HomeMy WebLinkAboutAmend 1DSHS CONTRACT NUMBER:
CONTRACT AMENDMENT 1763-98187 ft~~~~· DDA Employment & Day O£"bR ENT OF soc AL O1EAl:TH Amendment No. 01 SER ICES
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 Cou nty 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 tex t. 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 CO NT ACT 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.gov
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: o 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.
~~h
DSH ~~ /J;;hA:I-
DSHS Central Contract Services
6024PF Contract Amendment (3-31 -06)
~~MEAW \ ~~\fr)\ll) \S~~~
PRINTED NAME AND TITLE
Melissa Diebert. Contract Specialist
R i,;\ 9
o 13 t611 ~1
II
DDASPOKANE
DATE SIGNED
I (0(1(( '7
DATE SIGNED
;)-6 ~/cf
Page 1
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.
Fiscal
Year Fund Source
2018 State Only
Waiver
Local
Medicaid Match to
Local
Total Rev .
Fiscal
Year Fund Source
2019 State Only
Waiver
Local
Medicaid Match to
Local
Total Rev .
I
ADMINISTRATION
(CMIS/AWA BARS 11)
OTHER CONSUMER
SUPPORTS
(CMIS/AWA Code 31,32,41,
92,93,94)
CONSUMER SUPPORT
STATE-ONLY
DSHS Central Contract Services
6024PF Contract Amendment (3-31-06)
EXHIBIT B
Program Agreement Budget o Original Budget X Budget Revision
REVENUES
Original 1 sl Revision 2nd Revision 3m Revision
413,416 421,051
$820 ,341 $835,289
Original 1 sl Revision 2nd Revision 3rd Revision
COUNTY FY 2018 SPENDING PLAN
Planned Expenditures
Local PASRR Medicaid
Funds Funqs State Funds Funds TOTAL
651 29697 24298 54646
27754 22708 50462
I
464 6312 6776
Page 2
Child Developm ent
MEDICAID CLIENTS
ROADS to COMMUNITY
LIVING
TOTAL
DSHS Central Contract Services
6024PF Contract Amendment (3-31-06)
II
II
8829
9944
II
"11'-
357288 357288 723405
421051 404294 835289
Page 3
Today's Date
11/07/2017
Fund/Department
116-Public Health
Kittitas County
Review Form
Grants & Contract Agreement
II Agenda Date
Contract/Grant Information
1~/f1]l+-
Contract /Grant Agency: DSHS Developmental Disabilities Admin Amendment 1
Period Begin Date: qlr !l~77 I 1 Period End Date: &;2:/L-t5( r
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:¢;M ~ ,Administrator Date :~~~:....I .
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROV ED AS TO FORM:
Sign ature of Prosecuto r's Office
,>.9t~~
uditor's Office Date
Signature of Board of Health member Date
Financial Information
Total Amount $835,289.00 State Funds $835,289.00 Federal Funds $
Percentage County Funds Matching Funds $ CFDA#
In-Kind $
Explain
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 No D Why not
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:
Prosecutor Review
I Has the Prosecutor reviewed this agreement? I YesD No 0
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
I Signature:
Department:
I Date:
Assig,nment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer I Date
Grant/Contract Review Page 2