HomeMy WebLinkAboutDHSH KC InterlocalDSHS CONTRACT NUMBER:
COUNTY PROGRAM or INTERLOCAL 1563-32734 ~~~'r"" D EPART £NT OF
SOCI AL C.H .EALTH Amendment No . 01 SERVICES LONG-TERM PAYABLE AGREEMENT
AMENDMENT
This Amendment is between the State of Washington Department of Social and Program Contract Number
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
CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER
IDENTIFIER (UBI)
County Auditors Office
192-002-673 1225 205 West 5th Ave County Courthouse Ste 105
EliensburQ , WA 98926-
CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
Judy Pless (509) 962-7502 (509) 962-7687 judy.pless@co.kittitas .wa.us
DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE
Executive Administration Financial Services 8030CS-63
DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS
David Erickson PO Box 45842
Financial Coordinator
Olympia , WA 98504 -5842
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS
(360)664-5757 (360)664-577 5 erickdd@dshs.wa.gov
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS
No
AMENDMENT START DATE CONTRACT END DATE
07/01/2016 06/30/2017
PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT
$0 .00 NIA 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 inco rporated into
this Amendment by reference: o Additional Exhibits (specify):
This Amendment , inc l uding 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 su bject matter of this Amendment shall be
deemed to exist or bind the parties . All other terms and cond itions of the original County Program Agreement or Interlocal
Agreement remain in full force and effect. The parties s igning below warrant that they have read and un derstand this
Amendment, and have authority to en ter into this Amendment. OCTOR SIGNATURE r PRINTED NAME AND TITLE DATE SIGNED
_~1J<f~ Obie O'Brien Chairman , Board of Co Commission ~rs 04/19/16
DSHS S~n ATURE _ PRINTED NAME AND TITLE DATE SIGNED '-~ ~ Angela Wi ll iams, Contract Manager 5) 10 I III DSHS Central Co ntract Services
DSHS Central Contract Services Page 1
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.
DSHS Central Contract Services Page 2
6046 LF Long-Term Payable Amendment (3-13-14)