HomeMy WebLinkAboutG - Fully Executed Agreement\.-)
KITTITAS COUNTY
AGREEMENT FOR SERVICES
PHMH25.OO2
ThisAgreementforServices(hereinafter,,Agreement,,)isenteredintobyandbetweenKittitasCounty
(hereinafter "County"), a political subdivision of itre State of Washington' and Robin H Read Consulting
( he reinafter "Contractor" )'
The purpose of this Agreement is as follows: creation of plans for advisory committees including a 2-year
strategic plan for mental health and substance use disorder prevention, an action plan for homelessness and
affordable housing, and an updated biennial plan for developmental disabilities advisory committee'
The term of this Agreement shall be from the date of execution through March 31',2027, unless the
Agreementisterminatedearlyoritstermisextendedasprovidedherein.
The parties, addresses and points of contact for the administration of this Agreement are as follows:
eguNrY
507 N Nanum Street Ste 102
Ellensburg, WA 98926
Kasey Knutson
Human Services Manager
Kittitas County Public Health Department
Kasey. knutso n@co.kittitas.wa. us
5A9-962-75L5
coNIBACTOR
1301 N Main Street
Ellensburg, WA 98926
Robin Read
Owner, Robin H Read Consulting
robinhread@gmail.com
509-607-137s
This Agreement includes the following, which are attached hereto and hereby incorporated by this
reference
Attachment "A":
Attachment "8":
Attachment "C":
Attachment "D":
Attachment "E":
Kittitas County Agreement for Services lrev' 5/14/231
Page 1 of 19
Scope of Work
Compensation
General Terms and Conditions
w-9 (contractor must complete and return to the county for payment)
Retirement Status Form (Contractor must complete and return to the County
for payment f Contractoi is an individual, as opposed to a corporate business
entitY)
tN WITNESS WHEREOF, this Agreement has been executed by and on behalf of the parties through their
authorized representatives, effective as of the latest date written below'
Kittitas County Agreement for Services lrev ' 5/La/251
Page2 of 19
CONTRACTOR
Signature
Printed Name
42P}
Title
Date:
L$- 40b,.,,, |,l \lt,
lru2[
Julie Kiorsviki*"ffi.4j0ilr' LpKr,t^
KITTITAS COUNTY
MMISSIONERSCOUNWBOARD
Chair
Commissioner
Date:
Attest:
of the Bo
ATTACHMENT,,A,,
SCOPE OF WORK
uLOrH OF L%MENTAI HEALTH AND CHEMICAL DEPENDENCV ADVISORY BOARD - CREATION OF A 2 YEAR
STRATEGIC PIAN
Pre-work
oReviewKittitasCountyBehavioralHealthassessmentresults
oResearchandreviewbehavioralhealthplansfromothercounties
o Attend committee meetings
Data Collection
o create interview questions and interview committee members and staff
o Conduct Strengths, Weaknesses, Opportunities, Threats analysis with committee
o Compile and present report of data collection results
o Analyze services funded for duplication
o Analyze performance data for people served and cost per person
ln person strategic planning meetings
o Create vision, mission, and value statements
o ldentifY new name of committee
o ldentify and define strategic priorities
o Create goal statements and desired outcomes
o ldentify strategies and objectives
o create implementation plan including activities, responsibility, and timeline
Fi n a t Strate g ic P la n Docu me ntoti on
o Complete final strategic plan document
o Create presentation slides for communication of plan
Quorterly uPdotes
o Prepare quarterly updates on plan progress
oAttendquarterlypublichealthstudysessionstopresentupdates
7-2-hour workshop on facilitation
o Meetlngs with staff for feedback on content
o Development of content and octivities
o Provision of workshoP
a
a
HoMEtEssNEssANDAFFoRDABIEHoUSINGAcTIoNPLANCREATIoN
Pre-work
o Review Kittitas County Homeless Housing Plan
o Meet with HopeSource to identify strategies they will lead
o Observe HAHC meeting
Prioritizotion
o plan and conduct prioritization exercise with HAHC to identify strategies they want to work on
2026 lmplementation Plan
Kittitas County Agreement for Services (rev' 5/I /251
Page 3 of 19
rt
a
a
a
a
a
o create implementation plan with HAH€ for prioritized activities including activities' responsible
PartY, and timeline
Implementation Monitorinq . ,,.,,_- r -L-^,o Attend HAHC meetings to mOnitor progress on implementation of prioritized strategies
o ComPlete Progress report
DEVELoPMENTAIDlsABltlTlEsB|ENNlAtPIAN2025-2028cREATloN
a
a
a
a
Datd Updotes
o Update data and information in current plan
tn persoi strotegic planning meetings
o Review updated data and information
o Review vision, mission, and value statements
o Review strategic Priorities
o Review goal statements and desired outcomes
o Update strategies and objectives
o create implementation plan including activities, responsibility, and timeline
Final Biennial Plan Documentotion
o Complete final biennial plan document
o Create presentation slides for communication of plan
Kittitas County Agreement for Services (rev ' 5/14/25)
Page 4 of X9
ATTACHMENT'8"
COMPENSATION
THE COUNTY WILL NOT PROCESS PAVMENT FOR SERVICES RENDERED UNDER THIS AGREEMENT UNTIL
CoNTRACTOR SUBMITS A COMPLETED W-9 (SEE ATTACHMENT "E").
As full cornpensation for satisfactory performance of the work described in Attachment "A"' and within
thirty (30) days of receiving Contractor's itemized invoice, the County shall pay contractor the following amount(s)
plus any applicable taxes as detailed in Contractor's invoice: $z+,000; Contractor will bill 5150'00 per hour'
Unless otherwise provided herein, Contractor shall be solely responsible for Contractor's travel and
related exPenses.
Any uses of these funds outside of the listed allowable uses must be approved by Kittitas county in advance of the
expenditure, in writing.
All funding is based on localtax and fee revenue. lf local economic conditions result in insufficient funds to
compensate at the stated levels, the county reserves the right to renegotiate funding amounts to remain within
available revenue balances. The county will notify the contractor immediately if financial forecasting or actuals
indicate such a circumstance.
All funds must be spent by March 37,2027 ' No extension of the funding period will be granted'
Reimbursement Procedures
A. The Contractor shall submit invoices for services due once a month, which shall be emailed to Katie
Odiaga, Kittitas County public Health Department, at katie..odiasa@cQli!!!a5.JdA.!E'
B. Att invoices must be su bmitted by the end of the month fotl.owing the catendar month in which
services were delivered and wil.l. be reimbursement-based payment, only'
c. The contactor must provide adequate backup documentation to support costs in each invoice' This
includes a general ledger from the financial accounting system detailing transactions and expenditure
dates for allowable activities within the period of performance. Payroll expenses must show employee
names, hourly rate, number of hours, total pay, and project code' Benefits can be one line item but
should include project code. Non-payroll expenses must include a copy of the receipt or payment
invoice. payments to subcontractors must be listed as a specific line item per subcontractor'
D'Allinvoicesmustincludeinvoicedateandaninvoicenumber.
E. lnvoice must include hourly billing that clearly shows funding being invoiced for the strategic plan for
mental health and substance use disorder prevention (general fund), action plan for homeless and
affordable housing (general fund), and the Kittitas County Developmental Disabilities plan 2026-2028
(millage).
