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.JHt1t .... '"'' " , '"'' COUNTY DSHS Agreement Number <br />ocpa.lmcnl of Social PROGRAM AGREEMENT <br />1563-44899 <br />&. .Icallh Services <br />rransfo ,,-flJ ing lives DDA County Services <br />This Progra r"\1 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 vvith a County and DSHS Agreement On General Terms and Conditions, <br />which is incorporated by reference. County Agreement Number <br />DSHS ADMINI S TRATION DSHS DIVISION OS HS INDEX NUMB E R DSHS CONTRACT CODE <br />Developmental Disabilities Division of Developmental 1225 1769CS-63 <br />Admin Disabilities <br />OSHS CONTACT NA ME AND TI TLE D.SHS CONTACT ADDRESS <br />Roger Van Allen 1611 W Indiana Ave <br />Op erations Manager Spo kane.VVA 99205- <br />DSHSCONTACT TE LEPHONE I OSHS COI'ITACT FAX I DSHS CONTA CT E ·MAIL <br />(509) 329-2952 (509) 568-3037 va nalrl@dshs.wa .(lov <br />C0 UNTY NAM e: COUNTY AD DRES S <br />Kittitas County 507 North Nanum Street Suite 102 <br />Kittitas County DDA County Services EIJensbu rg l WA 98926- <br />COUNTY FEDERAL EMP LOYER IDENT IFICATION COUNTY CONTACT NAM E <br />NUMBER C{ I-V 00 ( ?J L{-or Sigrid Welker <br />COUI'ITY CONTACT TELEPHONE I COUNTY CONTACT FAX I COUNTY CONTACTE·MA1L <br />(509) 962-7567 <br />IS THE COUN'iY A SUBRECIPIE NT FOR PURPOSES OF THIS PROGRAM CFDA NUMB ERS <br />AGREEMEI'IT? <br />No <br />PROGRAM AG~eeMENT START DATE T PROGRAM AGREEMENT END DATE MAXIMUM PROGRAM AGREEMENT AMOUNT <br />07/01/2015 06/30/2016 $689,190.00 <br />EXHIBITS. The follow ing Exhibits are attached: Ex hibit A -Data Security Requirements ; Exhibit B -Program <br />Agreement Budget; Exhibit C -Local Match Certification <br />By their sIg natures 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 or 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 P(ogr~m Agreement. . <br />OOllNTY SIGNA TURE(S') PRINTED NAME(S) AND nnE(S) . OATE(S) SIGN ED <br />)0.., 'BJ1-elan" 8 e rnd:t J f3tJeu{MJU G ~11 6 h.5 <br />DSHS SIGNATURE PRINTED NAME AND TI TLE DATE SIGNED <br />flU~:v.LV1 Me·L\~:.·:._~ Melissa Diebert, Contract Manager 1-2)-/)- <br />ru:vt:;t y ........ <br />OCT 052015 <br />ODA SPOKANE <br />aece\vj.~ <br />s~p. a 1 iO'S <br />REC··-~···VED EI <br />SEP 252015 <br />DSHS Centra l contract Sen/Ices <br />1769CS county Agreement 7-14·2015 DDA sPOKA~il get, Finllnce & Contracts <br />Page 1