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Kittitas County <br />Review Form (e;;;.: <br />Today's Date <br />08/12/2009 <br />Fund/Department <br />116-Public Health Department <br />Grants & Contract Agreement <br />I I Agenda Date <br />Contract/Grant Information <br />Contract /Grant Agency: Medicaid Administrative Admatch <br />Period Begin Date: 01/01/2010 I I Period End Date: 12/31/2010 <br />Total Grant/Contract Amount : <br />Grant/Contract Number: <br />Contract/Grant Summary <br />This contract is to ensure that the staff of Kittitas County Public Health Department will <br />provide necessary staff, services and/or materials to serve individuals who are potentially <br />Eligible for Medicaid benefits. This is the "Ad Match" contract for which they do not set a <br />maximum amount of revenue. We budgeted for $20,000 in our 2009 budget and are <br />anticipating the same amount for 2010 . <br />Recommendation for Board of Health and Board of Health Review on <br />Department Head Signature: Q ifu !WtID I~~ Administrator Date: {Ok 4;>/01 <br />Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment: <br />APPROVED AS TO FORM: <br />Sig nature of Prosecutor's Office Date <br />Date I <br />10 1 0 1 <br />Signature of Auditor's Office <br />Signature of Board of Health member Date <br />Financial Information <br />Total Amount $20,000 per year State Funds $ Federal Funds $20,000 <br />Percentage County Funds Matching Funds $ CFDA#93.778 <br />Grant/Contract Review Page 1