HomeMy WebLinkAboutReview Form (2)Kittitas County
Review Form
Grants & Contract Agreement
Contract/G ra nt I nformation
Recommendation for Board of Health Review on
Department Head Signature Director Date n l>3
verification the contracting Agency is not suspended/Disbarred:
Today's Date
12/13/2022 PA Camas Request #:fr ]
Fund/Department
116-Public Health Agenda Date: /- f -l-*.->.,,
nCo rat ct ar tn e n bPSA/c eetw Kitten tasAgcy uCo n na Thod Sc oh o istD ctfl Aty m ne md nte 1.rp
Period Begin Date: 8/I/Z0ZT Period End Date: 07/3L/2O23
otT a raG Contr Aact mount/n t 2 5 00000 crn asee romf flo n a moa ntu fo t 00500.gr s 2,
Grant/Contract Number
The amendment to the PSA between Kittitas County and Thorp School District increases the total award
amount from $12,500,00 to 525,000,00.
Contract/G rant Su m mary:
Kittitas County Prosecutor, Aud itor, and Board of Health Review and Comment:
PR FORM
Signature f Prose s Date
Signature of Auditor's Office D ate
I Agency is not suspended/disbarred fl Not Checked (reason)
Grant/Contract Review Page L
Financial lnformation
Bu lnformation
Pass Through lnformation
Prosecutor Review
Total Amount S25,000 State Funds $Federal Funds SZ5,OOO
Percentage County Funds Matching Funds S CFDA#
ln-Kind S
ls Equipment being purchased?Who owns equipment?
New Personnel bei hired?Contact HR hirin orting uirements
Future impacts or liability to Kittitas County:
Bud Amendment Needed?
New Division Created?
Yes I attach budgetform No X Why not
Revenue Code 116.612.39. 26. 33 3. 93. 39 1
Expense Code 1"16. 612.39 .26.5 41,01
Agency to Pass Through
Amount to Pass Through Expense Code:
Sub-Contract Approved Date
Has the Prosecutor reviewed this agreement?Yes No
Cou De artments lm acted
BOCC Approval Needed?
nment of Tracking lnformation
Auditor Facilities Maintenance
lnformation Services Human Resource
Prosecutor Treasurer
Yes !NoE
Staff Mem ber Presenting
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2