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ublic I ieaftli <br />Universal Agreement Agreement Number: PH001 2019 <br />'' _.,,s Purchase Order Number: <br />Purpose: The purpose of this Agreement is to document the mutual understanding and respective obligations of the parties to facilitate the <br />successful completion of the identified project or objective. This Agreement is by and between Kittitas County, and the community partner identified <br />in section 3 below, hereinafter referred to as Other Party. <br />2. Kittitas County Program Information: <br />Originator (Kittitas County Employee): <br />Tim Roth, RN <br />Program: <br />Kittitas County Public Health <br />BAC Code(s): <br />N/A <br />Email Address: <br />Tlm.roth@co.kittitas.wa.us <br />Phone: <br />(509) 962-7515 <br />Web Address: <br />https:/Iwww.co.kittitas.wa.usLdefault.aspx <br />Federal Tax ID #: <br />91-6001349 <br />Mailing Address: <br />3. Other Party Information: <br />Name: <br />Ellensburg School District 401 Phone: <br />(509) 925-8000 <br />Contact Person: <br />finger Haberer, Superintendent i Email Address: <br />ii nee r. haberer@esd401.ora <br />Physical Address: <br />1300 E 3rd Ave <br />City: Ellensburg <br />State: <br />WA <br />Zip: <br />98926 <br />Mailing Address: <br />1300 E 3'd Ave <br />City: <br />Ellensburg <br />State: <br />WA <br />Zip: <br />98926 <br />Web Address: <br />https:I/www.esd4Ol.c(p/ <br />Social Security #: <br />Federal Tax ID #: <br />91-6001849 <br />DUNS #: <br />If an independent contractor or personal service contractor, did you retire from the Washington <br />State Retirement System using the 2008 Early Retirement Factor? <br />❑ Yes ❑ No ❑ N/A <br />4. Attachments Applicable to this Agreement: <br />® Attachment A — Statement of Work ❑ Attachment E — Federal Certifications <br />❑ Attachment B — Compensation ❑ Attachment F — Circular A-133 Requirements (subrecipient only) <br />® Attachment C — Standard Provisions ❑ Attachment G —Terms and Definitions: - <br />❑ Attachment D — Special Provisions ❑ Other: <br />5. Agreement Period and Amount: <br />This Agreement shall commence on the start date indicated below and will continue in effect until the end date, unless terminated prior to that date in <br />accordance with paragraphs 11 or 12 of Attachment C—Standard Provisions. If applicable, the Agreement Amount set forth below represents the estimated <br />proportional financial contribution of the Other Party, with Estimate as the Condition. In the event there is actual monetary exchange, the true value will <br />appear in Amount, with the appropriate Condition selected, and be set forth on Attachment 8 -Compensation. <br />Start: 07/01/2019 End= Until terminated by Condition: No financial contribution I Amount: $ <br />either party <br />By their signatures below, the parties agree to the terms of this Agreement: <br />Other Party Signature (including legible name, title, and date) Kittitas County Signature <br />Anger Haberer, Superintendent Tristen Lamb, Administrator <br />Ellensburg School District Kittitas County Public Health <br />