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DOCUMENTATION OF FUNDSENCLOSURE AContractor/Contract No:Kittitas County1763-98187Prepared by:Judy Pless, Budget & Finance ManagerEmail address:judy.pless@co.kittitas.wa.usDate Prepared: Contact Person:Judy Pless, Budget Finance ManagerPhone No:509-962-7502(CHECK ONLY ONE PROGRAM AREA PER ATTACHMENT)Program Area:xxxDevelopmental Disabilities Mental Health __________ Children's Administration Alcohol & Substance Abuse Aging(B) Date A19 Was SENT to DSHS OR(D) Date you receivedPaid to Contractors: (A) Amout Paid reimbursement was (C) Amount of DSHS reimburseme Payment from DSHSrequested (electronically) (see NOTE for column below)DAYSJuly-1758,781.58 10/16/201758,781.58 10/17/2017(1.00) Aug-17 62,755.33 10/16/201762,755.33 10/17/2017(1.00) - September-1753,165.08 10/25/201753,165.08 11/7/2017(13.00) October-1753,733.83 12/4/201753,733.83 12/7/2017(3.00) November-1751,501.83 12/31/2017 51,501.83 1/2/2018(2.00) December-1756,113.87 2/3/201856,113.87 2/6/2018(3.00) January-18 55,273.12 2/20/201855,273.12 3/5/2018(13.00) 3/30/2018 600.00 4/11/2018 (12.00) February-1849,870.37 3/30/201849,270.37 4/2/2018(3.00) March-1850,541.65 5/14/201850,541.65 5/16/2018(2.00) April-18 53,381.61 5/25/201853,381.61 6/5/2018(11.00) May-1852,205.36 6/28/201852,205.36 7/10/2018(12.00) 7/20/20181,350.00 8/7/2018 (18.00) June-18 51,378.61 7/20/201850,028.61 8/1/2018(12.00) 648,702.24 648,702.24 - INSTRUCTIONS -Column A: List the amount you paid vendor(s) for providing services in the DSHS program area.Column B: List the date you sent the A19 to DSHS or the date that a reimbursement request was made via an electronic system (SSPS).Column C:List the amount of the reimbursement request to DSHS. NOTE: For the Mental Health program, do not include PHP funds received.Column D: List the date you received payment from DSHS.Note: Column A represents all payments, including Manage Care payments, to providers.