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Home My WebLink AboutRes-2020-153BOARD OF COUNTY COMMISSIONERS COUNTY OF KITTITAS STATE OF WASHINGTON RESOLUTION No.2020- i53 RESOLUTION TO AUTHORIZE CONTRACT AMENDMENT EXECUTION WHER.EAS, Kittitas County and Contractor entered into a professional services contract; and WHEREAS, the contract authorizes modifications that are in writing and signed by the parties; and WHEREAS, both the County and the Contractor desire to amend the contract in the manner detailed in the attached Contract Change that is hereby incorporated by this reference; NOW THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Kittitas County, Washington, authorizes execution of the contract amendment attached hereto and incorporated herein. DATED this l.f'day of 2020, at Ellensburg, Washington. BOARD OF COUNTY SIONERS KITTITAS UNTY, V N lt ilt ffYL,DnClerk of the Board tr Deputy Clerk of the Board Service Agreement # 19-33 Amendment # 2 Between WALLA IVALLA COT.JNTY DEPARTMENT OF COMM{JNITY HEALTH And I{TTITAS COUNTY PIIBLIC HEALTTI DEPAR.TMENT Agreement 19-33 by and between Walla Walla County Department of Community Health, hereinafter "Collnfy," and Kittitas County Public Health Department hereinafter'tonfractoq" is amended as follows and in the attached Exhibit E (Expendihre and Buclget Workbook): Amendment 2: Add fi.rnding for July 2A2$ b June 2021 and extend Performance period. Aitachments:Exhibit A - Staternent cf Work Exhibit B - Budger Exhibit E - Budget and Expenditure Workbook All other conditions of Service agreement #lg-33 remain in full force and effect. By their signatures below, the parties agree to the terms and conditions of this Agreement and all documents incorporated by reference. T'heparties signing below certify that they are authorized to sign this Agreement. IN wlrNEss WHEREOF, the parties hereto bave signed this Agreement. COUNTY 4-2t-':ozo l- County Board of Commissioners c/o Deparhnent of Couununity Health 314 W ivlaill Sheet Walla Walla, WA 99362 Phone: (509) 524-2650 Fax; (509) 524-2642 Print Nanre & Title ol'Person ';; J'7t: ) t) LtS ri'lr ',pt()(t (l't!titl Date Date Telephone Number / Elnail Address: Mailing Address (Stleer adclress rcquired in acklition to pO Box.): CFDA# (ilappticabte): Social Secudty or Business Tax ID#: UBI#: State Industrial Account ID # (ifapplioablel: # I 9-3 3 Amend 2 GT&C Kittitas Couilty public Health yr 4 yMpEp I of I Exhibif A STATEMENT OF'WORI( Grantee Name: r\greement Numbcr': I(ittitas County Public Health Departrnerit l9-33 Anrend 2 Coutraot Periocl; 0710112019-06/3A/2021 Ta.sl< Number Task/Activity/ Description Delivera bles/Outcomes Ilue Date/Time Frame Payment Informatio n andlor Amount I Monthly Report Complete monthly lepoft form and email to YMPEP Proglam Coorciinator l0tl' of the month for the previous month in the conti'act N/A 1 Attend YMPEP regional rneetings and tlainings Suppofi YMPEP planning and evaluation Attend monthly YMPEP cont'elencs call meeting and attend quarterly YMPEP rcgional ttainings_-=_-- Attend planning and evaluation meetings ancl provide data and input as time allows, June 30,2021 Invoiced 3 (optional) June 30,2021 Invoiced 4 Adult Influencer Alvareness/Educat ion Deliver Hidden In Plain Sight presentations to commtmities .lune 30,202i Invoiced 5 Policy Advocacy Advocate for policy change to suppoll the plevention of youth mariiuana use in yorr community June 30, 2021 Invoiced 6 Promote Recovet'y Hotline Pulchase materials or publish media to promote recovery hotline June 30, 2021 Invoiced 7 Media Campaigns Under the Influence of You, Social Norms, other f)OH mariiuana reduction campaigns June 30,2021 Invoiced l9-33 Arnend 2 EXFIItslT A SOW Kittitas County Public Flealth Dept Yr 4 Y[\4PEP Page i ofl I Exhibit B BUDGET Agency Name: Agreement Number: Kiftitas County Public Health Departnent l9-33 Anrend 2 Contracr period: 07l0ll}0lg-06l30ll}2t Line ltemlDescription Arvard Program Operations - Year 3 (7lllt9 - 6130/20)$ 10,000 Program Operarions - Year 4 (7/U20 - 6BA|2D $ 12,500 $22,500TOTAL: Funded By WA State Department of Health Yotrth Marijuana Prevention and Education program l9-33 Amentl 2 EXHIBI'I' B Buclget Kittitas County Public Health Departrnent yr 4 yMpEp Page I of t Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box L753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. 