Fillable Third Party Billing Contract (Collin County Community College District)

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Third Party Billing Contract (Collin County Community College District)

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COLLIN COUNTY COMMUNITY COLLEGE DISTRICT
3452 Spur 399
McKinney, TX 75069
Telephone: (972) 758-3840
Page 1 of 4
Third Party Billing Contract
THIS CONTRACT (Contract) made and entered, BETWEEN:
Collin County Community College District
3452 Spur 399, Suite 322, McKinney, Texas, 75069
(Herein referred to as the "College") - AND -
________________________________________________
____________________________________________ (City)
(Hereafter referred to as the "Vendor")
BACKGROUND:
A. The College and Vendor enter into a third party billing contract (Contract) whereupon Vendor agrees to
pay College for tuition, fees, and/or other services as authorized by this Contract.
B. The duration of the Contract, specific costs covered, and amount for which the Vendor will be responsible
are defined in the spaces provided.
1. The contract Duration (not to exceed two years*):____________________________________
(*Exception: Recognized city and/or county/municipality government entities may specify “as needed”, and agree to
an open-ended agreement which will remain in effect until terminated in writing.)
2. The costs to be paid by Vendor:
(Indicate with an ‘X’): Tuition Fees Other*
Maximum per student: $
and/or Maximum per this Contract: $
and/or amount As Needed for Vendor identified eligible students.
Additional items funded*, details, and/or requests included in Exhibit A and/or a specific list of students
(their corresponding social security number and/or birthdate, course(s) in which to be registered, and
amount to be paid by the Vendor for each student), Exhibit B, is to be considered part of the Contract.
It is understood College will invoice the Vendor and payment is due upon receipt of invoice by Vendor.
This Contract may be cancelled by either party with thirty (30) day written notice. However, cancellation
does not preclude Vendor or College from fulfilling obligations incurred prior to Contract cancellation.
Vendor Name
Primary Contact
Billing Address
Phone Number
FAX Number ____________
E-mail Address ________________________________________________
Collin College Community College District
3452 Spur 399, Suite 322
McKinney, TX 75069 972-985-3716
Page 2 of 4
C. FERPA (Family Education Rights and Privacy Act) Vendor and College agree to the following:
The privacy of students’ education records, including those contained in the College’s automated systems, is
protected by the Family Educational Rights and Privacy Act 1974 (FERPA). Only directory information, as
specified in CCCCD’s catalog and Student Records Policy, may be released without the student’s prior
written permission. A vendor requiring additional information be included in the College’s invoice for these
contracted services acknowledges and stipulates they obtained the student’s written permission for the
College to release the vendor required information as a condition of the third party funding benefit provided
to the recipient/student.
PERSONALLY IDENTIFIABLE INFORMATION, INCLUDING EASILY TRACEABLE
INFORMATION, COURSE GRADES AND ATTENDANCE RECORDS, ARE NOT PROVIDED OR
RELEASED BY THE BURSAR OFFICE.
D. Additional Terms:
1. The College and the Vendor agree to perform all their obligations under this Contract in good faith.
2. No part of the Contract may consist of acts in violation of any local laws, codes, statutes, ordinances,
regulations, rules or any other requirements; and the College may immediately cancel this Contract for
any such violation.
3. The Vendor's representative warrants that by signing this Contract it has the authority to bind the Vendor
to the terms and conditions of this Contract. Facsimile and Electronic signatures are binding and are
considered to be original signatures.
4. This Contract contains the entire Contract between the parties relating to the Third Party Billing, including
Exhibits. Contract cannot be changed except by in writing.
5. This Contract and the terms and conditions contained in this Contract apply to and are binding upon the
Vendor's successors, assigns, executors, administrators, beneficiaries, and representatives, and the
College's successors and assigns.
IN WITNESS WHEREOF the Vendor and the College have duly executed this Contract as of the date last
written below.
Collin County Community College District
(College) (Vendor)
By:
(Signature) (Signature)
Deanna Brown
(Name of Signatory) (Name of Signatory)
Bursar
(Title of Signatory) (Title of Signatory)
(Date) (Date)
For Office Use Only: Vendor ID
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Collin College Community College District
3452 Spur 399, Suite 322
McKinney, TX 75069 972-985-3716
Page 3 of 4
Exhibit A
*Special Instructions, including but not limited to the Vendor’s preferred method for identifying to
Collin the individuals eligible for funding under this Contract, i.e., vouchers, Exhibit B listing, etc.:
____
__
.
Collin College Community College District
3452 Spur 399, Suite 322
McKinney, TX 75069 972-985-3716
Page 4 of 4
Exhibit B
CWID/Last 4 of SSN Date of Birth Term Limit Amount
1
$
2
$
3
$
4
$
5
$
6
$
7
$
8
$
9
$
10
$
11
$
12
$
13
$
14
$
15
$
16
$
17
$
18
$
19
$
Students Associated with Contract
-
Student Name (Please Print)
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Third Party Billing Contract (Collin County Community College District)

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Completed 6 October 2020

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