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• - r <br />m > <br />DEPARTMENT OF STATE HEALTH SERVICES <br />1100 WEST 49TH STREET <br />AUSTIN, TEXAS 78756-3199 <br />STATE OF TEXAS <br />COUNTY OF TRAVIS <br />DSHS Document No. 7560022067 2005 <br />Contract Change Notice No. 04 <br />The Department of State Health Services, hereinafter refened to as RECEIVING AGENCY, did heretofore enter into a contract in <br />writing with PARIS-LAMAR COLTNTY HE_ALTH DEPARTMENT herP;naftPr rPfP.TPA t„ - DT.DL'nD71RTATl' A/~TATl1c~ T <br />,ties thereto now desire to amend such contract attachment(s) as follows: <br />SUMMARY OF TRANSACTION: <br />ATT NO. 04 : BNS - WIC CARD PARTICIPATION <br />All terms and conditions not hereby amended remain in full force and effect. <br />EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN <br />CITY OF PARIS <br />Authorized Contracting Entity (type above if different <br />from PERFORMING AGENCY) for and in behalf of: <br />PERFORMING AGENCY: <br />PARIS-LAMAR COUNTY HEALTH DEPARTMENT <br />By: <br />(Signature of person authorized to sign) <br />(Name and Title) <br />Date: <br />RECO ED: <br />Bv:,~7_ 4~~ <br />NCi"AGENCY Director, if different <br />authorized to sign contract <br />__u-1 I v [iVLl\\.1. IIIG <br />RECEIVING AGENCY : <br />DEPARTMENT OF STATE HEALTH SERVICES <br />By: _ <br />(Signature of person authorized to sign) <br />Bob Burnette, Director <br />Procurement and Contractin Services Division <br />(Name and Title) <br />Date: <br />pcsn - RPv Fina <br />. <br />Cover Page 1 E X H I B I Th <br />