2. Fill in expenditures on the Expenditure Worksheet. This 3. Do not print and sign, form is to be emailed as an Excel document. STATEMENT FOR SERVICES - Claim payment for materials, merchandise or services. Show complete Vendor's Ceft ificdte. I hereby certify 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. Expenditure Report Form (ERF) ERF shall not be edited. (rrLE) BY electronic (DArE) ature INSTRUCTrcNS TO VENDOR OR CLAIMANT: YMPEP 19-33 Amend 2 Kittitas County Public Health Dept rt Period Program: Agreement Number: Jul-20 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE Program Operations So.oo TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo PREPARED BY TETEPHONE NUMBER DATE FOR COUNTY FINANCF USE ONLY UBI NUMBER FUND Code Disttibution qCCOUNTING APPROVAL FOR PAYMENT OATE So,oo WARRANT NUMEER Revised 1/5/15 Submit this form to Contractol County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. 2. Fill in expenditures on the Expenditure Worksheet. This ERF shall not be edited. 3. Do not print and sign, form is to be emailed as an Excel document. STATEMENT FOR SERVICES - claim payment for materials, merchandise or seryices. show complete detail for each item. vendot's Certificote. I hereby certify 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. Expenditure Report Form (ERF) BYt /s/ electron ic (rrLE) INSTRUCNONS TO VENDOR OR CLAIMANT: YMPEP 19-33 Amend 2 Kittitas County Public Health Dept Program: reement Number: Period:Aug-20 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE Program Operations s0.00 TOTAL PAYMENT REQUESTED WITH THIS ERF:s0.00 PREPARED BY TELEPHONE NUMBER DATE FOR COUNW FINANCE U'E ONLY U8I NUMBER FUND Code Distribution \CCOUNTING APPROVAL FOR PAYMENT DATE 5o.oo Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. 2. Fill in expenditures on the Expenditure Worksheet. This ERF shall not be edited. 3. Do not print and sign, form is to be emailed as an Excel document. STATEMENT FOR SERVICES - Claim payment for materials, merchandise or services. Show complete Vendor's Certificdte. I hereby certify 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 o. 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 clai m. BY: /s/ electron ic re DA 4.E bi Expenditure Report Form (ERF) I N ST RU CT rc N S TO V EN DOR OR CLAIMANT: YMPEP 19-33 Amend 2 Kittitas County Public Health Dept Program: Agreement Number: Reporting Period:Sep-20 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE Program Operations s2,8s7.80 TOTAL PAYMENT REQUESTED WITH THIS ERF s2,8s7.80 PREPARED BY TELEPHONE NUMBER DATE FOR COUNTY FINANCE USE ONLY r'ENOOR NUMBER FUND Code Distribution \CCOUNTING APPROVAL FOR PAYMENT )ATE So.oo Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. IN STRU CTIONS TO VEN DOROR cLAtMANi: ERt shall no! be edited. -" - 3. Do not print and sign, form is to be emailed as an Excel STATE M E NT FOR S E RVICES - claim payment for materials, merchandise or seruices. show complete detail for each item, vendor's Certificote, I herebv certify 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. document. e lectron ic (TrrLE) BY: U Expenditure Report Form (ERF) YMPEP 19-33 Amend 2 Kittitas County Public Health Dept Period: Program: Agreement Number: Oct-20 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE So.ooProgram Operations TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo DATEPREPARED BY TELEPHONE NUMBER FOR COUNW FINANCE USE ONLY UBI NUMBER FUND Code Distribution DATE So.oo ACCOUNTING APPROVAL FOR PAYMENT Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. 