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DOH Program Name or Title: Maternal & Child Health Block Grant - <br />Effective January l. 2015 <br />SOW Type: Revision Revision # (for this SOW) 3 <br />Period of Performance: January l. 2015 through September 30, 2017 <br />Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />AMENDMENT #10 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: C17114 <br />Funding Source Federal Compliance Type of Payment <br />~ Federal Subrecipient (check if applicable) ~ Reimbursement o State ~ FF A T A (Transparency Act) o Fixed Price o Other o Research & Development <br />Statement of Work Purpose: The purpose of this statement of work is to support local interventions that impact the target population of the Maternal and Child Health Block <br />Grant. <br />Revision Purpose: The purpose of this revision is to add new billing language to the "Special Billing Requirements" section. <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period <br />Revenue Index (LHJ Use Only) <br />Code Code Start Date End Date <br />FFY15 MCHBG CBP CONCON 93.994 333.93.99 78734250 01101 /15 09/30115 <br />FFY16 MCHBG LHJ & OTHER CONTRACTS 93.994 333 .93.99 78730260 10/01115 09/30116 <br />FFY 17 MCHBG LHJ & OTHER CONTRACTS 93 .994 333 .93.99 78730270 10/01116 09/30117 <br />TOTALS <br />Task *May Support PHAB <br />Number Task! Activity lDescri ption StandardslMeasures Deliverables/Outcomes <br />Maternal and Child Health Block Grant (MCHBG) Administration <br />la Participate in calls, at a minimum of every other Designated LHJ staff will <br />month, with DOH contract manager. Dates and participate in contract <br />time for calls are mutually agreed upon between management calls. <br />DOH and LHJ. <br />Ib Participate in DOH sponsored MCHBG-related Designated LHJ staff will <br />quarterly conference calls and/or webinars, participate in calls, webinars, and <br />including up to two (2) in-person meetings. meetings. <br />lc Complete 2015-2016 MCHBG Budget Workbook Submit completed MCHBG <br />for October 1,2015 through September 30,2016 Budget Workbook to DOH <br />using DOH provided template. contract manager. <br />Id Report actual expenditures for October 1,2014-Submit actual expenditures using <br />December 31,2014. the MCHBG Budget Workbook <br />Exhibit A, Statements of Work <br />Revised as of November 15,2016 <br />Page 3 of21 <br />Current Change Total <br />Consideration None Consideration <br />34 ,870 0 34,870 <br />44,196 0 44,196 <br />44,196 ° 44,196 <br />123.262 <br />-0 1 123,262 <br />Payment <br />Due DatelTime Frame Information and/or <br />Amount <br />September 30, 2017 Reimbursement for <br />actual costs, not to <br />exceed total funding <br />consideration. Action <br />September 30,2017 Plan and Progress <br />Reports must only <br />reflect activities paid <br />September 4, 2015 for with funds <br />provided in this <br />statement of work for <br />February 18,2015 the specified funding <br />period. <br />Contract Number C 17114-1 0