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AMENDMENT #17 <br />Exhibit A, Statements of Work Page 19 of 42 Contract Number CLH18249-17 <br />Revised as of September 15, 2020 <br />Exhibit A <br />Statement of Work <br />Contract Term: 2018-2021 <br /> <br />DOH Program Name or Title: Maternal & Child Health Block Grant - <br />Effective January 1, 2018 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH18249 <br />SOW Type: Revision Revision # (for this SOW) 5 Funding Source <br /> Federal Subrecipient <br /> State <br /> Other <br />Federal Compliance <br />(check if applicable) <br /> FFATA (Transparency Act) <br /> Research & Development <br />Type of Payment <br /> Reimbursement <br /> Fixed Price Period of Performance: January 1, 2018 through September 30, 2021 <br />Statement of Work Purpose: The purpose of this statement of work is to support local interventions that impact the target population of the Maternal and Child Health Block <br />Grant. <br />Revision Purpose: The purpose of this revision is to provide additional funding, add activities and deliverable due dates, and extend the perio d of performance and funding from <br />September 30, 2020 to September 30, 2021 for continuation of MCHBG -related activities. <br /> <br />Chart of Accounts Program Name or Title CFDA # BARS <br />Revenue <br />Code <br />Master <br />Index <br />Code <br />Funding <br />(LHJ Use <br />Start Date <br /> Period <br /> Only) <br />End Date <br />Current <br />Consideration <br />Change <br />Increase (+) <br />Total <br />Consideration <br />FFY18 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120281 01/01/18 09/30/18 34,040 0 34,040 <br />FFY19 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120291 10/01/18 09/30/19 44,196 0 44,196 <br />FFY20 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120292 10/01/19 09/30/20 44,196 0 44,196 <br />FFY21 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120293 10/01/20 09/30/21 0 44,196 44,196 <br />TOTALS 122,432 44,196 166,628 <br /> <br />Task <br />Number Task/Activity/Description *May Support PHAB <br />Standards/Measures Deliverables/Outcomes Due Date/Time Frame <br />Payment <br />Information and/or <br />Amount <br />Maternal and Child Health Block Grant (MCHBG) Administration <br />1a Participate in calls, at a minimum of every <br />quarter, with DOH contract manager. Dates and <br />time for calls are mutually agreed upon between <br />DOH and LHJ <br /> Designated LHJ staff will participate <br />in contract management calls. <br />September 30, 2018 <br />September 30, 2019 <br />September 30, 2020 <br />Reimbursement for <br />actual costs, not to <br />exceed total funding <br />consideration. <br />Action Plan and <br />Progress Reports <br />must only reflect <br />1b Report actual expenditures for October 1, 2017 <br />through March 31, 2018 <br /> Submit actual expenditures using the <br />MCHBG Budget Workbook to DOH <br />contract manager <br />May 26, 2018