2. Fill in expenditures on the Expenditure Worksheet. This ERF shall not be edited. 3. Do not print and sign, form is to be emailed as an Excel document. STATEMENT FOR SERVICES - Claim payment for materials, merchandise or services. Show complete Vendor's Certificote. I hereby certify under penalty of perjury that the items and totals listed herein are proper charges for materials, merchandise or services furnished to the CountV 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. wa.us BY: (electronic (rrLE) u Expenditure Report Form (ERF) a-wal I N ST RU C-N ON S TO V EN DO R O R CLAIMANT: PEP 19-33 Amend 2 Kittitas County Public Health Dept Program: Period: Number: Nov-20 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE Program Operations $6,678.0e TOTAL PAYMENT REQUESTED WITH THIS ERF:s6,678.09 PREPARED BY TELEPHONE NUMBER DATE FOR COUNTY FINANCE USE ONLY UBI NUMEER FUND Code Distribution \CCOUNTlNG APPROVAL FOR PAYMENT DAT€ So,oo Revised 1/5/15 Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure 2. Fill in expenditures on the Expenditure Worksheet. This ERF shall not be edited. 3. Do not print and sign, form is to be emailed as an Excel STATEMENT FOR SERVICES - Claim payment for materials, merchandise or services. Show complete vendot's Certificate. I hereby certify 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 clai m. Expenditure Report Form (ERF) Request Form as an Excel documefi- BY: /sl (DArE) re(electronic INSTRUC'ilONS TO VENDOR OR CLAIMANT: document. 4. Email to: bi (TITLE) Administrator YMPEP 19-33 Amend 2 Kittitas County Public Health Dept Re Period: Program: Agreement Number: Dec-20 AMOUNT THIS INVOICE LINE ITEM DESCRIPTION So.ooProgram Operations $o.ooTOTAL PAYMENT REQUESTED WITH THIS ERF DATEPREPARED BY TELEPHONE NUMBER FOR COUNTY FINANCF USF ONLY UBI NUMBER FUND Code Distribution So.oo dARRANT NUMBER\C'OlINTING APPROVAI FOR PAYMFNT )ATE Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box L753 Walla Walla, WA 99362 CLAIMANT Expenditure Request Form as an Excel document. This ERF shall not be edited. 3. Do not print and sign, form is to be emailed as an Excel document. STATEMENT FOR SERVICES - claim payment for materials, merchandise or seryices. show complete detait for each item. Vendor's Certificate, I hereby certify under penalty of perjury that the items and totals listed herein are proper charges for materials, merchandise or seryices 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 Expenditure Report Form (ERF) (rrLE) to sumbited usins this1. All invoices shall electronic si natu re BY; /s/ 2. Fi INSTRUCNONS TO VEN DOR OR CLAIMANT: PEP 19-33 Amend 2 Kittitas County Public Health Dept Program: Agreement Jan-2! LINE ITEM DESCRIPTION AMOUNT THIS INVOICE Program Operations So.oo TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo PREPARED BY TELEPHONE NUMBER DATE FOR COUNTY FINANCE USE ONLY VENDOR UBI NUMBER FUND Code Distribution ACCOUNTING APPROVAL F(DATE WARRANT So.oo WARRANT NUMBER Revised Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. CLAIMANT: shall not be edited. 3. Do not print and siRn, form is to be emailed as an Excel STATEMENT FOR SERVICES - claim payment for materials, merchandise or seruices. show complete detail for each item. vendor's Certificqte. I hereby certify 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 cla im. BYt /s/ (electronic s (rrLE) Expenditure Report Form (ERF) INSTRUCTrcNS TO VENDOR OR (DAIE) n atu re PEP 19-33 Amend 2 Feb-21 Kittitas County Public Health Dept Reporti Period Program: Agreement Number AMOUNT THIS INVOICELINE ITEM DESCRIPTION Program Operations So.oo So.ooTOTAL PAYMENT REQUESTED WITH THIS ERF: PREPARED BY TELEPHONE NUMBER DATE FOR COUNW FINANCE USE ONLY UBI NUMBER/ENDOR NUMBER FUND Code Distribution \CCOUNTING APPROVAL FOR PAYMENT DATE 5o.oo Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. INSTRUC'I rcNS TO VENDOR OR 2. Fill in expenditures on the Expenditure Worksheet. This CLAIMANT: ERF shall not be edited. 