All invoices must also be accompanied by an updated Contractor Spending Form, as provided by Kittitas
County, to ensure that billing record keeping matches County records'
Kittitas county is not liable for services provided unless the invoice is received on time or prior
arrangements are agreed to in writing signed by the County'
ln no event shall payments under this agreement total more than s24,000'
Kittitas County Agreement for Services (rev' 5/La/25)
Page 5 of 19
F.
G
ATTACHMENT "C'
GENERAT TERMS AND CONDITIONS
1. scoge of contractor,s-seryices: contractor agrees to provide to the county services as set forth in
Attachment ,,A". No materials, labor, or facillties will be furnished by the county' unless otherwise provided
herein. All work performed under this Agreement shall comply with applicable laws and regulations'
2. AccountinF and pavmgnt: compensation to contractor for services rendered under this Agreement
shall be as set forth in Attachment "B". Where Attachment "B" requires payment(s) by the county' payment shall
be based upon billings, supported unless provided otherwise in Attachment "8"' by documentation of units of
work actually performed and amounts earned, including, where appropriate, the total number of hours for the
month and the totar dolar payment requested. Unless specificaily stated in Attachmelrt "8", the county will not
reimbursecontractorforanycostsorexpensesincurredbycontractorinperformanceofthisAgreement'
where
required, the County shall, upon receipt of appropriate documentation, compensate Contractor, no more often
than monthly, through the County vor.h"r ryri.m, for Contractor's services pursuant to the fee schedule set forth
in Attachment ,,8,,. ln the event contractor fails to perform any of its obligations under this Agreement within the
time specified herein, then the county may withhold all monies due and payable to contractor until such failure
to perform is cured or otherwise adjudicated. The county will not process payment for services rendered under
this Agreement until Contractor submits a completed W-9 (See Attachment "E")'
3.Taxes:ContractorunderstandsandacknowledgesthattheCountywillnotwithholdFederalorState
income taxes from payments made to contractor. where required by state or Federar raw, contractor authorizes
theCountytomakewithholdingforanytaxesotherthanincometaxei(e'g',Medicare)'
Allcompensationreceived
by contractor will be reported to the lnternal Revenue service at the enJ of the calendar year in accordance with
appricabre rRS regurations. rt is the responsibirity of contractor to make its necessary estimated tax payments
throughout the year, if any, and Contractor is solely liable for any tax obligation arising from Contractot,s
performance of this Agreement'
TheCountywillpaysalesandusetaxesimposedongoodsorservicesacquiredhereunderasrequiredby
law. contractor must pay all other taxes, including but not limited to: business and occupation tax; or taxes based
on (1} Contractor,s gross or net income, or (2) personal property to which the County does not hold title. The
County is exempt from federal excise tax'
4'lndeBglcel!_Ea'1ll3glgl:contractor,sservicesshallbefurnishedbyContractorasanindependent
contractor, and nothing stated herein shail be construed to create a rerationship of employer-employee or a
guarantee of future ernployment. contractor acknowledges that its entire compensation under this Agreement
is specified in Attachment,,B,', and that contractor is not entitred to any county benefits, incruding but not limited
to: vacation pay, holiday pay, sick leave pay, medical, dental, or other insurance benefits' or any other rights or
privileges afforded to Kittitas County employees'
5. Assisnment and subcontractine: and subcontracting: No portion of ttris Agreement may be assigned
or subcontracted to any other individual, firm or entity without the express and prior written approval of the
county. The contractor may only subcontract work contemplated under this agreement if it obtains the prior
written approval of the county. lf the county approves subcontracting' the contractor shall maintain written
procedures rerated to subcontracting, as weil as copies of ail subcontracts and records rerated to subcontracts'
For cause, the county in writing may require the contractor to amend its subcontracting procedures as they relate
to this agreement, prohibit thJ Contractor from subcon'acting with a particular person or entity' or require the
contractor to rescind or amend a subcontract. Every subcontract shat bind the subcontractor to follow all
appricabre terms of this agreement. The contractor is responsibre to the county if the subcontractor fails to
Kittitas County Agreement for Services (rev' 5174/251
Page 6 of 19
compry with any applicabre term or condition of this agreement. The contractor shail appropriatery monitor the
activities of the subcontractor to assure fiscar conditions of this agreement. rn no event shail the existence of a
subcontract operate to rerease or reduce the riabirity of the contractor to the county for any breach in the
performance of the Subcontractor's duties'
Every subcontract shall include a term that county is not liable for claims or damages arising from a
Subcontracto r's performa nce of the subcontract'
6. Risht to Review; Maintenance of Records: This Agreement is subject to review by any Federal or state
auditor. The county or its designee shall have the right to review and monitor the financial and service
components of the work performed under this Rgreement by whatever means are deemed expedient by the
county. such review may occur with or without niti.", and may incrude, without rimitation, on-site inspection'
inspection of all records or other materials which the county deems pertinent' and any and all communications
with or evaruation by service recipients under this Agreement. contractor shail preserue and maintain all records
rerating to this Agreement for six (6) years after termination or expiration of the Agreement, and upon request
shall make them avairabre for review by any Federar or state auditor, the county, and/or any persons authorized
7.7. This Agreement may be amended by mutual agreement of the parties' Any such amendment
shall be in writing and signed by both parties'
7.2 The county may unilaterally amend this Agreement at any time by written notice ("change
Notice,,) to contractor, to modify the work jo be performed under this Agreement' within the general scope of
theAgreement.suchchangesmayinclude,butarenotlimitedto'changesintheexactscopeofworktobe
performed (including modification, substitution, addition, or deletion of required tasks) and changes to the
schedure of performance. rf any such change Notice causes an increase or decrease to contractot's cost of' or the
time required for, performance of the work, an equitable adjustment in the compensation to Contractor and/or
in the schedule for the performance of the work shall be made by the county to reflect such an increase or
decrease. Notwithstanding any dispute or deray in arriving at a mutuaty acceptabre equitabre adjustment,
contractor sha, proceed in accordance with alr change Notices. within thirty (30) days after receipt of any change
Notice which, in Contractor's opinion, lacks an adeluate adjustment, Contractor must submit to the County a
written statement requesting a modified adjustment; otherwise, contractor will forfeit its right to any such
modified adjustment. The county retalns the final right to determine adjustments hereunder'
by the CountY.
7. Modification
8. Termination
Kittitas County Agreement for Services (tev' 5/14/25)
Page 7 of 19
8.lThisAgreementmaybeterminatedatanytimebymutualwrittenagreementoftheparties.
