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.mt1t .... -""", '"'' COUNTY DSHS Agreement Number <br />I>e.pallmenl of Social PROGRAM AGREEMENT <br />1563-44899 <br />&. Ifealth Services <br />rransfo,.-m/ng lives DDA County Services <br />This Progra r"11 Agreement is by and between the State of Washington Department of Administration or Division <br />Social and Health Services (DSHS) and the County identified below. and is issued in Agreement Number <br />conjunction ""ith a County and DSHS Agreement On General Terms and Conditions, <br />which is incorporated by reference. County Agreement Number <br />DSHS ADMIN ISTRATION DSHS DIVISION DSHS INDEX NUMBER DSHS CONTRACT CODE <br />Developmental Disabilities Division of Developmental 1225 1769CS-63 <br />Admin Disabilities <br />DSHS CONTACT NAME AND TITLE DSHS CONTACT AODRESS <br />Roger Van Allen 1611 W Indiana Ave <br />Op~rations Manaaer Spokane. WA 99205- <br />DSHS CONTACT TELEPHONE I DSHS CONTACT FAX I DSHS CONTACT E-MAIL <br />(509) 329-2952 (509} 568-3037 vanalrl@dshs .wa.gov <br />COUNTY NAMe COUNTY ADDRESS <br />Kittitas County 507 North Nanum Street Suite 102 <br />Kittitas County DDA County Services E Uensburo. WA 98926- <br />COUNTY FEOERAL EMPLOYER IDENTIFICATION COUNTY CONTACT NAME <br />NUMBER c{ t -lp 00 ( ?JL{-q Sigrid Welker <br />COUNTY CONTACT TELEPHONE I COUNTY CONTACT FAX I COUNTY CONTACT E-MAIL <br />(509) 962-7567 <br />IS THE COUNTY A SUBRECIPIENT FOR PURPOSES OF THIS PROGRAM CFDA NUMBERS <br />AGREEMENT? <br />No <br />PROGRAM AG~EEMENT START DATE I PROGRAM AGREEMENT END DATE MAXIMUM PROGRAM AGREEMENT AMOUNT <br />07/01/2015 06/30/2016 $689.190.00 <br />EXHIBITS_ ihe following Exhibits are attached: Exhibit A -Data Security Requirements; Exhibit B -Program <br />A.greement Budget; 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 o r 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 they are authorized to sign this Program Agreement. . <br />COUNTY SIGNATURE(S) PRINTED NAME(S) AND TITLE(S) • DATE(S) SIGNED J"l ~Jj-e,aVl1 8Cr-hdt: ;~(J/tA.H-, Cf /I .5 /t fi <br />DSHS SIGNATURE PRINiED NAME AND TITLE DATE SIGNED <br />fl Vltv~ /},e L~_ ... _-Melissa Diebert, Contract Manager q,-.2)-/'J- <br />"c.v~' ~,.;;..- <br />OCT 052015 <br />DOA SPOKANE <br />DSHS Central contract SerVices <br />1769CS County Agreement 7-14-2015 <br />aece\v~q <br />s~p a 1 ie" <br />RECEIVED <br />SEP 252015 <br />OOA sPOKA~get, Finance & Con tracts <br />Page 1