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Percentage County Funds Matching Funds $ CFDA#93.757 <br />In -Kind $ <br />Explain _ <br />Is Equipment being purchased? Who owns equipment? <br />New Personnel being hired? I Contact HR hiring - reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needed? Yes ❑x attach budget form No F -]Why not <br />New Division Created? Will enter in budget center <br />Revenue Code <br />116-612.49.03.333.93.757 - Healthy Communities <br />Component #1 <br />116-612.49.04.333.93.757 - Healthy Communities <br />Component #2 <br />Pass Through Information <br />Agency to Pass Through <br />Auditor <br />Information Services <br />Amount to Pass Through <br />$ <br />Sub -Contract Approved <br />Date: <br />Prosecutor Review <br />Has the Prosecutor reviewed this agreement? Yes❑ No ❑ <br />County Departments Impacted <br />Submitted <br />Signature: _ Date: <br />Department: I <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 />Auditor <br />Information Services <br />Facilities Maintenance <br />Human Resource <br />Prosecutor <br />Treasurer <br />Submitted <br />Signature: _ Date: <br />Department: I <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 />