HomeMy WebLinkAboutAmendment 1Service Agreement # 19-33 Amendment # 1
Between
WALLA WALLA COUNTY DEPARTMENT OF COMMUNITY HEALTH
And
KITTITAS COUNTY PUBLIC HEALTH DEPARTMENT
Agreement 19-33 by and between Walla Walla County Department of Community Health,
hereinafter "County," and Kittitas County Public Health Department hereinafter "Contractor," is
amended as follows and in the attached Exhibit E (Expenditure and Budget Workbook):
Amendment 1:
Section 5 of the General Terms and Conditions is amended to eliminate references to
AmpliFund:
5.1 Contractor shall submit claims for reimbursement by the tenth (10th) working day
following the end of the month in which the expenses claimed were incurred. County
agrees to make payment with County warrants, as approved by the Auditor of County,
within forty-five (45) working days following receipt of Contractor's approved claim
for reimbursement, contingent on the availability of funds.
5.1.1 Claims for reimbursement shall be submitted thfetigh AmpliFund, to the
Department of Community Health email: DCHContractsBilling@co.walla-
walla.wa.us via Exhibit E — Budget and Expenditure Workbook,
Expenditure Report Form (ERF). . is gfant man agemeat systefn.
5.1.2 Submitting a Final Payment Request via the ERF the .,.h A fflpi: and will
signify that the Contractor certifies under penalty of perjury that the items
and totals listed herein are proper charges for materials, merchandise or
services furnished to the County of Walla Walla and that all goods
furnished and/or services rendered have been provided without
discrimination because of age, sex, marital status, race, creed, color,
national origin, handicap, religion, or Vietnam era or disabled veterans
status and the claim is just, due and unpaid obligation against the County of
Walla Walla and that I am authorized to authenticate and certify to said
claim.
5.1.3 Payment shall be based upon itemized billings supported by accompanying
documentation.
5.1.4 County shall compensate Contractor no more often than monthly for
Contractor's service. No payment shall be made in the month services are
rendered unless otherwise approved by County.
Attachments: Exhibit E — Budget and Expenditure Workbook
All other conditions of Service agreement #19-33 remain in full force and effect.
# 19-33 Amend #I GT&C Kittitas County Public Health Yr 3 YMPEP 1 of 2
By their signatures below, the parties agree to the terms and conditions of this Agreement and all
documents incorporated by reference. The parties signing below certify that they are authorized
to sign this Agreement.
IN WITNESS WHEREOF, the parties hereto have signed this Agreement.
COUNTY::
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Div,�oregor� A-70rnp� RC 1
314 W. Main
R3r
P.O. Box 1753
Walla Walla, WA 99362
Phone: (509) 524-2650 Fax: (509) 524-2642
CONTRACTOR:
rgAuthorized Date
Telephone Number / Email Address.
Mailing Address (Street address required in addition to PO Box.):
-t�� i61�i f&6 �
Print Name &'Gide of Person Signing
6D�N t�1�nu�h roti
Social Security or Business Tax ID#
CFDA# (if applicable): UBI#:161 rW
State Industrial Account ID # (if applicable): O V
#19-33 Amend #1 GT&C Kittitas County Public Health Yr 3 YMPEP 2 of 2
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date Agenda Date
10/10/2019
Fund/Department
116 -Public Health
Contract/Grant Information
WN
Contract /Grant Agency: KCPHD and Walla Walla County Department of Community Health Amendment
1
Period Begin Date: 07/01/2019
Total Grant/Contract Amount: $10,000
Grant/Contract Number: 19-33 Amendment #1
Period End Date: 06/30/2020
Contract/Grant Summary:
The Amendment to the agreement changes who the billings are submitted to. KCPHD is to submit
billings to Walfa Walla Community Health for services relative to the Youth Marijuana Prevention and
Education Program.
Recommendation for Board of Health and Board of Health Review on
Department Head Signatur Administrator Date:
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
5
Sippaure olt Pros cu is Office Date //
� L
Signat re of Auditor's Office Date
Signature of Board of Health member Date
Financial Information
Total Amount $10,000.00 State Funds $10,000.00 Federal Funds $0
Percentage County Funds Matching Funds $ CFDA# N/A
Grant/Contract Review Page 1
In -Kind $
Is Equipment being purchased? No Who owns equipment?
New Personnel being hired? No Contact HR hiring — re
Future impacts or liability to Kittitas County:
ng requirements
Budget Information
Budget Amendment Needed? Yes[M attach budget form No ❑ why not
New Division Created? (To be entered in budget center)
Revenue Code 116.6129133406902 $10,000.00
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub -Contract Approved Date:
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes ❑ No
County Deoartments Imnacted
F Auditor
Facilities Maintenance
Information Services
Human Resource
Prosecutor
Treasurer
Submitted
Signature: Date:
Department:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2