "your" partners, officers, directors, trustees, joint venturers, or "your" members or managers if "you" are a limited liability company; or 5) the employees or agents of 1), 2), 3), or 4) above, whether or not they are at work. This exclusion does not apply to acts of destruction by "your" employees, but "we" do not pay for theft by employees. This exclusion does not apply to covered property in the custody of a carrier for hire. c. Defects, Errors, And Omissions — "We" do not pay for loss or damage caused by or resulting from an act, defect, error, or omission (negligent or not) relating to: 1) design, specifications, construction, materials, or workmanship; 2) planning, zoning, development, siting, surveying, grading, or compaction; or Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 13 of 21 3) maintenance, installation, renovation, remodeling, or repair. But if an act, error, or omission as described above results in a covered peril, "we" do cover the loss or damage caused by that covered peril. d. Delay In Completion And Increased Construction Costs — 1) "We" do not pay for loss or damage caused directly or indirectly by a: a) delay in the completion of construction, installation, erection, or fabrication of: (1) a "building or structure"; (2) an "installation project'; or (3) any portion of a "building or structure" or "installation project"; or b) a change in the sequence of construction, installation, erection, or fabrication of: (1) a "building or structure"; (2) an "installation project"; or (3) any portion of a "building or structure" or "installation project" regardless of the cause of the delay in completion or change in sequence. 2) "We" also do not pay for increased construction or installation costs caused by or resulting from a delay in completion or change in sequence as described above under items d.1), a) and b). Increased construction or installation costs include, but are not limited to: a) general conditions; b) increased construction or installation costs and additional construction or installation expenses; c) increased overhead, increased material costs, and increased labor costs; d) soft costs; and e) loss of earnings and loss of rental income. 3) General conditions means general conditions and extended general conditions including, but not limited to, costs of additional: a) utility charges; b) maintenance; c) facilities; d) communications; and e) administrative personnel. e. Electrical Currents — "We" do not pay for loss or damage caused by or resulting from arcing or by electrical currents other than lightning. But if arcing or electrical currents other than lightning result in a "specified peril", "we" do cover the loss or damage caused by that "specified peril". f. Loss Of Use And Consequential Loss — "We" do not pay for loss or damage caused by or resulting from loss of use, delay, or loss of market. "We" also do not pay for any consequential loss or damage of any nature. g. Mechanical Breakdown — "We" do not pay for loss or damage caused by or resulting from: 1) mechanical breakdown; or 2) rupturing or bursting of moving parts of machinery caused by centrifugal force. But if a mechanical breakdown or rupturing or bursting of moving parts of machinery caused by centrifugal force results in a "specified peril", "we" do cover the loss or damage caused by that "specified peril". h. Missing Property — "We" do not pay for missing property where the only proof of loss is unexplained or mysterious disappearance of covered property, or shortage of property discovered on taking inventory, or any other instance where there is no physical evidence to show what happened to the covered property. This exclusion does not apply to covered property in the custody of a carrier for hire. Copyright, American Association of Insurance services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 14 of 21 i. Pollutants — "We" do not pay for loss or damage caused by or resulting from release, discharge, seepage, migration, dispersal, or escape of "pollutants": 1) unless the release, discharge, seepage, migration, dispersal, or escape is caused by a "specified peril" or 2) except as specifically provided under the Supplemental Coverages - Pollutant Cleanup And Removal. "We" do cover any resulting loss caused by a "specified peril". j. Steam Boiler Explosion — "We" do not pay for loss or damage caused by or resulting from an explosion of steam boilers, steam pipes, steam turbines, or steam engines. But if an explosion of steam boilers, steam pipes, steam turbines, or steam engines results in a fire or combustion explosion, "we" cover the loss or damage caused by that fire or combustion explosion. "We" also cover loss or damage caused by or resulting from the explosion of gas or fuel in a firebox, combustion chamber, or flue. k. Temperature/Humidity— "We" do not pay for loss or damage caused by or resulting from dryness, dampness, humidity, or changes in or extremes of temperature. But if dryness, dampness, humidity, or changes in or extremes of temperature results in a covered peril, "we" do cover the loss or damage caused by that covered peril. Voluntary Parting — Except as provided under Coverage Extensions - Fraud And Deceit, "we" do not pay for loss or damage caused by or resulting from voluntary parting with title to or possession of any property because of any fraudulent scheme, trick, or false pretense. m. Wear And Tear — "We" do not pay for loss or damage caused by or resulting from wear and tear, marring, or scratching. WHAT MUST BE DONE IN CASE OF LOSS 1. Notice — In case of a loss, "you" must: a. give "us" or "our" agent prompt notice including a description of the property involved ("we" may request written notice); and b. give notice to the police when the act that causes the loss is a crime. 2. You Must Protect Property — "You" must take all reasonable steps to protect covered property at and after an insured loss to avoid further loss. a. Payment Of Reasonable Costs — "We" do pay the reasonable costs incurred by "you" for necessary repairs or emergency measures performed solely to protect covered property from further damage by a peril insured against if a peril insured against has already caused a loss to covered property. "You" must keep an accurate record of such costs. "Our" payment of reasonable costs does not increase the "limit". b. We Do Not Pay — "We" do not pay for such repairs or emergency measures performed on property which has not been damaged by a peril insured against. 3. Proof Of Loss— "You" must send "us", within 60 days after "our" request, a signed, sworn proof of loss. This must include the following information: a. the time, place, and circumstances of the loss; b. other policies of insurance that may cover the loss; c. "your" interest and the interests of ail others in the property involved, including all mortgages and liens; d. changes in title of the covered property during the policy period; and But if wear and tear, marring, or scratching results e. estimates, specifications, inventories, and other in a covered peril, "we" do cover the loss or reasonable information that "we" may require to damage caused by that covered peril. settle the loss. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 15 of 21 4. Examination — "You" must submit to examination under oath in matters connected with the loss as often as "we" reasonably request and give "us" sworn statements of the answers. If more than one person is examined, "we" have the right to examine and receive statements separately and not in the presence of others. 5. Records — "You" must produce records, including tax returns and bank microfilms of all canceled checks relating to value, loss, and expense and permit copies and extracts to be made of them as often as "we" reasonably request. 6. Damaged Property— "You" must exhibit the damaged and undamaged property as often as "we" reasonably request and allow "us" to inspect or take samples of the property. 7. Volunteer Payments — "You" must not, except at "your" own expense, voluntarily make any payments, assume any obligations, pay or offer any rewards, or incur any other expenses except as respects protecting property from further damage. 8. Abandonment— "You" may not abandon the property to "us" without "our" written consent. 9. Cooperation — "You" must cooperate with "us" in performing all acts required by this policy. VALUATION Replacement Cost — The value of covered property will be based on replacement cost as described below. a. Replacement Cost Means — Replacement cost means: 1) the necessary and reasonable costs of materials and labor incurred to repair or replace, without deduction for depreciation, the part of the covered property that sustains direct physical loss or damage; 2) the reasonable overhead and profit related to the covered property that sustains direct physical loss or damage but not to exceed the overhead and profit being charged for the construction, installation, erection, or fabrication of a covered "building or structure" or "installation project" in accordance with the construction or installation contracts; and 3) other related construction costs and expenses that are re -incurred to repair or replace the part of the covered property that sustains direct physical loss or damage but only if such costs have been included as part of the "limit" for a covered "building or structure" or "installation project". b. Replacement Cost Limitations — Replacement cost is limited to the cost of repair or replacement with similar materials on the same site and used for the same purpose. c. Payment Limitation — If the part of the covered property that sustains direct physical loss or damage is repaired or replaced, the payment will not exceed the amount "you" spend to repair or replace the damaged or destroyed property. 2. Pair Or Set— The value of a lost or damaged article that is part of a pair or set is based on a reasonable proportion of the value of the entire pair or set. The loss is not considered a total loss of the pair or set. Loss To Parts — The value of a lost or damaged part of an item that consists of several parts when it is complete is based on the value of only the lost or damaged part or the cost to repair or replace it. HOW MUCH WE PAY 1. Insurable Interest — "We" do not cover more than "your" insurable interest in any property. 2. Deductible — "We" pay only that part of "your" loss over the deductible amount indicated on the "schedule of coverages" in any one occurrence. 3. Loss Settlement Terms — Subject to paragraphs 1. 2., 4., 5., and 6. under How Much We Pay, "we" pay the lesser of: a. the amount determined under Valuation; Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Pane 16 of 21 b. the cost to repair, replace, or rebuild the property with material of like kind and quality to the extent practicable; or c. the 'limit' that applies to the covered property. 4. Catastrophe Limit— The most "we" pay in anyone occurrence is the Catastrophe Limit indicated on the "schedule of coverages" regardless if an occurrence or loss involves: a. one or more "buildings or structures' b. one or more described "jobsites"; c. one or more coverages described under Property Covered: or d. any combination of "buildings or structures", described "jobsites", described coverages, or coverages described under Coverage Extensions or Supplemental Coverages. 5. Insurance Under More Than One Coverage — If more than one coverage of this policy insures the same loss, "we" pay no more than the actual claim, loss, or damage sustained. 6. Insurance Under More Than One Policy — a. Proportional Share — "You" may have another policy subject to the same "terms" as this policy. If "you" do, "we" will pay 'bur" share of the covered loss. "Our" share is the proportion that the applicable 'limit' under this policy bears to the 'limit' of all policies covering on the same basis. b. Excess Amount — If there is another policy covering the same loss, other than that described above, "we" pay only for the amount of covered loss in excess of the amount due from that other policy, whether "you" can collect on it or not. But "we" do not pay more than the applicable limit'. LOSS PAYMENT 1. Loss Payment Options — a. Our Options — In the event of loss covered by this coverage form, "we" have the following options: 1) pay the value of the lost or damaged property; 2) pay the cost of repairing or replacing the lost or damaged property; 3) rebuild, repair, or replace the property with other property of equivalent kind and quality, to the extent practicable, within a reasonable time; or 4) take all or any part of the property at the agreed or appraised value. b. Notice Of Our Intent To Rebuild, Repair, Or Replace — "We" must give "you" notice of "our" intent to rebuild, repair, or replace within 30 days after receipt of a duly executed proof of loss. 2. Your Losses — a. Adjustment And Payment Of Loss —"We" adjust all losses with "you". Payment will be made to 'you" unless another loss payee is named in the policy. b. Conditions For Payment of Loss —An insured loss will be payable 30 days after: 1) a satisfactory proof of loss is received; and 2) the amount of the loss has been established either by written agreement with 'you" or the filing of an appraisal award with "us". 3. Property Of Others — a. Adjustment And Payment Of Loss To Property Of Others -- Losses to property of others may be adjusted with and paid to: 1) 'you" on behalf of the owner; or 2) the owner. b. We Do Not Have To Pay You If We Pay The Owner — If "we" pay the owner, "we" do not have to pay "you". "We" may also choose to defend any suits brought by the owners at 'bur" expense. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Paoe 17 of 21 REPORTING CONDITIONS If indicated on the "schedule of coverages", the following reporting conditions apply. 1. Builders' Risk Coverages —The following reporting conditions apply to Builders' Risk Coverages. a. Reports — 1) You Will Report To Us — Within 30 days after the end of each reporting period indicated on the "schedule of coverages", "you" will report to "us" the estimated completed value of each "building or structure". "Your" report will contain the: a) estimated completion cost; b) address; and c) construction classification of each "building or structure". 2) Cancellation — If "your" coverage is canceled, "you" will report the estimated completed value of each "building or structure" up to and including the date of cancellation and pay any additional premium due. Premium Computation And Adjustment — The premium will be adjusted as of each adjustment period indicated on the "schedule of coverages". The computed premium will be determined by multiplying the estimated completed value of each "building or structure" by the rate indicated on the "schedule of coverages". 1) Annual Adjustment — When an annual adjustment period is indicated on the "schedule of coverages", "we" will compare the total computed premium to the deposit premium. If it is more than the deposit premium, "you" will pay "us" the difference. If it is less than the deposit premium, "we" will pay "you" the difference subject to the minimum premium indicated on the "schedule of coverages". 2) Other Adjustment Period —When any other premium adjustment period is indicated, "we" will apply the computed premium to the deposit premium until it is exhausted. "You" will pay "us" all premiums that exceed the deposit premium. At the end of the policy period, if the computed premium is less than the deposit premium, "we" will pay "you" the difference subject to the minimum premium indicated on the "schedule of coverages". c. Provisions That Affect How Much We Pay — The following provisions apply to reports that are submitted and may affect How Much We Pay: 1) Failure To Submit Reports — If "you" have failed to submit the required reports or no report has been submitted, the most "we" will pay is 90% of the "limit". 2) Reported Values Are Less Than The Full Value — If "your" last report before a loss shows less than the actual estimated completed value of a "building or structure", "we" will only pay a part of the loss. "We" will not pay a greater portion of the loss, prior to the application of the deductible, than the value of a "building or structure" "you" reported divided by the actual estimated completed value of the "building or structure" during the reporting period. 3) We Will Not Pay More Than The Limit — "We" will not pay more than the applicable "limit" regardless of any reported value used in computing the premium. 2. Installation Floater Coverage —The following reporting conditions apply to the Installation Floater Coverage. a. Reports — 1) You Will Report To Us — Within 30 days after the end of each reporting period indicated on the "schedule of coverages", "you" will report to "us" the total receipts (collected and uncollected) earned from "your" "installation projects" during the reporting period indicated on the Copyright, American Association of Insurance services, Inc., 2008 INSURED AAIS IM 7053 10 08 Paae 18 of 21 "schedule of coverages". Receipts include the amounts "you" earn from materials, labor, reasonable overhead and profit, and delivery charges that are part of "your" "installation projects". 2) Cancellation — If "your" coverage is canceled, "you" will report the total receipts (collected and uncollected) earned from "your" "installation projects" up to and including the date of cancellation and pay any additional premium due. b. Premium Computation And Adjustment — The premium will be adjusted as of each adjustment period indicated on the "schedule of coverages". The total computed premium will be determined by multiplying the total earned receipts by the rate indicated on the "schedule of coverages". 1) Annual Adjustment —When an annual adjustment period is indicated on the "schedule of coverages", "we" will compare the total computed premium to the deposit premium. If it is more than the deposit premium, "you" will pay "us" the difference. If it is less than the deposit premium, "we" will pay "you" the difference subject to the minimum,premium indicated on the schedule. 2) Other Adjustment Period — When any other premium adjustment period is indicated, "we" will apply the computed premium to the deposit premium until it is exhausted. "You" will pay "us" all premiums that exceed the deposit premium. At the end of the policy period, if the computed premium is less than the deposit premium, "we" will pay "you" the difference subject to the minimum premium indicated on the "schedule of coverages". c. Provisions That Affect How Much We Pay — The following provisions apply to reports that are submitted and may affect How Much We Pay: 1) Failure To Submit Reports — If "you" have failed to submit the required reports or no report has been submitted, the most "we" will pay is 90% of the "limit". 