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Signature of Board of Health member Date <br />Financial Information <br />Total Amount $ State Funds $ Federal Funds $ <br />Percentage County Funds Matching Funds $ CFDA# <br />In-Kind $ <br />Explain <br />Is Equipment being purchased? Who owns equipment? <br />New Personnel being hired? Contact HR hiring -reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needed? Yes 0 attach budget form No 0 Why not <br />New Division Created? <br />Revenue Code <br />Pass Through Information <br />Agency to Pass Through <br />Amount to Pass Through $ <br />Sub-Contract Approved Date: <br />Prosecutor Review <br />Has the Prosecutor reviewed this agreement? No 0 <br />County Departments Impacted <br />Auditor Facilities Maintenance <br />Information Services Human Resource <br />Prosecutor Treasurer <br />Submitted <br />I Signature: <br />Department: <br />I Date: <br />Assignment of Tracking Information <br />Auditor's Office <br />Human Resource <br />Prosecutor's Office <br />Grant/Contract Review Page 2