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Subrecipient Agency: Kittitas Countv <br />Grant and Year: Homeiand Seculrity Grant 2016 <br />Agreement Number: E17-075 <br />Completed Darren Higashiyama <br />by: <br />Commander <br />(509) 933-8206 <br />Name <br />Title <br />Telephone <br />Date Completed: 11 /16/2016 <br />�y. „'.'''�.��IS fl.�� �%3b a;"li.�tfi S" ow:..F... i`t5 r'n-... h->9f✓..�*r. <br />� $ . <br />:. ,.-. <br />YES <br />STOP, no further <br />NO <br />Is your grant agreement less than $25,000? <br />a <br />analysis needed, <br />a <br />GO to Step 2 <br />GO to Step 6 <br />In your preceding fiscal year, did your <br />YES <br />NO <br />STOP, no further <br />organization receive 80% or more of its annual1:1GO <br />to STEP 3 <br />❑ <br />analysis needed, GO to <br />gross revenues from federal funding? <br />Step 6 <br />1111 AW <br />ST1 IA S,- ' MM <br />ME <br />In your preceding fiscal year, did your <br />YES <br />NO <br />STOP, no further <br />organization receive $25,000,000 or more in <br />9 <br />FL <br />GO to STEP 4 <br />analysis needed, GO to <br />Y <br />federal funding? <br />-1 <br />Step 6 <br />F fid'• t_, 3_ <br />QST}Eia* <br />6 <br />Does the public have access to information about <br />YES <br />STOP, no further <br />NO <br />the total compensation* of senior executives in <br />analysis needed, <br />GO to STEP 5 <br />your organization? <br />GO to step 6 <br />❑ <br />., <br />Name: <br />Executive #1 <br />Total Compensationamount: $ <br />Executive #2 <br />Name: <br />Total Compensation amount: $ <br />Name: <br />Executive #3 <br />Total` Compensation amount: $ <br />Executive #4 <br />Name: <br />Total Compensation amount: $ <br />Name: <br />Executive #5 <br />Total Compensation amount: $ <br />------------- <br />If your organization does not meet these criteria, specifically identify below each criteria that is not met for your <br />organization: For Example: "Our organization received less than $25.000." <br />SignatureDate: If 116116 <br />N� <br />`Total compensation refers to: <br />• Salary and bonuses <br />• Awards of stock, stock options, and stock appreciation rights <br />• Other compensation including, but not limited to, severance and termination payments <br />• Life insurance value paid on behalf of the employee <br />Additional Resources: <br />http://www,whitehouse.goy/oc Vopen <br />hUp://www.hrsa,goy/Arants/ffata.html <br />http://www, apo.aov/fdsys/pka/FR-2010-09-14/r)df/2010-22705. pdf <br />http://www.prants.gov/ <br />Page 1 of 3 <br />