2) Reported Values Are Less Than The Full Value — If "your" last report before a loss shows less than the actual receipts earned during the reporting period for an "installation project", "we" will only pay a part of the loss. "We" will not pay a greater portion of the loss, prior to the application of the deductible, than the receipts "you" reported divided by the receipts "you" actually earned from "your" "Installation project" during the reporting period. 3) We Will Not Pay More Than The Limit — "We" will not pay more than the applicable "limit" regardless of any reported value used in computing the premium. 1. Appraisal — If "you" and "we" do not agree on the amount of the loss or the value of covered property, either party may demand that these amounts be determined by appraisal. If either makes a written demand for appraisal, each will select a competent, independent appraiser and notify the other of the appraiser's identity within 20 days of receipt of the written demand. The two appraisers will then select a competent, impartial umpire. If the two appraisers are unable to agree upon an umpire within 15 days, "you" or "we" can ask a judge of a court of record in the state where the property is located to select an umpire. The appraisers will then determine and state separately the amount of each loss. The appraisers will also determine the value of covered property items at the time of the loss, if requested. If the appraisers submit a written report of any agreement to "us", the amount agreed upon will be the amount of the loss. If the appraisers fail to agree within a reasonable time, they will submit only their differences to the umpire. Written agreement so itemized and signed by any two of these three, sets the amount of the loss. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 19 of 21 Each appraiser will be paid by the party selecting that 7. Recoveries — If "we" pay "you" for the loss and lost or appraiser. Other expenses of the appraisal and the damaged property is recovered, or payment is made compensation of the umpire will be paid equally by by those responsible for the loss, the following "you" and "us". provisions apply: 2. Benefit To Others — Insurance under this coverage will not directly or indirectly benefit anyone having custody of "your" property. 3. Conformity With Statute —When a condition of this coverage is in conflict with an applicable law, that condition is amended to conform to that law. 4. Estates — This provision applies only if the insured is an individual. a. Your Death —On "your" death, "we" cover the following as an insured: 1) the person who has custody of "your" property until a legal representative is qualified and appointed; or 2) "your" legal representative. This person or organization is an insured only with respect to property covered by this coverage. b. Policy Period Is Not Extended — This coverage does not extend past the policy period indicated on the declarations. 5. Misrepresentation, Concealment, Or Fraud —This coverage is void as to "you" and any other insured if, before or after a loss: a. "You" or any other insured have willfully concealed or misrepresented: 1) a material fact or circumstance that relates to this insurance or the subject thereof; or 2) "your" interest herein. a. "you" must notify "us" promptly if "you" recover property or receive payment; b. "we" must notify "you" promptly if "we" recover property or receive payment; c. any recovery expenses incurred by either are reimbursed first; d. "you" may keep the recovered property but "you" must refund to "us" the amount of the claim paid or any lesser amount to which "we" agree; and e. if the claim paid is less than the agreed loss due to a deductible or other limiting "terms" of this policy, any recovery will be prorated between "you" and "us" based on "our" respective interest in the loss. 8. Restoration Of Limits— Except as indicated under Limited Fungus Coverage, a loss "we" pay under this coverage does not reduce the applicable "limits". 9. Subrogation — If "we" pay for a loss, "we" may require "you" to assign to "us" "your" right of recovery against others. "You" must do all that is necessary to secure "our" rights. "We" do not pay for a loss if "you" impair this right to recover. "You" may waive "your" right to recover from others in writing before a loss occurs. 10. Suit Against Us — No one may bring a legal action against "us" under this coverage unless: a. all of the "terms" of this coverage have been complied with; and b. the suit has been brought within two years after b. There has been fraud or false swearing by "you" "you" first have knowledge of the loss. or any other insured with regard to a matter that relates to this insurance or the subject thereof. If any applicable law makes this limitation invalid, then suit must begin within the shortest period 6. Policy Period —"We" pay for a covered loss that permitted by law. occurs during the policy period. Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 20 of 21 11. Territorial Limits — "We" cover property while in the United States of America, its territories and possessions, Canada, and Puerto Rico. 12. Carriers For Hire — "You" may accept bills of lading or shipping receipts issued by carriers for hire that limit their liability to less than the replacement cost or actual cash value of the covered property. ADDITIONAL COVERAGE LIMITATIONS 1. Occupancy And Use — The following provision only applies to Builders' Risk Coverages, "we" do not provide coverage under this policy if, without "our" prior written consent, a covered "building or structure" as described under Property Covered is: a. occupied in whole or in part; or b. put to its intended use. However, this provision does not apply if Permission To Occupy is indicated on the "schedule of coverages". 2. When Coverage Ceases — Coverage will end when one of the following first occurs: a. this policy expires or is canceled; b. a covered "building or structure" or "installation project" is accepted by the purchaser; c. "your" insurable interest in the covered property ceases; d. "you" abandon construction or installation with no intent to complete it; or e. a covered "building or structure" or "installation project" has been completed for more than 90 days. DEFINITIONS 1. "Buildings or structures" means: a. buildings; b. structures; c. materials and supplies that will become a permanent part of the buildings or the structures; and d. foundations, excavations, grading, filling, attachments, permanent fencing, and other permanent fixtures. 2. "Earth movement" means: a. earthquake, including land shock waves or tremors before, during or after a volcanic eruption; b. landslide, mudslide or mudflow; c. mine subsidence whether or not the non -natural mine is currently in use; d. any other movement of earth, including sinking (other than "sinkhole collapse"), shifting, or rising of earth including, but not limited to, erosion, expansion, shrinking, freezing, thawing, improper soil compaction, and movement of water under the surface of the ground that cause cracking, settling, or shifting of foundations, buildings, or structures; or e. eruption, explosion, or effusion of a volcano. 3. "Flood" means an overflowing or inundation by water of an area that was previously and normally dry or not covered by water, whether caused artificially or naturally, by human or animal forces or by an act of nature. "Flood" includes, but is not limited to: a. overflow of inland or tidal waters, waves, tidal waves, or tsunamis, or spray that results from any of these, all whether driven by wind or not, including but not limited to storm surge; b. unusual and rapid accumulation or runoff of surface waters from any source; or c. mudslides or mudflows if caused by: 1) unusual and rapid accumulation or runoff of surface waters or waves; or 2) currents of water exceeding anticipated cyclical levels. 4. "Fungus" means: a. a fungus, including but not limited to mildew and mold; Copyright, American Association of Insurance Services, Inc., 2008 INSURED AAIS IM 7053 10 08 Page 21 of 21 b. a protist, including but not limited to algae and slime mold; c. wet rot and dry rot; d. a bacterium; or 9. "Schedule of coverages" means: e. a chemical, matter, or compound produced or released by a fungus, a protist, wet rot, dry rot, or 10. a bacterium, including but not limited to toxins, spores, fragments, and metabolites such as microbial volatile organic compounds. 5. 'Installation project' means an installation or construction project where "you" are in the process of installing, constructing, or rigging: a. materials or supplies; b. machinery; c. fixtures; or d. equipment. 6. "Jobsite" means any location, project, or work site where "you" are in the process of: a. constructing, erecting, or fabricating a "building or structure" or b. installing, constructing, or rigging materials or supplies, machinery, fixtures, or equipment. 7. "Limit' means the amount of coverage that applies. 8. 'Pollutant' means: a. any solid, liquid, gaseous, thermal, or radioactive irritant or contaminant, including acids, alkalis, chemicals, fumes, smoke, soot, vapor, and waste. Waste includes materials to be recycled, reclaimed, or reconditioned, as well as disposed of; and b. electrical or magnetic emissions, whether visible or invisible, and sound emissions. a. all pages labeled "schedule of coverages" or schedules that pertain to this coverage; and b. declarations or supplemental declarations that pertain to this coverage. "Sinkhole collapse" means the sudden settlement or collapse of earth supporting the covered property into subterranean voids created by the action of water on a limestone or similar rock formation. It does not include the value of the land or the cost of filling sinkholes. 11. "Specified perils" means aircraft; civil commotion; explosion; falling objects; fire; hail; leakage from fire extinguishing equipment; lightning; riot; "sinkhole collapse"; smoke; sonic boom; vandalism; vehicles; "volcanic action'; water damage; weight of ice, snow, or sleet; and windstorm. Falling objects does not include loss to: a. personal property in the open; or b. the interior of "buildings or structures" or to personal property inside 'buildings or structures" unless the exterior of the roofs or walls are first damaged by a falling object. Water damage means the sudden or accidental discharge or leakage of water or steam as a direct result of breaking or cracking of a part of the system or appliance containing the water or steam. 12. "Terms" means all provisions, limitations, exclusions, conditions, and definitions that apply. 13. "Volcanic action" means airborne volcanic blast or airborne shock waves; ash, dust, or particulate matter; or lava flow. "Volcanic action" does not include the cost to remove ash, dust, or particulate matter that does not cause direct physical loss or damage to the covered property. IM 7053 10 08 Copyright, American Association of Insurance Services, Inc., 2008 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS IM 7073 09 08 Paae 1 of 2 This endorsement changes the Builder's Risk Coverage — PLEASE READ THIS CAREFULLY — CONTRACT PENALTY ENDORSEMENT (The entries required to complete this endorsement will be shown below or on the "schedule of coverages".) CONTRACT PENALTY SCHEDULE Contract Penalty Limit: ❑ Equipment Breakdown And Testing Coverage included (check if applicable) Equipment Breakdown And Testing Limit: SUPPLEMENTAL COVERAGES Contract Penalty — 1. Coverage — 91 a "We" pay for the cost of contractual penalties for non -completion that "you" are assessed or are required to pay because "you" are unable to complete construction of a covered "building or structure" on time in accordance with the provisions or conditions of the construction contract. Except as described under Equipment Breakdown And Testing Coverage, the Contract Penalty Limit shown on the Contract Penalty Schedule is the most "we" pay in any one occurrence for all contractual penalties. 2. Coverage Limitation — "Your" inability to complete construction on time must be as a direct result of loss or damage by a covered peril to a covered "building or structure". "Limit" $ 25,000 3. Rehabilitation And Renovation Form — If this endorsement is attached to the Rehabilitation And Renovation Form, the references above to "building or structure" are replaced with "rehabilitation or renovation project". 4. Equipment Breakdown And Testing Coverage — If Equipment Breakdown And Testing Coverage is indicated on the Contract Penalty Schedule and the Equipment Breakdown And Testing Coverage endorsement is also attached to the Builders' Risk Coverage form, coverage under this endorsement is extended to contractual penalties for non -completion that "you" are assessed or are required to pay because "you" are unable to complete construction of a covered "building or structure" on time in accordance with the provisions or conditions of the construction contract. The assessment of the penalties must be the result of an "accident". Copyright, American Association of Insurance services, 2008 INSURED AAIS IM 7073 09 08 Page 2 of 2 b. The Equipment Breakdown and Testing Limit is the most "we" pay in any "one accident" for all contractual penalties resulting from an "accident". The Equipment Breakdown and Testing Limit cannot be combined with or added to the Contract Penalty Limit. c. Refer to the Equipment Breakdown And Testing Coverage endorsement for a definition of "accident" and "one accident". IM 7073 09 08 Copyright, American Association of Insurance services, 2008 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS This endorsement changes the IM 7076 09 08 Builders' Risk Coverage Page 1 of 1 — PLEASE READ THIS CAREFULLY — TESTING ENDORSEMENT (The entries required to complete this endorsement will be shown below or on the "schedule of coverages.") TESTING SCHEDULE "Limit" The most "we" pay in any one occurrence for loss resulting from testing is: $50,000 SUPPLEMENTAL COVERAGES Testing — 1. Coverage —"We" cover direct physical loss to a covered "building or structure" resulting from testing. 2. Testing Means — Testing as used in this endorsement means start-up, performance, stress, pressure, or overload testing of materials, supplies, machinery, fixtures, and equipment that will become a permanent part of a covered "building or structure". 3. Testing Limit — The testing "limit" indicated on the Testing Schedule is the most "we" will pay for any loss resulting from testing. However, if testing results in a "specified peril", the most "we" will pay for any resulting loss is the "limit" indicated on the "schedule of coverages" for the covered "building or structure". 4. Rehabilitation And Renovation Form — If this endorsement is attached to the Rehabilitation And Renovation Form, the references to "building or structure" are replaced with "rehabilitation or renovation project". 5. Exclusions That Still Apply —The exclusions for Electrical Currents, Steam Boiler Explosion, and Mechanical Breakdown still apply except to the extent that coverage is provided under this endorsement. ADDITIONAL PERILS EXCLUDED Testing — Except to the extent coverage is provided under this endorsement, "we" do not pay for loss or damage caused by or resulting from testing. But if testing results in a "specified peril", "we" do cover the loss or damage caused by that "specified peril". IM 7076 09 08 Copyright, American Association of Insurance Services, Inc., 2008 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS This endorsement changes the IM 7070 08 12 Builders' Risk Coverage Page 1 of 3 — PLEASE READ THIS CAREFULLY — REHABILITATION AND RENOVATION COVERAGE ENDORSEMENT Rehabilitation And Renovation -- Only regarding the "jobsite" indicated by the "jobsite" location number on the Rehabilitation And Renovation Schedule, all references to "building or structure" in the coverage form to which this endorsement is attached are replaced with "rehabilitation or renovation project". ADDITIONAL DEFINITIONS The following definitions are added to the Definitions section: 1. "Building materials" means materials, supplies, attachments, and fixtures that: a. will become; or b. since the inception date of this policy, have become a permanent part of the rehabilitation or renovation of an "existing building" or an extension of or addition to an "existing building". 2. "Existing building" means a structure or building constructed and standing prior to the inception of this policy and that will undergo renovation or rehabilitation. An "existing building" includes only those parts of a standing structure or a standing building that are intended to become a permanent part of the structure or building during and after construction, renovation, or rehabilitation. An "existing building" includes foundations, PROPERTY COVERED Only regarding the "jobsite" indicated by the "jobsite" location number on the Rehabilitation And Renovation Schedule, the Property Covered section is deleted and replaced by the following: "We" cover the following property unless the property is excluded or subject to limitations. 1. Coverage --"We" cover direct physical loss or damage caused by a covered peril to "building materials" and "existing buildings" that are part of "your" "rehabilitation or renovation project". 2. Coverage Limitations -- a. "We" only cover "existing buildings" when a "limit" is indicated on the Rehabilitation And Renovation Schedule for Existing Buildings. b. "We" only cover "building materials" that: 1) will become; or 2) since the inception date of this policy, have become a permanent part of the rehabilitation or renovation of an "existing building" or an extension of or addition to an "existing building". c. "We" only cover "existing buildings" and "building materials" at the "jobsite" described on the "schedule of coverages" and whose "jobsite" location number is indicated on the Rehabilitation And Renovation Schedule. attachments, permanent fencing, and other 3. Vacant Building Limitation —"We" only cover a permanent fixtures. vacant "existing building" for 60 consecutive days (or the number of days indicated on the Rehabilitation "Rehabilitation or renovation project" means a project And Renovation Schedule) from the inception date of involving the construction, rehabilitation, or renovation this policy unless: of a structure or building by "you" or "your" contractors or subcontractors. a. building permits have been obtained; and Copyright, American Association of Insurance Services, Inc., 2012 INSURED AAIS IM 7070 08 12 Page 2 of 3 b. rehabilitation or renovation work has begun on the "existing building". This limitation is waived when Vacant Building Limitation Waived is checked on the Rehabilitation And Renovation Schedule. 