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Signature of Board of Health member Date <br />Financial Information <br />Total Amount $25,514.00 State Funds $17,600 <br />Percentage County Funds Matching Funds $ <br />In -Kind $ <br />f Explain <br />Is Equipment being purchased? Who owns equipment? <br />Federal Funds $7,914 <br />CFDA#93.539 & 93.268 <br />New Personnel being hired? I Contact HR hiring β€” reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needed? Yes ❑ attac <br />New Division Created? <br />Revenue Code <br />116-615.02.2.346.26.64 - $2,800 <br />116.615.02.2.346.26.65 - $2,800 <br />116-615.02.2.346.26.66 - $2,000 <br />116-615.02.3.334.04.90 - $10,000 <br />116-612.32.12.333.93.539 - $1,805 <br />116-612.32.13.333.93.268 - $1,150 <br />116-612.32.14.333.93.268 - $695 <br />116-612.32.12.333.93.268 - $924 <br />116-612.32.11.333.93.268 - $3,340 <br />Pass Through Information <br />Agency to Pass Through <br />Amount to Pass Through $ <br />Sub -Contract Approved Date: <br />Prosecutor Review <br />Has the Prosecutor reviewed this agreemenO= Yes❑ No ❑ <br />County Departments Impacted <br />Auditor Facilities Maintenance <br />Information Services Human Resource <br />Prosecutor Treasurer <br />Grant/Contract Review Page 2 <br />