S.2Thecounty,bygivingwrittennotice,mayterminatethisAgreementatanytimewithoutcause
and without further obrigation to contractor except for payment due for deriverables provided and/or services
performed prior to the effective date of termination. An equitabre adjustment in the contracted price for partially
compreted tasks wiil be made by the county, but such adjustment shail not incrude compensation for loss of
anticipated profit on uncompleted work'
8.3 lf contractor defaults by failing to perform any of its obligations under this Agreement' or
becomes insolvent, is declared bankrupt oI. .oai-ri,, any act of bankruptcy or insolvency, or makes an assignment
for the benefit of creditors, the county may, by written notice to Contractor, terminate the Agreement' and at
theCounty.soption,obtainperformanceoftheworkelsewhere.lftheAgreementisterminatedunderthis
paragraph, Contractor shall not be entitled to receive any further payments under this Agreement until all of its
obligations hereunder have been fully performed, and any extra cost or damage to the county shall be deducted
from any money d ue or coming due to Contractor, Furthermore, in the event of termination under this paragraph'
contractor shall bear the costs of any extra expenses incurred by the county in completing the work' and all
damages sustained, or which may be sustained, by the County'
S.4TerminationofthisAgreementbyanymeansprovidedhereinshallnotexcuseanyparty,s
performance of its obligations hereunder through the effective date of termlnation' except that the County shall
not be obrigated to pay for services that have no-t b""n performed or deriverabres that have not been provided'
9. lndemnification
9.1 To the fullest extent permitted by law, Contractor aBrees to indemnify' defend and hold the
County and its departments, elected anO appointed officials, employees' agents and volunteers' harmless from
and against any and all claims, damages, losses and expenses, including but not limited to court costs' attorney's
fees and alternative dispute resolution costs, for any personal or bodily injury, sickness, disease or death' for any
damage to or destruction of any property (incruding the ross of use resurting therefrom), and for any other claims,
damages, losses, and expenses sustained by the C-ounty, which (L) are caused in whole or in part by any act or
omission, negligent or otherwise, of contractor, its employees, agents or volunteers' or contractor's
subcontractors, their employees, agents or volunteers; or (2) are directly or indirectly arising out of' resulting
from, or otherwise connected with ihe performance of this Agreement; or (3) are based upon contractor's or its
subcontractors' use of, presence upon or proximity to the property of the County' This indemnification obligation
of contractor shall not apply in the limited circumstance where the claim, damage' loss or expense is caused by
the sore negrigence of the county. This indemnification obrigation of contractor shail not be rimited in any way by
the washington state lndustrial lnsurance Act, RCW Title 51, or by application of any other workmen's
compensation act, disability benefit act or other employee benefit act, and contractor hereby expressly waives
any immunity afforded by such acts. The foregoing indemnification obligations of contractor are a material
inducement to the county to enter into this Ag-reeJrent, are reflected in contractor's compensation, and have
been mutually negotiated by the parties'
g.2Thecountyreservestheright,butnottheobligation,toparticipateinthedefenseofanyclaim
for damages, losses or expenses, and such participation shall not constitute a waiver of Contractor's indemnity
obligations contained in any section of this Agreement'
g.3 ln the event contractor enters into subcontracts to the extent allowed under this Agreement'
each such subcontractor shall indemnify the county on a basis equal to or exceeding contractor's indemnity
obligations to the CountY.
10. Venue and choice of Law: ln the event that any litigation should arise concerning this Agreement'
the venue for such action shall be in the superior court of the state of washington in and for the county of Kittitas'
This Agreement shall be governed by the laws of the state of washington'
ll.Non.ApproprilrtionofFunds:lftheCountydoesnotappropriatesufficientfundingforthisAgreement
for any future tir.rt piliUJil" Cor.ty witt not be obligated to make payments for seruices performed after the
end of the last fiscal period for which sufficient funding was appropriated. No penalty or expense shall accrue to
the County in the event this provision applies'
12. Contractor comrnitments. warranties. and Representations: contractor represents and warrants as
follows:
Kittitas County Agreement for Services (rev' 5/La/25)
Page 8 of 19
72.L contractor is duly incorporated, validly existing and in good standing under the laws of the state
of washington, and has all requisite corporate power and authority to enter into and to perform its obligations
under this Agreement.
tz.Z Contractor has the authority to execute this Agreement, to make the representations and
warranties set forth herein, and to perform its obligations hereunder.
1,2.3 This Agreement has been validly executed by an authorized representative of Contractor and
constitutes a valid and legally binding and enforceable obligation of contractor'
L2.4 Contractor holds, or will obtain prior to commencing work under this Agreement, such licenses,
permits and other authorizations from federal, itate and local governmental authorities, or from any applicable
industrial or professional certification or licensing bodies, as are necessary for the lawful performance of its
obligations under this Agreement, and will maintain such throughout the term of this Agreement'
I2.5 Contractor is not in violation of any applicable law, ordinance or regulation the consequence of
which will or may materially affect contractor's ability to perform its obligations under this Agreement' contractor
is not subject to any order or judgment of any court, tribunal or governmental agency which materially and
adversely affects its operations or assets in the state of washington, or its ability to perform its obligations under
this Agreement.
12.6 contractor is not presently debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded from covered transactions by any Federal or State department or agency'
12.7 None of the representations or warranties in this Agreement' and none of the documents'
statements, certificates or schedules furnished by Contractor in connection with the performance of the
obligations contemplated under this Agreement, contains or will contain any untrue statement of a material fact
or omits or will omit a material fact necessary to make the statements of fact contained therein not misleading'
13. ownership of ltems produced: All writings, programs, data, reports, films, recordings, or other
materials prepared OV Cor*racto r and/or its consultants or subcontractors, in connection with the performance
of this Agreement, shall be the sole and absolute property of the County' The County will have all rights of
ownership therein, including but not limited to the right to use, copyright, trademark, and/or patent, and the
ability to transfer any or all ownership rights'
14. lntellectual Propertv lnfriry:elnent: contractor will defend and indemnify the county from any
claimed action, cause or demand brought rgri*t the county, to the extent such action is based on the claim that
information and/or materials supplied by conractor infringe any intellectual property rights of any third
party(ies). contractor will pay all costs and damages attributable to any such claims finally awarded against the
County in any action. Such defense and paymeni, ur" conditioned upon the following: (1) Contractor shall be
notified promptly in writing by the county of any notice of such claim; and (2) contractor shall have the right
hereunder, at its option and expense, to obtain for the county the right to continue using the information and/or
materials that are the subject of such claim, provided no reduction in performance or loss results to the county'
15.UseofCountvNameandLogo:ContractormaynotusetheCounty,sname,logo(s},trademark(s),or
other identifying information, or identify the county as a current or former client' on its website or in any
marketing or promotional materials without the prior written consent of the county'
16. Disputes: Any dispute between the parties arising under or relating to this Agreement shall be
resolved informally if possible. However, in the event such a dispute cannot be so resolved' it shall be adjudicated
Kittitas County Agreement for Services (rev' 5/L4/25)
Page 9 of 19
by a dispute board (,.Dispute Board") in the following manner: Each party shallappoint one memberto the Dispute
Board, the members so appointed shall jointly appoint an additional member to the Dispute Board' and the
Dispute Board will evaluate the facts, Agreement terms, and all applicable statutes and rules' and make a
determination as to the proper resolution of the dispute. such determination shall be final and binding on both
parties. The cost of resolution will be borne as allocated by the Dispute Board. Alternatively, if agreed to in writing
by both parties, the parties may forego the option of establishing a Dispute Board to adjudicate the dispute' and
instead pursue arbitration, jointly selecting an arbitrator acceptable to both parties' ln the event the parties
choose to pursue arbitration, the parties agree that: (1) the fees and expenses ofthe arbitrator shall be shared
equally by both parties to this Agreement, (2) each party shall bear its own costs and attorney fees, (3) arbitration
shall be conducted according to the commeicial arbitration procedures of the American Arbitration Association'
and (4) the arbitrator's decision or award shall be final and binding on both parties'
17. Confidentialiw: Contractor, its employees, agents and volunteers' and any of Contractor's
subcontractors and their employees, agents and volunteers, shall maintain the confidentiality of all information
provided by the County or acquired by Contractor in performance of this Agreement' except upon the prior
written consent of the Kittitas county prosecuting Attorney or an order entered by a court after having acquired
jurisdiction over the county. contractor shall immediately provide the county notice of any judicial proceedings
seeking disclosure of such information. contractor agrees to indemnify, defend and hold harmless the county
and its departments, elected and appointed officials, employees, agents and volunteers from all loss or expense'
incruding but not rimited to settrements, judgments, setoffs, attorneys'fees and costs resurting from contractor's
breach of this provision. Notwithstanding the foregoing, and to the extent that any information obtained by the
Contractor hereunder is required to be shared with others by the explicit terms of the Scope of Work' this
provision shall not be construed as prohibiting such sharing, provided there are no applicable laws or regulations
prohibiting same.
