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MAAL <br />W ,0 shiN9104 Stiff <br />COUNTY DSHS Agreement Number <br />MnVpcpalmentofSocial PROGRAM AGREEMENT 1563-44899 <br />ilralth Services <br />Transfvo-rring lives DDA County Services <br />This Program Agreement Is by and between the State of Washington Department of <br />Social and Health Services (DSHS) and the County identified below, and is issued in <br />conjunction with a County and DSHS Agreement On General Terms and Conditions, <br />which is incorporated by reference. <br />DSHS ADMINISTRATION DSHS DIVISION DSHS INDEX NUMF <br />Developmental Disabilities Division of Developmental 1225 <br />Admin Disabilities <br />DSHS CONTACT NAME AND TITLE~ <br />Roger Van Afien <br />329-2962 <br />Kittitas County <br />Kittitas County DDA County Services <br />COUNTY FEDEFRAL EMPLOYER IDENTIFICATION <br />NUMBER jV r i _ Do I �4q <br />COUNTY CONTACT TELEPHONE <br />15091962-7567 <br />AGREEMENT? <br />No <br />A SUBRECIPIENT FOR <br />START DATE <br />DSHS CONTACT ADDRES <br />1611 W Indiana Ave <br />Spokane, WA 99205- <br />'ONTACT FAX <br />568-3037 <br />:OUNTY ADDRESS <br />507 North Nanum Street Suite 102 <br />Ellensburg. WA 98926 - <br />COUNTY CONTACT NAME <br />Sigrid Welker <br />COUNTY CONTACT FAX <br />CFDA <br />COUNTY <br />Administration or Di <br />Agreement Number <br />County Agreement Number <br />DSHS CONTF <br />1769CS-63 <br />E-MAIL <br />END DATE MAXIMUM PROGRAM AGREEMENT AMOUNT <br />07/01/2015 1 06/30/2016 1 $689,190.00 <br />EXHIBITS. The fallowing Exhibits are attached: Exhibit A — Data Security Requirements; Exhibit B — Program <br />Agreement Buhr et; Exhibit C — Local Match Certification <br />By their signatures below, the parties agree to the terms and conditions of this County Program Agreement and all <br />documents incorporated by reference. No other understandings or representations, oral or otherwise, regarding the <br />subject matter of this Program Agreement shall be deemed to exist or bind the parties. The parties signing below certify <br />that thev are authorized to sign this Program Agreement, <br />PRINTED NAME(S) AND TITLE(S) DATE(S) SIGNED <br />� C' -J i3 a,,& <br />DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED <br />Melissa Diebert, Contract Manager <br />IV ED <br />OCT 0520155tfR�CIVED <br />DDA SPOKANE SER 2 5 ?(1,15DSHS Central Contract SeNlces Page 1 <br />1769CS County Agreement 7-14-2015 <br />DDA SPOKAMFdget, Finance o",aritracts <br />