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HomeMy WebLinkAboutDSHS Developmental Disabilities Admin Amendment 1Kittitas County Review Form Grants & Contract Agreement Today's Date 11/07/2017 Fund/Department 116 -Public Health Contract/Grant Information Agenda Date Contract /Grant Agency: DSHS Developmental Disabilities Admin Amendment 1 Period Begin Date: Period End Date: Total Grant/Contract Amount: $835,289.00 (increase of $14,948.00) _ Grant/Contract Number: 1763-98187 Amendment 1 Contract/Grant Summary: Contract amendment increases the amount of contract by $14,948.00 for a new revised maximum of $835,289.00. The attached shows the amended spend plan. Recommendation for Board of Health and Board of Health Review on Department Head Signature: Kittitas County Prosecutor, Auditor, and Board of I APPROVED AS TO FORM: Signature of Prosecutor's Office Date Signature of Auditor's Office Date Signature of Board of Health member Date I Financial Information Total Amount $835,289.00 Percentap,e Countv Funds Administrator Date: State Funds $835,289.00 Matching Funds $ In -Kind $ Explain Federal Funds $ CFDA# Is Equipment being purchased? Who owns equipment? Grant/Contract Review Page 1 New Personnel being hired? I Contact HR hiring — reporting requirements Future impacts or liability to Kittitas County: Budget Information Budget Amendment Needed? Yes © attach budget form New Division Created? Will enter in budget center Revenue Code 105.568.334.04.68- $835,289.00 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 Intormation Auditor's Office Human Resource Prosecutor's Office Who Signed the grant application Reviewer I Date Grant/Contract Review Page 2 DSHS CONTRACT NUMBER: CONTRACT AMENDMENT 1763-98187 Wnsh1?WEQ0n srarc PAR& ENT HDDA Employment & DaC1 iTFi�/ Amendment No. 01 A*7 5EnV,C SE12 V [CES This Contract Amendment is between the State of Washington Department of Program Contract Number Social and Health Services (DSHS) and the Contractor identified below. Click here to enter text. Contractor Contract Number CONTRACTOR NAME CONTRACTOR doing business as (DBA) Kittitas County Kittitas County DDA County Services CONTRACTOR ADDRESS WASHINGTON UNIFORM DSHS INDEX NUMBER BUSINESS IDENTIFIER (UBI) 507 North Nanum Street Suite 102 Ellensburg, WA 98926- 192-002-673 1225 CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS Joann Schaan (509) 933-8233 Click here to enter text. Click here to enter text. DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE Developmental Disabilities Admin Division of Developmental 1769CS-63 Disabilities DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS Seanna Woodard 1611 W Indiana Ave Operations Manager Spokane, WA 99205 DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS 509)329-2952 (509)568-3037 woodas dshs.wa. ov IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS No AMENDMENT START DATE CONTRACT END DATE 09/01/2017 06/30/2018 PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT $820,341.00 $14,948.00 $835,289.00 REASON FOR AMENDMENT; CHANGE OR CORRECT MAXIMUM CONTRACT AMOUNT ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into this Contract Amendment by reference: ❑ Additional Exhibits (specify): This Contract Amendment, including all Exhibits and other documents incorporated by reference, contains all of the terms and conditions agreed upon by the parties as changes to the original Contract. No other understandings or representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract Amendment. CONTRACTOR SIGNATURE PRINTED NAME AND TITLE DATE SIGNED DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED Melissa Diebert, Contract Specialist DSHS Central Contract Services Page 1 6024PF Contract Amendment (3-31-06) This Contract between the State of Washington Department of Social and Health Services (DSHS) and the Contractor is hereby amended as follows: 1. The Total Maximum Contract Amount is hereby increased in the amount of $14,948 for a new Contract Amount of $835,289. The additional amount is reflected in the attached amended Spend Plan. All other terms and conditions of this Contract remain in full force and effect. EXHIBIT B Program Agreement Budget ❑ Original Budget X Budget Revision REVENUES Fiscal Year Fund Source Original 1 St Revision 2nd Revision 3`d Revision 2018 State Only 413,416 421,051 Waiver Local Medicaid Match to Local Total Rev. Medicaid Match to Local Total Rev. 1 $820,341 $835,289 Fiscal Year Fund Source Original 1St Revision 2nd Revision 3`d Revision 2019 State Only Waiver Local Medicaid Match to Local Total Rev. ADMINISTRATION (CMTS/AWA BARS 11) OTHER CONSUMER SUPPORTS (CMIS/AWA Code 31, 32, 41, 92, 93, 94) CONSUMER SUPPORT STATE -ONLY COUNTY FY 2018 SPENDING PLAN Planned Expenditures Local PASRR Medicaid Funds Funds I State Funds Funds I TOTAL 651 l! 29697 1 24298 _� 54646 27754 22708 1 50462 464 11 6312 6776 DSHS Central Contract Services Page 2 6024PF Contract Amendment (3-31-06) Child Development MEDICAID CLIENTS 8829 357288 357288 723405 ROADS to COMMUNITY LIVING TOTAL 9944 421051404294 835289 DSHS Central Contract Services Page 3 6024PF Contract Amendment (3-31-06)