1g. Notices: Written notices required or permitted to be provided by one party to the other party under
this Agreement may be provided by personar derivery, regar courier service, or certified mair, postage prepaid and
return receipt requested. Notice may be provided by relurar first crass mair if simurtaneous notice is provided by
email. Notices given by contractor shall be provided to the county's point of contact listed on page 1 of this
Agreement, at the address there listed, and to the department head of the county department for which services
under this Agreement are rendered. Notices given by the county shall be provided to contractor at contractor's
address listed on page 1 of this Agreement'
19. prevailine Wagq: where labor to be performed under this Agreement is considered "public work" as
defined in RCW 39.04.010, contractor shall pay the prevailing rate of wages to all workers' laborers' or mechanics
employed in the performance of work under ihis Agreement in accordance with RCW 39'12 and the rules and
regulations of the washington state Department of Labor and lndustries. The schedule of prevailing wage rates
for the applicable locality or localities is determined by the lndustrial statistician of the Department of Labor and
lndustries. lt is contractor,s responsibility to verify the applicable prevailing wage rate' lt is understood that
contractor is responsible for obtaining and completing all required government forms relating to prevailing wage
and submitting same to the proper authorities. oisp-utes regarding prevairing wage rates shail be referred for
arbitration to the Director of the Department of Labor and tndustries. The arbitration decision shall be final and
conclusive and binding on all parties involved in the dispute as provided for in RCW 39'12'060'
20. standard of care; contractor shall perform its duties hereunder in a manner consistent with that
degree of care ,nd ,kitGrdi*rily exercised by members of the same profession or industry as Contractor currently
practicing or working under similar circumstances. contractor shall, without additional compensation' correct any
of its services not meeting such a standard'
21. Nondiscrimination
Kittitas County Agreement for Services $ev'51L4/25')
Page 10 of 19
z!.J" ln the performance of this Agreemenf Contractor will not discriminate against any employee or
applicant for employment on the grounds oi.g", race, creed, color, national origin' citizenship or immigration
status, sex, sexual orientation, marital status, hJnorably discharged veteran or military status' or the presence of
any sensory, mental or physical disability or the use of a trained dog guide or service animal by a person with a
disability; provided that the prohibition against discrimination because of such disability shall not apply if the
particular disability prevents th" prop"|' performance of the particular worker involved' contractor shall ensure
that applicants are employed, and that employees are treated during employment' without discrimination
because of their age, race, creed, Color, national origin, citizenship or immigration status' Sex' sexual orientation'
maritar status, honorabry discharged veteran or miritJry status, orthe presence of any sensory, mentalor physical
disability or the use of a trained dog guide or service animal by a person with a disability' Such requirements
apply, without limitation, to the following: employment, promotion, demotion' transfer' recruitment or
recruitment advertising, layoff or terminatioir, rates of pay or other forms of compensation' and programs for
training, including apprenticeships. contractor shall take such action with respect to this Agreement as may be
required to ensure fult compliance with local, state and federal laws prohibiting discrimination in employment'
zL.2 contractor will not discriminate against any recipient of any services or benefits provided for
under this Agreement on the grounds of age, race, creed, color, national origin, citizenship or immigration status'
sex, sexual orientation, marital status, honorably discharged veteran or military status' or the presence of any
sensory, mental or physical disability or the use or a trained dog guide or service animal by a person with a
disabilitY.
zL.3 lf any assignment and/or subcontracting has been authorized by the county, said assignment or
subcontract shall include appropriate safeguards against discrimination'
22. Waiver: The waiver of any default or breach of this Agreement, or the failure of a party to enforce
any provision hereof or to exercise any right or privilege hereunder, shall not be deemed to waive any prior or
subsequent default or breach, the enforcement of any provision hereof, or the exercise of any right or privilege
hereunder, unless otherwise stated in a writing, signed by the parties hereto'
23. Headings: The headings of sections and paragraphs of this Agreement are for convenience of
reference only and are not intended to restrict, affect, or be of any weight in the interpretation or construction of
the provisions of such sections or paragraphs'
24' survival: The provisionsof paragraphs 2'3'4'6'8'g'Lo'13'L4']'5'L6']7'!g'20'22'24' and 28of
these General rerms and conditions shall ,r.,-iu" the cornpletion, expiration, termination or cancellation of this
Agreement for anY reason.
25. cgmplete Aqreement: This Agreement constitutes the entire agreement between the parties and
supersedes any and all other agreements, understandings, negotiations and discussions' oral or written' express
or implied, regarding the work to be performed hereunder' The parties agree that no other representations'
inducements, promises, agreements, or warranties relating to this Agreement' oral Or otherwise' have been made
betwedn the parties. Except as provided elsewhere in this Agreement, no modification or waiver of this
Agreement shall be valid or binding unless in writing and signed by the parties'
26. severabiliw: lf any term or condition of this Agreement or the application thereof to any person(s)
or circumstances is held invalid, such invalidity shall not affect other terms, conditions or applications which can
be given effect without the invalid term, condition or application. To this end, the terms and conditions of this
Agreement are declared to be severable'
Kittitas County Agreement for Services (rev' S/Ia/251
Page 11 of 19
27.Time:TimeisoftheessenceintheperformanceofthisAgreementunlessotherwiseagreedbetween
the parties in a signed writing'
28. Construction: This Agreement has been mutually reviewed and negotiated by the parties, and should
not be construed against the drafter'
29. Asreement Not for Benefit of Third partieg: This Agreement is entered into solely for the benefit of
the parties hereto ana vests no rights in, nor is it enforceable by, any third parties'
Kittitas County Agreement for Services (rev ' 5l t4/25],
Page 12 of 19
AfiACHMENT'D"
,",,,lllf-9 Request for TaxPaYer
ldentification Number and Certification
Go to wu ,v,itsgo vlFomwglor instuctions and ths lalest information'
Give form to the
requester. Do not
send to the lRS.{B€v. March 2024)
Doparlmml ol lho TmGury
lntomal Rcvolluo
gefor€relatad to the of Form W-9, see ?uPcsc o{ Fom,beilow
,1n gnlry is required.lFor a $le prcprielor or disregnrded *lrty cntcr ihe o\vns's nffi oo lirc 1 dd enler ihe businesvdis.egardcdFar
I Nme oi entityrnd,vidual
eniity s nffg oF line 2 )
ci
oo(a
ao
"'Eoo>!
