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DOCUMENTATION OF FUNDSENCLOSURE AContractor/Contract No:Kittitas County Contract #1763-98187Prepared by:Tina Rowan Date Prepared:13-Mar-20Contact Person: Phone No:509-962-7583(CHECK ONLY ONE PROGRAM AREA PER ATTACHMENT)Program Area:xxxDevelopmental Disabilities Mental Health __________ Children's Administration Alcohol & Substance Abuse Aging(B) Date A19 Was SENT to DSHS OR(D) Date you receivedPaid to Contractors: (A) Amout Paid reimbursement was (C) Amount of DSHS reimbursemenPayment from DSHSrequested (electronically) (see NOTE for column below)DAYSJuly-18 45,492.11 7/31/201845,492.11 9/4/2018 (35.00) Aug-18 45,686.37 8/31/201845,686.37 10/1/2018 (31.00) - September-1846,367.69 9/30/201846,367.69 11/13/2018 (44.00) October-1848,033.43 10/31/201848,033.43 12/10/2018 (40.00) November-1846,299.30 11/30/2018 46,299.30 1/16/2019 (47.00) December-1844,841.72 12/31/2018 44,841.72 2/12/2019 (43.00) 17,785.75 3/15/20193,354.00 4/2/20193,457.50 4/2/201922,686.00 4/2/2019600.00 8/27/2019January-19 47,883.25 1/30/2019 3,802.38 * 10/30/2019 (273.00) 43,623.27 4/11/2019February-1944,211.27 2/28/2019 588.00 8/27/2019 (149.00) March-1959,582.33 3/31/201959,582.33 8/27/2019 (149.00) April-19 42,346.50 4/30/2019 42,346.50 8/27/2019 (119.00) 66,183.40 8/27/2019May-19 66,183.40 5/31/2019 339.00 * 9/27/2019 (119.00) - June-19 50,230.22 6/30/2019 50,230.22 8/27/2019 (58.00) 587,157.59 591,298.97 (4,141.38) INSTRUCTIONS -Column A: List the amount you paid vendor(s) for providing services in the DSHS program area.Column B: List the date you sent the A19 to DSHS or the date that a reimbursement request was made via an electronic system (SSPS).Column C:List the amount of the reimbursement request to DSHS. NOTE: For the Mental Health program, do not include PHP funds received.Column D: List the date you received payment from DSHS.Note: Column A represents all payments, including Manage Care payments, to providers.