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Contract - Heathstat, Inc. - 1/26/2017 TERM RENEWAL AGREEMENT NO. I TO "CITY OF ROUND ROCK AGREEMENT FOR ON SITE MEDICAL CLINIC SERVICES WITH HEALTHSTAT,INC." CITY OF ROUND ROCK ) STATE OF TEXAS ) KNOW ALL BY THESE PRESENTS: COUNTY OF WILLIAMSON ) COUNTY OF TRAVIS ) This Term Renewal Agreement No. 1 to "City of Round Rock Agreement for "Onsite Medical Clinic Services with Healthstat, Inc.," hereinafter called the "Renewal Agreement," is made by and between the City of Round Rock, Texas, a Texas home-rule municipality, whose offices are located at 221 East Main Street, Round Rock, Texas 78664-5299, hereinafter called "City," and Healthstat, Inc., whose offices are located at 4651 Charlotte Park Drive, Suite 300, Charlotte,NC 28217,hereinafter called"Services Provider." WHEREAS, City and Services Provider previously executed the referenced"Agreement for On Site Medical Clinic Services with Healthstat, Inc.," hereinafter called the "Agreement" pursuant to R-14-01-23-G2; and WHEREAS, pursuant to Section 2.01 of the Agreement, the initial term of the Agreement was for thirty-six (36) months with two (2) allowable successive twelve (12) month renewal periods from the effective date of the Agreement; and WHEREAS, the parties desire to extend the term of the Agreement for the first of two (2) allowable consecutive twelve (12) month renewal terms; and NOW THEREFORE,premises considered, and in consideration of the mutual promises and obligations in the Agreement and this Renewal Agreement, the City and Services Provider agree as follows: I. Pursuant to Section 1.01 of the Agreement, the term of the Agreement is renewed for the first allowable twelve (12) month renewal period. The twelve (12) month renewal is effective upon expiration of the initial term of the Agreement. II. This Renewal Agreement embodies the first of two (2) allowable twelve (12) month renewal periods and shall extend the original Agreement as to time only with no other changes in terms or conditions of the original Agreement. 00370591/ss2 IN WITNESS WHEREOF, the City and Services Provider have executed this Renewal Agreement to be effective as of the last date of due execution by both parties. CITY OF ROUND ROCK, TEXAS HEALTHSTAT, INC. By: Qe2 By: 4to-�L�,4A Printed Name: QV Printed Name: S' s , Title: Title: CFG L k _�'�or p t Date Signed: Date Signed: 1AS2ar� ATTEST: By: Sara L. White, City Clerk FOR CITY, PROVED AST FORM: By: 1 Stepha . Sheets, City Attorney 2 CERTIFICATE OF INTERESTED PARTIES FORM 1295 101`1 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 1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number: of business. 2017-153591 Healthstat Inc. Charlotte, NC United States Date Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 01/12/2017 being filed. City of Roundrock 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. Health Clinic Services Onsite Health clinic for the employees of the City of Roundrock Nature of interest 4 Name of Interested Party City,State,Country(place of business) (check applicable) Controlling I Intermediary 5 Check only if there is NO Interested Party. X 6 AFFIDAVIT 1 swear,or affirm,under penalty of perjury,that the above disclosure is true and correct. �I Iltil INNI e, JWP,''. Signature of authorized agent of contracting business entity AFFIX NOTARMID 1 SWI OVE=U 11,10 i Sworn to and subscr'Q/ � rT1e said �`'� this the 1 day 20 ,to certify whic7 ft%s my hand and seal of office. �`I C�MM1 S IL'r i Ey-fitQ�S ( {—(i3 2�:( l ion, Urp-D -Mira Signatur f officer administering oath Printed name of officer administering oath Title of officer administering oath Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.277 CERTIFICATE OF INTERESTED PARTIES FORM 1295 10f1 7-7 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 1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number: of business. 2017-153591 Healthstat Inc. Charlotte, NC United States Date Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 01/12/2017 being filed. City of Roundrock Date Acknowledged: 01/12/2017 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. Health Clinic Services Onsite Health clinic for the employees of the City of Roundrock Nature of interest 4 Name of Interested Party City,State,Country(place of business) (check applicable) Controlling I Intermediary 5 Check only if there is NO Interested Party. X 6 AFFIDAVIT I swear,or affirm,under penalty of perjury,that the above disclosure is true and correct. Signature of authorized agent of contracting business entity AFFIX NOTARY STAMP/SEAL ABOVE Sworn to and subscribed before me,by the said this the day of 20 ,to certify which,witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.277