oC
gq
o6Au)
o
@tt
2 Susi.sss nme/disregsdod onaity .mo, rf drllcront lrom abovo'
SigoatuG ot
U,S. p€Eqn
4 ExomptioPs {codos aPP}Y st to
ceriain cniiliE, not i.dividudjs;
ss lnslnrc{igns s Psge 3):
Exmqt PaYw ?odq fl *Yl .*_--
Exmpllon ksn Foreign Account Tax
Co6plimce Acl (FATCA) rspo.lilg
codo {il 0Y)
Apgtias lo lccpnls mainlained
ersiCo ihe uniled Sta.E-)
I sl &ctunl .umb"rfsl hera {oplionrt
EntsI your TIN il) the appropriats box. The fiN providsd must match ihe name given on line 1 1o avoid
backuP wilhhoiding.For Individuals, this is gen6/alh/ your social security numbor (SSN). Howovar, for a
resident alien, sole Proprietor or disr€arded eniity. seo lhe irslructions for Parl I, ialer. Fot olher
enliti6, il is your employer idmliiication n!mb€r {ElN}. lf You do not have a numb€r, see Hos to gel a or
7'lN, late..
Nots:lllhoaccountisinmorethanonenams,seeiheinstrucfionsfor|ins1'Seealsw/'e.Namsafid
|lumbor To Givo lho Requoster for guid€lines on whosa numbel 10 enltr'
3. I am a U.S. citrzen or othet U.S. pxson (defined Delow); and
4. The FATCA code(s) eniered on this iorm {if any) indiating lhat I am exempl kom FATCA reponing ;s cor'ect
C€r{ltica'lion instruoliom' You must cross oul itffi 2 above il you have bsn 0olilled
youf tax rstum. Fol realbecauso you have lajied to reporl all intsresl and dividmds on
acquisihon or abandontnsnt of secured prop€rty'cancellation of dsbt, conlributions io
olher thm inlBrest and di!idond:i'ate not lho cdrtilication, but
Sign
Here
Under penalties of pequry' I certity thal:
1 The numbsr snown on this form js my coltecr iaxpayel rdentification number (o' I am waiting ior a numbet to b€ issued io me); and
2. I am nof subject to backup wlhhold;ng becauss {B) I am exempl lrom backupwithholding' ot (b} i nave not been nolitied by ihe lntemzl Sevenua
s*rvice (lFS) lhat I am subjtrl to backup wilhholding as a.6ult oi a failu.e to teport a!l interest or dividends' or (c) lhe IFS has noiilied me lhal I am
no longe/ sub,ect to backup wilhholding; ild
Rgquste/3 nanl€ snd addr4s (optloneJ
Dats
General Instructions
Sslion.eferences ate to the lntemal Revenue Code unless olherv/ise
noted.
FLlur€ dsvelopmsnts. For th€ laiesl informaljof, aboul develcpments
,"f"i"a ro forrn W-g and ils inslruclions' such 6l€islalion enacted
ailer they were publisned, go la **e/.i$.govlFotttlwq'
What's New
tj e 3a has bren moditied to clarily how a disregarded enlity completss
this lire. An LLC that is a ciisregardod snliv should check the
oooroodut" oox for the tax claisification of ils owns. Olhe^visc' it
ifiiuii cr'e.i< the "t LC" box tnd ente' tls appropnale lax classrlication'
Naw lin8 3b has b*n addad lo lhis fom' A flow-lhrough enlily is
roq;'*.f tc, a:c!!rlriel€ tili:. lire lo it'4icata lt'ilf :l lli):; j::r4';l ol it ciroct
lof*rd,r ;!l4t'fit!. c?llers' or oereticialies
"'rhel!
li provideS ihe l;oni !v-9
l;';;i";,i;.; lrnrl,-'"to,.slixnr'ry,d whicil I hes 1r" ovrl\c,shrt, rrlirrasr' This
""nonoe
is nt"nOeO ro-provide a llow-through entity v'ith jnfoilnation
,u""r"c rrJ lhe SLalus ol rts l (Jirst 'o'eign p.'tt|ors. o&tlrjr:;' or
"ri'"t. .i'"", so that il cari ril;sfy drr'/ appliJxt'id 'o!forlilq
rsq!ifer-ents. Fol axatnpla, a pilnl)orship ihi]t ril3-lr1/ xJ r,6cl rcrelgn
ral,'nrs may be'cquired to cootplctD Scic€!r{c'ii (-l'nl'rl K-3 S* lhB
PadnershiP lnstrqcl;ons lor Scheduies K-2 3'd (':' lFom lub))
Furpose of Forrn
,cn indlvidual or snti:y (Fcrm W-9 requ6ter) 4ho rs requrrDd lo lile an
inlormation relum "riih
lhs IRS i3 givir'9 you ihis iorm b':cause Iney
onl/ ono ot tho lol{ow.ng s{tr botos
fl Indiyiduat/slopBlriotor I cccrpoiulon t] scorpotalio' l: Pa"treEhiD ! t;ustlostatc
I LLC. intc. lhelanchssiticallon {C " C@Podils, S = 3@tptrallo^' P = Padrersbip)
Not!:CheckO€"Li,i:'Lcxaboveand inllrrl{'l!'lsr)itE.silf':l! lt$'oi}rialoclr's{C'$ rrt" i}t|!'ri'nr
cta3eifcatloil ot thn l;_C, untss il is'aii;,.1 i ,:".f',rirti. i ,f. ",,,;rr,l,;ri rcrry shc,''{i ineki;x, if'nrk lr.l 't3f;,totialo
ircx for itt€ ifr clsif€tion 9f i"€ ownet
tr Olhw(ssinskuctjons)
..vhoR narne i9 sltred on lne 1- Chrck3s Chwk ibe trppeptiale bcl i6 (adatal l3x claa3rlicirlion ol ihd eoltyrndivrduel
s'P'tsits cjqssifiqtion,0nd"LLC'€nte.edor cheked'lrusU€iat€,on 3ilin€chtrkod "PfftnaFhip"3b '/ou chekinler41,whicn have ownecr jparir16:r;lnl9 youlolarl&)1:l!urilt:i,.tl'€you t{ovcln9ud insltucliof,9Smlbi rlrcirl4t.lhis box Itratlx l)E' I
Addre$ inlrmber, 5tr*l ed apt, or suii6 no ). Se in$!ruclions.
6 Crt/, etate. md ZIP codo
numbgrPart I
Pari
Cal. No. 102:]'X
Kittitas CountY Agreement for Services (tev' 5/14/25l,
Page 13 of 19
icm Y/-t Eev.3'2024)
Page2
Fom W-g (Flev.3-2024)
must obtarn vour correcl laxPayer iddnliiic€iion number [IlN]' vrhich
mav be your'social security nurnber {Ss}'i}. rndrvlduallaxpayer
iJ"irir*iti"" number (lTlNi, adoplion taxpayer rdentifi cation number
IATIM- or €mFlover rdentific€lion number (ElNl' to reporl on an
i,"roi"tuiio" ,urutit the amounl pard lo you. or other amount tepodable
on - ;niot-"tion refum, ExamPles of information retums include' but
are not limiled to, the following.
