HomeMy WebLinkAboutDSHS Contract Amend 2CONTRACT AMENDMENT
Transforming lives
DSHS CONTRACT NUMBER:
1763-98187
Amendment No. 02
This Contract 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 tex t.
Contractor Contract Number
CONTRACTOR NAME
Kittitas County
CONTRACTOR ADDRESS
507 North Nanum Street Suite 102
Ellensbur , WA 98926-2886
CONTRACTOR CONTACT
Joann Schaan
DSHS ADMINISTRATION
Developmental Disabilities Admin
DSHS CONTACT NAME AND TITLE
Seanna Woodard
Operations Manager
DSHS CONTACT TELEPHONE
509 329-2952
CONTRACTOR doing business as (DBA)
Kittitas County DDA County Services
WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER
IDENTIFIER (UBI) 1225
192-002-673
CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
509) 933-8233 Click here to enter text. Click here to enter text.
DSHS DIVISION DSHS CONTRACT CODE
Division of Developmental 1769CS-63
Disabilities
DSHS CONTACT ADDRESS
1611 W Indiana Ave
S okane , WA 99205
DSHS CONTACT FAX
509 568-3037
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT?
No
AMENDMENT START DATE CONTRACT END DATE
05/01/2018 06/30/2018
PRIOR MAXIMUM CONTRACT AMOUNT
$835,289.00
REASON FOR AMENDMENT;
AMOUNT OF INCREASE OR DECREASE
$-8,442.00
CHANGE OR CORRECT MAXIMUM CONTRACT AMOUNT
TOTAL MAXIMUM CONTRACT AMOUNT
$826,847.00
ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into
this Contract Amendment by reference:
_cg] Additional Exhibits specif : Exhibit B
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.
CONTB.AC:ro PRINTED NAME AND TITLE DATE SIGNED ,. ·0 J;-7 I
Melissa Di ebert. Contract S ec_ialist
20\
DSHS Central Contract Services Page 1
6024PF Contract Amendment (1-26-2018) I »•·-
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 decreased in the amount of ($8,442) for a new
Contract Amount of $826,847. The decreased amount is reflected in the attached amended Spend
Plan.
All other terms and conditions of this Contract remain in full force and effect.
EXHIBIT B
Program Agreement Budget
D Original Budget X Budget Revision
REVENUES
Fiscal
Year Fund Source Original 1st Revision 2nd Revision 3rd Revision
2018 State Only 413,416 421,051
Waiver
Local
Medicaid Match to
Local
Total Rev . $820,341 $835,289 $826 ,847
Fiscal
Year Fund Source Original 1st Revision 2nd Revision 3rd Revision
2019 State Only
Waiver
Local
Medicaid Match to
Local
Total Rev .
COUNTY FY 2018 SPENDING PLAN
I
-
Planned Expenditures
Local PASRR Medicaid
Funds Funds State Funds Funds TOTAL
ADMINISTRATION 98
(CMIS/AWA BARS 11) 29697 24298 54093
OTHER CONSUMER
SUPPORTS I
(CMIS/AWA Code 31, 32, 41,
92, 93,94) 27754 22708 50462
CONSUMER SUPPORT . II
I
STATE-ONLY 464 6312 6776
Child Development
DSHS Central Contract Services Page 2
6024PF Contract Amendment (1-26-2018)
II
MEDICAID CLIENTS 940 357288 357288 715516
---
ROADS to COMMUNITY
LIVING
-
TOTAL
1502 421051 404294 826,847
DSHS Central Contract Services Page 3
6024PF Contract Amendment (1-26-2018)
Kittitas County
Review Fo.rm
Grants & Contract Agreement
Today's Date
06/19/2018
Fund/Department
116-Public Health
Contract/Grant Information
Agenda Date 7 f I l
Contract /Grant Agency: Kittitas County DDA County Services Amendment 2
Period Begin Date: May 1, 2018 I I Period End Date: June 30, 2018
Total Grant/Contract Amount: -$8,442.00
Grant/Contract Number: 1763-98187
Contract/Grant Summary:
The contract agreement revises the program agreement budget by decreasing the budget by $8,442.00.
Recommendation for Board of Health and Board of Health Review on
ce Date
1/1(!1
Date
Signature of Board of Health member Date
Financial Information
Total Amount $-8,422 State Funds $-8,422 Federal Funds$
Percentage County Funds Matching Funds$ CFDA#
In-Kind$
Explain
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring -reporting requirements
Grant/Contract Review Page 1
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes D attach budget form No D Why not
New Division Created? Will only need if actual amount billed exceeds
Contract amount -will do at year end
Revenue Code Amount Decrease New Total
105.568.334.04.68 $-8,442 $826,847
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 Yes • No D
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
I Signature :
Department:
I Date:
Assignment 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