4. We Do Not Pay -- a. Penalties -- "We" do not pay for any penalties for: 1) noncompletion or late completion of a "rehabilitation or renovation project" in accordance with the provisions or conditions in the construction contract; or 2) noncompliance with any provisions or conditions in the construction contract. b. Diminution In Value -- "We" do not pay for any loss of value or any diminution in value of a "building or structure", however measured, that remains following the repair or replacement of a covered loss. PROPERTY NOT COVERED The exclusion for Standing Building Or Structure is deleted and replaced by the following: Standing Building Or Structure -- Except for a covered "existing building", "we" do not cover any: 1. standing building or standing structure; or 2. part of a standing building or standing structure that has been wholly or partially constructed, erected, or fabricated prior to the inception of this policy. ADDITIONAL PROPERTY NOT COVERED Excavations, Grading, Filling, Pipes, Flues, And Drains -- "We" do not cover: 1. the cost of excavations, grading, or filling; and 2. underground pipes, flues, and drains. VALUATION The Replacement Cost provisions under Valuation are replaced by the following provisions. 1. Existing Building -- Stated Value -- If Stated Value is indicated on the Rehabilitation And Renovation Schedule for Existing Building, the value of an "existing building" that sustains direct physical loss or damage will be based on the "limit" shown for Existing Building on the Rehabilitation And Renovation Schedule. b. Actual Cash Value -- If Actual Cash Value is indicated on the Rehabilitation And Renovation Schedule for Existing Building, the value of the part of an "existing building" that sustains direct physical loss or damage will be based on the actual cash value at the time of loss (with a deduction for depreciation). 2. Building Materials -- a. Actual Cash Value -- If Actual Cash Value is indicated on the Rehabilitation And Renovation Schedule for "building materials", the value of "building materials" will be based on the actual cash value at the time of loss (with a deduction for depreciation). The actual cash value of "building materials" means: 1) the necessary and reasonable costs of materials and labor incurred to repair or replace, with a deduction for depreciation, the part of the covered "building materials" that sustains direct physical loss or damage; 2) the reasonable overhead and profit related to the covered "building materials" that sustains direct physical loss or damage but not to exceed the overhead and profit being charged for the "rehabilitation or renovation project" in accordance with the construction contracts; and Copyright, American Association of Insurance Services, Inc., 2012 INSURED AAIS IM 7070 08 12 Page 3 of 3 3) other related construction costs and expenses that are re -incurred to repair or replace the part of the covered property that sustains direct physical loss or damage but only if such costs have been included as part of the 'limit' for a covered "rehabilitation or renovation project'. Replacement cost is limited to the cost of repair or replacement with similar materials on the same site and used for the same purpose. If the part of the covered property that sustains direct physical loss or damage is repaired or replaced, the payment will not exceed the amount "you" spend to repair or replace the damaged or destroyed property. HOW MUCH WE PAY 1. Coinsurance -- The Coinsurance provisions under How Much We Pay are replaced by the following: When Coinsurance Applies -- "We" only pay a part of the loss if the 'limit' is less than the coinsurance percentage of the estimated value of "building materials" at the completion of the 'rehabilitation or renovation project'. The applicable coinsurance percentage is indicated on the Rehabilitation And Renovation Schedule. b. How We Determine Our Part Of The Loss -- "Our" part of the loss is determined using the following steps: 1) multiply the coinsurance percentage indicated on the Rehabilitation And Renovation Schedule by the value of "building materials" at the completion of the 'rehabilitation or renovation project' had no loss occurred; 2) divide the "limit" for "building materials" by the result determined in b.1) above; and 3) multiply the total amount of loss, after the application of any deductible, by the result determined in b.2) above. The most "we" pay is the amount determined in b.3) above or the Building Materials Limit, whichever is less. "We" do not pay any remaining part of the loss. This procedure applies to the total of all 'building materials" to which the 'limit' applies. 2. Limits -- The following provisions are added under How Much We Pay: a. Building Materials Limit -- The most "we" pay in any one occurrence for loss to "building materials" is the Building Materials Limit indicated on the Rehabilitation And Renovation Schedule. b. Existing Building Limit-- The most "we" pay in any one occurrence for loss to an "existing building" is the Existing Building Limit indicated on the Rehabilitation And Renovation Schedule. IM 7070 08 12 Copyright, American Association of Insurance services, Inc., 2012 INSURED Policy Number: ILM0707079 RLI Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BROAD ADDITIONAL INSUREDS - BUILDERS' RISK Any person or organization "you" are required in a written contract to show as an Additional Insured is also protected under "your" Builders' Risk coverage to the extent of their financial interest in "your" property. The Limit of Coverage provided for the additional protected persons or organizations will not: a. be greater than the limit required in the contract; or b. increase the Limits of Coverage in this agreement. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. OMIM 604 (08/06) Contains copyrighted material of American Association of Insurance Services Page 1 of 1 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS This endorsement changes CL 0273 07 19 the policy Page 1 of 2 — PLEASE READ THIS CAREFULLY — AMENDATORY ENDORSEMENT TEXAS 1. If this policy covers a one -family dwelling or a duplex, 4) the department has determined that or if this policy has been issued to a governmental continuation of the policy would result in a unit, as defined under Texas regulations, under violation of the Texas Insurance Code or any Common Policy Conditions, Cancellation is deleted other law governing the business of and replaced by the following: insurance in the state. Cancellation And Nonrenewal a. "You" may cancel this policy at anytime by notifying "us" of the date cancellation is to take effect. "We" will send "you" any refund due when the policy is returned to "us". b. "We" may cancel or not renew this policy by delivering or mailing written notice to "you" at the address shown in the policy. Such notice may be delivered by electronic means if "you" have affirmatively consented to that method of delivery and have not withdrawn such consent. Proof of delivery or mailing is sufficient proof of notice. The notice will state the reason for cancellation or nonrenewal. c. If this policy has been in effect for less than 90 days, "we" may cancel for any reason, except that under the provisions of the Texas Insurance Code, "we" may not cancel solely because "you" are an elected official. If this policy has been in effect for 90 days or more, or if it is a renewal of a policy issued by "us", "we" may cancel only if one or more of the following reasons apply: 1) "you" have not paid any portion of the premium when due; 2) "you" have submitted a fraudulent claim; 3) there has been an increase in the hazard covered by this policy that is within "your" control and that would produce a rate increase; or "We" will give "you" notice at least 10 days before cancellation is effective. d. If "we" do not renew this policy, "we" will give "you" notice at least 30 days before nonrenewal is effective. "We" may nonrenew for any reason except that, under the provisions of the Texas Insurance Code, "we" may not nonrenew solely because "you" are an elected official. e. "Your" return premium, if any, will be calculated on a pro rata basis and will be refunded at the time of cancellation or as soon as practicable. Payment or tender of the unearned premium is not a condition of cancellation. 2. If item 1. above does not apply, under Common Policy Conditions, Cancellation is deleted and replaced by the following: Cancellation And Nonrenewal a. "You" may cancel this policy by returning the policy to "us" or by giving "us" written notice and stating the date coverage is to stop. b. "We" may cancel or not renew this policy by delivering or mailing written notice to "you" at the address shown in the policy. Such notice may be delivered by electronic means if "you" have affirmatively consented to that method of delivery and have not withdrawn such consent. Proof of delivery or mailing is sufficient proof of notice. The notice will state the reason for cancellation or nonrenewal. Copyright, American Association of Insurance Services, Inc., 2019 INSURED AAIS CL 0273 07 19 Pace 2 of 2 c. If this policy has been in effect for 60 days or less, "we" may cancel for any reason, except that under the provisions of the Texas Insurance Code, "we" may not cancel this policy solely because "you" are an elected official. If this policy has been in effect for more than 60 days, or if it is a renewal of a policy issued by "us", "we" may cancel only if one or more of the following reasons apply: 1) the premium has not been paid when due; 2) there has been fraud committed in obtaining coverage; 3) there has been an increase in hazard within "your" control that would produce a rate increase; 4) there has been a loss of "our" reinsurance covering all or part of the risk covered by this policy; or 5) "we" have been placed in supervision, conservatorship, or receivership and the cancellation has been approved or directed by the supervisor, conservator, or receiver. "We" will give 'you" notice at least 10 days before cancellation is effective. d. If "we" do not renew this policy, "we" will give "you" notice at least 60 days before nonrenewal is effective. "We" may nonrenew for any reason except that, under the provisions of the Texas Insurance Code, "we" may not nonrenew solely because "you" are an elected official. If such notice is given to "you" later than 60 days before nonrenewal is effective, coverage remains in effect until the 61 st day after the date on which the notice is provided. Earned premium for any period of coverage that extends beyond the expiration date of this policy will be computed pro rata based on the rate charged for the expired policy. The transfer of a policyholder between admitted companies within the same insurance group is not considered a refusal to renew. e. "Your" return premium, if any, will be calculated on a pro rata basis and will be refunded at the time of cancellation or as soon as practicable. Payment or tender of the unearned premium is not a condition of cancellation. CL 0273 07 19 Copyright, American Association of Insurance services, Inc., 2019 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS This endorsement changes CL 0454 12 00 the policy Page 1 of 1 — PLEASE READ THIS CAREFULLY — AMENDATORY ENDORSEMENT Under the Common Policy Conditions, the Cancellation condition is amended by the following addition: "We" may not cancel or refuse to renew this policy solely because "you" are an elected official. CL 0454 12 00 Copyright, American Association of Insurance services, 2001 INSURED Policy Number: ILM0707079 RLI Insurance Company AAIS This endorsement changes IM 2089 03 19 the policy Page 1 of 3 — PLEASE READ THIS CAREFULLY — AMENDATORY ENDORSEMENT TEXAS This mandatory endorsement must be attached to all b. We Do Not Pay -- "We" do not pay for such Texas policies. repairs or emergency measures performed on property which has not been damaged by a peril 1. Under Definitions, the following definition is added: insured against. "Business day" means a day other than Saturday, Sunday, or a holiday recognized by the state of Texas. 2. Under Definitions, if applicable, the definition of "pollutants" is deleted and replaced by the following: "Pollutant" means a. any solid, liquid, gaseous, or thermal irritant or contaminant; b. electromagnetic (visible or invisible) or sound emission; or c. waste, including materials to be disposed of as well as recycled, reclaimed, or reconditioned. 3. Under What Must Be Done In Case Of Loss, Notice is deleted and replaced by the following: Notice -- "You" must promptly notify "us" or "our" agent in the event of a loss. The notice must be in writing. "You" must promptly notify the police if the loss may have been the result of a violation of the law. 4. Under What Must Be Done In Case Of Loss, You Must Protect Property is deleted and replaced by the following: You Must Protect Property -- "You" must take all reasonable steps to protect covered property at and after an insured loss to avoid further loss. a. Payment Of Reasonable Costs -- "We" will pay the reasonable costs incurred by "you" for necessary repairs or emergency measures performed solely to protect covered property from further damage by a peril insured against. "You" must keep an accurate record of such costs. 5. Under What Must Be Done In Case Of Loss, Proof Of Loss is deleted and replaced by the following: Proof Of Loss -- Upon request, "you" must send "us" a signed, sworn proof of loss within 91 days of the request on a form supplied by "us". "We" must request a signed, sworn proof of loss within 15 days after receipt of "your" written notice or "we" waive "our" right to require a proof of loss. Such waiver will not waive "our" other rights under this policy. a. This proof of loss will state, to "your" best knowledge and belief: 1) the time and cause of loss; 2) "your" interest and all other's interest in the property involved including all liens on the property; 3) other insurance which may cover the loss; 4) the actual cash value of each item of property and the amount of loss to each item; and 5) if applicable, the name of the occupant and the occupancy of the building at the time of the loss. b. If this policy provides replacement cost coverage and "you" elect to make a claim under the "terms" of the replacement cost provision, this proof of loss will also state, to "your" best knowledge and belief: 1) the replacement cost of the described property; and 2) the full cost of repair or replacement of loss without deduction for depreciation. Copyright, American Association of Insurance Services, Inc., 2019 INSURED AAIS IM 2089 03 19 Page 2 of 3 6. In the Data Compromise Coverage form under What Must Be Done In Case Of A Personal Data Compromise, Sworn Statement is deleted and replaced by the following: Sworn Statement -- "You" must send "us", within 91 days after "our" request, a signed, sworn statement. "We" will provide "you" with the necessary forms. 7. Under What Must Be Done In Case Of Loss, Examination is deleted and replaced by the following: Examination -- As often as "we" may reasonably require, "you" must submit to examination under oath and sign and swear to it. If "we" examine a minor, a parent or guardian of such minor may be present during the examination. 8. Under What Must Be Done In Case Of Loss, Records is amended to include the following: "You" will not be required, as a condition of settling a claim, to produce "your" federal income tax returns unless: a. "you" have been ordered to produce such tax returns by a court; or b. the claim involves: 1) a fire loss; or 2) a loss of profits or income. 9. Under What Must Be Done In Case Of Loss, Damaged Property is deleted and replaced by the following: Damaged Property -- As often as "we" may reasonably require, "you" must permit "us" to have access to the damaged property before it is disposed of or repaired. 10. Under Loss Payment, the following provision is added: Acceptance Or Rejection Of Claim -- a. Within 15 days after "we" receive written notice of claim, "we" must: 1) acknowledge receipt of the claim; if the acknowledgment of the claim is not in writing, "we" will keep a record of the date, method, and content of the acknowledgment; 2) begin any investigation of the claim; and 3) specify the information "you" must provide in accordance with the "terms" of the Proof Of Loss condition. b. "We" may request more information, if during the investigation of the claim such additional information is necessary. c. After "we" receive the information requested, "we" must notify "you" in writing whether the claim will be paid or has been denied or whether more information is necessary: 1) within 15 "business days"; or 2) within 30 days if "we" have reason to believe the loss resulted from arson. d. If "we" do not approve payment of the claim or require more time for processing the claim, "we" must: 1) give the reasons for denying the claim; or 2) give the reasons "we" require more time to process the claim. But, "we" must either approve or deny the claim within 45 days after requesting more time. 11. Under Loss Payment, Your Losses, Conditions For Payment Of Loss is deleted and replaced by the following: Conditions For Payment Of Loss -- If "we" notify "you" that payment of the claim or part of the claim will be made, "we" must make payment within five "business days" after "our" notification to "you". If payment of the claim or part of the claim requires the performance of an act by "you", "we" must make payment within five "business days" after the date "you" perform the act. 12. Under Other Conditions, Misrepresentation, Concealment, Or Fraud is deleted and replaced by the following: Misrepresentation, Concealment, Or Fraud -- This coverage is void as to "you" and any other insured if, before or after a loss: a. "you" or any other insured have willfully concealed or misrepresented a material fact or circumstance that relates to: Copyright, American Association of Insurance services, Inc., 2019 INSURED AAIS IM 2089 03 19 Pacie 3 of 3 1) this insurance or the subject thereof; or 2) "your" interest herein; or b. there has been fraud or false swearing by "you" or any other insured with regard to a material fact or circumstance that relates to this insurance or the subject thereof. 