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Signature of Board of Health member Date <br />Financial Information <br />Total Amount $ 665,415 State Funds $ 223,200 Federal Funds $ 442,215 <br />Percentage County Funds Matching Funds $ CFDA# see below <br />In -Kind $ <br />Explain <br />Is Equipment being purchased? Who owns equipment? <br />New Personnel being hired? j Contact HR hiring — reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />....... -.......... - <br />Budget Amendment Neede�V?j Yes ❑ attach budget form No ® why not <br />New Division Created? Consolidated Contract Amendment #10 <br />....... — ... <br />Revenue Code see below <br />116.612.94.333.10.561 $ 20,603 FFY20 SNAP ED PROGRAM <br />116.612.88.3.333.93.069 $ 49,133 FFY19 PHEPR LHJ FUNDING <br />116.612.31.333.93.439 $ 60,000 FFY19 LSPAN PROGRAM <br />116.615.02.333.40.490 $ 20,000 GFS GROUP B (FO -E) (7/20-12/20) <br />116.612.39.17.336.04.25 $ 42,000 FPHS FUNDING LHJ's (7/20-12/20) <br />116.612.39.17.336.04.25 $ 42,000 FPHS FUNDING LHJ's (7/19-6/20) <br />116.615.02.2.346.26.64 ($-3,200) YR21 SRF (FS) SS (END 06/30/19) <br />116.615.02.2.346.26.64 $ 3,200 YR22 SRF (FO -E) SS (1/19-12/19) <br />116.615.02.2.346.26.66 ($-4,000) YR21 SRF (FS) TA (END 06/30/19) <br />116.615.02.2.346.26.66 $ 2,000 YR22 SRF (FO -E) TA (01/19-12/19) <br />Pass Through Information <br />Agency to Pass Through <br />Amount to Pass Through '$ <br />I Sub -Contract Approved I Date: <br />Prosecutor Review <br />Has the Prosecutor reviewed this agreement? Yes El No ❑ <br />rtments Im <br />Auditor <br />Information Services <br />Prosecutor <br />Facilities Maintenance <br />Human Resource <br />Treasurer <br />=--._ <br />Grant/Contract Review Page 2 <br />