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Washington State AaQ HCA CONTRACT NUMBER: <br />Health Care uthority CONTRACT AMENDMENT 1863-28733 <br />Prevention Services Amendment No. 01 <br />This Contract Amendment is between the State of Washington Health Care Program Contract Number <br />Authority (HCA) and the Contractor identified below. TM010056 / SP020155 <br />Contractor Contract Number <br />CONTRACTOR NAME CONTRACTOR doing business as (OBA) <br />Kittitas County Kittitas County Health Department <br />CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS ACD INDEX NUMBER <br />507 North Nanum Street Suite 102 IDENTIFIER (UBI) 1225 <br />192-002-673 <br />Ellensbura., WA 98926-2886 <br />CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS <br />Kasey Knutson (509) 962-7515 (509) 962-7581 kasey.knutson@co. kittitas. wa .u <br />s <br />HCA PROGRAM AREA HCA CONTRACT CODE <br />Division of Behavioral Health 1644CS-63 <br />HCA CONTACT NAME AND TITLE HCA CONTACT ADDRESS <br />Sarah Mariani 4500 Tenth Ave SE <br />Program Administrator PO Box 45330 <br />Olympia, WA 98504 <br />HCA CONTACT TELEPHONE HCA CONTACT FAX HCA CONTACT E-MAIL ADDRESS <br />(360)725-377 4 Sarah. Mariani®hca. wa.aov <br />IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? I CFDA NUMBERS <br />Yes 93 .959 <br />AMENDMENT START DATE CONTRACT END DATE <br />01/01/2019 06/30/2019 <br />PRIOR MAXIMUM CONTRACT AMOUNT AMOUNT OF INCREASE OR DECREASE TOTAL MAXIMUM CONTRACT AMOUNT <br />$158,037.00 $0.00 $158,037.00 <br />REASON FOR AMENDMENT; <br />CHANGE OR CORRECT CHOOSE ONE: <br />ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into <br />this Contract Amendment by reference: <br />181 Additional Exhibits (specify): Exhbit B <br />This Contract Amendment, including all Exhibits and other documents incorporated by reference, conta ins all of the terms <br />and conditions agreed upon by the parties as changes to th e original Contract. No other understandings or <br />representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or <br />bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing <br />below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract <br />Amendment. <br />c~~ PRINTED NAME AND TITLE DATE SIGNED <br />Tr,~t:,kn Ul)n/:), PJ! !UlnA1uifra6 !,' 2-ln/1°1 <br />~CASl(ATiURE ~?J ~1-~ PRINTED NAME AND TITLE DATE IS;{r2'°[q ( /./4.A;,. ') Jim Gayton, HCA Contracts Administrator ~ <br />I I <br />HCA Contract Services Page 1 <br />7024PF HCA Custom Contract Amendment (5-2-2018)