Business and Finance Division

S

DESTINATION

PREPAID

ITEM          DESCRIPTION                 QTY       U/M        UNIT PRICE       EXTENSION
     THIS IS FOR PAYMENT PURPOSES ONLY FOR AN EMERGENCY HOSPITAL VISIT.
     FRANK SWORD #02586280 WAS BEING TRANSPORTED VIA EXTRADITION AND
     WAS ADMITTED TO THE HOSPITAL FROM FEBRUARY 24, 2017 THROUGH
     FEBRUARY 28, 2017.
     CONTACT: ZELDA URIBE
     PHONE: 512-406-5614
001  952-94                                1.0000    EA       34223.420000       34223.42
     FOR PAYMENT PURPOSES ONLY
     PAYMENT TO: ATTN: PAYMENT FINANCIAL SERVICES
                 NEBRASKA MEDICINE
                 PO BOX 3839
                 OMAHA, NE 68103-0839
     BYRD UNIT RECEIVING:  936-295-5768
     PAYMENT:
      PAYMENT SHALL BE MADE THIRTY CALENDAR DAYS AFTER THE LATTER OF
      (1) THE DATE AN UNCONTESTED INVOICE IS RECEIVED, (2) THE DATE
      GOODS ARE RECEIVED, AND (3) THE DATE SERVICES ARE COMPLETED.
      REFER TO TEXAS GOVERNMENT CODE, CHAPTER 2251.
     AWARDED VENDOR AGREES THAT ANY PAYMENTS DUE UNDER THE PURCHASE
     ORDER OR CONTRACT SHALL BE DIRECTLY APPLIED TOWARDS ELIMINATING
     ANY DEBT OR DELINQUENCY IT HAS TO THE STATE OF TEXAS INCLUDING,
     BUT NOT LIMITED TO, DELINQUENT TAXES, DELINQUENT STUDENT LOAN
     PAYMENTS, AND DELINQUENT CHILD SUPPORT.
     VENDOR MAINTENANCE DIRECT DEPOSIT AND SUBSTITUTE W-9 FORM
     (ELECTRONIC FUNDS TRANSFER):
     GOVERNMENT CODE 403.016 (C) (3) ENCOURAGES STATE AGENCIES TO
     TRANSMIT PAYMENTS TO VENDORS THROUGH ELECTRONIC FUNDS TRANSFER
     (DIRECT DEPOSIT). TO SET UP YOUR ACCOUNT, CONTACT AGENCY ACCOUNTS
     PAYABLE AT (936)437-8761 OR (936)437-6357.
     REGARDLESS AS TO WHETHER DIRECT DEPOSIT IS CHOSEN, THE AWARDED
     VENDOR SHALL SUBMIT A COMPLETED VENDOR MAINTENANCE DIRECT
     DEPOSIT AND SUBSTITUTE W-9 FORM TO TDCJ ACCOUNTS PAYABLE. VENDORS
     WHO HAVE ALREADY SUBMITTED A FORM FOR ANOTHER SEPARATE PURCHASE
     ORDER ARE NOT REQUIRED TO SUBMIT ANOTHER FORM. THE VENDOR FORM AND
     INSTRUCTIONS ARE FOUND AT THE FOLLOWING LINK ON THE TDCJ WEBSITE:
     WWW.TDCJ.STATE.TX.US/DIVISIONS/BFD/ACCT_ACCTS_PAY.HTML
     TO ENROLL FOR ADVANCE NOTIFICATION OF ELECTRONIC FUNDS TRANSFER TO
     YOUR ACCOUNT, PLEASE CONTACT THE NUMBERS LISTED ABOVE. PAYMENT
     INFORMATION MAY BE OBTAINED BY CALLING THE COMPTROLLER OF PUBLIC
     ACCOUNTS TOLL FREE AT (800) 531-5441, EXT. 3-3660 OR IN AUSTIN, TEXAS
     CALL (512) 936-3461, SELECT OPTION 3 (PIN NOT REQUIRED) AND ENTER
     THEIR VENDOR IDENTIFICATION NUMBER AND 696 FOR THE AGENCY NUMBER.
     INFORMATION IS AVAILABLE VIA THE INTERNET AT:
     HTTPS://FMX.CPA.TEXAS.GOV/FMX/PAYMENT/INDEX.PHP
     (NOTE: THIS ADDRESS MUST BE IN LOWER CASE LETTERING WHEN ENTERED
     IN THE ADDRESS BAR OF YOUR BROWSER.)
     IN ACCORDANCE WITH SECTION 2252.907, GOVERNMENT CODE, THE VENDOR
     ACKNOWLEDGES THAT THIS CONTRACT AND INFORMATION CREATED OR
     MAINTAINED IN CONNECTION WITH THIS CONTRACT IS PUBLIC INFORMATION
     AND SUBJECT TO DISCLOSURE AS PROVIDED BY CHAPTER 552, GOVERNMENT

     CODE (TEXAS PUBLIC INFORMATION ACT).  THE PUBLIC INFORMATION ACT
     MAY REQUIRE THE VENDOR TO MAKE INFORMATION RELATED TO THIS CONTRACT
     AVAILABLE TO THE PUBLIC PURSUANT TO A REQUEST FOR PUBLIC INFORMATION.
     THE VENDOR AGREES, UPON REQUEST, TO MAKE INFORMATION RELATED TO THIS
     CONTRACT THAT IS NOT OTHERWISE EXCEPTED FROM RELEASE BY THE PUBLIC
     INFORMATION ACT AVAILABLE TO THE PUBLIC IN HARD COPY, UNLESS THE
     REQUESTOR OF THE INFORMATION CONSENTS TO RECEIVE THE INFORMATION IN
     ANOTHER MUTUALLY AGREEABLE FORMAT. THE VENDOR ACKNOWLEDGES THAT THE
     AGENCY SHALL NOT PROVIDE LEGAL COUNSEL RELATED TO THE VENDOR'S
     COMPLIANCE WITH THE PUBLIC INFORMATION ACT.
     FOR QUESTIONS OR INQUIRIES CONTACT:
     JASON ANDREWS, CTCD CTCM
     TDCJ CONTRACTS AND PROCUREMENT
     TWO FINANCIAL PLAZA STE. 525
     HUNTSVILLE, TX 77340
     PH:  936-437-7116  FAX:  325-223-0310
     EMAIL: JASON.ANDREWS@TDCJ.TEXAS.GOV
ORDER TOTAL:$     34,223.42