3. Do not print and sign, form is to be emailed as an Excel STATEMENT FOR SERVICES - Claim payment for materials, merchandise or services. Show complete Vendot's Certificote, I hereby certify under penalty of perjury that the items and totals ljsted 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 dlscrimination 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. (electronic (TrrLE) BY u Expenditure Report Form (ERF) billi wal YMPEP 19-33 Amend 2 Kittitas County Public Health Dept rt Period Program: Agreement Number: Mar-21 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE Program Operations so.oo TOTAL PAYMENT REQUESTED WITH THIS ERF:5o.oo PREPARED BY TELEPHONE NUMBER DATE FOR COUNTY FINANCE USE ONLY /ENDOR NUMBER FUND Code Distribution qCCOUNTING APPROVAL FOR PAYMENT DATE So,oo Submit this form to Contractor County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure 2. Fill in expenditures on the Expenditure Worksheet. This INSTRUCilONSTOVENDOR OR ERF shallnot be edited. CLAIMANT: 3. Do not print and sign, form is to be emailed as an Excel document. STATEMENT FOR SERVICES - claim payment for materials, merchandise or seryices. show complete detail for each item. vendor's Certificote, I hereby certify 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 certifv to said cla im. e lectron ic (rrLE) 8Y: /s/ u Expenditure Report Form (ERF) YMPEP 19-33 Amend 2 Kittitas County Public Health Dept Period: Program: Agreement Number: Apr-27 LINE ITEM DESCRIPTION AMOUNT THIS INVOICE so.ooProgram Operations TOTAL PAYMENT REQUESTED WITH THIS ERF:$o.oo TELEPHONE NUMBER DATEPREPARED BY FOR COUNW FINANCE USE ONLY UBI NUMBER FUND Code Distribution DATE So.oo qCCOUNTING APPROVAL FOR PAYMENT Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box L753 Walla Walla, WA 99362 CLAIMANT 1. All invoices shall be sumbited usins this Expenditure Request Form as an Excel document. INSTRUCflONS TO VENDOR OR 2. Fill in expenditures on the Expenditure Worksheet. This CLAIMANT: ERF shall not be edited. STATEMENT FOR SERVICES - claim payment for materials, merchandtse or seruices. show comptete detait foreach item. Vendot's Certificote. I herebV cenify under penalty of perju.y 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 cla im. electronic (rrLE) is to be emailed as an Excel3. Do not Drint and sipn. BY: /s/ Email Expenditure Report Form (ERF) YMPEP 19-33 Amend 2 Kittitas County Public Health Dept Re Period: Program: Agreement Number: May-21 tINE ITEM DESCRIPTION AMOUNT THIS INVOICE Program Operations So.oo TOTAL PAYMENT REQUESTED WITH THIS ERF:So.oo PREPARED BY TELEPHONE NUMBER DATE FOR COUNW FINANCE USE ONLY FUND Code Distribution \CCOUNTING APPROVAL FOR PAYMENT DATE So.oo Revised 1/5/15 Submit this form to Contractor: County of Walla Walla, Washington Department of Community Health PO Box 1753 Walla Wall wA 99362 CLAIMANT 1. All invoices shall be sumbited using this Expenditure Request Form as an Excel document. 2. Fill in expenditures on the Expenditure Worksheet. This ERF shall not be edited. 3. Do not print and sign, form is to be emailed as an Excel document. STATEMENT FOR SERVICES - claim payment for materials, merchandise or seryices. show complete detail for each item. vendot's Certificote. I hereby certify 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 cla im. Expenditure Report Form (ERF) BY: /s/ (electronic (TrrLE)(DArE) natu re I N ST R U CT rcN S T O VEN DOR O R CLAIMANT: YMPEP 19-33 Amend 2 Jun-21 Kittitas County Public Health Dept Program: Reporting Period: reement Number: AMOUNT THIS INVOICELINE ITEM DESCRIPTION So.ooProgram Operations So.ooTOTAL PAYMENT REQUESTED WITH THIS ERF: TELEPHONE NUMBER DATEPREPARED BY FOR COUNW FINANCE USE ONLY UBI NUMBER FUND Code Disttibution DATE So.oo \CCOUN]ING APPROVAL FOR PAYMENT