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Exhibit A <br />Statement of Work <br />Contract Term: 2022-2024 <br />DOH Program Name or Title: Office of Drinking Water Group B Programs - Effective <br />January 1, 2022 <br />SOW Type: Ori�alal Revision # (for this SOW) <br />Period of Performance: January 1 202 through June 30, 2023 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH31015 <br />Funding Source Federal Compliance Type of Payment <br />❑ Federal <Select One> (check if applicable) ❑ Reimbursement <br />® State ❑ FFATA (Transparency Act) ® Fixed Price <br />❑ Other ❑ Research & Development <br />Statement of Work Purpose: The purpose of this statement of work (SOW) is to provide financial support to LHJs implementing local Group B water systems programs. <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 <br />Code <br />LHJ Funding Period <br />Current <br />Start Date End Date Allocation <br />Allocation <br />Chan e <br />g <br />Increase (+) <br />Total <br />Allocation <br />GFS Group B (FO -E) 24240103 <br />N/A <br />334.04.90 <br />01/01/22 06/30/22 0 <br />25,877 <br />25,877 <br />An executed Memorandum of Agreement (MOA) with <br />January 1, 2022 <br />Lump sum payment (See <br />0 <br />0 <br />0 <br />thru June 30, 2022 <br />Special Billing <br />0 <br />0 <br />0 <br />Requirements) <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />TOTALS <br />0 <br />25,877 <br />25,877 <br />Task <br />Activity <br />Deliverables/Outcomes <br />Due Date/Time <br />Payment Information <br /># <br />Frame <br />and/or Amount <br />1 <br />Implement a Group B water system program through a <br />An executed Memorandum of Agreement (MOA) with <br />January 1, 2022 <br />Lump sum payment (See <br />Local Ordinance. Reference DOH MOA #CLH23577 <br />DOH identifying responsibilities of a full Group B <br />thru June 30, 2022 <br />Special Billing <br />program through a LocalOrdinance. <br />Requirements) <br />DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other <br />finance -related inquiry, may be sent to financendoh.wa.gov. <br />*For Information Only: Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might <br />contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: <br />http: //www.phaboard.org/MM -content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf <br />Special Billing Requirements: For January 1, 2022 —June 30, 2022, the LHJ shall submit one invoice not later than June 30, 2022 and payment cannot exceed a maximum <br />cumulative fee of $25,877. <br />Exhibit A, Statement of Work Page 1 of 1 Contract NumberCLH31014 <br />Template September2021 <br />