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In -Kind $ <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? <br />New Division Created? <br />Yes ❑ attach budget form I No ❑i Why not <br />Revenue Code <br />116.116.34.397 - $70.00 per x-ray as needed <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? Yes ❑ No ❑ <br />County Departments Impacted <br />Auditor Facilities Maintenance <br />Information Services Human Resource <br />Prosecutor Treasurer <br />Submitted <br />Signature: Date: <br />Department: <br />Assignment of TracKing Intormation <br />Auditor's Office <br />Human Resource <br />Prosecutor's Office <br />Who Signed the grant application <br />Reviewer I Date <br />Grant/Contract Review Page 2 <br />