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Home My WebLink AboutDSHS DDA AgreementToday's Date Fund/Department 116-Public Health Kittitas County Review Form Grants & Contract Agreement Agenda Date Contract/Grant Information Contract /Grant Agency: DSHS DDA County Services Agreement LP/l/110 Period Begin Date: 04/18/2016 I I Period End Date: 06/30/2016 Total Grant/Contract Amount: $738,941.00 Grant/Contract Number: 1563-44899 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 DO services within the county as set in the agreement. Recommendation for Board of Health and Board of Health Review on , Administrator Date :~ f.Q 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 $ Explain Is Equipment being purchased? Who owns equipment? New Personnel being hired? Contact HR hiring -reporting requirements Future impacts or liability to Kittitas County: Bud get Information Budget Amendment Needed? Yes[B attach budget form No 0 Why not 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: Prosecutor Review I Has the Prosecutor reviewed this agreement? I YesD No D Cou nty De pa rtments Im pa cted Auditor Facilities Maintenance Information Services Human Resource Prosecutor Treasurer Submitted I Signature: Department : I Date: Assignment of Trackin g Information Auditor's Office Human Resource Prosecutor's Office Who Signed the grant application I Reviewer I Date Grant/Contract Review Page 2 DSHS CONTRACT NUMBER: CONTRACT AMENDMENT 1563-44899 ~~W""",'."' •• 01!PAR·r.~T OF Amendment No. 01 s9CJ1;~VI~:rH I 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 Coun ty Kitti tas County DDA Co un ty Services CONTRACTOR ADDRESS WASHINGTON UN IFORM DSHS INDEX NUMB ER BUSINESS IDENTIFIER (UBI) 507 North Nanum Street Suite 102 Ellensbu rg. WA 98 926-192-002-673 1225 CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS Robin Read 509-962-7515 509-962-7581 ~obin.read@co.kittit~ DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE Developmental Disabilities Admin Division of Developmental 1769CS-63 Disabilities DSHS CO !'/TACT NAME AND 'r1:r LE DSHS CONTACT ADDRESs Roger Van Allen 1611 W Indiana Ave Operations Man~er. S pokane. WA 99205 - DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS (509) 329-2952 (509) 568-3037 va naJr!@ dshs,wa.gov 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 $738,941.00 REASON FOR AMENDMENT ; CHANGE OR CORRECT MAXIMUM CONTRACT AMOUNT ATTACHMENTS. When the box below Is marked with an X , the following Exhibits are attached and are incorporated into this Contract Amendment by reference: 181 Additional Exhibits (specify): P(ogram Agreement Budget This Contract Amendment, including all Exhibits and other documents Incorporated by reference, contains all of the terms and conditions agreed upon by the parties as changes to the original Contract. No other understandings or representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract Amendment. CONT ~ nD. DSHS SIGNATURE &~ /Jtjlj/~ A.lA '_ DSHS Cent~ 6024PF Co Ir&_~.~ V-ED JUL 06 2016 BY: PRINTED NAME AND TITLE ¥o ~ 1"'-' +\. Q{aL I -M~, ~j:S~ ~(~i~~ PRINTED NAME AND TITLE (/$!j£:Jt Dt;SI,GNED Melissa Dieberf '1ti~ -4?-I6 E C E I E JUN 24 2016 Budget, Finance & Contracts (/ RECEIVED JUN 1 . ~J~W DDA SPOKi~NE 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 1 s( Revision 2nd Revision 3rd Revision 2016 State only Waiver Local Medicaid Match to Local Total Rev . Fiscal Year Fund Source 2017 State Waiver Local Medicaid Match to Local Total Rev . I II ADMINISTRATION (CMIS/AWA BARS 11) DSHS Central Contract Services 6024PF Contract Amendment (3-31-06) 358425 383595 $738941 689190 $ $ Original 1S ( Revision 2nd Revision 3rd Revision - $ $ $ $ COUNTY FY 2016 SPENDING PLAN Planned Expenditures Local PASRR .. ' , Medicaid. Funds Funds State F~l1ds FYIJOS TOTAL 748 , 26177 '2 141"7 ' 47594 Page 2 OTHER CONSUMER SUPPORTS (CMIS/AWA Code 31,32,41,92, 93, 94) CONSUMER SUPPORT DSHS Central Contract Services 6024PF Contract Amendment (3-31-06) Page 3