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HomeMy WebLinkAboutFinal DSHS DDA County Services Agrememnt Amendment 1ry:r r, s\ Kittitas County ,. Review Form Grants & Contract Agreement Today's Date Agenda Date Fund/Department 116 -Public Health Contract/Grant Information Contract /Grant Agency: DSHS DDA County Services Period Begin Date: 04/18/2016 Total Grant/Contract Amount: $738,941.00 Grant/Contract Number: 1563-44899 !ement Period End Date: 06/30/2016 Contract/Grant Summary: The amendment to the contract between the State of Washington Department of Social and Health Services and Kittitas County is established to increase the original contract amount of $689,190.00 by $49,751.00. The new contract total maximum is $738,941.00. The agreement allows the county to provide services and allow staff to administer DD services within the county as set in the agreement. 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: APPRO ED AS TO FORM: Signature of rosecutor' Office Date .5. Signator of uditor's Office Date e, Signature of Board of Health member Date Financial Information Total Amount $738,941.00 State Funds $738,941.00 Federal Funds $ Percentage County Funds Matching Funds $ CFDA# Grant/Contract Review Page 1 In -Kind $ 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? Will enter in the budget center Revenue Code 105-568.334.04.68 -$738,941 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 LJ No Countv 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 I Date Grant/Contract Review Page 2 DSHS CONTRACT NUMBER: CONTRACT AMENDMENT 1563-44899 INasl" gr' Srerc L7C[� ERMU@�.}T OH 7 5C7C SE VI[ESTH Amendment No. 01 t— 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 WASHINGTON UNIFORM DSHS INDEX NUMBER CONTRACTOR ADDRESS 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 Robin Read 509-962-7515 509-962-7581 Robin.read@co.kittit DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE Developmental Disabilities Admin Division of Developmental 1769CS-63 Disabilities DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS Roger Van Allen 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 vanalrl@dshs.wa.gov 1 IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS No AMENDMENT START DATE CONTRACT END DATE 04/18/2016 06/30/2016 PRIOR MAXIMUM CONTRACT AMOUNT _ AMOUNT OF INCREASE OR DECREASE _ TOTAL MAXIMUM CONTRACT AMOUNT $689,190.00 $49,751.00 $738,941.00 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): Program Agreement Budget 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 DSHS Central Contract Services Page 1 6024PF Contract Amendment (3-31-06) 3s. �S�•��� This Contract between the State of Washington Department of Social and Health Services (DSHS) and the Contractor is hereby amended as follows: Maximum contract amount is increased by $49,751 to fund additional clients added during this contract period. The new maximum amount is $738,941 and is reflected in the amended Spend plan incorporated to this revision All other terms and conditions of this Contract remain in full force and effect. EXHIBIT B Program Agreement Budget Original Budget XX Budget Revision REVENUES Fiscal Year Fund Source Original 1s` Revision 2"d Revision 3rd Revision. 2016 State only 358425 383595 Waiver Local _ Medicaid Match to Local $738941 $ $ Total Rev, 689190 $ $ J.. Fiscal Year Fund Source Original 13` Revision 2nd Revision 3`d Revision 2017 State Waiver Local _ Medicaid Match to Local $ Total Rev. $ $ $ J.. ADMINISTRATION (CMTS/AWA BARS 11) COUNTY FY 2016 SPENDING PLAN Planned Expenditures Local PASRR ' Medicaid Funds Funds State Funds Funds TOTAL 748 26177 21417: 47594 DSHS Central Contract Services Page 2 6024PF Contract Amendment (3-31-06) 1 OTHER CONSUMERSUPPORTS Code ., 21500 17591 39091 CONSUMER SUPPORT Child Development 1 '•' 1• -i .1• �. MEDICAID CLIENTS1 u ROADS. COMMUNITY LIVING DSHS Central Contract Services Page 3 6024PF Contract Amendment (3-31-06)