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Exhibit A <br />Statement of Work <br />Contract Term: 2022-2024 <br />DOH Program Name or Title: Maternal and Child Health Block Grant - <br />Effective January 1. 2022 <br />SOW Type: Orip-ina Revision # (for this SOW) <br />Period of Performance: January 1.2022 through September30.2022 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH31015 <br />Funding Source Federal Compliance Type of Payment <br />® Federal Subrecipient (check if applicable) ® Reimbursement <br />❑ State ER FFATA (Transparency Act) ❑ Fixed Price <br />❑ Other ❑ Research & Develo ment <br />Statement of Work Purpose: The purpose ofthis statement of work (SOW) is to support local interventions that impactthe target population ofthe MaternaIand Child Health <br />Block Grant. <br />Revision Purpose: N/A <br />Master <br />Index <br />DOH Chart of Accounts Master Index Title Code <br />Assistance <br />Listing <br />Number <br />BARS <br />Revenue LHJ Funding Period <br />Code Start Date End Date <br />Current <br />Allocation <br />Allocation <br />Change <br />g <br />Increase (+) <br />Total <br />Allocation <br />FFY22 MCHBG LHJ CONTRACTS 78101221 <br />93.994 <br />333.93.99 01/01/22 09/30/22 <br />0 <br />33,147 <br />33,147 <br />October 1, 2021 through March 31, 2022 <br />MCHBG Budget Workbook to DOH <br />0 <br />0 <br />0 <br />contractmana er <br />consideration. Action Plan and <br />Progress Reports must only reflect <br />0 <br />0 <br />0 <br />September9, 2022 <br />October 1, 2022 through September 30, 2023 using DOH <br />0 <br />0 <br />0 <br />provided template. <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />TOTALS <br />See Program Specific <br />0 <br />33,147 <br />33,147 <br />Task <br /># <br />Activity <br />Deliverables/Outcomes <br />Due Date/Time Frame <br />Payment Information and/or <br />Amount <br />Maternal and Child Health Block Grant (MCHBG) Administration <br />la <br />Report actual expenditures forthe six-month period <br />Submit actual expenditures using the <br />May 27, 2022 <br />Reimbursement for actual costs, <br />October 1, 2021 through March 31, 2022 <br />MCHBG Budget Workbook to DOH <br />not to exceed total funding <br />contractmana er <br />consideration. Action Plan and <br />Progress Reports must only reflect <br />lb <br />Develop 2022-2023 MCHBG Budget Workbook for <br />Submit MCHBG Budget Workbook to <br />September9, 2022 <br />October 1, 2022 through September 30, 2023 using DOH <br />DOH contract manager <br />activities paid for with funds <br />provided template. <br />provided in this statement of work <br />for the specified funding period. <br />See Program Specific <br />Requirements and Special Billing <br />Requirements. <br />Implementation <br />Exhibit A, Statement of Work Page 1 of 3 Contract NumberCLH31015 <br />Template Created September 2021 <br />