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• Universal A Agreement Number: PH00l-2019 <br />I <br />Purchase Order Number: <br />Purpose: The purpose of this Agreement is to _oc tlo,e (lt the. m ~ua i..undeFst nd i ng and respective obligations of the parties to facilitate the <br />successful completion of the identified project or o bj ective . This Agreement is by and between Kittitas County, and the community partner identified <br />in section 3 below, hereinafter referred to as Other Party. <br />2. Kittitas County Program Information: <br />Originator (Kittitas County Employee): Tim Roth, RN <br />Program ; Kittitas County Public Health BAC Code(s): N/A <br />Email Address : Tim.roth@co .klttltas .wa.u s Phone : (509) 962-7515 <br />Web Address : http_s:l}_w ww .co.kiltitas ,wa.us[de(l!ult .asl!l! Federal Tax ID#: 91-6001349 <br />3. Other Party Information: <br />Name : Ellensburg School District 401 Phone : (509) 925-8000 <br />Contact Person : Jinger Haberer, Superintendent Email Address : jinger.haberer@esd4,01 .org <br />Physical Address: 1300 E 3rd Ave <br />City: I Ellensburg I State : WA I Zip : 1 98926 <br />Mailing Address: 1300 E 3rd Ave <br />City: I Ellensburg I State: WA I Zip: I 98926 <br />Web Address: httgs:Llwww .esd401 .o re/_ Social Security#: <br />Federal Tax ID#: 91-6001849 DUNS#: <br />If an independent contractor or personal service contractor, did you retire from the Washington <br />0Yes 0No ON/A State Retirement System using the 2008 Early Retirement Factor? <br />4. Attachments Applicable to this Agreement: <br />r:gJ Attachment A -Statement of Work <br />D Attachment B -Compensation <br />r:gJ Attachment C - Standard Provisions <br />D Attachment D -Special Provisions <br />5. Agreement Period and Amount: <br />D Attachment E -Federal Certifications <br />D Attachment F -Circular A-133 Requirements (Subrecipient Only) <br />D Attachment G -Terms and Definitions: __ <br />D mher: __ <br />This Agreement shall commence on the start date indicated below and will continue in effect until the end date, unless terminated prior to that date in <br />accordance with paragraphs 11 or 12 of Attachment C -Standard P.rovisions. If applicable, the Agreement Amount set forth below represents the estimated <br />proportional financial contribution of the Other Party, with Estimate as the Condition . In the event there is actual monetary exchange, the true value will <br />appear in Amount, with the appropriate Condition selected, and be set forth on Attachment 8-Compensation. <br />Start: 07/01/2019 End : Until terminated by <br />either party <br />Condition : No financial contribution Amount: $ <br />By their signatures below, the parties agree to the terms of this Agreement: <br />Other Party Signature (including legible name, title, an <br />Cf/lb//7 <br />I',