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Total Amount $11,750 <br />State Funds $11,750 <br />Federal Funds $ <br />Percentage County Funds <br />Matching Funds $ <br />CFDA# <br />In -Kind $ <br />Explain <br />Is Equipment being purchased? Y <br />Who owns equipment? KCPHD <br />New Personnel being hired? <br />Contact HR hiring — reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needed? Yes E]New Division Created? <br />Revenue Code <br />116-615.02.6.1.334.03.10.6 - $11,750 <br />Pass Through Information <br />Agency to Pass Through <br />Amount to Pass Through $ <br />Sub -Contract Approved Date: <br />attach budget form No 0 Why not <br />Included in 2016 budget <br />Prosecutor Review <br />i Has the Prosecutor reviewed this agreement? Yes El No ❑ <br />County Departments 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 />