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AMENDMENT #14 <br />Restrictions on Funds (what funds can be used for which activities, not direct payments, etc) <br />1. At least 30% of federal Title V funds must be used for preventive and primary care services for children and at least 30% must be used services for children with <br />special health care needs. [Social Security Law, Sec. 505(a)(3)]. <br />2. Funds may not be used for: <br />a. Inpatient services, other than inpatient services for children with special health care needs or high risk pregnant women and infants , and other patient services approved by <br />Health Resources and Services Administration (HRSA). <br />b. Cash payments to intended recipients of health services. <br />c. The purchase or improvement of land, the purchase, construction, or permanent improvement of any building or other facility, or the purchase of major medical <br />equipment. <br />d. Meeting other federal matching funds requirements. <br />e . Providing funds for research or training to any entity other than a public .or nonprofit private entity. <br />f. payment for any services furnished by a provider or entity who has been excluded under Title XVIII (Medicare), Title XIX (Medicaid), or Title XX (social services block <br />grant).[Social Security Law, Sec 504(b)]. <br />3. If any charges are imposed for the provision of health services using Title V (MCH Block Grant) funds, such charges will be pursuant to a public schedule of charges ; will not <br />be imposed with respect to services provided to low income mothers or children; and will be adjusted to reflect the income, resources, and family size of the individual <br />provided the services. [Social Security Law, Sec . 505 (l)(D)]. <br />Monitoring Visits (frequency, type) <br />Telephone calls with contract manager at least one every other month. <br />Special Billing Requirements <br />Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable A19-1A invoice voucher. Payment to completely expend the "Total Consideration" <br />for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly on the 30th of each month <br />following the month in which the expenditures were incurred and must be based on actual allowable program costs. Billing for services on a monthly fraction of the "Total <br />Consideration" will not be accepted or approved. <br />Special Instructions <br />Any materials or communication products developed regarding work related to this Statement of Work should include the following text: "Supported by the Washington State <br />Department of Health, Office of Healthy Communities through the Maternal and Child Health Block Grant award from the Maternal and Child Health Bureau (Title V, Social <br />Security Act), Health Resources and Services Administration". <br />DOH Program Contact <br />Mary Dussol <br />Healthy Communities Consultant <br />Office of Healthy Communities <br />Washington State Department of Health <br />Street Address: 310 Israel Rd SE, Tumwater, WA 98501 <br />Mailing Address : PO Box 47848, Olympia, WA 98504 <br />Telephone: 360-236-3781/ Fax: 360-236-3646 <br />Email: mary.dussol @doh.wa.gov <br />Exhibit A, Statements of Work <br />Revised as of September 15,2017 <br />Page 10 of 10 Contract Number C 17114-14