13. Under Other Conditions, Your Reimbursement To Us is deleted and replaced by the following: Your Reimbursement To Us -- This provision applies only if the insured is a household goods motor carrier or a household goods freight forwarder. "You" must reimburse "us" all sums for a loss that "we" have paid and that "we" would not have been required to pay except for the attachment to this policy of any federal, state, or other regulatory endorsement. "You" must reimburse "us" within 30 days after "we" have notified "you" that "we" have paid a loss that "we" would not have been required to pay except for the attachment of a required regulatory endorsement. 14. Under Other Conditions, the following condition is added: Catastrophe Claims -- If a claim results from a weather related catastrophe or a major natural disaster, each claim handling deadline shown under What Must Be Done In Case Of Loss and Loss Payment is extended for an additional 15 days. Catastrophe or Major Natural Disaster means a weather related event which: a. is declared a disaster under the Texas Disaster Act of 1975; or b. is determined to be a catastrophe by the Texas Department of Insurance. 15. In all coverage forms except Cold Storage Locker Coverage, Contingent Cargo Coverage, Motor Truck Cargo Legal Liability Coverage, Riggers' Legal Liability Coverage, and Warehouse Legal Liability Coverage, under Other Conditions, paragraph b. of Suit Against Us is deleted and replaced by the following: b. the suit has been brought within two years and one day from the date the cause of action first accrues. 16. In the Data Compromise Coverage form under Other Conditions, paragraph b. of Legal Action Against Us is deleted and replaced by the following: b. the suit has been brought within two years and one day after the cause of action first accrues. IM 2089 03 19 Copyright, American Association of Insurance services, Inc., 2019 INSURED Policy Number: ILM0707079 RLI Insurance Company SIGNATURE PAGE In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative. gqk--od 13 Secretary President ILF 0001 (04/22) INSURED # 09 I NO-] ICE OF MEETING - 11/29/2023 9. Consider and take necessary action to approve a lease agreement with Great American Financial Services for a Toshiba e-STUDIO7518A copier and authorize the District Clerk to sign the agreement. (RHM) pass Page 6 of 11 Mae Belle Cassel From: anna.kabela@calhouncotx.org (Anna Kabela) <anna.kabela@calhouncotx.org> Sent: Monday, November 20, 2023 3:46 PM To: MaeBelle.Cassel@calhouncotx.org Subject: GREAT AMERICA FINANCIAL SERVICES CONTRACT WITH FORM 1295 Attachments: GREAT AMERICA FINANCIAL SERVICES CONTRACT WITH FORM 1295.pdf Hi, Mae Belle! I am asking the Commissioners' Court to consider and take the necessary action to authorize District Clerk Anna Kabela to sign the lease agreement from Great America Financial Services for a Toshiba e-STUD107518A copier. Thank you so much. Happy Thanksgiving! ANNA KABELA District Clerk Calhoun County District Clerk's Office anna.kab el a.@ calhouncotx,ory.. (3611 553-4631. Phone (3611 553-4637 Fax 211 S. Ann - Courthouse, Suite 203- Port Lavaca, Texas. 77979 Calhoun County Texas AGREEMENT GREATAMERICARNANCIAL SERVICES CORPORATION 1♦1♦ n PAYMEWr ADDRESS: : GreatAmerica PO BOX 660831, DALLAS TX 75266-0&11 F 1 N A N. C.1 A L S IS R V I C r.S, AGREEMENT NO.: 1936246 FULL LEGAL NAME' Calhoun. County of ADDRESS: 211 S Ann St Port Lavaca TX 77979.4203 •• EOUIPMENT LOCATION: As Stated Above ('PLUS TAX) TERmwfuct THS: 63 MONTHLY PAYMENTAMWNT': $244.00 PURCHASEDPHow: Fair Market Value amounts us to naw' pay your we begn an the date the Equipment is delNan!d b you or any later date we designs arge you a aria., me origremain lee of $100.00, If we do rot recohm by the due dale, all address indicated on your inw.m. any amour,: payah'e b us, you will pay a late char the greater a: con 110) can's for each dclar overdue or tweny-son den ($28.00): or NET AGREEMENT. THIS AGREEMENT S NON-CANCEL46LE FOR THE ENTIRE AGREEMENT TERML YOU UNDERSTAND WE ARE PAYING FOR THE EQUIPMENT BASED ON YOUR C UNCONDITIONAL ACCEPTANCE OF IT AND YOUR PROMISE TO PAY US UNDER THE TERMS OF THIS AGREEMENT, WITHOUT SET -OFFS FOR ANY REASON, EVEN IF THE EQUIPMENT(' DOES NOT WORK OR IS DAMAGED, EVEN IF R IS NOT YOUR FAULT. ` EQUIPMENT USE You WII keep the Equpment in goad w0di artier, use it fa business purposes only, and not modify cr move tt from its final location without our consent. You mast resolve any dispute you may have cxncemgng the Equipment with the mmukcbrer or Vendor. Payments under this Agreement may Inc£rde amounts you owe your Vmdcr under a sepamle arrangement (for marnlermnca, servtoe, suppfes, et,). which amounts may be invoiced by as on yew Vondoes behal bryour Wnvenience. SOFTWAREIDATA. Except as provided in this, paragraph, retrenas b'Egcpmem' ncude any mMrme referenced above or instilled on the Equipment. We do not am To sotwi m and cannot tamale: any merest In it to Mil. We am not responsible fan the safivare or the &gaTms of you or the licensor sutler any Ikanse agreement You am solely responsible far protecting Bad removing any con£denEadiriu magus shred on too Equipment prior rots return fcrany mason. NO WARRANTY. WE MAKE NO WARRANTIES, EXPRESS OR IMPLIED, INCLUDING WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE YOU HAVE ACCEKEO THE EQUIPMENT "AS•IS". YOU CHOSE THE EQUIPMENT, THE VENDOR AND ANYIALL SERVICE PROMOERIS) BASED ON YOUR JUDGMENT. YOU MAY CONTACT YOUR VENDOR FORA STATEMENT OF THE WARRANTIES, IF ANY. TKAT THE MANUFACTURER OR or tl Me 49reemenl and alyrlem related to Mrs Agreement w ill begovemed by Iowa law. d,ud'mied n a slatear ladeW mu:t bea:M in Linn County, laws. You consent to and venue in such mums and wave bms'er of venue. Each party waives any LOSS OR DAMAGE. You are responsible br any damage to or loss of the Equipment. No such loss or damage wl mreve you from your payment uh(ga ass hereunder. We one ml respms3le kr, and ycu will ndemaidy us against any cla9ns, losses or damages, indudrg aaeTay lees, in any way rebating to the Fqu:prrmnl or data sunned onjit This ndomniy W.3 sumve the ewprztnn of this Armament In no eventwl we be bable for any:Co tsequeneal or Ini iremdamages. THISAGREEMENT IS NON -CANCELABLE FORTHE FULL AGREEMENT OWNER: GreatAmerica Financial Services Corporation a'so agree to: 1) keep the Equipment fully insured against loss at its replacement mM, with in named as Mil payee: and 2) provide proof of treurmw saustachry to in no later lien 30 days folbwhg the commencement of this Agreement, and thorealor upon our written request. K you fal to ma:nlan pmpedy toss Insurance satisfactory to us ardkr you fell to Emery provide picot of such insurance," have the option, but not the ahtgatim, to secure property loss insurance on the Equipmmnt from a camer of our crici in such tons and amounts as we deem reasonable ID protect our interests. If we secure insurance on the Equipment, we will not name Mil as an insured party, your inumists may not be N:ry pralacled. and you w 11 rehnbuse as the premium which may be higher glen the preraum you weed pay if you obtained insurance, and wft may result in a Me Agreement at the tone of lass, my insurance proceMs receAM wA be apt to repair or some the Equipment, or to pay us the remaining payments due by reimbursing us, ail tan due upfront VA be END OF TERM. At the end of the term of this Agreement (air any renewal hum) (the'End Dao% this Agreementwil renew month to mouth um'ess a) we receive wr8km m5ca from you, at least 60 days prior b the End Date, of your intent In return the Equipment end b) you tnaely man the Equipment to the location tlatagnasd by us, at your expense. N a Purchase Opecn is indicated above and you are not in tlefaa:t an the End Dab, you trey puaihase the Epulpmenl from us'AS IS' kr the Purchase Op£cn price. If the returned Equipment is not immediately available kr use by another Without need of mpai, you will reimbone us for all repair msm. You carrot pay of this Agreement or realm am Equ'pmmt prior to the End Oa:o without our Consent. If we mncent, we may charge you, in adai5'm to other amounts owed, an early lamination fee equal to 6%of dw amcunl we paid for the Equipment. OEFAULTIREMEDIES. If a payment betimes 10. days past due, or if you Wienvfso beach this Agresti you w'I be in defeat, aid w• may require that you return me Equipment to us at your excursion and pay us: I of past dal amounts and 2) all meaning payments for the unexpired tram, pin cur hocked ms'ci discounted at 3%per amum: and we may d'sab!a Mrrepcssess to Equipment and no al other legal mm ales avatNye to us. You agree to pay al ousts and taperers (ndujing reasonable atomey fees) we incur in any tl'apule win you related to this Agreement. YW agree a pay us nfereslm a5 past due amountsat the con of 15%per mwtl, a at the highest ram a3owed by app'imV.e law, K less. UCC. You agmt that this Agrec=nt is (artlkr shag the teabd as) a'Flname Lease' as that term isde5ned In Adc'e 2Aoflhe Unifon Commercial We ('UCC7. You agree to forgo the lights and remedws prodded under sectors 507.522 ctAr clo 2A aline UCC. MISCELLANEOUS. This Agreement's the entire agreement between you and us relating to the Equipment and scpesetles any pdx mpro ntaticns or agreements, IMMuding any pumhme orders. An owls payab'e under tk's Agreement may Include a prefl to rs. The panes agree that the odgnal he:eal far enforcement and perfection purposes, and cos sats'fectV mnactu5rg 'chapel papEe rider the UCC, is the paper copy hereof testing G) me ag:nat or a copy of either your must s.gnalum or an dCctot im'',y app'.ed kd. auon of your ntent In enter Into Its Agreement, and (ii) air o igmal manual ragnamre. If airy provision of this Agreement a unenkrmabte, the other provisions herein che'I remain In Al tree and excel to me fullest edent CUSTOMER: The Cusbmernerebycer es Iha ail ale Equipment l)hats hem received,ireto:ed, and nspeVmd,and 2)is bnymembcnal and uatandthmalfyectepued. SIGNATURE: X NAMEAND TIRE: DATE: ZGO1(rL) 0510 11120/23 135 Amendment � GreatAmeri.ca FINANC.IAL ;SER;VICRS This Amendment amends that certain agreement by and between GreatAmerica Financial Services Corporation ("Owner") and Calhoun. County of ("Customer') which agreement is identified in the Owners internal books and records as Agreement No. 1936246 (the "Agreement"). All capitalized terms used in this Amendment, which are not otherwise defined herein, shall have the meanings given to such terms in the Agreement. Owner and Customer have mutually agreed that the following modifications be made to the Agreement. The Section entined INSURANCE is hereby deleted in its entirety and replaced with the following; "You Agree: (a) to keep the Equipment fully insured against loss at its replacement cost; and (b) to maintain comprehensive: public liability Insurance." Except as specifically modified by this Amendment, all other terms and conditions of the Agreement remain in full force and effect. If, and to the extent there is a conflict between the terms of this Amendment and the terms of the Agreement, the terms of this Amendment shall control. A facsimile copy of this Amendment bearing authorized signatures may be treated as an original. This Amendment is not binding until accepted by Owner. GreatAmerica Financial Services Corporation Calhoun, County of Omer Customer By: i ; By., X Signature I Signature Print Name & Tide Date Accepted: Print Name & Title Dale: 013675ZQ31ns_F1107 NON -APPROPRIATION ADDENDUM This is an addendum ("Addendum's to and part of that certain agreement between GreatAmerica Financial Services Corporation ("we", "us", "our") and Calhoun, County of ("Governmental Entity", "you", "your"), which agreement is identified in our records as agreement number 1936246 ("Agreement"). All capitalized terms used in this Addendum which are not defined herein shall have the meanings given to such terms in the Agreement. APPLICABLE TO GOVERNMENTAL ENTITIES ONLY You hereby represent and warrant to us that as of the date of the Agreement: (a) the individual who executed the Agreement had full power and authority to execute the Agreement on your behalf, (b) all required procedures necessary to make the Agreement a legal and binding obligation against you have been followed; (c) the Equipment will be operated and controlled by you and will be used for essential government purposes for the entire term of the Agreement; (d) that all payments due and payable for the current fiscal year are within the current budget and are within an available, unexhausted, and unencumbered appropriation; (a) you intend to pay all amounts payable under the terms of the Agreement when due, if funds are legally available to do so; (f) your obligations to remit amounts under the Agreement constitute a current expense and not a debt under applicable state law; (g) no provision of the Agreement constitutes a pledge of your tax or general revenues; and (h) you will comply with any applicable information reporting requirements of the tax code, which may include 8038-G or 8038-GC Information Returns. if funds are not appropriated to pay amounts due under the Agreement for any future fiscal period, you shall have the right to return the Equipment and terminate the Agreement on the last day of the fiscal period for which funds were available, without penalty or additional expense to you (other than the expense of returning the Equipment to the location designated by us), provided that at least thirty (30) days prior to the start of the fiscal period for which funds were not appropriated, your Chief Executive Officer (or Legal Counsel) delivers to us a certificate (or opinion) certifying that (a) you are a state or a fully constituted political subdivision or agency of the state in which you are located; (b) funds have not been appropriated for the applicable fiscal period to pay amounts due under the Agreement; (c) such non -appropriation did not result from any act or failure to act by you; and (d) you have exhausted all funds legally available for the payment of amounts due under the Agreement. You agree that this paragraph shall only apply W, and to the extent that, state law precludes you from entering into the Agreement if the Agreement constitutes a multi -year unconditional payment obligation. If and to the extent that the items financed under the Agreement islare software, the above -referenced certificate shall also include certification that the software is no longer being used by you as of the termination date. The undersigned, as a representative of the Governmental Entity, agrees that this Addendum is made a part of the Agreement. ZGVNANC 0320 CERTIFICATE OF INTERESTED PARTIES FORM 1295 1011 Complete Nos. i • 4 and 61f there are Interested parties, OFFICE USE ONLY Complete Nos,1. 2. 3, S. and 61! there we no Imeorwao parties. CERTIFICAT)ON 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. 2023-1096285 DEWITT POTH & SON, LLC YOAKUM, TX United States Date Filed: 11120/2023 Name of governmental tent y ar state agency that Is a parry to the contract tar c the roan is being filed. Calhoun County Date Acknowledged: 3 Provide the Identification number used by the governmental entity or state agency to track or identity the contract, and provide descripdon of the services, goods, or other tomperry, to be provided under the contract. 1936246 COPIERS b Name of Interested Parry City, State, Country (place of business) Nature of Interest (cheek applicable) Controlling Intermediary Dewitt Poth & Son, LLC Yoakum, TX United States X 5 Check only It there Is NO Interested Party. ❑ 6 UNSWORN DECIARATiON My name Is JESSIE LEMKE and my date of birth Is , Myeddressis 102WESTST YOAKUM TX 77995 u5 itbeet) 0mr) (slate) (ZIP coda) (rnunlry) I declare under penalty of perjury that the foregoing is true and correct. Executed In DEVATT County, State of TEXAS . on the 20 day of NOVEfABER, 20 23 , (month) (year) Signature of a th lrized agent of contracting business entity (Dedaram) Forms orovided by Texas Ethics Commission w,vw.ethfcs.stwA.tx.us Version W.S. 1.01`381ah6 #10 NOTICE OF MEETING—11/29/2023 10. Consider and take necessary action to declare the attached list of equipment from the District Clerk's Office as Waste. (REM) RESULT: APPROVED [UNANIMOUS] MOVER: Vern Lyssy, Commissioner Pct 2 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 7 of 11 Calhoun County, Texas WASTE DECLARATION REQUEST FORM Department Name: Calhoun County District Clerk's Office Requested By: Anna Kabela, District Clerk Inventory Number Descri tion Serial No. Reason for Waste Declaration Fellows Desk Shredder PS-77Cs Broken Patton jriootHeater PUH682 Broken yr„ IIII7/ZD Z3 #11 I NOTICE OF MEETING - 11/2.9/2023 11. Consider and take necessary action to declare a 2011 GMC pickup VIN # 2GTP2WE29BG275578 from Precinct #1 R & B as Surplus/Salvage. (DEH) RESULT: APPROVED [UNANIMOUS] MOVER:. Joel Behrens, Commissioner Pct 3 SECONDER: 'David Hall, Commissioner Pct 2 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 8 of 11 David E. Hall Calhoun County Commissioner, Precinct #1 202 S. Ann Port Lavaca, TX 77979 Honorable Richard Meyer Calhoun County Judge 211 S. Ann Port Lavaca, TX 77979 RE: AGENDA ITEM Dear Judge Meyer, (361)552-9242 Fax (361)553-8734 Please place the following item on the Commissioners' Court Agenda for November 29th, 2023. • Consider and take necessary action on Surplus Salvage Declaration form Sincer I L . David . Hall DEH/apt Calhoun County, Texas SURPLUS/SALVAGE DECLARATION REQUEST FORM Department Name: RB1-540 Requested By: Commissioner David Hall Inventory Reason for Surplus/Salvage Number Description Serial No. Declaration 2011 GMC pickup 12GTP2WE29BG275578 I Frame Rusted #12 NO-1 ICE OF MEETING—11/29/2023 12. Approve the minutes of the November 15, 2023 meeting, APPROVED [UNANIMOUS] Vern Lyssy, Commissioner Pct 2 t: Joel Behrens, Commissioner Pct 3 Page 9 of 11 Richard H. Meyer County judge David Hall, Commissioner, Precinct 1 Vern Lyssy, Commissioner, Precinct 2 Joel ]Behrens, Commissioner, Precinct 3 (Gary Reese, Commissioner, Precinct 4 The Commissioners' Court of Calhoun County, Texas met on Wednesday, November 15, 2023, 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. Attached are the true and correct minutes of the above referenced meeting. 