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DSHS CONTRACT NUMBER: <br />COUNTY PROGRAM or INTERLOCAL 1563-32734 ~~~'r"" D EPART £NT OF <br />SOCI AL C.H .EALTH Amendment No . 01 SERVICES LONG-TERM PAYABLE AGREEMENT <br />AMENDMENT <br />This Amendment is between the State of Washington Department of Social and Program Contract Number <br />Health Services (DSHS) and the Contractor identified below. Click here to enter text. <br />Contractor Contract Number <br />CONTRACTOR NAME CONTRACTOR doing business as (DBA) <br />Kittitas County Kittitas County <br />CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER <br />IDENTIFIER (UBI) <br />County Auditors Office <br />192-002-673 1225 205 West 5th Ave County Courthouse Ste 105 <br />EliensburQ , WA 98926- <br />CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS <br />Judy Pless (509) 962-7502 (509) 962-7687 judy.pless@co.kittitas .wa.us <br />DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE <br />Executive Administration Financial Services 8030CS-63 <br />DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS <br />David Erickson PO Box 45842 <br />Financial Coordinator <br />Olympia , WA 98504 -5842 <br />DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS <br />(360)664-5757 (360)664-577 5 erickdd@dshs.wa.gov <br />IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS <br />No <br />AMENDMENT START DATE CONTRACT END DATE <br />07/01/2016 06/30/2017 <br />PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT <br />$0 .00 NIA Based on Annual Review <br />REASON FOR AMENDMENT; <br />CHANGE OR CORRECT PERIOD OF PERFORMANCE <br />ATTACHMENTS . When the box below is marked with an X, the following Exhibits are attached and are inco rporated into <br />this Amendment by reference: o Additional Exhibits (specify): <br />This Amendment , inc l uding all Exhibits and other documents incorporated by reference , contains all of the terms and <br />conditions agreed upon by the parties as changes to the original County Program Agreement or Interlocal Agreement. No <br />other understandings or representations , oral or otherwise , regarding the su bject matter of this Amendment shall be <br />deemed to exist or bind the parties . All other terms and cond itions of the original County Program Agreement or Interlocal <br />Agreement remain in full force and effect. The parties s igning below warrant that they have read and un derstand this <br />Amendment, and have authority to en ter into this Amendment. OCTOR SIGNATURE r PRINTED NAME AND TITLE DATE SIGNED <br />_~1J<f~ Obie O'Brien Chairman , Board of Co Commission ~rs 04/19/16 <br />DSHS S~n ATURE _ PRINTED NAME AND TITLE DATE SIGNED '-~ ~ Angela Wi ll iams, Contract Manager 5) 10 I III DSHS Central Co ntract Services <br />DSHS Central Contract Services Page 1 <br />6046 LF Long-Term Payable Amendment (3-13-14)