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6046 LF Long-Term Payable Amendment (3-13-14)
COUNTY PROGRAM or INTERLOCAL
LONG-TERM PAYABLE AGREEMENT
AMENDMENT
DSHS CONTRACT NUMBER:
1563-32734
Amendment No. 01
This Amendment is between the State of Washington Department of Social and
Health Services (DSHS) and the Contractor identified below.
Program Contract Number
Click here to enter text.
Contractor Contract Number
CONTRACTOR NAME
Kittitas County
CONTRACTOR doing business as (DBA)
Kittitas County
CONTRACTOR ADDRESS
County Auditors Office
205 West 5th Ave County Courthouse Ste 105
Ellensburg,WA 98926-
WASHINGTON UNIFORM BUSINESS
IDENTIFIER (UBI)
192-002-673
DSHS INDEX NUMBER
1225
CONTRACTOR CONTACT
Judy Pless
CONTRACTOR TELEPHONE
(509) 962-7502
CONTRACTOR FAX
(509) 962-7687
CONTRACTOR E-MAIL ADDRESS
judy.pless@co.kittitas.wa.us
DSHS ADMINISTRATION
Executive Administration
DSHS DIVISION
Financial Services
DSHS CONTRACT CODE
8030CS-63
DSHS CONTACT NAME AND TITLE
David Erickson
Financial Coordinator
DSHS CONTACT ADDRESS
PO Box 45842
Olympia,WA 98504-5842
DSHS CONTACT TELEPHONE
(360)664-5757
DSHS CONTACT FAX
(360)664-5775
DSHS CONTACT E-MAIL ADDRESS
erickdd@dshs.wa.gov
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT?
No
CFDA NUMBERS
AMENDMENT START DATE
07/01/2016
CONTRACT END DATE
06/30/2017
PRIOR MAXIMUM CONTRACT AMOUNT
$0.00
AMOUNT OF INCREASE OR DECREASE
N/A
TOTAL MAXIMUM CONTRACT AMOUNT
Based on Annual Review
REASON FOR AMENDMENT;
CHANGE OR CORRECT PERIOD OF PERFORMANCE
ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into
this Amendment by reference:
Additional Exhibits (specify):
This 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 County Program Agreement or Interlocal Agreement. No
other understandings or representations, oral or otherwise, regarding the subject matter of this Amendment shall be
deemed to exist or bind the parties. All other terms and conditions of the original County Program Agreement or Interlocal
Agreement remain in full force and effect. The parties signing below warrant that they have read and understand this
Amendment, and have authority to enter into this Amendment.
CONTRACTOR SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
DSHS SIGNATURE PRINTED NAME AND TITLE
Angela Williams, Contract Manager
DSHS Central Contract Services
DATE SIGNED
Obie O'Brien Chairman, Board of Co Commissioners 04/19/16
DSHS Central Contract Services Page 2
6046 LF Long-Term Payable Amendment (3-13-14)
This Agreement between the State of Washington Department of Social and Health Services (DSHS) and the
Contractor is hereby amended as follows:
1.DSHS extends the Agreement End Date twelve months from July 1, 2016, to June 30, 2017, as stated
on Page One of this Amendment.
2.DSHS revises the DSHS Contact Name and Contact Address to David Erickson as stated on Page One
of this Amendment.
All other terms and conditions of this Agreement remain in full force and effect.