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Percentage County Funds <br />Matching Funds $ <br />CFDA# 93.069 EPR PHEP <br />In -Kind $ <br />Explain <br />Is Equipment being purchased? <br />Who owns equipment? <br />New Personnel being hired? <br />Contact HR hiring — reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needed? <br />New Division Created? 1 <br />Revenue Code 612.88.3.333 <br />Pass Throueh Information <br />Agency to Pass Through <br />Amount to Pass Through 1 $ <br />Yes ❑ attach budget form <br />93.06 EPR PHEP <br />Sub -Contract Approved I Date: <br />NO ® Why not — already in budget <br />$885.00 <br />Prosecutor Review <br />Has the Prosecutor reviewed this agreement? YesEl No ❑ <br />County Departments Impacted <br />'� Auditor <br />Information <br />Prosecutor <br />Submitted <br />Signature: <br />Department: <br />Assignment of Tracking Information <br />Auditor's Office <br />Human Resource <br />Prosecutor's Office <br />Who Signed the grant application <br />Reviewer Date <br />Grant/Contract Review Page 2 <br />