HomeMy WebLinkAboutWashinton State DOH Amendment 1 to N19411Today's Date
02/08/2017
Fund/Department
116 -Public Health
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Kittitas County
Review Form
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Grants & Contract Agreement
Agenda Date
Contract/Grant Information
Contract /Grant Agency: Washington State DOH Amendment 1
Period Begin Date: April 18, 2014 Period End Date: December 31, 2018
Total Grant/Contract Amount: None
Grant/Contract Number: N19411
Contract/Grant Summary:
Amendment 1 to the Contract N19411 changes the contact person information for DOH only to:
Dorothy Tibbetts
Office of Drinking Water
16201 E Indiana Suite 1600
Spokane Valley, WA 99216
509-329-2105
Recommendation for Board of Health and Board of Health Review on
Department Head Signature: Administrator Date:
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Signature of Prosecutor's Office Date
Signature of Auditor's Office Date
Signature of Board of Health member Date
Financial Information
Total Amount $ State Funds $ Federal Funds $
Grant/Contract Review Page 1
Percentage County Funds
Matching Funds $
CFDA#
In -Kind $
Explain
Is Equipment being purchased?
Who owns equipment?
New Personnel being hired?
Contact HR hiring — reporting requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes ❑ attach budget form
New Division Created?
Revenue Code
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub -Contract Approved Date:
No ❑ Why not
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes ❑ No ❑
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
Signature: Date:
Department:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2
Washington State Department of
Hea I th
CONTRACT AMENDMENT
1. NAME OF CONTRACTOR
2. CONTRACT NUMBER
Vittitas County Public Health De artment
N19411
Ia. ADDRESS OF CONTRACTOR (STREET)
2a. AMENDMENT NUMBER
507 N Nanum Street, Suite 102
1
lb. CITY, STATE, ZIP CODE
Ellensburg, WA 98926
3. ® THIS ITEM APPLIES ONLY TO BILATERAL AMENDMENTS.
The Contract identified herein, including any previous amendments thereto, is hereby amended as set forth in Item 5 below by
mutual consent of all parties hereto.
4. ❑ THIS ITEM APPLIES ONLY TO UNILATERAL AMENDMENTS.
The Contract identified herein, including any previous amendments thereto, is hereby unilaterally amended as set forth in Item 5
below pursuant to that changes and modifications clause as contained therein.
5. DESCRIPTION OF AMENDMENT: The purpose of this amendment is to update the Contact Person
information for DOH. The rest of the agreement remains unchanged.
5a. AGREEMENT MANAGEMENT:
The Contact Person for DOH is:
Dorothy Tibbetts
Office of Drinking Water
16201 E Indiana Suite 1600
Spokane Valley, WA 99216
(509) 329-2105
6. All other terms and conditions of the original contract and any subsequent amendments thereto remain in full force and
effect.
7. ❑This is a unilateral amendment. Signature of contractor is not required below.
® Contractor hereby acknowledges and accepts the terms and conditions of this amendment. Signature is required below.
8. CONTRACTOR SIGNATURE (also, please print/type your name)
DATE
9. DOH CONTRACTING OFFICER SIGNATURE
DATE
I his document has been approved as to form only by the Assistant Attorney General.
DOH Amendment N19411-1 Page 1 of 1