. Form I099-INT (interest eamed o. paid).
o Form 1099-DlV (dividends, including thos€ from sldcks or mutual
tunds).
. Form 1099-MISC (various types of income, prizes, alvards' or gross
proceeds).
. Form 1099-NEG (nonemployee compensation)'
. Form 1099-8 (stock or mutud fund sales and cerlain other
tr"nsctions bY brokers).
. Form 1099-5 (proceeds from real estate tratsactions)'
. Form lo99-K imerchant card and thir+party network transactions)'
' Form 1098 (home mortgage interest), 1098-E (student loan interesl)'
and 109&.T (tu;tion).
. Form 1o99-C (canceled debt).
. Form to99-A (acquisilion or abandonment of secured property)'
Use Form W-g only if you are a U.S' person (including a residenl
alien|, to provide your conect TIN'
Caution: lf you don't retum Form W-9 to -tie requeste.r ttith a TIN' you
ngtt ire sibiot to backup rvithholding. See lryfta{
's
bac&up
,!ilhhold;rtg "
tale( '
By signing lhe lilled'out form, You:
1. Certify that the TIN you are giving is correct (or you are waiting for a
numb€r to be issued);
2. Certiry that you ate not subiect to backup wilhholding; or
3. Claim exemption from backup withholding if you are a U'S' exempt
payee; and
J Certifu lo vour non'for€lqn stalus for purPoses of *ithholding under
chdpler 3 6r + bf trre Code (it'aPplicable); and
5. Cerlify thal FATCA c{r'd4s} :ntertd oo thrs fomr {if anyl indicating
m"i t ou
"t'*
*"*,npt from lht FATCA .eportrng b Goneci' See !?hal Is
FAIAA Repofting, later, tor turther information'
Note: li you ara a U.S- person and a rtquesl€r giees you a iorm othtr
than Fomr !,V-9 to F4ui'l your T1N, yo$ nlust use lhg requestet's form if
it is substantially similar to this Form W-9.
Definilion of a U.S. person. For federa.l tax purposes' you ate
considered a U.S Person i{ You are:
o An individual who is a U.S. citizen or U.S. resident alieni
' A oartnersllrp, corporalion. company. Dr assoclahorr cr€ited or
orgJn"J in rtre Unit*o Slates or trndir lh+ laps of the United States:
. An estate (other than a foreign estatel; or
o A domestic trust (as defined in Flegulations section 301'7701-7)'
Establishing U.S, status for purPoses of chapter 3.and chapter 4
"ritl noru;ni Pavmenls madi lo iorergn p+rsons. including certain
;i;j;;;ftni. alldcilrons of 'ncome. oitninsfers of sales procr-e<ts' ntay
i" "rUi*t to *ifitholding under chapter 3 or chapter 4 of the Code
tsaions 1441-1474lt' Uirder those rules, if a Form W-9 or olher
ir'*]r;f,""r,o" of non-f6rerqn status has t<lt been received, a vrllhbolding
,1..i. i'iii-t"l'*"-. ot birinurstt,p {Bayot} g?nsrally appries presunlptrn'r
;];; ,h;i nray require the payoi to ru;tnnold applicable. tax
"rom
ihe
iiio,"nt. ov;ner. transleror , ot Parlnet lpayes). See Pub 5 t5'
!Vithhol.Ji'lg ol Ta on llonresldenl Alir"ns and Foreign Entitles
The tollovirfiq p€rsonE must protride Fomr W-9 lo the payor for
purposes of es-tdblishrng rts non-[oreign status
. ln the c€se of a disregatded entity with a U'S' owner, the U'S' owner
of lhe disregarded entity and not fre disregarded entity'
. ln the cese cl a granlor tausl \'/ilh a U.S. granloJ r)r olher-U S' ol'rner'
q;;;;;jt. id- U.Slgiintoi ot ort',et U"s. o!';r€r ot the grantor lnrs{ end
nol the grantor trust
. ln the case of a U.S. lrust (other than a grantor fusl), the U'S rust
and not the beneficiaries ot the FusL
See Pub. 515 for more information on providing a Form W-9 or a
certification of non'foreign slatus lo avoid 'nilhholding'
Kittitas County Agreement for Services (rev' 5/14/25)
Page 14 of 19
Foreim oer$on' lt vou are 3 forergn person or lhe
^U
S branch of a
;#:;X'ffiffi;i'r'',iJl*ci.u t" l,i trLated as a u s' person (under
h;"i;tioni;tlon i. r.r'r t - t1ul1epv) or olher applicable sectron (or
cha'oter 3 olt orimoses), do oot use Foml W-9' lnstead' u3€ me
lpplii.i," r.l- W-s oiForm eagg (see Pub s15,' li vou arE a
drafifie.l foreron D€ftslon luno under Regulations seclion 1 897fi'l{d}' or
"';fffi;;';ih;iGi'noriv o*".4 ov qJamea loteisn pansion tunds'
th:il;;i;d;; a non'toieign ptrsdn {o' purposes of s€ctiqn ld^ts
',lil;h;ld;dA;or ,u" ro#rni-s. lnstead, uie Form w-88(P (or other
certification of non-f,oreign sutus)'
Nonresident alien who becomes a resident alien' Generally' only a
;;;;;il;fi"" inJiviuuat may use the terms ot a tax reaty to educe
liliiti""i" n.s' tax on certain-types ol income'. However' most tax
tr€alies contain a provision known as a saving clause' ExcePfons
;;;i#; th- saiing clause mav permil an oxempton from u:t to
ilniinue ror ceriarn t)foes of incoftb evan after the payee h€s other'/tse
become a U.S. resident alien for tax purposes'
lf vou are a U.S' resdent alien who is rel;'ing 4;r 3n g'xc€plion
.""r:"i'iJ rln" o"ng clause o{ a lsx Featy to claim an exenlplion
i** *.S. l"x on
"srtain
rype$ of incomc. you tntet aliach a statement
to Form W-9 that specifies lhe following five items'
l- Th* lrealv counlry. Gencrally' lhis must b€ $e sams teaty under
which you claimed eximplion ftom lax as a nontesident alren
2. The keaty article addressing the
'ncome'3. The article number (or location) in he tax treaty that contains the
saving clause and ils excePtions.
4. The type and amount of income that qualifies for the exemplion
from ta/-
5- Sufficienl facts to jus{ify lhe exemption from tax underlhe terms of
lhe trsatl article-
Exannle. Micle 20 o{ lh* U.S"China illcome tax tteory€llo\?s Jn
.r.-"rlln fiom lax for :cholarship lncon]e rsceived by 3 u-nrnesc
;;l;;;I";o;tr;lt present rn theUnited srales' under U'S law th's
;;;;;i ;;1i ft;m+ i residenr alrsn for tax purposes rl their slav in the
iililJbt"d;;eeds 5 calendar years. However,.para-g-raph.2 of &e
i.iiit.r,*rr t" irt* r-l.s"Cnina rr+ity loated Apnl 3,0' 1gsl) aro\''s the
orou,oo* of Artrcle 20 lo conlinue lo apply even afler the Unrneso
'studenr b+contes a resident align of lhe United States A chlnese
.i"i-"i r,i,o'orilifies {or lhis oxception (under paragraph ? of lhe first
p'-iJ*ii'"ia-iii;-ty,ng-.tn rh's u*ceplion to claim,an €xemplion from lax
";-il;;;h;;"h,ti o/tettor',st"p iniome vroultl anach to Form w's a
.Li."i""iirtiiii"l-udes the infoimrtion descnbed above lo support lhal
exemPtion.