47 Richard H. Meyer, Cou Judge Calhoun County, Texas Anna Goodman, County Clerk Deputy Clerk - Z`%- 'Z 0- -- Date i I -aq a-3 Date Page 1 of 1 NOTICE OF MEETING—11/.15/2023 November 15, 2023 MEETING MINUTES RQRS OF CALHOUN COUNTY COMMISSIONERS' COURT MET IN A REGULAR MEETING 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. THE FOLLOWING MEMBERS WERE PRESENT: Richard Meyer David Hall County Judge Vern Lyssy COmmISSloner.Pct 1 Joel Behrens Commissioner Pct 2 Gary Reese Commissioner Pct 3 Anna Goodman Commissioner Pct 4 By: Kaddie Smith County Clerk Deputy Clerk The subject matter of such meeting is as follows: 1. Call meeting to order. Meeting was called to order at 10:00am 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. Cindy Krause thanked commissioners for their work. S. Hear reports from Calhoun County AgriLife Extension agents, Emilee DeForest, Halley Hayes, Stephen Biles and Karen Lyssy gave their reports and updates of the last few months. Pagel of 5 NOTICE, OF MEETING— 11/15/2023 6. Public Hearing regarding a Request to Vacate and Abandon a portion of unconstructed public road being a 0.469-acre tract of land situated in the Jose Mancha Survey, Abstract No. 236, Calhoun County, Texas, and being a portion of Foester Street (a 60- foot Right -of -Way), Luccia Subdivision of Tilke and Crocker First Addition according to the established map or plat thereof and being more fully described by metes and bounds in the Posted Notice and Application. ClEsed ibEMnn Dennis Aririaga pco.fained regluesttd vacate- Oened IK 2iDS3Qaln 7. Consider and take necessary action on a Request to Vacate and Abandon a portion of unconstructed public road being a 0.469-acre tract of land situated in the Jose Mancha Survey, Abstract No. 236, Calhoun County, Texas, and being a portion of Foester Street (a 60-foot Right -of -Way), Luccia Subdivision of Tilke and Crocker First Addition according to the established map or plat thereof and being more fully described by metes and bounds in the Posted Notice and Application. (DEH) RESULT' APPROVED [UNANIMOUS] MOVER Dayid Hall; C&ninlssioner.Pct 1 SECONDER Vern Lyssy, Commissioner Pct 2 AYES: `Jude Meyer, CbmrnissloherTall, Lyssy, Behrens, Reese' 8. Consider and take necessary action to approve the Scope of Work contract documents between Mott Macdonald and Calhoun County for the Crabbin' Bridge Project and authorize all appropriate signatures. (DEH) RESULTS APO-W ED [UNANIMOUS] N[OVER, .,:: David Hall, Commissioner PcE,1 SECONDER Vern Lyssy, Commissioner Pd 2 AXES Judge Meyer, Corilmissioner Ha11, Lissy, Behrens, Reese ` 9. Consider and take necessary action to approve the contract documents between Matagorda Bay Mitigation Trust and Calhoun County for the Crabbin' Bridge Project and authorize all appropriate signatures. (DEH) RESU LT. ' APPROVED [UNAN31MIOUSj MOVER• David Hall,..,Commissioner Pct 1 �5ECC.— DERV Vein Lyssy, Comm ssiorreP•Pct 2 / Y-' E Judge'Meyer, Commissioner Hall, yssy, Behrens, Reese Page 2 of 5 i NOTICE OF MEETING;-11/15/2023 10. Consider and take necessary action to amend the Contract for Professional Services between Calhoun County and G & W Engineers, Inc. for Engineering, Architectural and Surveying Services for the Combined Dispatch Building. The Changes being made are referenced in Attachment B in the amended contract. (DEH) scoff M2WD0 with-G&HIV engineers explained the changes RESULT. APPROVED [UNANIMOUS] MOVER• Gary Reese, Commissioner Pct 4 SE.CONDEFt Vernjyssy, Commissioner P)t 2 AY9S* Judge Meyer, Commjssioner_Hall, Lyssy, Behrons, Reese 11. Consider and take necessary action to accept a donation from the M.G. and Lillie A. Johnson Foundation, Inc. in the amount of $275,000.00 to construct a building to house a First Responder Training Facility and authorize the EMS Director to sign the grant acceptance letter. (RHM) i )r 7LTi . APPROVED,[UNANIMOUS]. MOVER, David Halt; Cdhimissioner PdI SECONDER 9oel Behrens, Ommissioner Nt 4 Judge Meyer, Commissioner H[I, Lyssy, Behrens, Reese= 12. Consider and take necessary action to approve the Specifications and Invitation to Bid Packet, Bid Number 2023.09 for the following combined services: Inmate Telephone Services and Inmate Banking Software, Commissary Service and Fiduciary Management Services for the Calhoun County Adult Detention Center for the two-year period beginning February 15, 2024 and ending February 14, 2026 with the option to renew yearly for one-year terms upon Commissioners' Court approval and authorize the County Auditor to advertise for bids. Bids will be due before 2:00:00 pm, Tuesday, January 16, 2024. (RHM) RIESULT: = APPROVED [UNANIMOUS] M`CVER Uern Lyssy,..-Commissioner Pet 2 SECONDER. Gary Rees.e 'Commissioner'Pct 4 AYES Judge Meyer, Com. missioner'Hall, Lyssy, Behrens, Reese 13. Consider and take necessary action to approve the renewal option for the contract between Calhoun County and Performance Food Service/PFG for Food Services for the Calhoun County Adult Detention Center for the contract year beginning January 1, 2024 and ending December 31, 2024 and authorize the County Judge to sign all necessary documents. (RHM) RESULT:'; APPROVED [UNANIMOUS] MOVER. :Vern Lyssy, Commissioner PGt 2 : . ,$&I)NDER. Joel Behrens; Commissioner Pot 3 ALES: Judge Meyer., Commission@r Hall, Lyssy, Behrens, Reese Page 3 of 5 I NOTICE OFMEETING—11/15/2023 14. Consider and take necessary action to approve the Canvass Report with Official Results of the Calhoun County, Texas 2023 Constitutional Amendments Election. (RHM) 15. ConsIder and take necessary action to approve the purchase of CopSync for all Calhoun County Constables to be compliant with state regulations to submit monthly reports to the Texas Depart of Public Safety. (RHM) pass 16. Accept Monthly Reports from the following County Offices; i. County Clerk — October 2023 !I. District Clerk — August 2023, second revision iii. District Clerk — October 2023 iv. Justice of the Peace, Precinct 4 — October 2023 v. Texas Agrillfe Extension Service — October 2023 1. 4-H and Youth Development 2. Agriculture and Natural Resources 3. Family and Community Health 4. Coastal and Marine esuLt. - ---APPRNED cbmkirmouti 0)6',.1 Commissioner n: L -SE P l8sloner Wh.m pct I., AYES tdgeMayeh-Clam: Misiloner Hell, Lyssy, Pehreli%:Reese.. 17. Consider and take necessary action on any necessary budget adjustments. (RHM) UNAW RESULT:. APPROVED lmbusi] Gary -Reese, Commissioner Ptt MOVER. Gary 4 SECQN!69R•.��-�: bi 86htoens,,C ommissioner pct 3 AYES -Judge Meyer�. onmit rH-411'I Lyssy Behrens Reese. Page 4 of 5 i NOTICE OF MEETING-- 11/15/2023 18. Approval of bills and payroll. (RHM) Go:unty Bills - RESULT, APPROVE iD [U0010.4IDUSy , MC Y�R. 0. vid Hall; Commissioner Pct X SECON6ER: Vern Lyssy, CbmmissloW U 2 AYES Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese:. Adjourned 10:48am Page 5 of 5 #13 I NO I ICE OF ME_ETIN(i--11./29/2023 13. Consider and take necessary action on any necessary budget adjustments. (RHM) RESULT: APPROVED [UNANIMOUS] MOVER: Gary Reese, Commissioner Pct 4 SECONDER: Joel Behrens, Commissioner Pct 3 AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese Page 10 of 11 �mulawo 6 )� � §z § §K & 2 2 k Uzi q 7 2 2 ■ & � � � @ ■ z B § i L .§ § § a § 2 U 2 0 .� 0 w � § §w K O� B § U / ■ LU § k -) :0 :z !z )§ )� )L )§ e ■�"_£EE® § §�aaaasa ■B} §§aaasaa §�aa____ . § �SS&&�F� �»&»< < 000w o. of ;22222; §I$IR±3§ �■o |C.4 !0 �z :■ :L �§ � z 0 0 � � z . ■��\\� ;© ■ — |�� Ez �� Lu gill �. ■ . \ § � _ � ■ & ■e _ [ )$ ( E k� S Em �° � k , §) § §© ■ ; a \k : 1 z ( iL -z S (W $ § ! z. k� ) )■ B § �' !� § 93 @ k � \( ' )lu �■ ' §we\7/«° c §f0\\0® §� _ §�%aaa° QI ! f 2- aaaaa a saa°a fill _ a � § ■ § ■&ww; § }\� m 2 R. § � U _22! ■ ■m0 c lq § ■__, o ¥� I- | § k § $ / � to uj COL to § K IL . l ee §\/» §$ KSa/ § |§■ �$ k/\\\ / j \ �M |o ;z Ez (§ )r (� )§ F� §® _■ §2 :z :■ ■ § :� I- :w ; § 3 i) § B - E . 19 �LLI \ !� § § ■ ! § I al 0 w k ( 2 § §§§}\ -■ ■w0 f§2 G ■sae z § §§aa §2 § LU � �§aa B §� uj § § �SS&� t <«� o 222% / 0®&®� LU CL a ■ m .§ § } ) » § § \/ ; z §)j �-_ §jU) 'k.% ` � § § � §\\\ �� I $ k � k j LU § � a z §ms §� §■ � § ( � § % § z � LLI k B 0 Z 4. § LU . f.z :§ � § ■ • ■ ; § ■ B 1 Z 0 �i at o LC I WIFA 191 V) w a a N F- C K m W W ? J 2 U 2> Z o 0 N O Q UMin J a 0 x ro Q J z C7 0 O ui w 0 K a z U. rn rn rn rn B Coco hill `a e �Qz z Qz z2 K KKK ,¢ (9 C7 C7 C7C O O O O C z z z z z e = OM @ T S a - m a -MCI m m m rn a U) w w LL W W O ma- ¢¢O r, D z uj m 0 LL m 0 H a1 `w z(D0 a w z K 7 00 p W 0 0 F-w ? ui °> Q�� CIO N O O W v M O M (a (O Off = r � � `o v M � m 0 =Z 0. 'o k 0 z I- LLI � L § 2 7 k z Q) B 7 2 2 ■§ " §■ 21 k� k� al =1 / k� § 2| \| §| al �al k ! 2 k a z � � § § IN � � al a z z § � � § §ae B�B 2 §�@ §\ § B a � U § K 2 7 uj ? § k 7 2 2 � ■—■Q§ § Es ) ■w^® _ / .■2& io ■ & § - $ )N §z` §k�� 2 s zlu �. §�22 :CL EIL :§ a §§. § §§aa §■ � § a = ■ :z ! § ■ - :W ; ? §&G :L z00 z )� ■ ) ■ S IC = § u — k ) 2 =� ui j� 0 uj a. § e !a =■ .o B )a )a z ) § § )z ■_Z § & z § ■ (\ )§ ) ; $ I- \ k � ■ =CL �j I� � ■ « B % § to #14 NOTICE 01-. MEETING—11/29/2023 14. Approval of bills and payroll. (RHM) MMC Bills RESULT: APPROVED [UNANIMOUS] MOVER: David Hall, Commissioner'Pct 1 SECONDER: Vern Lyssy, Commissioner Pct 2 - AYES: Judge Meyer, Commissioner Hall, Lyssy, Behrens, Reese County Bills RESULT: APPROVED [,1 MOVER: David Hall, Cor SECONDER: Vern Lyssy, Co AYES: Judge Meyer, ( IMOUS] oner Pct 1 loner Pct 2 ssioner Hall, Ly! Adjourned 10:40am Page 11 of 11 MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---November 29 2023 TOTALS TO BE APPROVED - TRANSFERRED FROM ATTACHED PAGES E0TALPAYAB� ESQ PAYROLL AND ELECTRONfc BANK PAYMENTS _ $ 3CE� 823 &8,;, ✓ �E'Els[LILT'ErJkNSEERS,�EiYIWEEN�EUNQS_ S __ ttxak,3.'fs` �/ TAL NtiRStN kmME'beL EkPENSS ti0%tLfnrT-�ar�E�eNnrt��I�A�is�ER�, ,/ MEMORIAL MEDICAL CENTER COMMISSIONERS COURT APPROVAL LIST FOR ---November 29 2023 PAYABLES AND PAYROLL 1112212023 Weekly Payaales 11/22/2023 Patient Refunds 1112712023 McKesson-3'40B Prescription Expense 11/2712023 Amerisoume Bergen-34013 Prescription. Expense Prosperity Electronic Bank Payments 11120-11/24123 Pay Plus -Patient Claims Processing Fee. 1 L24/2023 ExperiPay child support ff YI C`IaA� E4 L"ES,`P8l1iELtlLB E NOP CTriF1NC :BANtC PAYMENTS1 TRANSFER BETWEEN FUNDS FROM MMC TO NURSING. HOMES 11/22/2023 MMC Operating, to Crescent -correction of NH insurance payment deposited'. into MMC Operating in error 1112212023, MMC Operating, to Golden Creek correction of NH insurance payment deposited into MMC Operating ; in error 1112212023. MMC Operating. to Gulf Pointe Plaza -correction of NH. insurance payment deposited into MMC Operating, 1.112212023 MMC Operating to Bethany -correction of NH'.. insurance payment deposited. into: MMC Operating. T+it'f,iEiiCSiEES07N FtI"Ch NURSING HOMEUPL EXPENSES 1112712023 Nursing Home. UPC-Cantex Transfer. 11127=23 Nursing Home UPL-Nexionn Transfer 11127/2023. Nursing Home UPL-HMG Transfer 11127/2023 Nursing Home. UPL-Tuscany Transfer 11127/2023 Nursing Home UPL-HSL Transfer QIPP CHECKS TO MMC 1112T12023 Ashford: 1.11271202.1 Broadmoor 1112712023 Crescent 1112712023. Fort Bend 1.1127/2023 Soiera 11/2712023 Tuscany ''��T [tCdii56N�i-[Qi9![F ttPOs; EltPElii3 364,443,95 1,47M6 2,892.44 1,228.80 207.94 870.69 $ ` 3m&23 68': 4,560.00' 6„130,57 576.91 30577 771,790.72. 157,339,68 71,265A0 107,589.17 49,41..3.70 32,764.41 12„116-.44 9,031.75 10,226.72. 9,809,87 191369r63 S 'ItB�6,T�a; INTER -GOVERNMENT TRANSFERS 11127120231GT QIPP Second Half of Year? SFY2,4 to be paid Oecember04,. 2023'.. $1,983,403.28. 1112712023 IGTRAPPS to be paid November30, 2023 25,379,561 110'rEl z[l Y i` EkY N1YAr FT"FIE"' _ $2Qb��8�yH44 Gft_ tL8:'2Q23 x ,„�itI889B< Page l of 12 ?"ECEXt' D5V7w r46¢p7Y aaantmrx�gitAtiM la/ 2 2023 11/22/2023. ;,2at 4k 094P0F 1iE Vendor# Vendor Name 10950 ACUTE CARE INC .Invoice# Comment INV15361 MEMORIAL MEDICAL CENTER AP Open, Invoice List Due Dates Through: 12115/2023 Class Pay Code. 0. ap upen_invoice.template Tran Ot Inv Dt Due Dt Check D: Pay Gross Discount No -Pay Net 1,112112011/20/201.2/1.5120 1,400.00 0.00'. 0;00 li,400.00, u/ RFID. FEE. Vendor Totak Number Name: Gross. Discount No -Pay Net. 10950 ACUTE CARE. INC 1.,400.00 0.00. 0.00 11,400.00 Vendor# Vendor Name: Class. Pay Code r' R1200 ADTCOMMERCI'AL. Invoice# Comment Tran Dt Inv Dt Due Dt Check D: Pay Gross. Discount Na-Pay Net. 152728377 11/21/201110512011130/20 53.61 0.00' 0100. 53.61 FIRE MONITORING Vendor TotaleNumber Name Gross. Discount No -Pay Net R1200 ADTCOMMERCIAL 53.61. 0.00. 0.00' 53.61 Vendor#Vendor Name / Class Pay Code t4846 AMERICAN HOSPITAL ASSOCIATION Invoice# Comment Tran or Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net f. 570683./ 11120/2011/1512012115/20 5,900.00 0.00' 0.00 �+ 5,000.00 ✓'" PLEDGE: -SW HW S24 VICTORI Vendor Totals Number- Name Gress. Discount No -Pay Net. 14846 AMERICAN HOSPITAL ASSOCIATION 5,000.00 0.00 0-.00 5,0.00,00 Vendor# Vendor Name Class- Pay Code. A22118. AQUA: BEVERAGE: COMPANY .�^'� M. Invoice# Comment Trap Dt Inv Dt Due Dt Check: D Pay Gross Discount No -Pay Net 9302023 11/21/20 09/30120 10/26/20 51.50 0.00 Q100 54.50: •"`� WATER' 14RO 11121/2010/311r201.1/26120 12.00 Oi00 0,00 12.00 1$401 LATE FEE Vendor Total,, Number Name Grass. Discount. No -Pay Net: A2218: AQUA. BEVERAGE COMPANY 53,50 0.00 0,00 63.50 Vendor# Vendor Name ,. Class. Pay Code 11756 AYA HEALTHCARE ING- Invoice# Comment Tran. Dt Inv Dt Due: Dt Check D Pay Gross. Discount No -Pay Net 3701925W,/ 11/21/2011/1.612012115/20 2,,976.75 0.00: 0.00 2;976.75 KARI'ANN DUNN 11.17.11/9123 LVPJ .. Vendor TotalsNumber Name Gross Discount No -Pay Net. 11756 AYA HEALTHCARE INC 2,976,75 0.00 0.00 2,976,75 Vendor# Vendor Name Class Pay Cade / $1150 BAXTER'. HEALTHCARE.! W" Involce# Comment Tran Dt Inv Ot. Due Dt. Check D Pay Gross Discount No -Pay Net 806498721(11/1.5/2010/09t2011/09/20 43.06 0.00 0.00 43.00 ✓" SUPPLIES 80785093J/1.1/15/2010/2312D 11/17/20 361.65 0.00. 0.00'. 361..65 )UPPLIES - 80932158 11/i5/2011/02/2011/2TE2Q 262.92 0.00 0.00 282.92. 41'~� SUPPLIES Vendor Tot&Number Name Gross. Discount No -Pay Net. B1150 BAXTER HEALTHCARE 667.63' 0.00 0'.00. 667.63 file:///C:/Users/Itrevino/cpsi/memmed.cpsinet.com/U88 l25/data_5/tinp_ew5report 14121... 11/22/2023 Page 2 of 12 Vendor# Vendor Name Class.. Pay Code 11544 BAY STORAGE: Invoice# Tran. Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net. /Comment 20230263 1/1.1121/2011/01/2012/01/20 2,82000 0.00: 0.00 2,820.00 DEC23-MAY24 #175118011,91/25$ Vendor Totals Number Name. Gross. Discount No -Pay Net 1.1.544 SAYSTORAGE 2,82000 0.00 0.00 2,320.001 Vendor#Vendor Name Class Pay Code B1220 BECKMAN COULTER INC ✓' l M. Invoice# Comment Train . Dt Inv Dt Due. Dt Check D' Pay Gross Discount No -Pay Net 110884731 �/ 11/01/20 0912712010122/20 1,808.62 0.00 0.00 1,808.62 ✓� SUPPLIES 110960331 11115/201110612012/01/20 1.513W(iia 0.00: 0.00 15,359168' ✓' 1109856206/ 11/20/2011/161201211.1120 1,472,49 0.00 0.00'. 1,472.49+f SUPPLIES 110970146 1111221201111,0/1.9 12/0511.9 77.25 0.00 0,00 77.25 ✓'r `-SUPPLIES 5481,023 J 111221201111312012108/20. 5,0016.58 0�00 0.00 ,. 5,01'.6,58, "f CONTRACT Vendor Totals Number Name Grass Discount No -Pay Net 81'.220 BECKMAN. COULTER INC 23,744.62. 0,00: 0.00, 23„744.62 Vendor# Vendor Name Class Pay Code. B1'..320' BEEKLEY CORPORATION r`A M: Invoice# Co manTran. Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net: MIN0025262 11/1512008/1512009116/20- 311..00 0.00: 0.00 311'..00 SUPPLIES ,. Vendor Totals Number Name, Grass: Discount No -Pay Net B1320 BEEKLEY CORPORATION. 311.00 0.00 0.00 31'..1_00 Vendor# Vendor Name Class Pay Code / 81650 BOSARTLOCK & KEY INC rf"' M Invoice# Comment Trani Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net / 1.27175' 11121120 11/14120 12101/20 213.95 OAO 0.0o 213.95 KEYS Vendor Totals Number Name. Gross. Discount No -Pay Net B650 BOSARTLOCK&KEYING 213.95. 0.00 0.00 21'.3.95 Vendor# Vendor Name Class- Pay Code: $1655' BOSTON SCIENTIFIC CORPORATION' ✓ M. Invoice# Comment Train Dt Inv Dt Due Dt Check Pay Gross Discount No -Pay Net 995343835,/ 11/15/2011/0712012107/20 759.00 0.00: 0.00 759.00 SUPPLIES ,. Vendor Total:: Number Name Grosse Discount No -Pay Net 811655'. BOSTON SCIENTIFIC CORPORATION. 759,00. 0.00 0.00: 759.00 Vendor# Vendor Name Class. Pay Code 11.224 CABLES AND SENSORS ✓ Invoice# Comment Tran Dt Inv Dt Due Ot. Check D Pay Gross Discount No -Pay Net / 158285. 11/0112010/2312091/22/20 88,00 0.00 0.00 88.010 SUPPLIES Vendor 'Totals Number Name Gross: Discount No -Pay Net. 1..1224 CABLES AND SENSORS 88.00 0100 0.00 88.00 Vendor# Vendor Name Class Pay Code file:///C:lU serslitrevino/epsi/memmed.cpsinet. com/u88125/data_5/tmp_cw5report19121... 11 /22/2023 Page 3 of 12 11295 CALHOUNCOUNTY INDIGENT ACCOUN ,,/ Invoice# Comment Tran Dt Inv Dt Due or Check D' Pay Gross Discount No -Pay Net 11121'.23 11/21/2011.121/20 11/22/20 10.00 0'.00 0.00 10'A0 L ,, INDIGENT ,. Vendor TotalE Number Name Gross. Discount No -Pay Net 11295 CALHOUNCOUNTY INDIGENT 'ACCOUNT 10.00 0.00' 0.00 10.00' Vendor# Vendor Name Class Pay Code C1325 CARDINAL HEALTH'. 414, INC./ W Invoice# Cornment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount. No -Pay Net. 8003351538 / 11/20/2011/05/2011130120 165.47 0.00 0.00 165.47 SUPPLIES Vendor TotaIFNumber Name. Grosse Discount No -Pay Net C1325 CARDINAL HEALTH 41'.4, INC.. 165.47 0.00 0.00 165.47 Vendor# Vendor Name Class Pay Code 12768 CHEMAQUA w/ Invoice# Comment Tran. Dt Inv Dt Due Dt Check. D` Pay Gross. Discount: No -Pay Net 8460081✓ 11/21/2011/10/20: 11/20/20 593.69 0.00 0.00: 593.69, WATER. TREATMENT Vendor 'ToWIENumber Name Gross Discount. Na-Pay Net 12768' CHEMAOUA. 593.69 0.00 0.00 593,69' Vendor# Vendor Name Class Pay Code 15060 CHRISTY SILVAS wf Invoice# Comment Tran Dt Inv DI Due Dt Check D Pay Grosse Discount. No -Pay Net 1121'.23 11/21/2011191120. 11/29/20 93A8 0.00: 0.00 93.68'. rr TRAVEL REIMS-TORCH'. CONE �tU44Wi;aa. U,�,t vvv- .. Vendor Totals Number Name Grosse. Discount No-Psy Net. 15060, CHRISTY SILVAS 93,68: 0.00 0.00 93.68 Vendor# Vendor Name Class Pay Code 10786 CLINICAL PATHOLOGY ✓- en Invoice# Ct Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No,Pay Nel: 17656-2023t0cm . 11/21/20 10/31/20' 11/26/20 20,065.83 0.00 0.00 20,065.83 f LAB SERV Vendor Totals Number Name Gross Discount No -Pay Net 10786. CLINICAL PATHOLOGY 20,065.83 0.00 0100 20.065.83 Vendor# Vendor Name, Class Pay Code 11 C1166 COASTAL OFFICE SOLUTONS.✓ W Invoice# Corn ant Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net. OE-QT-2---, '.. r" 11/01/20 08/11/20. 08/21/20 1199.98 (X00 0'00 1.99198 r/ SUPPLIES. Vendor Total§.Number Name. Gross Discount No -Pay Not C1166 COASTAL OFFICESOLUTONS 199.98 0.001 0.00 1.99.98, Vendor# Vendor Name. Class Pay Cede 14292 DEARBORN. LIFE INSURANCE. COMPAN. pf Invoice# Comment Tran: Dt Inv Dt: Due Dt Check D Pay Gross Discount No -Pay Net. 111323 1.1/21/2011/1362612/13/20 4,1.79.36 0.00 0.00 4,179.38 LIFE INSUR. t 111 - V1-131173� . VendorTotalt Number Name Gross. Discount No -Pay Net 14292. DEARBORN. LIFE INSURANCECOMPAN 4,179.36 0.00 0.00 4,179.38 Vendor# Vendor Name Class Pay Code 14800 DIRECTV ENTERTAINMENT HOLDINGS u/1 Invoice# Comment Tran. Dt Inv Dt Due Dt Check D Pay Grosse Discount No -Pay Net file:/1/C:1Userslltrevinolepsilmenuned.cpsinet.comlu88125/data 51tmp_cw5reporti9121... 