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,-r <br />., <br />Department of State Health Services <br />Signature of utho zed Officia <br />Date: / ? I f 01 <br />Evelyn Delgado <br />Assistant Commissioner for Family and Community <br />Health Services <br />1100 WEST 49TH STREET <br />AUSTIN, TEXAS 78756 <br />(512) 458-7321 <br />Evelyn.Delgado @dshs. state. tx.us <br />Page - 2 of 2 <br />Contractor <br />Signa u of/Authorized Official <br />Date: 3 <br />Name: CK?i?L(tCt CG- <br />Title: l? ?1 PT <br />Address: b a i?, ?? vs <br />Sow. Nkv r-os:1-? W&L ? <br />Phone: -,c; Q .3q3 • V00 <br />Email: 1 f C'66a lw - <br />-)()/11(n G1(Co?-` ?f . ???