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~ F <br />y s <br />~ <br />-ONTRACT FOR PUBLIC HEALTH SERVICES <br />DSHS DncuMF.1vT tv() 75()00??067a')005 <br />Contract Issued by: DEPARTMENT OF STATE HEALTH SERVICES W W <br />(RECEIVING AGENCY) 1100 WEST 49T" STREET <br />AUSTIN, TEXAS 78756-3199 <br />Legal Authority to Contract: Chapters 12 and 121, Health and Safety Code. <br />Venue: The provisions of this Contract shall be interpreted in accordance with Texas law. Venue for any court disputes shall be in Travis Counry <br />, <br />Texas. <br />PERFORMING AGENCY NAME: PARIS-LAMAR COUNTY HEALTH DEPARTMENT <br />I <br />MAILING ADDRESS: PO BOX 938 PARIS TX 75460-0938 <br />STREET ADDRESS: 740 6TH ST SW PARIS TX 75460-8530 <br />NAME OF AUTHORIZED <br />CONTRACTING ENTITY: CITY OF PARIS <br />(If different from PERFORMING AGENCY) <br />PAYEE DATA (If not the same as PERFORMING AGENCY or AUTHORIZED CONTRACTING ENTITY; must be on file with the Texas State <br />Comptroller's Office.): <br />NAME: PARIS-LAMAR COUNTY HEALTH DEPARTMENT <br />ADDRESS: PO BOX 938 PARIS TX 75460-0938 <br />(City, State, Zip) <br />I <br />State of Texas Vendor ldentification No. (14 digits) <br />PAYEE AGENCY Fiscal <br />17560022067001 <br />Year Ending Month: September <br />PAYEE BUSINESS INFORMATION FOR STATISTICAL REPORTING: Please check the categories that apply to your business. <br />r <br />_ Small Business - A corporation, sole proprietorship, or other legal entity formed for the purpose of making a profit which is <br />independently owned and operated and has fewer than 100 employees or has less than $1,000,000 in annual gross receipts. <br />_ Historically Underutilized Business (HUB) - A corporation, sole proprietorship, or joint venture formed for the purpose of making a <br />profit in which at least 5 1 % of all classes of the shares of stock or other equitable securities are owned by one or more persons who have <br />been historically underutilized (socially disadvantaged) because of their identification as members of certain groups: Black American, <br />Hispanic American, Asian Pacific American, Native American, and Women. The HUB must be certified by Texas Building and <br />Procurement Commission or ano[her entity. <br />_ For Profit Organization <br />SUMMARY OF CONTRACT DOCUMENTATION: <br />COVER PAGE 1- Receiving and Performing Agency Data GENERAL PROVISIONS - 6/2004 <br />COVER PAGE 2- Details of Attachment(s) ATTACHMENT(S) <br />COVER PAGE 3- Authorized Signatures EXHIBITS, IF APPLICABLE <br />cover Page 1 EXHIBIT A <br />