lf vou are a nonresident alien or a foreign entity' give lhe requester the
appiopriale completed Form W'8 or Form 8233'
Backup Withholding
lvlrat is backup rvithholding? Persons nra.krnq certilrn paymenls lo yoo
-rii""J*i iuriuin csnditroris vrlhhold and pa!-to lhc lRS.g{y' of such
o"utn"nf" fnit rs called'backup vrithholding'iPayrnenls thai may b€
lrit*i io oucf<rp srithholding include, but are nol limiled io' interesl'
i".'"i. - i i^re.esL divrdendi. broket and barter exchange
iA;;;i.i";. ;;"-"G.iJvariies. nonemplovee pav. pavtnenls made tn
.Jnr#"nt of qavmeni card and thrrd'piny nehvork lransaclions' and
"rrt"'n
grv*"nti ftom fFhing boat operalors' Fpal estate lransactons
are not subiea to backup wilhholding'
Ytu ryill not be 5ubiect to backup vrilhholdtng cn pa!flenls yotl rdc€we
rl vou siv* ihe t*quegtAt your conect Tll'.l, maki the proper certiiieations'
rrli ru"por, all your taxauie 'nleregl and dividentJs on your lax retutu
Payments you receive will be subjecl to backup withholding if:
1, You do not tumish your TIN to the requestet
2. You do noi certity your TIN when required {see the instrtrclions for
Part ll for details);
3- The IRS lells the tequester that you fumished an inconecl TIN:
4. The IFS tells you that you ate subiect to backup withholding
o".auit vou did not repori all your interest and divrdends on your lax
refum (foi reportable interest and dividends only); or
5. You tjo nol c€rlify to tha requesler lhal you a/;-not subiecl to
n""i"iir,rit oro;ncr. is d+gcnhtit 'n ilem 't Jnder "8y srynitg lhe {ttled'
JJ;;;i-;;";; ii"'i t"-porriot* int€resr and di'rirjend accounts open€d
after I 963 only).
Paqe 3
C€dain oavee3 and payments are exernpt flom backup $r4hholding'
SJ ii.#t;f A;t;e ioJa,'tater, and lhe s€iarate lnsiruchons lor the
Requestei oi F6rm W-9 for more informalion'
See also €sEbrb hi ng Ll.S. slatus fol' pl,@os€s of chaPter 3 end
chapter 1 t\ilhhhlding, eafiar-
What ls FATCA RePorting?
The Foraion Account Tax C,omplianc, Act (FATCAI requires a
o"rri.;oatinq foreiqn financial rnslitulion 1r) report all U'S' account
ffi;;;;;iil "iecrllecl
u.S perion6. Certain payees are *xempt frorn'i;T;;6;;;$-se. Ci*n,priin hom FArcAnportins 19de' laler' and
ift"'fn#iItion""for the Requ$ter of Form W-9 for more informalfon'
Updating Your Information
You must provide updated informaton lo any petson lo whom you
claimed to be an exempt payee if you are no longer an exempt payee
irJi"ti.ipit* ,tceivini rip6rraH6 Paymsnls.in the tuture {rom this
iniin. i5**"nrple, y-ou may neeci td provide updated rnform-ation rf
irou nt* a C co.Poratron that elects to be an S corpomtioo' o( ll you are
l; ;;;;; i"* "i*nlpr.
ln addition. you musl iumish a new Form w'e if
ir,r i,iii- ii tir'r ihlnges {or lhe account, for example' if the grantor ol a
grantot trust dies.
Penalties
Failure to fumish TlN. lf you fail to fumish your conecr TIN to a
,*L""t*t, vou are subieci to a penalty of S5O {or each such farJure
,"i"*t v""i taf"ts rs due lo reasonabie ccuse and nol lo rvrllful neglect'
Civrl oenaltv tor falso inlornralion willt respect to withholding' lf you
niakoa {alsd slatemenl vJilh no raasonable basls thal r€Eulls in no
backup withholding, you are subiect to a 5500 p€natty'
Criminal penafty for fatsifying informalion' Wltfulty ialsifying-
""rl'ni"ri6n"
ot
"ffirmations
may subiect you to crimina' penahies
including fi nes and/or imprisonmenl.
Misuse of TlNs. lf the requester discloses or uses TlNs in violation of
i;;n;;, Ft"quester'may be subiect to civil and criminal penalties'
Specific lnstructions
Line I
You must enter one of lhe following on this line; do not leave lhis line
blank. The name should match the name on your tax relum'
lf this Form W-9 is for a ioint account (oiher thil an account
nraintained by a lor*ign finincial rnslitution tFFl)}. ftst first' and.then
li*i*, iii" n**" oi lhi person or entity ','Jhose numb€r you €ntered in
Firt i'oi fo-t W-9. ll vou are provirting Fomr $/'9 to an FFI to document
njoi^ti."or"t each flolder of ihe acc-ounl lhat is a U S petson rnust
provide a Form W-9.
. lndiuidual. Genera.lly, enter the narne shown on yorlr bx tsttrm' lf you
f ra*" "Gnged
your taii name withotrt informing lhe Social Security
l?*iiilit"il*issA1 ol thu nu*u "hanga'
enter yout firsl name' lhs last
nime ai snot*n on your social security card, and'/our n91'/ iast rienre'
Note for lTlN applicant Enter your indtvidual narne.as il w-as entered
on vour Form W-7 application, line la. fhis should dlso be lhe sa'rne as
ittu'nit* vo, entutid ou the Fo.m lodo you filed rvrth your applicauon'
. Sole prot:rietor. Enler your individual name as shovrn on your Form
r i,io .[i,^" i . E"t"1 voui busin"ss. trad€' or 'doing bostne$s as" IDBA]
name on line 2.
. Partrrerslrio. C cornoration, S corporalion, or LLC. olher than a
,ti;;;;;;;;",;^titv. dniei ihe inrrlv'd nanre as sho\r' on lhs enrit!''s tax
rutu**on line 1 anil any business, trade, or DBA name on line 2'
. Other entities. Enter your name as shown on required U'S- federal tax
aocu."ni" on line t. This name should malch the name shown on the
;ffi;;;th;/i[at aoiutn"nl
"reating
the entitv' Enter anv business'
trada, or DBA nam€ on line 2.
o Disreqarded entity" ln general' a business entity thal has a single
"*'""r,
i""f"ai^g "n
LlC, i"U is not a corporalion, is disregarded as an
"nr'tu *oarare irr:nr ire o\rner (a drsregarded entity)' See Reg.ulatlons
i*cL''on io r. I lOl .?(c\l2l. A disrtgarded *ntity should check the
rooioorlt" box for'the iax classification ol rti owner' Enter the ovnels
"!i." ",i
rin" l. The narne of lh€ orvner entered cn line I should oe'rer
u* " .lis.eaarAed eniitv' The name on line 1 should be the nam* shorTn
ii il.e iffi;;i;iteirm on ,',i'icrt lha income shou{d be (eporled For
Fom W-9 (Rsv.3-2024)
Kittitas County Agreement for Services (rev' 5/74/251
Page 15 of 19
lF the entitY/individual on Iine I
is a(nl ..
