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Exhibit A <br />Statement of Work <br />Contract T erml 2022-2024 <br />DOII ProgramName or Titlel Matemalandchild H ralth Block Grant - <br />Effsctw e Januaw 1 . 2 122 <br />Local Health Jurisdiction Name : Kittita s county Public Health Department <br />Contract Number: CLH3 1 0 15 <br />SOW Type: Original Revision # (for this SO\\ I <br />Type of Payment <br />X Reimbursement <br />n Fixed Price <br />Federal Compliance <br />(check if applicable) <br />X rnefa (fransparency Act) <br />n Research & Development <br />Funding Source <br />El Federal Subrecipientn stute <br />flothetPeriod of Performance: JSny?E-1-Mthrough Seotr rnber30' 2022 <br />statement of workpurpose: The pulpose of this statr nentofwork(sow) is to support localinterventions thatimpaatthetargetpopulationof theMatemalandchildHealth <br />Block Grant. <br />Revision Purpose: N/A <br />DOH Chart of Accounb Master Index Title <br />Activity <br />Maternal and Child Ilealth Block Grant Administration <br />Report actual expenditures forthe six-monthp :riod <br />October I, 2021 through March 3 1', 2022 <br />Develop 20 22-2023 MCHBGBudget Workbo :kfor <br />October 1,2022through <br />provided template. <br />September 30 ,2023 t sing DOH <br />Implementation <br />Exhibit A, Statement of Work <br />Template Created SePte mber 202 | <br />3?-147 <br />Total <br />Allocation <br />33.t47 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />33.147 <br />Allocation <br />Change <br />Increase (+) <br />33,147 <br />0 <br />0 <br />Current <br />Allocation <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />09130122ot/0U22 <br />LHJ Funding Period <br />Start Date End Date <br />333.93.99 <br />BARS <br />Revenue <br />Code <br />93.994 <br />Assistance <br />Listing <br />Number <br />7810122r <br />Master <br />Index <br />Code <br />1a <br />1b <br /># <br />Task <br />Payment Information and/o r <br />Amount <br />Reimbursement for actual costs, <br />not to exceed totalfunding <br />consideration. Action Plan and <br />Progress Reports must onlY reflect <br />activities paid for with funds <br />provided in this statement of work <br />for the specified fundingperiod. <br />See Program Specific <br />Requirements and Special Billing <br />ents" <br />Due Date/Time Frame <br />May27,2022 <br />Septernber9,2022Submit MCHBGBudget <br />DOH contractmanager <br />Workbookto <br />Deliverables/Outco mes <br />Submit actual expenditures using the <br />MCHBG Budget Workbook to DOH <br />contract <br />Page 1 of3 ContractNumberCLH3 I 0 I 5