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HCA CONTRACT NUMBER: <br />Washington Statekt-h-Or7i <br />Health Care CONTRACT AMENDMENT 1863-28733 <br />Prevention Services Amendment No. 01 <br />This Contract Amendment is between the State of Washington Health Care Program Contract Number <br />Authority (HCA) and the Contractor identified below. TMO10056 / SP020155 <br />Contractor Contract Number <br />CONTRACTOR NAME <br />CONTRACTOR doing business as (DBA) <br />Kittitas County <br />Kittitas County Health Department <br />CONTRACTOR ADDRESS <br />WASHINGTON UNIFORM BUSINESS <br />ACD INDEX NUMBER <br />507 North Nanum Street Suite 102 <br />IDENTIFIER (UBI) <br />1225 <br />192-002-673 <br />Ellensburg, WA 98926-2886 <br />CONTRACTOR CONTACT CONTRACTOR TELEPHONE <br />CONTRACTOR FAX <br />CONTRACTOR E-MAIL ADDRESS <br />Kasey Knutson (509) 962-7515 <br />(509) 962-7581 <br />kasey.knutson@co.kittitas.wa.0 <br />s <br />HCA PROGRAM AREA <br />HCA CONTRACT CODE <br />Division of Behavioral Health <br />1644CS-63 <br />HCA CONTACT NAME AND TITLE <br />HCA CONTACT ADDRESS <br />Sarah Mariani <br />4500 Tenth Ave SE <br />Program Administrator <br />PO Box 45330 <br />OI m ia, WA 98504 <br />HCA CONTACT TELEPHONE <br />HCA CONTACT FAX <br />HCA CONTACT E-MAIL ADDRESS <br />(360)725-3774 <br />1 1 <br />Sarah.Mariani@hca.wa.gov <br />IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? <br />CFDA NUMBERS <br />Yes <br />93.959 <br />AMENDMENT START DATE <br />CONTRACT END DATE <br />01/01/2019 <br />06/30/2019 <br />PRIOR MAXIMUM CONTRACT AMOUNT <br />AMOUNT OF INCREASE OR DECREASE <br />TOTAL MAXIMUM CONTRACT AMOUNT <br />$158,037.00 <br />$0.00 <br />$158,037.00 <br />REASON FOR AMENDMENT; <br />CHANGE OR CORRECT CHOOSE ONE: <br />ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into <br />this Contract Amendment by reference: <br />® Additional Exhibits (specify): Exhbit B <br />This Contract Amendment, including all Exhibits and other documents incorporated by reference, contains all of the terms <br />and conditions agreed upon by the parties as changes to the original Contract. No other understandings or <br />representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or <br />bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing <br />below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract <br />Amendment. <br />CONTRACTOR SIGNATURE <br />PRINTED NAME AND TITLE <br />DATE SIGNED <br />HCA SIGNATURE <br />PRINTED NAME AND TITLE <br />DATE SIGNED <br />Jim Gayton. HCA Contracts Administrator <br />HCA Contract Services Page 1 <br />7024PF HCA Custom Contract Amendment (5-2-2018) <br />