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DSHS Agreement Number <br />COUNTY <br />0963 -53332 ~-""r'." PROGRAM AGREEMENT DEPART ENT OF <br />SOCIAL &H EALTH <br />SERV ICES <br />Amendment No. AMENDMENT <br />Medicaid Administrative Match 0963-53332-01 <br />This Program Agreement Amendment is by and between the State of Washington Administration or Division <br />Department of Social and Health Services (DSHS) and the County identified below. Agreement Number <br />County Agreement Number <br />0683-88565 <br />DSHS ADMINISTRATIO N I DSHS DIVISION I DSHS INDEX NUMBER CCS CONTRACT CODE <br />Health and Recovery Services 1225 1225 <br />Administration <br />DSH S CONTA CT NAME AND TITLE DSHS CONTACT ADDRESS <br />William McCandless PO Box 45508 <br />Olympia, WA 98504 -5508 <br />DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSH S CONTACT E-MAIL <br />1360)725-1657 Ext: (360 586-9585 mccanwm@dshs.wa.Qov <br />COUNTY NAME COUNTY ADDRESS <br />Kittitas County 507 North Nanum St ree t, Su ite 102 <br />EllensburQ , WA 98926 - <br />COU NTY FEDERAL EMPLOY ER IDENTIF ICAT ION COUNTY CONTACT NAME <br />NUMBER <br />916001349 <br />COUNTY CONTACT TELEPHONE COUNTY CONTACT FAX r.OI INTY c;ONTACT E-MAIL <br />So Q-Q fi2-706 8 ..s!ifl g ·962.75P.l lin da.na v arre~c o .k itt i a r <br />IS THE COU NTY A SUB RECIPIENT FOR PURPOSES OF THIS PROGRAM CFDA NUMBERS <br />AGREEMENT? 93.778 <br />Yes <br />AMENDMENT START DATE PROGRAM AGREEMENT END DATE <br />01/01/2010 12/31/2010 <br />PRIOR MAXIMUM PROGRAM AGREEMENT AMOUNT OF INCREA SE OR DECREASE TOTAL MAXIMUM PROGRAM AGREEMENT <br />AMOUNT AMOUNT <br />$0,00 $0.00 <br />$0.00 <br />REASON FOR AMENDMENT; <br />CHANGE OR CORRECT CONTRACT TERMS OR SOW, SEE PAGE TWO <br />EXHIBITS. When the box below is marked with a check (4) or an X, the following Exhibits are attached and are <br />incorporated into this Program Agreement Amendment by reference: <br />D Exhibits (specify): <br />This Program Agreement Amendment, including all Exhibits and other documents incorporated by reference, contains all of <br />the terms and conditions agreed upon by the parties as changes to the original Program Agreement. No other <br />understandings or representations , oral or otherwise, regarding the subject matter of this Program Agreement Amendment <br />shall be deemed to exist or bind the parties. All other terms and conditions of the original Program Agreement remain in full <br />force and effect. The parties signing below warrant that they have read and understand this Program Agreement <br />Amendment, and have authority to enter into this Pro :jram Agreement Amendment. <br />COUNTY SIGNATURE(S) PRINTED NAME(S) AND TITLE(S) DATE(S) SIGNED <br />~~~ ~ nl rtio 1 <br />DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED <br />0u~ftl1J-; Charles Pugh, Manager el.{· ~ov· Oq Contracts and Supplemental Rebate Agreements <br />Medical Assistance Divisions <br />DSHS Central Contract Services <br />6026CF County Program Agreement Amendment (3-31-06) Page 1