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In -Kind $ <br />Is Equipment being purchased? Who owns equipment? <br />New Personnel being hired? Contact HR hiring — reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needej Yes ❑ attach budget form <br />New Division Created? <br />Revenue Code <br />116-612.34.397 - $58.96 or $71.14 per xray as needed <br />Pass Through Information <br />Agency to Pass Through <br />Amount to Pass Through $ <br />Sub -Contract Approved Date: <br />No 0 Why not <br />Expenditures included in 2017 budget <br />Prosecutor Review _ <br />Has the Prosecutor reviewed this agreement? Yes ❑ No ❑ <br />county Uepartments Impacted <br />Auditor Facilities Maintenance <br />Information Services Human Resource <br />Prosecutor Treasurer <br />Submitted <br />Signature: Date: <br />Department: <br />Assignment of Tracking Information <br />Auditor's Office <br />Human Resource <br />Prosecutor's Office <br />Who Signed the grant application <br />Reviewer Date <br />Grant/Contract Review Page 2 <br />