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AMENDMENT #17Exhibit AStatement of WorkContract Term: 2018-2021DOH Program Name or Title: Matemal & Child Health Block Grant -Effective January l. 2018Local Health Jurisdiction Name: Kittitas county Public Health DepartmentContract Number: CLH18249SOW Type: Revision Revision # (for this SOW) 5Type of PaymentI Reimbursement! Fixed PriceFederal Compliance(check if applicable)X fnern (Transparency Act)n Research & DevelopmentFunding SourceI Federal SubrecipientE stateflottrerStatement 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 BlockGrant.Revision Purpose: The purpose ofthis revision is to provide additional fnding, add activities and deliverable due dates, and extend the period ofperformance and funding fromSeptember 30,2020 to September 30,2021 for continuation of MCHBG-related activities.Period of Performance: Januar.v 1.2018 through September 30.2021Exhibit A, Statements of WorkRevised as ofSeptember 75,2020TotalConsideration34.04044.19644,19644,196166,628ChangeIncrease (+)00044.19644.196CurrentConsideration34.04044.19644.1960122,432Funding Period(LHJ Use Only)Start Date End Date09130t180913011909/30t2009130t21TOTALS0 l/0 l/l 8r0l01/181010111910101/20MasterIndexCode78120281781202917812029278120293BARSRevenueCode333.93.99333.93.99333.93.99333.93.99CFDA #93.99493.99493.99493.994Chart of Accounts Program Name or TitleFFYl8 MCHBG LHJ CONTRACTSFFY19 MCHBG LHJ CONTRACTSFFY2O MCHBG LHJ CONTRACTSFFY2I MCHBG LHJ CONTRACTSPaymentInformation and/orAmountMaternal and Child Health Block Grant (MCHBG) AdministrationReimbursement foractual costs, not toexceed total fundingconsideration.Action Plan andProgress Reportsmust only reflectDue Date/Time FrameSeptember 30,2018September 30,2019September 30,2020May 26,2018Deliverables/OutcomesDesignated LHJ staff will participatein contract management calls.Submit actual expenditures using theMCHBG Budget Workbook to DOHcontract manager*May Support PHABStandards/lVleasur€sTask/Activity/DescriptionParticipate in calls, at a minimum of everyquarter, with DOH contract manager. Dates andtime for calls are mutually agreed upon betweenDOH and LHJReport actual expenditures for October 1,2017through March 31,2018TaskNumberla1bPage 79 of 42Contract Number CLHI 8249 - 17