11/22/2023 Page 4 of 12 088862205X21.112 1 1112012011112/2012O1120 487.25 0.00 0.00 487.25 SATELLITE Vendor Totals Number Name Gross Discount No -Pay Net 14800 DIRECTV ENTERTAINMENT HOLDINGS 487.25 0.00 0.00 487.25, Vendor# Vendor Name Class Pay Code / 10789 DISCOVERY MEDICAL NETWORK INC ✓ Invoice# Co`rr�ment Tram Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net MMC111523 I 11/22/2011/2212011123/20. 134,104.79 0.00 0.00 134,104.79, y/ PHYSICIAN SERV � tt 170--7� VendorTotale Number Name Gross. Discount No -Pay Net 10789' DISCOVERY MEDICAL NETWORK INC 134,104.79 0.00. GAD 134,104.79 VendorC Vendor NameClass Pay Code C2510 EVIDENT ✓f M Invoice# Comment Tran Dt Inv or Due Dt Check D Pay Gross.. Discount No -Pay Net T231'..1151378 ✓ 11/21/201.111512011116/20 7,678.86. 0.00 0.00 7,678.86: BUSSERVICES Vendor Totals Number Name Gross. Discount No -Pay Net. C251.0 EVIDENT 7.678.86 0.00 0.00 7,678.86 Vendor# Vendor Name Glass Pay Code. F1400 FISHER HEALTHCARE M Invoice# Comment Tran Dt Inv Ot Due Dt Check D Pay Gross Discount No -Pay Net P677059 ,// 11/01/20 05/03/20 05/28/20 $4.02 0,00 0.00 84.02 ✓`� SUPPLIES 3631699 t.✓t 11/01120 06108/20 07103/20 33.20 0100, 0.00: 33.20� SUPPLIES 5058767 ✓ 11/01120 08/02/20 08/27/20 107.69 0.00. 0,00 107.69 SUPPLIES .. 5469362111011200811.772009111/20. 826.45 0,00. 0.00 826.45 . SUPPLIES .. 01..08887 j° 1110.1120 09/12f2010/07120 1,277.54 0.00. 0100 1,277.54 � SUPPLIES. .. 7481.604. 11/1,5/2011/02/201'.1/27/20 1.011.92 0.00 0.00 101i.92 ^ SUPPLIES 75164.02/ 11/1512011103/201I1/28120: 5.84 0.00 0.00, 5.84 SUPPLIES . 7590258. ✓'� 11/15/20 11107120 12/02/20 328'.78. 0.00 0.00 328,78 yd.' SUPPLIES 7590257y/'7 1111512011/07/2012102/20. 819.15 000'. 0.00 619.'15 ✓"` SUPPLIES 76e5869 "'`� 11/15120 1.1109/20 12/04/20 1140.84 0.00. 0.00 1':40.84.r^r SUPPLIES 766,9870 11115/2011109/20. 12104/20. 1,047.47 0.00 0.00 1,047.47,,,,,`' Vendor Totals Number Name Gross Discount No -Pay Net F1400 FISHER HEALTHCARE 4,572,20 0.00 O.Oo 4,572.90 Vendor# Vendor Name , Class Pay Code. 14156. FUJI. FILM ✓ Invoice# Tran Dt Inv Dt Due Ot Check D Pay Gross Discount No -Pay Net ,r 'Comment 911398742 11/21120 10125/20 11125120 7,908.33: 0.00 0,00. 7.906.33' CONTRACT VendorTotal:Numher Name. Gross Discount No -Pay Net. file:///C:/Users/Itrevino/epsi/memmed.cpsinet.com/u88125/data_5/tmp_cw5report19121._ 11/22/2021 Page 5 of 12 14156 FUJI:. FILM 71908.33. 0.00. 0.00 7,908.33 Vendor# Vendor Name Glass Pay Code 11149 GBS ADMINISTRATORS, INC Invoice# Cam ant Tran Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net 8017028699967 11,2112010/1.912011/01/20 2,009.70 0.00 0.00 2',009.70 ✓Y. LIFEINSUR Vendor Totals Number Name. Gross. Discount No -Pay Net 11149 GBS ADMINISTRATORS, INC 2.009.70 0.00, 0.00 2,009.70. Vendor# Vendor Name Class. Pay Code 10283 GE HEALTHCARE �/f Invoice# C mment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 20289762E 11/201201111512012/10120 51.95 0.00 0.00 51_96 SUPPLIES'. Vendor TotalsNumber Name Gross Discount No -Pay Net 10283 GE HEALTHCARE 51..95 0.00 0.00 51.95 Vendor# Vendor Name / Class Pay Cade W7300 GRAINGER M Invoice# Comment Tran Dt Inv Dt Due Dt Check D, Pay Gross Discount. No -Pay Net 9894046847 �/ 11/15/20 11/03/20' 11/28/20' 203.85 0.00 0.00 203.86 . SUPPLIES / 9894431247 ✓ 11/15/20 11/06/20 1.2101120. 202,77 0600 0.00 202.77 SUPPLIES, .. Vendor Totals. Number Name Gross. Discount No -Pay Net W1.300 GRAINGER.. 406.62' 0:00 0.00 406.62 Vendor# Vendor Name Class Pay Code. / G1210 GULF COAST PAPER. COMPANY k'' M. Invoice# Comment Tran Dt Inv D1. Due Ot Check O Pay Gross Discount No -Pay Net 2446935 ./`� 11/1'..6/2011/15/Z0 I Z115120 792.11. 0-00 0.00 792.111'*YA. SUPPLIES. 2460226 r,. 11/21/2011/14/2012(14/20 144.76 0.00, Ot00 144.76� ,!SUPPLIES 2469229, ✓ 11121/20, 11114120,112114/2.0 144.76, 0100 0.00 1,44.76 SUPPLIES 2469273 .1 1.1/2112011/1..4/261,2114120Q 962,43 0.00- 0.00. , 962.43. SUPPLIES. ,. Vendor Totals Number Name Grass. Discount No -Pay Net. G121.0. GULF COAST PAPER. COMPANY 2,044.06 0.00 0-00. 2,044.06 Vendor# Vendor Name ; Class Pay Code 1.1784 HALF LEAGUE STORAGE: Invoice# Comment Tran. Dt Inv Dt Due. Dt Check D Pay Gross Discount No -Pay Net: 111523. 11/21/2011/15/20. 12/01/20 360.00- 0.00 0.00 360.00 v* STORAGE UNITS. 1..1/1235 N01),Oet "jfol .. Vendor Totals Number Name Gross Discount No -Pay Net: 11784. HALF LEAGUE STORAGE 360.00 0.00 0.00 360.00, Vendor# Vendor Name. Class Pay Code H1399 HILL -ROM COMPANY, [NO w( M. Invoice# Comment TranDt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 3219095 1112112010/311/2011130/20, 520.00 0.00. 0.00 52000. X' 45"5 11/22/2010/31.120. 11/30120 751.75 0.00. 0.00. 751_75 6,. BED file:/UC:lUserslitrevinolcpsi/memmed.cpsinet.conT/u88125/data_51tmp_cw5report1412.1... 11 /22/2023 Page 6 of 12 Vendor Totals Number Name Gross Discount No�Pay Net H1399 HILL -ROM COMPANY, INC. 1,271.75. 0.00 0.00 1.271..75. Vendor# Vendor Name Class Pay Code. 15076 KNOX ASSOCIATES"ING `f Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount. No -Pay Net INV-KA-239295 ./� 11/15/2011/13/2012113/20 1102000 0.00 0.00 1!,020'.00 „r / LOCKBOXES Vendor Totals Number Name Gross Discount No -Pay Net 1..5076 KNOX ASSOCIATES ING 1.020.00 0.00: 0.00 1.,020.00 Vendor# Vendor Name Class Pay Code f 1.1600 LEGALSHIELD Invoice# Comment Tran Dt Inv Dt Due. Dt Check a Pay Gross. Discount No -Pay Net 111823'. 11/21/201 VIS/20121011PO 345.15 0,00 0.00 345.15,,�' PAYROLLDEDUCT ,. Vendor Totals Number Name. Gross. Discount No -Pay Net 11600 LEGALSHIELD 345.15 0.00 0.00 346.15 Vendor# Vendor Name �. Class Pay Code: 1.5068 LRS HEALTHCARE Invoice# `Comment Tran or Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 643264 ✓' 11/21120 10/27/20r 12M 1120. 3,078.00 0.00 0.00 3,078,00 DELICIA GARCIA loll 3-10/15/2a IL[LCOIB X.f 'Jeer, 645357 v1 11121/2010/27/20,12115/20 3,078.00 0,00 0,00 3,078 00: DELICIA. GARCIA 10Mo-1 0/22/23 ., VendorTotelE Number Name Gross. Discount No -Pay Not 1',5068, LRS-HEALTHCARE 6115600 0.00 0,00 6„1:66.00 Vendor# Vendor Name Class Pay Cede: 10972 M. G TRUST . / Invoice# Comment Tran. Dt Inv Dt Due Dt Check D Pay Gross: Discount No -Pay Net 1.12023 11/21/2011/20120: 11/29/20 1,1,15,86 0,00 0,00 11,1.15,86 v, PAYROLLDEDUCT .. Vendor Totals Number Name Gross Discount No�Pay Net. 1.0972 MOTRUST 1,11586 0.00: 0,00- 1„115,86' Vendor# Vendor Name Class Pay Code: 10613 MEDIMPACTHEALTHCARESYS, INC. ✓ A/P Invoice# . Comment Tran. Or Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net. 51102. / I lt2l/2011108/2012/01120 1I3.65 0.00 0.00 13.65 INDIGENT ,. Vendor Totals. Number Name Gross" Discount No -Pay Net. 10613 MEDIMPACT HEALTHCARE. SYS,: INC. 13.66,, 0.00. 0100 18..65 Vendor# Vendor -Name Class. Pay Code M2470 MEDLINE INDUSTRIES: INC M Invoice# Comment. Tran Dt Inv Dt Due Dt Check D Pay Gross. Discount No -Pay Net 2284574235,/ 11101/20 09/13/20 10/29/20 7,464.24, 0.00 0100 7,464.24 ar" SUPPLIES 228902803B,e 11101120 10/1 PJ2011106120 51_63 0.00. 0.00 51.63: SUPPLIES 22897929951/ 111011201011712011/11/20 66.1.2 0.00 0,00. 66.112 ✓^` SUPPLIES 2292345229 ✓s- 1.1/1512011/01/20' 11/26120 354.56 0,00 0.00 354.66 ✓'� SUPPLIES 2292345231 v/ 11115/2011/0112011126120 1,068.63 0.00 0100: 1,0680a ftle:lllC:/Users/ltrevino/cpsilmemmed.cpsinet.comlu881251data_5/tmp_cw5reportl9121... 11 /22/2023 Page 7 of 12 SI/APPLIES 2293382033 e' 11/15/2011/08/2012/03/20 549.90 S .PPLIES 0.00 0,00 548.90 f 2294237962' 11/1512011/1412012/OS/2p 47.00 0.00 0.00 0.00 ✓.. SUPPLIES 47.00 2294404975 �/ 11/20/20 11/1.5120 12/10/20 206,80� 0.00 0.00' / 206.80' q/ :SUPPLIES 2294404967 1.1120/20 11/15/2012110/20 117.95 SUPPLIES. 0.00 0.00 1.1.7,95 2294404972M/ 11/20/2011/15/2012110/20 50,89 0:00. 0.00 / 50-,89'�✓" SUPPLIES 2294404976 / 111201201111.5/2 012110/20. 4, 1'4827 0.00 0,00. SUPPLIES 4,149.27 ✓F! 2294404969Y'.✓ 11/20/2011/15120. 12/10/20 248.08' a�1PPLIES 0.00 0.00" 248.08� 2294404984 1.1/20/2011(15/20.12/10/20 40.13. 0.00 SUPPLIES MOO40,131'` 2294404973,/ 11/20/2011H5/2012/10/20 SUPPLIES- 23.99 0.00 0.00� 23,99 2294735353 o/r 11/2012D 11/17/2012(1.2/20 67.14 0.00. 0.00 SUPPLIES 67,111 Vender Tolals Number Name M2470 MEOLINEINDUSTRIES INC Gross Discount NO: -Pay Net Vendor# Vendor Name. 14,506.30: 0.00 0.00'� 1 4,506:30. Class Pay Code M26PI MMC AUXILIARY GIFT SHOP tr'` w Invoice,Y Comment Tran Dt Inv Dt. Due Dt Check DPay Gross Discount. No -Pay Net 111' 623. 11121 /20 11 /16/20. 11 /29/20 PAYROLL DEDUCT 329.28 0.00 0.00; 329.28,"` Vendor TOtalsNumber Name. - M2621 MMC AUXILIARY GIFT SHOP Gress. Discount No -Pay Net Vendor# Vendor Nama. 329.28 0,00 0.00 329.28 Class Pay Code 10536, MORRIS&: DICKSON' CO,. LLC I,! Invoice# Comment Tran Ot Inv Dt Due. Dt Check Pay Gross Discount 922030 11/20/20 02/12/2o o2/22/20. No -Pay Net CREDIT •67a6 0.00. 0'-00 �. •87,18 t� CM4117iy,t'f 11/2012006/23/20-07/03120 -4.93. 0,:00: ..' CREDIT 0.00 -4.93: 1147069, / 11/20/20 10/10/201012o/w INVENTORY 1 81,3.44 0.00 0'00 1.,813.44 11471..4� 1'1/20/2010/1I12010/21/20 "INVENTORY 3,35a.75 0:00 0,00. .r- 3,35L15 w* 1292328 ✓ 1.1/21/20 11/1512011/25120 33.78 0.00 0-.00 „,INVENTORY 33,7g, 1293229�/ 11/21/20 11/15120 11/25120 INVENTORY 2,915.34 0,00, 0:00 2,91:5.34 �'•� 1288666 r 11/2112011115120 11/25/20 3,51.1.54 0400 NVENTORY 0.00 ' 3,61154y,,,' 1289409') 11/21/2011/1512011/25/20 250,23 .. JNVENTORY 0100 0,00 250,23 � 1290891. �!/ 11/21/2011/1.51201.1/25/20. 534,94 0,00 O.Oo. 534.94 INVENTORY file:///C:lUserslltrevinolcpsilmemmed.cpsinet.comlu8 81251data_5ltmp_ew5report19121... 11/22/2023 Page 8 of 12 1298112 ref 1.101201.1/16/2011126120 10,816.61. 0.00 0.00, 10.816.ei fNVENTORY 1238111 .r/' 11/21/2011/18/2011128/20 4,032.58 0,00' 090 4.032.58. -`fF INVENTORY 10615 1304126 11121120 11/19/20 11129/20 106.15 0,00 0.00 INVENTORY .. 1305409� " 11/21/20 11/19/20 11/29120 181.04 0.00 0.00 181_04 t INVENTORY 1304126/7 11/21/2011119120,11129/20 18.404,27 0,00 0.00 18.404.27' i INVENTORY 1.305408, 11/21/2011/19/2011129120. 68.32 0,00 0.00 68.32. INVENTORY / 1310424 „/ 11/21/20 11/20/20 11/30120 1,5036C 0.00 0.00 1,503,6a INVENTORY 130721.5 f� 11/21/2011/20/20' 11130120 96.11 0.00 0.00 96.1'.1: ✓ .. /INVENTORY CM74986 *" 1112112011/20/20' 11/30/20 -7,37 0.00 M00 -7.37 CREDIT 1310425 yr'F 11/21.120 11120/20 11130/20 934.61 0.00 0.00 934.61 INVENTORY Vendor Total: Number Name. Gross. Discount No -Pay Net 10536 MORRIS.& DICKSON CO, LLC 481S74.85 0.00 0.00'. 48,574.85 Vendor# Vendor Name Class Pay Code / M2659 MXR IMAGING, INC M Invoice# Cafnrnent Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 8801089119' 11/1.5/201111412012/14/20 159.62 0.00 0.00 159.62. SUPPLIES .. Vendor Total: Number- Name Gross. Discount No -Pay Net M2659 MXR' IMAGING,. INC 159.62. 0.00 0.00. 1'.59'.62 Vendor# Vendor Name Class Pay Code 12388 NATIONAL. FARM'. LIFE. INSURANCE Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross: Discount No -Pay Net. 4083533 ✓rr 11/21/2011113/20 12/01/20 3,176,59 0.00: 0.00 3,1'.75.59; r,,•' LIFE. INSUB', Vendor Total:. Number Name. Gross. Discount No -Pay Net 1'.2388 NATIONAL FARM LIFE. INSURANCE 3,175.59 0.00- 0.00 3,175.59' Vendor# Vendor Name Class Pay Code 1.3624 NEXION HEALTH AT NAVASOTA INC :f Invoice# Comment jTran Dt Inv Dt Due Dt Check DPay Gross Discount No -Pay Nei TELEMED20230702 i,000.00 0'400: 0.00 1,000,00 " TELEMEDICINE REIMB OCT 2: .. Vendor Totals. Number Name Gross. Discount No -Pay Net. 13624 NEXION' HEALTH AT NAVASOTA INC 1,000.00 0.00 0.00 1,000m Vendor# Vendor Name. Class. Pay Code 01500 OLYMPUS AMERICA.INC M Invoice# Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net !Comment 35283973✓ 11115/20 11108120 12101/20 145.00 0.00 0.00 148.00 1_/ SUPPLIES 35295188 11/15120. 1112012012115/20 1,,12500 0,00 0'.00. 1.,125.00. CONTRACT Vendor Totals Number Name. Gross Discount: No -Pay Nei. file:///C:/Users/ltrevinolepsi/memmed.cpsinet.con1/u88125/data_5ltmp_cw5reportl9121... 11 /22/2023 Page 9 of Ii 2 01,500 OLYMPUS AMERICA INC 1.,270.00 0.00 0.00 1,570.00 Vendor#Vendor Name. class Pay Code J,,- 01416 ORTHO CLINICAL DIAGNOSTICS ✓ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount. No -Pay Net 1./ 853224380 11a t12o 10/27/2011/25120 190.04 0.00 0,00 190.04 SUPPLIES Vendor Totals Number Name Gross Discount No -Pay Net. 01.416 ORTHO CLINICAL DIAGNOSTICS. 1190.04 0.00 0,00 190604 Vendor# Vendor Name Class Pay Code f. 10152 PARTSSOURCE,LLC of Invoice# rComment Tran of Inv or Due. Dt Check D Pay Gross Discount. No -Pay Net 050050831/'11115/2011/02/2012N2/20 438.07 0.00 0.00 438,07 � SUPPLIES .. Vendor TotalsNumber Name. Gross Discount No -Pay Net 10152. PARTSSOURCE,.LLC 438.07 0:00. 0.00 438.07 Vendor# Vendor Name Class Pay Code 14764 PL-CPR, LLC � Invoice# Cam t Tran or Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 258 % 11/21/2010/171201.1/17/20 275.00 0.00 0.00 f 27500, BLS. RECERT .. 260' �.,�" 11121/2010/20/2011120/20' 525.00 0.00 0= 52500 „Ie^ PALS 263 �11/2112010/261201T/26/20 525.00 0.00 0= 525.00• � �. ACLS .. 265 11121/20 10/30/20,11/30120 525.00 0.00 O'.00 525.00. ,..% PALS 266 t% 1.1121/20 1 V09/20 12101./20 526.00 0.00 0.00 525.00 fir` ACLS Vendor Totals Number Name Gross Discount No -Pay Net. 1.4754 PL-CPR,LLC 2,375,00 0.00'. 0.00 2,375,00- Vendor# Vendor Name Class Pay Code 1.2480 PRO ENERGY PARTNERS LLC Invoice# Comment Tran Dt Inv Dt Due or Check D Pay Gross Discount No -Pay Net 231 U-0600 y/ 11/21./2010/31/2011/15120 2,009.93 0.00 0.00 2,009.93: �lr GAS Vendor TotalsNumber Name Grass. Discount. No -Pay Net 12480 PRO ENERGY PARTNERS LLC 2,009.93-. 0.00 0.00 2,009.93 Vendor# Vendor Name. Class. Pay Code. 1'..1080 RADSOURCE. e!`� Invoice# Co ment Tran Dt Inv D1 Due or Check D Pay Gross Discount No -Pay Net SC32691223: 11/20/2011/1612012111120 1.,708.33 0.00 0.00 1,708.33;, "' SERVICEAGREEMENT .. Vendor Totals Number Name Gross Discount No -Pay Net 11080 RADSOURCE 1..,708..33 0.00 0.00 1,708.33 Vendor# Vendor Name . Class- Pay Code 81001 SANOFI PASTEUR, INC "r w Invoice# Comment Tran or Inv or Due Dt Check D Pay Gross Discount No -Pay Net �; 921287946J/10/31/2009/1312012112120 31.,271.28 0.00 0.00 33.271.28✓"� INVENTORY Vendor Totals Number Name Gross. Discount No -Pay Net 51001 SANOR PASTEUR INC 31..271,28 0.00 0.00 31,271.28 file:l//C:/TJsers/ltrevino/cpsi/memmed.cpsinet.com/u88125/data_5/tmplcw5report19121..., 11/22/2021 Page 10 of 12 Vendor#Vendor Name Class Pay Code io699 SIGNAD, LTD. +/ Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 294156 ✓` 11/21/20 11/16/20 11/25/20 410.00 0100 0.00 4%00' ADVERTISING .. Vendor Total,Number Name Gross Discount. No -Pay Net. 10699 SIGN AD, LTD. 41.0.00 0.00 0.00 410.00 Vendor# Vendor Name Class Pay Code 11296 SOUTH. TEXAS BLOOD &TISSUE CEN v/ Invoice# Qomment Tran Dt Inv Dt Due Ot Check D' Pay Gross Discount No -Pay Net. 10703603E 11/21/20 11115/20 12/10120 5,0260E 0.00 0,00 5,026.00' ✓� e/I,aaD CM109020 ✓ 1.1121/2011/1.5/2012110120 -2,1112.00 0;00' 0.00 -2,112.00 ✓ CREDIT Vendor Weir Number Name Gross: Discount No -Pay Net 11296 SOUTH TEXAS. BLOOD B TISSUE CEN 2,914.00 0.00 0.00 2,914.0E Vendor# Vendor Name f,. Class Pay Code S2694 STANFORD VACUUM SERVICE ✓` M Invoice# Comment Tran Dt Inv Dt Due Dt Check D Pay Gross Discount No -Pay Net 295432 w""/11/20/2011/10/201.2/01/20 550.00 0.00 0.00 �r 550.00,A" GREASETRAP' 295356 "' 11/20/20 11/16120 12/01120 550.00 0.00 0.00 550.00 GREASE TRAP Vendor Totals. Number Name Gross Discount No -Pay Net. S2694 STANFORD VACUUM SERVICE 11100.00 0,00 0.00 1..,100.00 Vendor# Vendor Name Class Pay Code: / S3940 STERIS CORPORATION ✓ M Invoice# �iomment Tran Dt Inv Dt Due Dt f Check D Pay Gmss Discount No -Pay Net 11772346 11/15/20 11/13120 12/08/20 446.32 0.00 0.00 446.32 L,' SUPPLIES .. 11759693' / 11121/2011/09/2012104/20 317.45' 0.00 0.00 317.45 SUPPLIES. Vendor Totals.Number Name Gross Discount No -Pay Net. 53940 STERIS CORPORATION: 763,77 0.00 0.00 763.77 Vendor# Vendor Name Class Pay Code. F 10735 STRYKER SUSTAINABILI?Y 1 Invoice# �. Comment Tran Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net 4787800r 11/21/20 08/29120 09128/20 2,770.16 0.00 0.00 2,77016, SUPPLIES. Vendor Total.- Number Name- Gross Discount. No -Pay Net 10735 STRYKER. SUSTAINABILITY 2,77016. 0.00' 0.00 2,77MI 6'. Vendor# Vendor Name Class Pay Code 10758 TEXAS SELECT STAFFING, LLC d/" Invoice# Comment Tran. Dt Inv D1 Due Dt Check D Pay Gross. Discount NO -Pay Net 0023108-rDli•-1?lt-110 11120/2011116/20111,17/20 4,235.00' 0100 0'.00 r, 4,236..00 w✓- BRANDON. BATES. WE I Ill 1/2 f.'p„( .. 0022885 - pJ 11121/20 10/18/2010119/20 1'.,07250 0.00. 0.00 1,072.5E BRANDON BATES 10/14/23 0), Vendor TctQ Number Name Gross Discount No -Pay Net 10758. TEXAS SELECT STAFFING, LLC 6,307,50 0:00 0.00 5.307.50 Vendor#Vendor Name Class Pay Code fite:///C:f Users/Itrevino/cpsi/memmed.opsinet.coni/u88l 25/data_5/tmp_ew5report1912.1... 11 /22/2023 00080 UAL I/ _ LL...... Involce# ,C€o mend TranDt Inv Ot Due Dt Check D°Pay Gross,. 0019901 O3 y" 11/1.5/20 OW07/20 10/07/20 SUPPLIES j,.1laiq 21q;:8 Vendor Total:. Number Name Gross 00080 UAL ,ki -6ppia Vendor#Vendor Name Class Pay Code U1064 UNIFIRSTHOLDINGS ING Invoice# Cufmment. Tran Dt Inv Dt Due Ot Check.D Pay Gross 292101.6517 ✓` 11/20/20 11/16/20 12111120 29.95. LAUNDRY 2921018518 „/1 11/20/2011/1612012 I1/20 299,18 LAANDRY 2921018515 •/ 11/20/20 11/16/2012/11/20 176,71 LAUNDRY 29210018519,E 11/20/2011'./16/20 12/1.1/20 244.19 LAUNDRY 292101851..6✓ 11120/20 11116/20, 12/11/20 2,235.42 LAUNDRY 292101852T LAUNDRY 11/2012011/16/20. 12/11/20 102.46 LA 2921018520 +/ 11/20/20 Imam 12r11/20 235533 LAUNDRY 2921018,914 u` ,+11/20/20 11/1,6120. 12/11/20 100,51. LAUNDRY Vendor Totals Number Name. Grass U1064 UNIFIRSTHOLDINGS INC 3,423.75 Vendor#Vendor Name Class. Pay Code V1056 VICTORIA AIR ;CONDITIONING LTD 1/ W' Invoice# ,r,. Comment Tran Dt Inv Dt Due Dt Check D, Pay Gross, 207468 „r DUCTWORK 11/1.5/2011/16/2011/15/20 2,700.00 Vendor Totals Number Name Gross V1056 VICTORIA AIR CONDITIONING LTD 2,700.00' Vendor# Vendor Name F Class Pay Cade 12208 WA43EWORKS Invoice# Comment Tran Dt Inv Dt Due Dt Check. D Pay Gross. INV5782563 ya' 11/21/201.0125/201.1/25120. 475.25 MONTHLY COMPLIANCE Vendor Totals Number Name Gross. 12208 WAGEWORKS 475.25 Vendor# Vendor Name. Class Pay Cade. 11110 WERFEN USA. LLC ,V, Involce# CcrTment TranDt Inv Dt Due Dt Check D Pay Gross 9111412678 1 11 / 15/2011 / 13/20 12/05120 1.953.00 SUPPLIES 9111414674 71120/2011115/2012/10120 1.571.67 CONTRACT Vendor Totals. Number Name Grass. 1111U' WERFEN USA. LLO 3.524,67 Vendor# Vendor Name Class Pay Code Discount No -Pay 0.00 0.00 Discount. No -Pay 0.00 0.00 Page I of 12. Net 214 � pqu wl Net Discount. No -Pay Net 0.00 0.00 29.95 V' ' 0,00, 0299.18 WiO,,00. i 0.00 0.00 176.71. vz 0.00 0..00 244.1.9 ✓� 0.00, 0,00 2,235.42 ✓` 0.00 0100 102.46 0.00 040 235.33 f" 0.00 0'.00 1;00.51A Discount No -Pay Net. 0.00' OlGo. 3423.75 Discount No -Pay Net 0.00'. 