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Financial Information <br />Total Amount $62,942.00 <br />State Funds $5,000 (GFS) <br />$250 (Grp A Water) <br />Federal Funds $12,692 (HCCW) <br />$45,000 (Shape Up) <br />Percentage County Funds <br />Matching Funds $ <br />CFDA# 93.575 (HCCW) <br />93.283 (Shape Up) <br />In -Kind $ <br />Explain <br />Is Equipment being purchased? No <br />Who owns equipment? <br />New Personnel being hired? No <br />Contact HR hiring—reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needed? <br />Yes ❑ attach budget form <br />No ❑x Why not These Funds were anticipated <br />during the 2009 budget process <br />New Division Created? <br />Revenue Code 61292433395750 (HCCW) <br />6123633404910 (GFS), 6123633392830 (Shape Up), <br />61502233404980 (Grp A Water) <br />Date: <br />Pass Through Information <br />Agency to Pass Through <br />n/a <br />Amount to Pass Through <br />$ <br />Sub -Contract Approved <br />Date: <br />Prosecutor Review <br />Has the Prosecutor reviewed this agreement? Yes El No ❑ <br />County Departments Impacted <br />Auditor Facilities Maintenance <br />Information Services Human Resource <br />Prosecutor I ITreasurer <br />Submitted <br />Signature: Date: <br />Department: <br />Assignment of Tracking Information <br />Auditor's Office <br />Grant/Contract Review Page 2 <br />