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Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment: <br />APPROVED AS TO FORM: <br />Signature of Prosecutor's Office Date <br />Signature of Auditor's Office Date <br />Verification the Contracting Agency is not Suspended/Disbarred: <br />❑ Agency is not suspended/disbarred ❑ Not Checked (reason) <br />Financial Information <br />Total Amount $ State Funds $ Federal Funds $ <br />Percentage County Funds Matching Funds $ CFDA# <br />In -Kind $ <br />Explain <br />Is Equipment being purchased? Who owns equipment? <br />New Personnel being hired? Contact HR hiring — reporting requirements <br />Future impacts or liability to Kittitas County: <br />Budget Information <br />Budget Amendment Needed? I Yes ❑ attach budget form No ❑ why not <br />New Division Created? <br />Revenue Code <br />Expense Code <br />Pass Through Information <br />Agency to Pass Through <br />Amount to Pass Through <br />Sub -Contract Approved Date: <br />Prosecutor Review <br />Has the Prosecutor reviewed this agreement? <br />County Departments Impacted <br />Expense Code: <br />Yes ❑ No ❑ <br />Grant/Contract Review Page 2 <br />