0100 2,700 00. Discount No.Pay Net 0.00 0.00 2,70Q,00 Discount No -Pay Net, 0.000,00 47525 Pam. w, Discount No -Pay Net 0.00 0.00 475.25 Discount No -Pay Net 0.00 0.00 1.953,00 > 0.00 0.00. 1,571.67 f Discount No -Pay Net 0.00 0.00 3,524.67 file:fllC:/Userslltrevinolcpsilmemmed.cpsinet.com/u88l25/data 5/tmp_cw5reporti9121... 11/22/2023 Page 12 of 12 11400 WEST COAST MEDICAL RESOURCES ✓ Invoice# Comment Tran Dt: Inv Dt Due Dt Check Pay Gross. Discount. No -Pay Net INV104273 ✓ 11/0112009/18/2010/16/20. 895.00 0,00 0.00 895.00 SUPPLIES Vendor TotalE Number Name Gross. Discount No -Pay Net. 11400 WEST COAST MEDICAL RESOURCES. 895.00 0.00 0.00 895.00 Report Summary Grand Totals: Gross Discount No -Pay 364,460.33 0.00 0.00 Net 364 460.33 file:///C:/Userstltrevino(cpsi/memmed.cpsinet. com/it881251data_5/tmp_cw5report14121... 11 /22=23 co RUN. OA E 1T/32/l] 21D29!23 TOTAL ARID=0001 TOTAL NOV 2 E 2023 y, 1lVI' 11p MEMORIAL MEDICAL. CENTER EDIT LISTFOR PATIENT REFUNDS ARID-0001 PAGE 1 APCDEDIT PAY PAT PE AMOUNT CODE TYPE DESCRIPTION GL NUM !3 160.00 ✓ ] REFUIID' FO !3 SOAC 1 REFUND FO '3 1269..E6 V--2 REFUND. FO ---------------------------------- 1479.8E 1479.86 WKESSON criamr: Gets CVS PHCY 7476IMBA. MC PHS MEMORIAL MEDICAL CENTER� 815 N VIROINIA ST PORT LAVACA TX 77979 USA STATEMENT CA13dt. MCK INITIATED. ACH DEBIT AMTDUE REMITTED. VIA ACH DEER` Statement for Information only USA A.of: 11124/2023 DC: 8115 Territory: 7001 Cusemer location:. Cmseeman 835438. Date: 11/2612023. Page:. 001: 10 seems: familiar more to your account, awaand, mm.thk seuhwith: you smptarM, As. of: 11112412023'. Page:. 0011 Map: to;: Comp: 8000 CAP' NICK INITIATED ACH. DEBIT AMT DUE NAIITTED VIA ACH. DEBIT Statement. for Information.. only USA CM: 835438 PLEASE'. CHECK: ANY Dvroe. RBNR. Nm min EINrp Dee. pglvae42850245 Order Dam edption Cash AmeuM a AmauM '',. IsOwn RxeNahh '', a e, men ;me u 11112212023 11128/2023 745988771 1.15tmcice 0.68: 34.01 33.33 7459667719 �.... - see... Dulms Due. Nem OTAL Lture Due: 0.00 Suhtatafar 34.01 USD last Dun: 0.00 If field By 111121112023. Pay Thai Amount: 33.33. USD aat Payment: 11.739.80 111312023 If Pald. Alter 1112812023 34.01 USD Pay This.. Amount:. 'Mel OHtsuM: 0.68 33.3� 1. 2,846,19 12- °�1.Sb'4�-414 s, AWFIAW on NOV 272112t For AN Inquiries. please Contact 80"67-0333 One If field On. Time: 33.33. USE 0.88 Olin; lose If paidlate:: us, 34.01 Dee K Mid.. late: U50_ nnsKesso" STATEMENT camwav: auto WALMART 1098/MBA Mm. P115 CAFH MCK INITIATE ACH DEBIT ME4ORAL MEDICAL. CENTER AMTDUE REMITTED VIA ACH OMIT 815 N VIRGINIA ST Statement for Information. only PORT LAVACA TX 77979 USA. USA An A: 11/24/2023 Page: 001 to ansum Proper cleanto year seeourd, delaehand return this. and, w8n your rarnMann. DC: ails Ae. of: 11/24/2023 Page. 001: Mall. to: ComP:: 8000 Tannery: 7004. CAD11: MCK INITIATED ACH DEBT Cuatemar, Lcealfon: AMT' DUE REMITTED - VIA. ACH. DEBIT' Clatterer. 256342 Statement for Infarmetlbn. only Clean 1.112512023 USA. Clmt:. 256342 PLEASE'. CHECK ANY muing Date Due Dee t11/28/2023 Reowaole. Nmtr 7458861880 er 1918' De Ptian Ceara. D u Amwmt 68.99 P Amount 65.65 P ReeaNable •, •. 11/20/2023 1151nvoica.. 1130. 74588613a0 11/2012023 11/28/2023 7458861683' 1004 1151nvolm 8.03 401.44 393.41 7458881681 11/20/2023 11 f20/2023 11/28/2023 11/26/2023 7458878737 7459064494 2041 319. 115lrwaice 195lnvoice 0.01' 0-03 0.63 1.27 0.82 1.24 I7458878737 7459004494 1112012023 . 11/28/2023 7459064495 376 1:96IINoice 0.36 17.87 17.51. 7458064495 11120/2023 1112812023 74591�38235 437 W115tneolce 1.151nvolce 20.20 fi,013OB 89280! 7459198236; it/21l2023 t1Y18/2023 7459208896. 027 1151mome 0.03 1.581.55 17669208896 11/21/2023 11/2812029 74593586T8 147 1151nvoice 0.02. 0.95 0,93. 745935987a 11/21/2023 11/2812023. 7459359879 819 1451nvaice 0.36 16.1817.82 71593598T,9 T1M2/2023 11/28/2023 7459A8S3S8. 897 1151nvoice 18.28 B13B0 6.62. 7459485356.'11/2212023 11/28/2023 7459643948 530. 19516voice 3'.489 30 745884394611/22/2023 : 1112812023'. 7459643947 183. 1151nvoice 0.57 HAD 27.83. I. 7459643947 t1/2d/2023 11/282023 745983187L 090. 1151nvolee 5.94: 286.92 281'.SB: 7459431871 41/24/2023 11/28/2023 7459958229 1 96614043 1951nvoice 1 0.02. 0.95 0.93 7459858229 ' For AR Inquiries.. please cantacl. 800487-0333, MSKESSON'. As 01'. 11124/2023 Pepe:: ao2 10 enure propr Bell to, your 1 11. STATEMENT ee� �. dte� mrd mNm MN Cenran: eaoe stub with: ymPmmhMrNe DCr. 8115 Ae of:. 11/24/2023, Peps:. 002: VVALMARt 1098/MEM MED PHIS CARR NICK INITIATE: ACH DEBIT Men W. Comp:, 6000. MEMORIAL MEDICAL CENTET� AMT DUE REMITTED VIA. ACH DEBIT TenBery; 7001 CARR MCK INITIATE, ACH DEBIT 815 N VIRGINIA ST Statement for Information. only Customer L ion:: AMT DUE'. REMITTED VIA. ACH I DEBIT PORT LAVACA TX 77979 USA Custemer. 256342 Statement for Information. only USA Detr. 1112512023. USA. Cult:. 256342'. P6EA8E CHECK'. ANY Date: ITEMS: NOT PAID It Win: Duo Receivable. Onter Oeseddlan Cash. Amount P Amount R Reneaba, Unt. lc D IF column lepand; P = Pas[ Due Hem, F Fut. Due Item;. 1,11col, = Current. Duo Item. 'MAL 'ntum Due: 0.00 Subtotals: 2.904.90 USD f Due. If Paid, On.Tilne: 2,846.79t/ USD ast Due: 0.00. It Paid By 11/2812023 58.11' Pay This Ammmt: 2.846.79 USD Disc bet d pld.. late. USD ast Payment: 12.898.63 2',904:90' 1/2012023 If Pald. Aker 11/2812023 2.904.90 USD Due. K paid Iste: J Pay' This Amount: USD.. 'We[ Demount: 88d.1 For AR Inquiries. please Contaml 8W867-0333. MWESSON da,yav: CVS PHCY 89231MEM MC PHS MEMORIAL MEDICAL CENTER 815 N VIRGINIA ST PORT LAVACA TX 77979 USA STATEMENT CARR MCK INITIATE ACH. DEBIT AMT DUE REMITTED VIA ACH; DEBIT Statement. for Information only USA As. oft. 1112412023 DC: 8115 Terdmry. 7001.. Customer Locatlam Customer. 835434. Data: 1.112612023 Page: 001'.. /0 anaum, Ifmpw ands, Ia your ateaunt,: date4hend.. nation this dub with your remkterso, "o1. 111/24/2023. Pees:: 001 Malt to: Cone. 8000 CAR- MCK: INITIATE. ACH DEBIT ANIT DUE REMITTED VIA. ACHDEBIT Statement Pot Informathm only USA Custe 835434 PLEASE CHECK ANY BOiBp me nd•. Ow RmshabM Older Deaadptlon Cash Annount P. AmoQ232 P Paaalvaala: '. Dab Dale N ea11/22/2023 IF colu tl/28/2023 P 7459488453' 2849138. 1151nvaice 0'.28 72.5] �7459488463 Nge Pad Ow Sam, F: Rltum V. Item, blank.. Comfort Item VIAL More Ow: 0.00. Subtaah:: 12.57 USED haf Dw: 0.00 If Pala. By 1112912023 PaY' This Amount: 12.32 LSD. Ad Payment:'. 12.898.53. 1/2012023 If Paid) Aker 1112812023. 12.57 USD. Psy This Amount:. 'otal Dlecmm: 0.25 r r AR Inquiriesplease. contaol. 800A67-0333 Dun If Paid. 0. Tins:. 12:32'. USD 0.26 Oleo. lost. K "Id'.. late: USDd 12'.57 Dna if peld, lele:. USD (,iI�1,a 1�.r4'l� XI Items Report BIOCWMER, 4 .bb Isems'.1 pNe .*.RNoeewMbNeAree.B.Nea3blemwtof�nl.Mrn mmgalallelNwNhM4g4rvdwaeMeyuGwntrlMrelq. k-k-fllp WfttllmXetlonl.. M.... A,"."B.' a.h w edhe ..'.96eve.n...-NI FvdwaN bwmanauwwbl�Munlll'.wm0191ewMe. Malwn.brewbeE.. McuntNUMq- Aawnnl Nvw CAB' Imok Wmser IMIOBD la meD.Os Imaq Oewmtlpn. P.O.Mmbae SblemwmeeO cNeNNampeo 1pp1]ERBp WALGflEEN$pIN9i NOB CkMm,alp. BIaNv gypCb2 Tev Mnunl Imnire hlwnl: p ]10100a030. "OUK0A. 13101rs023. Iwactem, 7004Tn003 p p {' WALGPE@1fitl13991.MOB . p ]1NBBB5]1 11rzW2023 VNId033.INWILE($R31. Own. 0 0.00 2831 WALGRFENBk1249p11pB p 315aB0p9]0 vaaxp23 1RN1RpT] INVOICC{IFRI iop MABla p OMm 0 p.W. 21£9R ✓✓✓/// p.. ..open. p. oo. 1WAs WlLLGgEENStlIR9W.]9W b S1W296TW.. 112dN33 1L011T033 INWMERFTI MMBO2R09 tl p.. �. WALCgEENfip12<91310B p, 31W995712 112142023 1]AlIR023 INVGICE(2E]) TOMNINIb GAort. 0, moo M30: WALGREE1130I2994]900. x p ]fsstappa llrsvmz] Izmlrspz] INva1LE1zE3E )pwBisnp x own 0 CIOIz99 WALGflEENfip129W ]9GB p p 3165R18006- 11/39/tpII 12NVt021 IM/010EIIFRI ]OOINORIB p M. owm 0: 0.001 1332a WALGREENSY129013bB. p 3Ifi62210BS 11/34OM23 III011ROA INVOICE,,21.. 7OwB31931 p p' open. 0'. Oft. 13]QB W/rLGgEEN0b1T1W N00. p ]16032800) IN2?1023 lw'.] M.CE1RF2). 200ie3113] ♦ p OPaq 0 O.W 313A Y� 1pp135T99 OAe2 p 0.00� 0:84. F:Sk)anp 1a. Noy 217 ign <,U 2):%:!!•�ry..,h; u�,!C'��,1��JIbn•1fiVte�. lN112A23" MEMORIAL MEDICAL CENTER PROSPERITY BANK. ELECTRONIC TRANSFERS. FOR OPERATING ACCOUNT— Nov20, 2023. Nov26, 2023 Ps. Date BankDescalpthm/0100009 MM[Nvles Amount 11124/2023 PAY PLUS ACHT[ans N00000N07355533;1O10006999 3rd.Party Payer Fee f 10$6V 11124/2023.EKPERTPAY EKPERTPAY 746003411.91000018984436 Child: Support Payment $ 11/24/2023 AMERISOURCE BERG PAYMENTS 01000017682100002 340B Drug Program Expense: $ 1,163.1 ' 11/24/2023 MEMORIALMEDICAL PAYROLL 746003411113122650. -Payroll. $ 393',2f2'.95 11/22/2023 PAY PLUS ACHTrans OOD000007223763'. 101UM089 - 3rd. Party Payor Fee 11/21/2023 PAY PLUS ACHTrans 0000000071061411010006977 - 3rd.. Party Payee Fee $ 'L'•' 11/2112023 MCKESSON DRUG AUTO ACH ACH05747411. 910000129. -3408Drug Program Expense $ 12,898:53:�- 11/2012023 PAY PLUSACHTrans0000000069556941010006965 - 3rd'Party Payor Fee $ 13244' 408,393:29 ,/ Novemher27,.2023. ANDREW DE LOS SANTOS Memorial Medical Center PROSPERITYBANK ` {{6Wva�� VONff'¢t9?L Orr ELECIRONICTRANSFERS FOR OPERATING ACCOUNT — ESTIMATED ACHS Date .r Descrlotiyn MMC Notes. 11/3012023 i STATECOMPTRER:TEKNETOT952329 RAPPS IGT Payment 12/4/2023 /STATET MPTRLR TEKNET_0T_9531aa18QIPPIGTPayment JkhCtia ✓rI J xt ti:1'v Nbvemher 27_20A ANDREW OE LOS SANTOS Memorial Medical. Center 4Q,6•:29 Il r. t, 5 39 (' ._ Amount $ 25,n se 2,008yT82.84: '7r Yi IN' • c.: p:. Id• h. z. •• "W/f'CE2 UN I�4t ' wAh'1�"11� Transaction Summary Transaction Complete Trace # Texas Health and Human Services Commission Memorial Medical Center Operating County Page No:1 of 1 Run Date m21=23 Run Time:. 18:44:12 Transaction Summary Transaction Complete Trace Texas Health and Human Services Commission Memorial Medical Center Operating County Page No: t of r Run Date: 11127120e3 Run Time: 10s3:01 Andrew DeLosSantos From: Texas Health and Human. Services Commission <txhhs@publicgovdelivery.como Sent: Thursday, November 16, 2023 9:31 PM To: Andrew DeLosSantos Subject: (BULK] QIPP IGT Notification Second Half of Year 7 (SFY24) p% TTTIIM This email affglnated'ftant outside of the organkatl©n. Do not click Onks or open attachments onkess you recognize the sender, andTknoWthe content is safe. -. - �20(,:7 C)io L— QIPP IGT Notification Second Half of Year 7 (SFY24) The Texas Health and Human Services Commission (HHSC) is providing notification of the second half Intergovernmental Transfer (IGT) call for Quality Incentive Payment. Program (QIPP) Year. 7. The IGT amounts can be found in column D on the December IGT Calk tab of the "QIPP Year 7 IGT CaH — May 2023 & December 2023" fife. This file can be found under QIPP Year 7 (SFY24) Related Documents on the HHSC Provider Funance websiite. The IGT must be entered into TexNet no later than close of business Dec. 1, 2023, with a settlement date of Dec. 4, 2023.. • This settlement date is non-negotiable. • The funds need to be placed in the "QIPP" Bucket. Please transfer funds through TexNet. TexNet instructions are available on the Texas Cortmptroller`swebsite. - Send an email with a screenshot or PDF of the confirmation/trace sheet.�� to PFD QIPP Payments. Please email any questions regarding this change or the calculation in general to PF_D QF QIPP. You. have subscribed to get updates about Texas Health and Human Services (HHS) For more information. about HHS.oleasevisit our w bsite. St a Cnnonnected�� >] J D.I x.',(an espano4. Subscriber Services. Manage Preferences I. Unsubscribe. I. Helit, This email was sent to adelossanlos•S.ninbcPonlavaca. cam umng. gov Delivery Cotnnur iitdlions Clpud on t Bnaff of Texas. Hea,llr. San Human Services Commission d07 Rth St Style 5000 Der vec.. Cn 80202 This list contains thesuggested. requested'.amounts,. No excess fundskayo been added. SuggestedIGY wasupdatedas a, result o6 Changes In, ownership for enrolled facilities.. FA IIDL[TV'' FpCILLTY"NPME FACIUILT'OWNER DECEMBER� REQUEST , 106081 SORRENTO HAMILTON'. COUNTY HOSPITALDISTRICT l6]4A0.93 06546 WINDE ERE ATWESTOVER HILLS HAMILTON COUNTt, HOSPITAL DISTRICT HRMRTQN GOUNTY HOSPITALDIRRiCT HAMILTON COVNTYHOSPITAL DISTRICT 19T OB6�50 1. 106566 FORUM PARKWAY. HEALTH'. aREHABUTATION'. 322161.59 10>65 THEIRESERVEATRICHARDSONI 122,520165: 110116 ADVANCED HEALTH'. aREHRBCENTELOFGAlAND' HA ILTON'. COUNTY HOSPITAL DISTRICT.' SOUA2N.B41 W'3 110356 CEDAR HOLLOW' REHABILITATION CENTER HAMILT0N COUNTY HOSPITAL DISTRICT' HANSFORD COUNTY HOSPITAL. DISTRICT 235Z6 g491. MICASIPA: NURSING I AND, PEHABRUTATIONI 239Q14 Z95,32' 4942 5L76 HANS. RD COUNRY: H0SPRALOLS14UCT 0BALAKERIUGE NURSING HANSFOFD MANOR. HANSFORO: C0IlNTY'HDSPITALOISIAIR- 261009'.01. HANSFORBCOLINTY'HOSPITALLDISTIIIC' 3526,2'. 101587 THE ZA. AT WBBOCK. WINOFLOWFRNEALTH!CENTER. MAN5E0R0; COUNT HOSPITALOISTRICR HEMPHRLCQUNEY HOSPITAL DISTRICT N MRHILLC0UNTY'H0SPLTALLOIST0.ICit 463 AB413B IF 179,011,68: 110431 MeSAVIEWSENIORIUVING 112A6.5311 4633 ROSIJRAIL.N RSINGANDKEHAIRLMA NCENTE0. N PNINSCWNTY'H06PRAEDI C HOPKI NWH0SPITAL.DISTRICF 328199:50 5186 5213 FETAL HILL NURSINGIAND REHA A.ONCENTER - COLLONIPL. NUR IN -REIA0IIN RCE ER 3A9 Z3],'.891 HOPKINSCOLINTY' HOSPITAL pIST0.1C- HGPKINS COURTn'HpSPITAl O15TRICT' 5218 LONGVIEW'NIILN 0. 1NG:AND:REHAB A:ON:CENTER. 598534.21. 5390 PARK PLACE NURSING lREHABILITATION . CENTE' H0PKINB CO2Eq.O.PITALGISTRICt' I3 358359J3 ':105966 48L0. TREVISO T. 1 NAL. 0. PARK VILLACAPECENTER. HOPKINS 2U.TY'HOSRITAL.DISTRICT' 9ACKG0UNTYNDSMALDISTRIC' 2' 4 ZAS Bq,I 14fi�3t 4852 ARLINGTON'. RESIMPNCf AND REHAILITATION NTER JACKCOUNTY HOSPITAL GISTRICT.' 31fi-06128i 4886 FAEHCOMMLINIT,T HLIRSWG--HABLITATI OACKC0UHTY'HOSFITALO RICE 09498',21 4202 NEW COUNTY NURSING HOME RENTODUATY 156921.LA 4T56 Ml1N0AY'NURSINGCFMER KNOK COUNTY'HO WA m5Tg1C 14PA02:p6 41T0 COLONIAL PINESHEALTHCARE'.CENTER'. UBE0.tt C0UNT'H0SPITALOLRTRIC N01 LIDF0.tt GGUNTY H06RRAL DISTRIC-N0,I I' Z6028Z.46 g593 C0LLEGEST0. HEALTH GRECENTOR. I 94�72,24 460 CASCADES'.ATSENwKRfHAR UBERTYCOUNWHOSPITAL DISTRICT NO, 51'1066,03A 4003' TWIROAKS HEALTH, a REHASIMAN0NI CENTER LIBERTY C0UNTYH0SRRPLL 015'611i[TN :L UBERTYCOUNTOTHOSP,rEm DISTRICT NO LL LLIBE0.TYfAUNTYIH0SPLTgLDI4TPILT. N0.1 pUNTY'H05PITgLDISTPIRNO I' IBE0.TYC0UNTV HOSPITALL DISTRI N LIBERTW NTMHDSP[FAL DISTPICf N01 173282.21 4902 LASS VALLCEY HEALTHCARECENITER 145,597%281 4 29 WHISPERWOODNURSI G a REHABILITATION CENTER 3I 951t50: 4989 PINETREE LODGE NURSING CENTE0. 'UBE0.'LY 290525.43; 50 0' MESA HIU5 POST ACUTE is 40340Y85 Moe PAAG NA POUACUTE 51641112. Seel GREENDRIER'. NV Ga PENABBSTATI00 CENIEKOFTLER LIBERTW NTY' HOSPITALDIS'TRIZ: NO L ❑BERTYr WBUNTYH PITAL.OISTRILTNQl UBER1YCCUNTH PITALDISTRICI:'NO.I Z59'40P. 01 Sim VIOO N RB.REHABiLITATION NT R. 36Y820,82 St61. BREMONON 1 A D HABILITAT1 MCNTER 16fi0BN.15 51" 301 RIVERPoINTEOFTRINIfY HEALTHCAREAND-REHABILITATION' CE AVAL0NPIACENIROWRIE LIBERTY COUNtt NOSPITALDISWICONDI 13G6951A1 LIBERTY COVNWH0SPETAL OISTRICT NO LIBERTY COUNTY' H0SPITAL DISTRICTN0. 1 USERTT, '4 WH0SPRAL DISTRICTNO I LIB 0.TY' WUNtt HOSPITALOISTRICT'N0I 271130AX 222 PINEGRWENLISING CENTER 255,E41.5% 5745 TIMBERWOOD NURSINGANDREHABILITATIONCENTER, 32804£08' 52N NO NEPLTHCARECENTER ]2L 56BiYS S 0 IDAWHEA4MAND.REHAIRUTATI0N LIBERW 641UNtt'H SPIT LOISTRICTNQL 358 S82f66: 5329 BR1ARCLIFFSKIU.ED NURSING FACILITY UOERTYCOUNTY'H ALOISTRICN01 299430,941 53A LEGACY AT TWN'. CREEK UDEAtt'C0VNl,Y'HOSPRgL GI5T0.ICTNDIis 513468,06, 536E ITHE PHOENIX POSTACUTE LIBERTY'COIINIAt'HOSPtTA p STRI. NOS UBMW COUNttHOSP.ITAL DISTRICT' NO I 362 SB6.3L 102359 EASr VIEW' HEALTHCARE 39542.2 102704 FAIRFIELD NURSING a REHABILITATION. CENTER is 30022L02 102907 103086 LEGEND O"SHEALTHCAREANDAIDIABILITATION CENTER NORTHW THECOURTYAROS AT PASADENA. UBERTYE0'Ntt'N0SPITAL015IRlC'N0L Is. 30.5669.16 UDERTIF OIINRT'H PITP- 2VYFRICT NO 435 798.16 113421 FI. N"CREEK'TMRSITIONALCARS OF KATY LLIBEPTYI .FTLNO :1 EAQNHDRAL DS6 OIBERT"C0UN YH0SPITAL 0IST0.ICTN01 is 345326.01 103ng JEFFERSON'NURSING ANaREHASN T I 54752.35 103965 COPPERFIELD HEALTHCAREAND PENAGMATION 3611351.16'. L"200' MISTY WILLOW HE4LTHCAREAND: REHAB=ATION,,CENTER 1236597& 104599 THEHEIGHTS0F TYUR LIBERWCOUNTY MSPTALDISTRIC N2,1 5 413 25t.97,' ID5462 CAPROCK'. NURSING 6 REHABILITATION LIBERTY COUNTYCOUNTY H 1 274133.00.- 11055" BRIDGECREST REHABILITATION SUITES LIBERTHCOUNTY'NDSFIIALDI5TRICR'NQ.1 Is 32617,411.91 RIS652 THFHIRGHTS0FTOMBAl1 LIBERTYCOUNTY'H0SPMA2 OISTRICi NO R90B440 '. I1056R THEHESKSOF'RORTH.HOUSTON. UNENT COUNTY' HOSPITAL DISTRICT N0: 1. 4598]1.AA T.W 1GTCa11 ###0#14 OSMALDIMIR 396,115,16. OSPITALDI51RIa OSPUALDISTRIC[' 267,568,,90, I6836Z145 05P AL DISTRICT OS' AL DISTRIR 3763714W1/ I02419:99: OSPITAL DISTRICT 396,984,05 OSPRALDIM= OSPITAL Dl TR 375,488,64. 542,204,18. OSPITAL DISTRICT OSPITALOISTRIR 323,621.96. 4909B9,M. MPUA DIVRTICT )SP[TALOtSTRICT' 143,829.01 HOSPHALDISTRIR' 362,037.27 3620 9'.ZT D15TBICT 4Y622.24 ..SftTALL H05MAL OISTPICI' 30B9Z2,08 HD PU ALOISTRICC 159,632',00: HDSPTTA6 YL- ICT HOSPITALDISDIIR 175,471,73 305309.31. HOSPM IST0.ICT HOSPRALO ICT iPRaIDISTI{ICR 18%705.30: 201,935.07 1638 9.)1 iRITALDI5l0.1Q 470.67A62 kITA4 DISTRICC iPITAL 0151RI12[ 3 "'696166: 260L03.01 iPMALDIWA= s 304 560.35. iRD:'. LDISTR0.T 42009An2 m y 5WAL0DJ I iPRAL5T0.1Ct :SPUALDISTiICT 101 ]31.02( 339` lLSAS. SPITALQI TRICE 460',968. iSPITALOISTRICT 2671380,16 262'380:31 SMALDISTRICf SPRALL015TIIU 3m:T2i31 S 319,57: PITAL D5TRICT' IUALDISTRIaCC 30642,1.9T. 200, ?ITALOIIMI 144 7 8. 0 8FTA4 DISTRICT s 140'924.34. HY' OSP ALOISIRICT DT' HDSPITALDIVAR R HOSWALOISTRICT IFRl S LTALOISTRICF ISTRICT 329'.994.35 254,,50.62: 254 .M 202945.0 322,943.62'. ISTRICC ' S . ISTRIQ U%UM.41 101699:SD, ISTAICT S' 300695.8S, ISTRILT 128954'.65 STRIA ISTBICT 563,361..0 ISTWCIi M475.63 RTRICT 700431.72 T00431.22 ISTBICT 'B 1)O.592.47 28459281 ",.L,, !STRICT" 272 BBZ.6T IST0.1C1 39T329.94 E929:V..ml gYlpB?1RR t;ri9f TaeFse 3.2G1f uub Page 1 of I AEG:'E1VEIIU'.S" IKE r�yyn,)�Y rta�.:rFtllFd R:M%4 �� 1'NOY 0 3 MEMORIAL MEDICAL CENTER 1 _ r+it�2e�i6�➢?JlitiDl°7dr 1w�e;= AP Open Invoice List. 0 ap_open_invoice.template Dates Through: Vendor# Vendor Name Class. Pay Code 11824 THE CRESCENT Invoice# Comment Tran. Dt Inv Dt Due Dt Check 0 Pay Gross Discount No -Pay Net 111.623 1.1/21120 11116/2012/1.6120 4,560 00 0',00 00 / 4,560.00 5e" T 4ANSFEFT 04 'I-ft& NA tk p q tj Atpe i t0A Vk-h lqk)�t e opil& Vendor Totak Number Name Gross Discount No -Pay .. Not 11824 THE£RESCENT 4,550.00 0.00 0.00 4,560,00' Report Summary Grand Totals: Gross Discount No -Pay Net 4,560.00 0.00 0.00 4,5W00 �r i 1•gl 1%"�' G file:///C:/Userslltrevino/cpsilmemmed.cpsinet.com/u881251data_51tmp_cw5report45486... 11 /22/2023 Page l of l RECENEt1 W THE C9rJIffY AdiEqP(R M' NOY 1112 2023 2023 MEMORIAL MEDICAL CENTER AP Open Invoice List Dates Through:. 0 ap_open involce.template Vendor# Vendor Name Class Pay Code 1.1836 GOLDENCREEK HEALTHCARE. ,/ Invoice# Comment Tran Dt Inv Dt. Due Dt Check D Pay Gross 111423 111120/20 11/14/20 1'.2/16120 ,y 3,760.57 TRANSFER W1-IftW'�eM p!'y$�G«i t 1.1423A 11/20/2011/14/2012/1620 2,370.00 TRANSFER V Vendor Totals Number Name Gross 11836 GOLDENCREEK HEALTHCARE 6,130,57 Report Summary Grand Totals: Gross Discount. 6,130.57 0.00 ON ,�IgIy 2 2 20,,3 Discount No -Pay Not 0.00 0,0o 3,760.57,ys"'r 0.00 0.00 2,370.00 L/ Discount No -Pay Net 0.00 0.00 6,1'.30.57 No -Pay Net. 0.006,130.57 file:///C:/Users/ltrevino/cpsi/memmed.cpsinet.com/u88125/data_5/tmp_ew5report3 8555... 11 /22/2023 4tErz_ a'ED BWME +%4C BAYA annORl Qyi "111YAU26Wc3 10:24 Vendor# Vendor Name 12696 GULF POINTE PLAZA I MEMORIAL MEDICAL CENTER. AP Open Invoice List Dates Through: Class Pay Code. nvotce# Comment Tran Dt Inv Dt Due Dt Check. D Pay Gross 111423 1p1/20/2011/1412012/t6/2dd0 EE 357.33 111523 TRANSFER. P� ®dp d�iIBA�- R ka4 11l21l20 11/1512Q 12�Q 21.9.58. Sk/PPL,+ES.-t"jitj 4 Vendor Totale Number Name Gross t2696 GULF POINTE PLAZA $76.91 Report Summary Grand Totals: Gross Discount 576.91 0.00 MY 2 2 2023 Page 1 of 1 0 ap_open_invoice.template Discount. No -Pay Net 0...00 000 357.33' kkt, yp&kl K. 0.00 y 0.00 21.9,58, a : 4 Discount No -Pay Net 0.00 0.00, 576.91'.. No -Pay Net. 0.00 576.94 11/22/2023 pF CENEDSV C0;11h ,�,�!;E'S1IiiXR f7dD Page 1 of 1 $40V 22 QU2s e �h0 4 10:23 MEMORIAL MEDICAL CENTER AP Open Invoice List Dates Through: ap_open_lnvoice.template Vendor#Vendor Name Class Pay Code 12792 BETHANY SENIOR LIVING Invoice# 111423 Comment Tran Dt Inv DI Due- Dt Check D Pay Gross. 11/2.0/2011/14/20 12<16/20 1.57.38 Discount 0.00 No -Pay 0.00 Net ,. 1,57.38 111523 TRANSFER j" ',IW4"a"Atill ea ll&+ J t Wr.'tp1�Ij 'lk+ ok ill- 1, 1121/2011/15/201211.6120 148.39 0.00 0.00 ( 1148.39 TRANSFER 0 0' .. Vendor Totals Number Name Gross. Discount No -Pay Not 12792 BETHANY SENIOR LIVING. 305.77 0.00 0.00: 305.77 Report. Summary Grand Totals: Gross Discount No -Pay Net. 305.77 0.00 0.00 305.77 ari, CCU CIALMUNW file:///C:/Userslltrevinolcpsi/memmed.cpsinet.coin/u881251data_5/tmp_cw5report35241.-. 11 /22/2023 MwIJVIM ffle UI Onto. Xunln[Xpmp UPL W-AN WYLTr .,.r 3I/s)(SOxi xe •n.xx. «uYY [[`n xrcn IN.[4. 14Nf Sf..:111AM'.m.. .] r'Wµi mmm�. NO..mY. Nnmxr«lxrxmr9xnuMy. xmn �: anLNbur ll{pLpf WwNNWn IWm. YMY[\afr9mnW aW 1LNgS).�� .�wynwms.x.n«,eN• nau.e �P� Ia..]fu, �]CA�p.v�pumy L34KI.. W/M. LS gtK$ISlp6�/ vnpu..n{Au]L,aan,. . qW:Y Vfla.fK)6 i)I.Oq.p 83FQ4C1-<y 771 s79Lfj Lµx wMylrrWxalxx4R4Wn1wnwVwP}N WI Irp�xlmnxnllffll MnrmMwnrn qLl), r(' xeux«Ynnlnan4ruR [[YrW[,r� an • n ;51)I.L 91314]3 WnNYwv. 1(pm.. Wlu]pYu[nwePr 414P3� A^�YxY\wYNx[br YY IAIA«. WnmW MxM F IKY. lau�pYun/)rMxxMe'. IVPAL«�W 1KW51 // flnYeJanN Niy)L54Y vMMn Wx NYMs. 1p]y. XYw\InL[xrn4w9 xgrv. L+"� Nrryr[.pM)Ypmbr«q. S.WIS' e% •uw]wMnmmlN.m. m.KwL�lf� VMxxe V)YNgaTglVxPm�aWLa _p •VP^'V")+x4nYnanr ].xKlD�. 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IO.II6._R. 10yB ]I 066[OS MMCPORMON.. I.,sl W Torft,I OIPP/Clav1. OIM/@mP2. qM/Unpll. OIM/0JmPAMILM . OIMTI. NNPORTH)" 3695' suit 6,1TG.63 462151. 6U,W E76;3W.93I1 9IEOG. ffiN _ SRw: .11 AO - LS4km p:AC US law - law 9.1ffiw 9;16Meplw4Q I:px w.nb rwa.nle.omo+,ao.awonm..uponwwenNM{xx e..Noenl..e u.mn-rim.mz3 va=l )ylymil NGVR4 mlY90x NC0.VMlMTi)tl10a4W])ff {69.pA)1 I69a9333 INl/]Yii MYwXXOUGiX xfq.UMIM11llR1W )9pW19 136E /." IljllMWi.. NBF WMFREF19 - B6G33' 57269 s" 6K6:IR'M` LNam 1VN UMCFHIALM 111MM - 9.N1].vl S... 1N30.W INO/M33 UN[WMMUFIry IIXfpMNIMf))iWM1191MW 5umem mumanN6WMIMilYA414lt,. /. 1N0/IDU. XOUR4f 30lYROX NCCUYMIMIm4mxTLLW 0 d 19110.1 amt / p 'M39 19A3N _ ISA56]6� L;04.M v 9AWA3 - ,P .3N o 9.FF➢A> 3i3,iTNA3 �j TffN 47;41T 339.311% 93.94:19 ".Wm M39143 Balances Overview Account Name •4357 MEMORIAL. MEDICAL CENTER- $3,047,847.53 $3,018,516.78 $3,047,847.53 $3,157,118.18 OPERATING '4365 MEMORIAL MEDICAL CENTER— $539.81 $539.81 $539.81 $539.81 CLINIC SERIES 2014 *4373 MEMORIAL MEDICAL CENTER• PRIVATE WAIVER $434.57 $434.57 $434.57 $434.57 CLEARING *4381 MEMORIAL / MEDICAL CENTER 1 / $116,087.07 ✓ $128,724.20. $116,087.07 $127,152.00 NH ASHFORD ✓ `4403 MEMORIAL ` MEDICAL CENTER 1 f $153,274.71 ✓ $166,704.60 $153,274.71 $145,202.87 NH BROADMOOR ✓✓✓ '4411 MEMORIAL. MEDICAL. CENTER// $246,903.54. $263,688.95 $246,903.54 $212,96915. NH CRESCENT' `4438 MEMORIAL MEDICAL CENTER 1 SOLERA AT WEST �/ $232,416.92 $232,888.63 $232,418.92 $234,360.34 HOUSTON': *4446 MEMORIAL MEDICAL CENTER 1 / $185,402.75,/ $192,292.74 i NH $185,402.75 $158,444.85 FORT BEND �( 64454 MEMORIAL MEDICALINH GOLDEN CREEK GOLDE $1.57,623.18. $162,629.33 $157,623..18 $1.53,121.50 HEALTHCARE •4551 CAL CO INDIGENT $13.340.52 $13,340.52 $1,3,340.52 $13,340.52 HEALTHCARE •5433 MMC -NH.. GULF POINTEPLAZA - $850.80 $5.476.50 $850.80 $850.80 PRIVATE PAY *5441 MMC -NH' GULF POINTEPLAZA- $71,365.10 $78,908.65 $71,365.10 $68,543.94 MEDICAREIMEDICAID •5506 MMC -NH BETHANY SENIOR $49,745.95 $49,745,95 $49,745.95 $88,458.94 LIVING `3407 USCAN VILLAGE TUSCANYVILCAGE $127,341.82 $139,660.70 $127,341.82 $164,11'6.95. *3660 MMC -BETHANY SR LIVING -DACA. $100.00 $.100.00 $100.00 $100.00 *2998 lI FUND -MONEY MARK MARKETFUND $2,094,298.35 $2,094,298.35 $2,094,298.36 $2,094,298.35 Total Balance $6,497,572.62 $6,547,952.28 $6,497,572.62 $6,619,053.37 Report generated an 111271202308;58;44.AM. CST Page 2of3 Memorial medial Center Nursing Home UPL Weekly Ne3don Transfer Prosperity Rtaounts 10/23/2023. preulvu. M..,A I 191.V3.13 mWe2:6lVbalanm p/av¢S.[WOwill beh$10da Mthe nurtMg4am<. Nate 3:fv[ha[awnt Mrabmebvinre�eaf$jMNplMM6depmlKCtvaprn atteun[. �a 1 '�� I I o �$11 .i Ab It PeMIM Taday'ISUI.MnS nmpuntm Be.TranaferredroMunln� 3apvYtr 6a1an[e Nome ISi;633'.!B ®' � 13T,339.fiB. Oant BaYnce 33];623'.t8 .y(q� Vadmb 4avl.Inevlenm. iCO.W ,p/ Nnvemben lntemb 163.W.rrl mlun Baian[a(Tnnrlerbm3 1SE384:fiR�f / �l �i1.we MppNeI ANoek 3 6woewsspmos. um/3ozr I:\NH WcN v Tuntlna\tM VIL 11. ler3ummary\3n3$raHYpl Tnmler Summary I3A.33 [9F9M3s U!Q 11 4=i NMTHHUNU SVCKC mu 1LM/IDi3 NExETN NpM MNHim[WM9Ml IT16WH[9]@31.E ll/31JA]3 WM[pNIX[11gH M[rl1N Y9/g4pl@fXCN[{[.N[. ]LEUM3 Aptl[. I]/t]/Ali XH@�[tMp MCCWWMI'TIW9M11Y(9Fp]Y6M 11p]/]Y3 4p{OPMU[{[Y[A[LMPpC4b {i]a5491a11@Yil Y/il/NE3 NNB-F[Xp XC[WIMFM]][YFMyIM JpU3fiT1 lLl9/AR ISY9/]MX]flgM[q[@ 9FI9AilYYF11b1T91 MY6roXnoM I avv7[9mrq, J Ip�Clp iavr (qm arr/4Ym9: obrrcomp3. XYn. avn� ,. xnroM14N T Sr;Yuu �I 6).HES9 ;31[.9} "MIN 9T,YI36 i:319.@3 ' 91:669:33. ' Y91.93 - 91,669.3E - ;9ffia. 1.i93.93 ' 4>3.31 f@92W. 1.MLN I@1.36 e-3T-7 Balances Overview Account Name '4357 MEMORIAL MEDICAL CENTER- $3,047,847.53 $3,018,516.78 $3,047,847.53 $3,157.118.18 OPERATING '4365 MEMORIAL MEDICAL CENTER- $539.81 $539.81 $539.81 $539.81 CLINIC SERIES 2014 '4373 MEMORIAL. MEDICAL.CENTER- $434.57 $434.57 $434.57 $434.57 PRIVATE WAIVER CLEARING '4381 MEMORIAL MEDICAL CENTER 1 $116,087.07 $128,724.20 $116,087.07 $127,152.00 NH ASHFORD '4403 MEMORIAL MEDICAL CENTER 1 $153,274.71 $166,704.60 $153,274.71 $145,202.87 NHBROADMOOR '4411 MEMORIAL MEDICAL CENTER 1 $246,903.54 $263,688.95 $246,903.54 $212,969.75 NH CRESCENT '4438 MEMORIAL MEDICAL CENTER I $232,416.92 $232,888,63 $232,416.92 $234,360.34 SOLERA AT WEST HOUSTON "4446 MEMORIAL. MEDICAL CENTER 1 $185,402.75 $192,2MU $185,402.75 $158,444.85 NH FORT BEND '4454 MEMORIAL MEDICALINH $157,623.18 / % $162,629.33 $157,623.18 $153,121.50 GOLDEN CREEK w` HEALTHCARE '4551 CAL CO INDIGENT $13,340.52 $13,340.52 $13,340.52 $13,340,52 HEALTHCARE '5433 MMC -NH GULF POINTEPLAZA .- $850.80 $5,478.50 $850.80 $850.80 PRIVATE PAY '5441 MMC 44H. GULF POINTE PLAZA - $71,365.10 $78,908.65 $71,365.10 $68,543.94 MEDICAREIMEDICAID '5506 MMC -NH BETHANY SENIOR $49,745.95 $49,745.95 $49,745.95 $88,458.94 LIVING USCMMC NH USC TANY VILLAGE $127,341.82 $139,660.70 $127,341_82 $164,116.95 *3660 SR LIVI- DACA -BETHANY SRLI LIVING $100.00 $100.00 $1100.00 $100.00 *2998 MARK TFUNDNEY MARKETFUND $2,094,298.35 $2,094,298.35 $2,094,298.35 $2,094,298.35 Total Balance $6,497,572.62 $6,547,952.28 $6,497,572.62 $6,619,053.37 Report generated on 11/27/2023 08:58:44 AM CST Page 2. of 3 Merrodal. Medical Center Nursing HorneUPL. Weekly HMG. Transfer Prosperity ACCountS 11/2712023 hnbua AgeunN Beemlry P[edoua PNYY11[ 4Yinnb{ NUN.. Num6ve 41uw NMe:OiJY bNunand/dw5S0.V tl4.gerulmedm A nYmnehane. Nqe}; (qh acauntllaYPGgebol cedSICB Mn:MMCOepssrtedm pBM.mrount Y1nxw..m N�rtnlxxun]r.ndnwmm.NUBx3wx un]a.mrmmmm.m3vn.n Am.1.Ba T.dmedw Iya'd6 f' aF - RBQIB ys 4ny41anca ISQIO` VarNn<v LNVNnBahnN IBB.W. GdIw141N.e/irnaler4nl �y10` ]ypgl Amewuo Be TNnnanmw: Tech. Be N'n BUWxe N Moma: ]LleyaQ ',iBS.10 Ban44Bn[e 7ll10f16 � Vnhnn lNNln 4hn[e IOa.W MM4a0ncv/rnnYlerNnl: 'Q •BBlYP. My4 TBGNir[R RBIyp MPmaed.UL41�N.YYnr •' Yln l.. �.,.�i3 �(.I/uHr irinRLW OF.LQSBYIIM i ll/b/IB23 MMCPQRTI4N. 41PP/Come QIPP/Cem0: 111211=3 HN3-ECHOHCCIAIMPMT)960¢WIH90DOOMM2. Tnnehr-Oul Tn .m. CIPP/COMPI 2 41RPIComP3. &I.,. 41PPTI NH PORTION 19a.36 194.36 11/29/2023 MERCWWTBpN1IC0OFW51F99N]831BM9.9100001 1 IN/2019' NOM04NNRSKCUIMPMT6]56929300001W15J9 II(ZVH23. WIRE OUT HMG RtxII,d:SNP;.L]-CommWMP 11/22/3023-0aomR ll/31/3023 NOMPAN131.HC IMPMT3/58924NMOI]2480] 11/20/20B MERC NTfANKC0.0EPOSIT996976SIRM99WO001 I11"nO13 MEflGIUNTBPNN(O pEPO51i<9p1JB5IBB9991pWOS ' 194.361 OPC TnnAer-0- ut Tnofi OPP/Qampt NN PORTON ..�Mmcl 23600.. 475,16 .. 2.30W C;923.11 ORab 1,MSb f.J99.36 - 62.09,38 2,WGO0 - fi2�6B9.9B SAO"GOo 6923ll „( 6.933;1) )IAIRAO - 7IA936 Balances Overview Account Name *4357 MEMORIAL MEDICAL CENTER- $3,047,847.53 $3,018,516.78 $3,047,847.53 $3,167,118.18 OPERATING *4365 MEMORIAL MEDICAL CENTER- $539.8.1 $539.81 $539.81 $539.81 CLINIC SERIES 2014 •4373 MEMORIAL MEDICAL CENTER - $434.57 $434.57 $434.57 $434.57 PRIVATE WAIVER'. CLEARING •4381 MEMORIAL MEDICAL CENTER! $116,087.07 $128,724.20 $116,087.07 $127,152.00 NH ASHFORD •4403 MEMORIAL MEDICAL CENTER $153,274.71 $166,704.60 $153,274.71. $145,202.87 NH BROADMOOR •4411 MEMORIAL MEDICAL CENTER t $246,903.54 $263,688.95 $246,903.54 $212,969.75' NH CRESCENT *4438 MEMORIAL MEDICAL CENTER/ SOLERA AT WEST $232,416.92 $232,888.63 $232,416.92 $234,360.34 HOUSTON •4446 MEMORIAL MEDICALCENTER1 $485,402.75 $.1.92,292.74 $1..85,402.75 $158,444.85 NH FORT BEND *4454 MEMORIAL MEDICAL INH. GOLDEN CREEK - $1.57.623.18 $162,629.33 $157,623.18 $153,121.50- HEALTHCARE. •4551 CAL CO INDIGENT $13,340.52 $13,340.52 $13,340.52 $13,340.52 HEALTHCARE •5433 MMC-NH GULF POINTE PLAZA.- $850.804/ $5,478.50 $850.80 $850.80 PRIVATE PAY *5441. MMC -NH GULF POINTE. PLAZA- $71,365.10,/ $78,908.65 $71,365..1..0 $68,543.94 MEDICAREIMEDICAID *5506 MMC-NH BETHANY SENIOR $49,745.95 $49,745.95 $49,745.95 $88,458.94 LIVING TUSCANYVILL. TUSCANY VILLAGE $127,341.82 $139,660.70 $127,341:.82. $164,116.95 SR LIVING - DACDACA ANY SR $100.00 $100.00 $1'00.00 $100.00 *2998 MARKET FUND -MONEY MARKE7FUN0 $2,094,298.35 $2,094,298.35 $2,094.298.35 $2,094.298.35 Total Balance $6,497,572.62 $6,547,952.28 $6,497,572.62 $6,619,053.37 Report generated on 11/272023 08:58:44 AM CST Page 2 of 3 Memorial Medio6Center Nursing Nome UPL Weekly Tuscany Transfer PreSPtdty Accounts 33/27/2023 emo. atmunt aslnnbr. xmel (eM ip..vubn rya VaKamuaagsl(pMotMM('tlerorrtetl(ommocmunt. nmwntb ba a.wabnb �� u},lu.0 4adn atl.nb Moa.gSSephmhbyW sm.ta 46SLSE.../ MneMrlwO Yb}SRlrmbb.Qi11 1;}Yli. 8f� Mw.mbnlnbnn Sai,ai yr aN nb i R ,µadr.ame lanw.ln f ob � lYi}/AI3. r MMC PORTION QIPP/COMP. QIPP/ComP QIPP/Comp Tn0ik,-Out rTnnSferin 1 QIPP/COmp2 3 4R1Ap3e. QIPPTI'. NHPORTION 1//2412023 Cluck 39271.62 ✓ 0 - - 11/24/2023 HNB- ECHO HCCWMPMT7460341144W00225165 0 2496.49 - 2,496.49 11/22/20M WIRE OUTUNRAR.ENTORPRISE5,11C. 792Z7.23 0 - - W22/2023 OeP441. a 2400 - 2,400,00 11/22/2023 Oepmit 0 22300 - / 22,SO .W lvnt201ZM4)NA NFALTMOtP.MOlIMA4Oi0313i4®,4200WI4 0 IDQE9 6&auQ 6'�623.90:.0 xwsoa 11/22/2023 HN8-ECHO HCCUOMPMT74MI3411440a00398861 0 36.74 -- 36.74 11/22/2023 HNB-ECHO HCCIAIMPMT 746013411440000288644 0 30191.98 - 30,191.98.. 11/21/2023 HNB-ECHOHCCWMPMT74600341144W00243621 0 17222,28 - 27,222.28 11/21/2023 HN8-ECHOHCCIAIMPM77MI3411440W0243268 0 17462.57" l 17,46L57 FIQ21110I3 AME111GR0UPE0RP4TErBRYMEN4EB2T081®1210� O. > YBI�FRIM1 IF,TBB'SII 12;717f4MSA r✓'d'3L4Z51O Balances Overview Account Name •4357 MEMORIAL MEDICALCENTER- $3,047,847.53 $3,018,516.78 $3,047,847.53 $3,1,57,1.18.18 OPERATING '4365 MEMORIAL MEDICAL CENTER - $539.81 $539.81 $539.81 $539.81 CLINIC SERIES 2014 '4373 MEMORIAL MEDICAL CENTER- $434.57 $434.57 $434.57 $434.57 PRIVATE WAIVER CLEARING '4381 MEMORIAL MEDICALCENTERI $116,087.07 $128,724.20 $116,087.07 $127,1.52.00 NHASHFORD `4403 MEMORIAL MEDICAL CENTER $153,274.71 $166,704,60 $153,274.71. $145,202.87 NH BROADMOOR 64411. MEMORIAL. MEDICALCENTER/ $246.903,54 $263,688.95 $246,903.54 $212,969.75 NH CRESCENT '4438 MEMORIAL MEDICAL CENTER $232.416.92. $232,888.63 $232,416.92. $234,360.34 SOLERA AT WEST HOUSTON '4446 MEMORIAL MEDICAL CENTER 1 $1185,402.75 $192,292.74 $185,402.75 $158,444.85 NH FORT BEND %454 MEMORIAL MEDICAL INH $157,623.18 $162,629.33 $157,623.18 $1153,121.50 GOLDEN CREEK HEALTHCARE '4551 CAL CO INDIGENT $13,340.52 $13,340.52 $1.3,340.52 $13,340.52. HEALTHCARE •5433 MMC -NH GULF POINTE PLAZA - $850.80 $5,478.50 $850.80 $850.80 PRIVATE PAY '5441 MMC -NH GULF POINTEPLAZA - $711,365.10 $78,908.65 $71,365.1'0 $68,543.94 MEDICARE/MEDICAID '5506 MMC -NH BETHANYSENIOR $49,745.95 $49,745.95 $49,745.95 $88,458.94 LIVING *3407MMC -NH TUSCANY VILLAGE,/✓ $127,. 82 341 $139,660.70 $127,341.82 $164,118.95 - DACA 0 MMC -BETHANY SR LIVING SR LIVING $100.00 $100.00 $1'00m $100.00 *2998 MC -MONEY MARKETFUND $2.094,298.35 $2.094,298.35 $2,0094,298.35. $2,094,298.35 MARKE Total Balance $6.497,572.62 $6,547 952.28 $6,497,572.62 $6,619 053.37 Report generated an 11127/2023 0"&44 AM CST Page.2 0[ 3 Memorial Medical. Center Nursing Home UPL Weekly HSLTransfer ProsPerltTAcwun[s' 11/27/2023 PW.u. ae..uM B.FrmMt Nwc Fx(y bvlonaa of vvrS£IXb will Ee hvm/arvd ro Menurtlnp A.mv Nwe2: F.N xvvunr Mf vGatbdancepjFlwlborMMCdfpxrfeala tVchv6Wnr. r:\aixwnkkM1+ntlmlxN ull"'*Vpl Tralgf umm.n s,,.... wnai.a M.Mw. 4mwM[..6. rmml.amam. rea..B. x.:.m Bank Bahnn � .9a9s.9s 9.<13.>p.,, Wrian[v a9.)as.99 telve in Balance 1BO.w N..MnMrrnrm>t ni.ic �ry// RQ n&I Rnrule Am[ aeill.M� k/ tA4a u. swru. l a9/x>/x19 IaOL[�J 11/$yd1A QRt b 2M Wze/ma. xxe[Woxawx[Mriumvuummzusss e ss/u/na xasei[[assovW [ssm.�Mx[sAua[sootersx o Wii(lms vnt[ourramuvquxx; uc iwmn sLWsess eelmx a MMC W WIOM [iaef4rin. W"/GMvl WWtMpz WP/WApi' QIII(GmpYlgn. gNPI[. '. NR.M f o 4N 2O.- U..A - x,iae:u a Balances Overview Account Name *4357 MEMORIAL. MEDICAL CENTER- $3,047,847.53 $3,018,516.78 $3.047,847.53 $3,1'67,118.18 OPERATING '4365 MEMORIAL MEDICAL CENTER- $539.81 $539.81 $539.81 $539.81 CLINIC SERIES 2014 •4373 MEMORIAL MEDICAL CENTER- PRIVATE WAIVER $434.57 $434.57 $434.57 $434.57 CLEARING '4381 MEMORIAL. MEDICALCENTERI $11.6,087.07 $128,724.20 $11.:6,087.07 $127,1.52.00 NH. ASHFORD '4403 MEMORIAL. MEDICAL CENTER 1 $153,274.71 $166,704.60 $153,274.71. $145,202.87 NH BROADMOOR '4411 MEMORIAL. MEDICAL CENTER 1 $246,903.54 $263,688.95 $246,903.54 $212,969.75 NH CRESCENT '4438 MEMORIAL MEDICAL SOLERA AT WEST OLE A AT NTERWEST $232,41.6.92. $232,888.63 $232,416.92. $234,360.34 HOUSTON '4446 MEMORIAL MEDICAL CENTER 1 $185,402.75 $192,292.74. $185,402.75 $158,444.85 NH FORT BEND *4454 MEMORIAL INH GOLDEN CREEK GOLDS CREEK $157,623.18 $162,629.33 $157,62318 $153„1.21.50. HEALTHCARE '4551 CAL. CO INDIGENT $13.340.52 $13,340.52 $13,340.52 $13,340.52' HEALTHCARE •5433 MMC -NH'. GULF POINTE PLAZA.- $860.80 $5,478.50 $850.80 $850.80 PRIVATE PAY •5441 MMC -NH: GULF POINTEPLA2A- $71,365.10 $78,908.65 $71,365.10 $68,543.94 MEDICAREIMEDICAID '5506 MMC -NH B.ETHANYSENIOR $49,745.95 $49,745.95 $49,745.95 $88,458.94 LIVING TUSCA YVILL TU5CANYVIILAGE $127,341.82 $139,660.70 $127,341.82 $164,14..6.95 SRLIVI G -DAC ANY SR LIVING - DACA $100.00 $100.00 $100.00 $100.00 *2998 MMC -MONEY MARKE MARKET FUND $2,094,298.35 $2,094,298.35 $2,094,298.35 $2,094,298.35 Total Balance $6,497,572.62 $6,547,952.28 $6,497,572.62 $6,619,053.37 Report generated on 1112712023 03:50:441 AM CST Page 2 of 3 Ashford v1 MEMORIAL MEDICAL CENTER CHECK REQUEST P MMC Date Requested: 11/27/2023 A lu E FOR ACCT USE ONLY Aplpmw oN ❑I Imprest. Cash E ❑ A/p check NOV 2 7 202 ❑ Maim. Check to Vendor .p I ll _ Ali ❑', Return. Check to Dept AMOUNT: $ 32,764.41 �{ G/L NUMBER: 10255040 EXPLANATION: Molina YR7 September QIPP, Amerigroup YR7 September QIPP' REQUESTED BY: Michelle Cumberland AUTHORIZED BY: Broadmoor lu MMC A Y MEMORIAL MEDICAL CENTER CHECK REQUEST Date Requested: 12/27/2023 E APPPZMM ON 2 7 2023 s��FND7ll�1��IF FOR,ACCT USE ONLY ❑' Imprest Cash ❑'.. A/P Check Q Mail.. Check to. Vendor Return Check to Dept AMOUNT: $ 12,116.44 / G[LNUMBER: 10255040 EXPLANATION: Molina YR7 September QIPP, Amerigroup YR7 September QIPP REQUESTED BY: Michelle Cumberland AUTHORIZED BY: ILlf,�!y- I�� .�.�.'�fI14n•. � rui �w1'4, Crescent/ MEMORIAL MEDICAL CENTER CHECK REQUEST P MMC Date Requested': 11/27/2023 A Y E E APPRadW CM NOY 2 7 2973 FOR ACCT USE ONLY ❑. Imprest Cash. El I All' Check. Mail: Check to Vendor Return Check to. Dept. AMOUNT: $ 9,031.75 E GA NUMBER: 10255040 EXPLANATION; Molina YR7September QIPP,AmerigroupYR7September QIPP REQUESTED BY: Michelle Cumberland li a II L-7 Fort Bend P A Y E E MEMORIAL MEDICAL CENTER CHECK REQUEST MMC Date Requested': APPRovM ON CARgymmoma 11/27/2023 FOR ACCT USE ONLY ❑. Imprest Cash ❑ A/P. Check. ❑', Mail Check to Vendor ❑', Return Check to Dept AMOUNT: $ 10,226.72 G/LNUMBER: 10255040 EXPLANATION: Molina, YR7 September QIPP, Amerigroup YR7 September QIFP REQUESTED BY: Michelle Cumberland AUTHORIZED BY: It 1'2-7, �2- Solera 0 MMC A Y MEMORIAL MEDICAL CENTER CHECK REQUEST Date Requested: 11/27/2023' E EAPPROVED ON AMOUNT: EXPLANATION: FORACCr USE ONLY El ImprestCash.. A/P Check ❑.: Mail', Check to Vendor 0Return Check to: Dept $ 9,809.87 .f G/L NUMBER: 10255040 Molina YR7 September QIPP, Amerigroup YR7 September QIPP REQUESTED BY: Michelle Cumberland AUTHORIZED BY: P A Y E E AMOUNT: MEMORIAL MEDICAL CENTER. CHECK REQUEST MMC Date Requested: 11/27/2023 . I[.,...e,.,, 41..,5;. FOR ACCT USE ONLY El Imprest cash El A/P Check ❑' Mail Check to Vendor Return.. Check: to Dept $ 19,369.63- GA NUMBER: 10255040' EXPLANATION: Molina YR7 September QIPP, Amerigroup YR7September QIPP REQUESTED BY: Michelle Cumberland AUTHORIZED BY:��'' �� V N O N a T H b H rl ti aaa w44 H O how W E a � asa N O P oaw Nau xww wAH w u z H a ow �0a aC14 uam wES zF w � w O a 0.H0.H0.HJ H z x H0u aO°a o I I I o o o 0 I I U < C P N N s 0 U y =z � C44] 04 Q4' G �i r Nvhi 4 tllZZm! �NN ash a@ h UO U N C1z .LU tl� 0wN P N f E y E` O O O O N p ? 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