THEN check lhe box for
Conoralion.
. lndividual or
o Sole
I ndividuat/sole ProPnietor'
. LLC classified as a parlnershiP
for U.S. federal tax PurPoses or
. LLC that has filed Form 8832 or
2553 electing to be taxed as a
corporation
Limited liability ctmPany
enter the apPropriate tax
classification:
P = PaftenhiP,
C=Ccorporation.or
and
5=S
. TrusVeshle TrusVestate-
exarnple, if a for+ign LLC thdl is treited ds a drveg€-rd€d cnhty. tor U'S'
ftrIeml Lax DurDoses nas a snqtJo*ner ttut
's
a ti's person' ihe U'S'
;;;;;-?il-;Lq''.aio ud ptovtdect on line,r' lf (he drrecl owner o'
irr* lntit" i" aso a dLrcqarded enlrty, enter tlre firsl orvner lhat b not
ilt;;;il;;t fte'at-&i putposei Ente' th€ distegerded entitv's
;";;;; line 2. lf the orvner ofihe divegarded enlrry 's a lor4rgn p€{son'
iii,'tl;;H;i ;;;pr-;i; ;;il;.p-ti no'-''v's if !u:d-oi: Fo*
W.9. This rs lhe case even i, the lorei€n p4rson has a u'> l lN'
Line 2
lf vou have a business natne, trade name, DBA name' or disreganded
"titity
nam", enter it on lina 2'
Line 3a
Ctleck the appropdals box on line 3a for the U'5' ledeml tar ^.;tffifi;;il;i lf,a pErson r',t ose oarne b enlered on line l' Check only
one box on line 3a
Line 3b
ch*ck lhrs box if vou are a pattnershrp flncluding an LLC classified ae a
oartnersllo for U.b. federal tex purposes), trusl' or *stale lhal has any
i';;;;;;;;*. owne.s. or benefiiran+s' and y':u are providing lh's.
i;i;:;;t;;'o t*rt. ot n"tut*. rn vhich vou hav? an ovmership
iii;,esi.'ffiil;i Jne"[]nJuox on trne 3b if v6' recirve a Form sl-a
tor docum+ntarv erTdence) frorn an'/ patlfler, ovJnst' or b-en*fictary
sstablishrnq lcrerqn stalus or if you receive a Fofm !v-9 rom any
;;;;;;i;-;. ;i uenenuary rhar h&e ch€{hed rhe box on lrrre 3b
Note: ,1, oafirr€rshro lhal proudes a Fonn W-9 and ch*cks box 3b rnay
;;;;;I;;;";molete Schedul=s K-2 and K-3 (Form 1065l For more
il;*lli,;; t".;;I pirrn'ersnrp rnelruclions ior Schedules K-2 and K'3
(Form 1065).
lf vou are recurred io complete lne 3b bu: larl to d{} so' you may not
r";;t;;'fi;';i;;ut'o" ^-"'d.",y to file d corr+cl 'nfotmahon retum unlh
lhe IRS or fumish a corect payee slalement to your paqlf-gr
i"-"iln"iiti"". S*Joiexa-'pt6' seaions 669s' 6722' 4\d 6724 lot
penalties lhat may aPPIY-
Line 4 ExemPtions
lf you are sxenlPt k.]m backup wtfihololog 4d/or FATCA reporting'
enter In th+ aFptopnat€ space on line r an! c<'dei's) lhat may apply tc
you.
Exempt payee code-
. $qn6rally, individuals {includrng ssle ptop't€tof3i at+ act exampt lront
backup withholding.
. Ercepl as provid-'d belorv' corporations ate +refnpt flombecklp
*ittrnoiii.ng flt
"ertain
payments' includinq rnt€r€61 and dividends'
' co'mGltotls ale Rot cxelnpl ironl backup v/'lhholdrng for payrnents
rnJUe in r"-nf *r*nt o{ payment cdrcl or lhird-9a,ty n€tworfi lmnsacllorrs
. CorpCrations ar€ no! elefnpt lrorn backop urilhholding vrilh fEsp€cl fu
anomsvs' leas ot qtoss proce€ds pald to attomayS' and corporations
ifi"l",,j"ia* .".liil or n"attt care services are not exempl with rEsp€e t
to paym€nts reportable on Form 1099-MISC-
The followinq codes identifu payees thal are exempt from backup
wilhholding. Eiter the appropriate code in the space on lrne 4'
I -An organi:slion exemPt fmm tan trnder seclion 501(ai' any IFA' or
u.ustoOiaiae"ount under'ssclion 'lo3tbi{7l tf lhe account satrsfies the
requirements of seclion 4o1$e|
pase 4
Form t4t'9 (Rev. 3-:'lcr24)
above, 1 13.
lF the paYmenl is for
. lnterest and dividend PaYments
. Barter exchangP
and
p.ior to 2012.
lransactions Exempt payees 1 through 4'
dividends
lHEll the payment is exemPt
tot ., .
All exempt PaYEes except
for 7.
Generally, exempt Payees
1 firough 5.'z
of Exempt payees 1 through 4.
2-The Uniled Stales o. any 6l ils agencies or inslrumenlaliti€$'
3-A state, the Oisttict of Cofumbia a U'S' comm.orwealth or tenitory
oiany of their political subdivisions or insuumenlalities'
4-A foreign govemment or any of its pol-rtical suMivisions' agencies'
or instumentalilies'
5-A corporation.
6-A dealer in securilies or commodrlies required to register in the
u-"it"i Siti*t, the Distict of Columbia' or a U'S' commonwealth or
tenitory.
7 -A {t tures commission merchant registered wilh the Comtnodity
Futures Trading Commission-
8--A real estaG investment tust.
g -An gntity registered €t all fimes during the lax year undar the
lnvestment C'omPanY Act of t9'lO
1o-A common ttust fund op€rated by a bank under section 584(a)'
1 1 *A financial institution as delined under s€clion 541'
12-A middleman known in lhe investrnent community as a nominee or
cusiodian,
13-A trust exempt ftom tax under section 664 or described in section
4947.
ThE lollovrina chart 3holvs lypes of paymsnts lhat ntay be exempt
rr"t"i..r.rp ,it'noic,ng. nu'in"d aipiies to ihe exempt payees listed
F - A deaiet rn secunlies. comrnoditles' or derivatrv€ financral.
i"ttru*i'ni' inciudinq nodonal principar contracts' fu lures' toflt ards'
;;;ft;il;;i,s .{is re'ea as such und:r the la\rs of lhe united
Slate$ or sny state.
G-A real €staie ttl$*sltfleni trust-
t { -.A rmulated rnve€lment compsny as d+fined in 3€clion 851 ot an
"^ii v og'Jri*J it all trm?s dunng tha rdx year under the Investment
Company Act of 1940.
l-A common Uust fund as defined in s€clron 584(a)'
J-A bank as defined in section 581 '
K-A broker.
L-A tust exempt lrom tax undersecfon 5€4 or described in section
aeaT(a)(1).
M -A tax-exempt trust und6r a section 403(b) plan or secdon 457(9)
plan,
Note:Youmaylvishtoaccsultwtththefinancialinslitulionr€qre{lrng
irli*iorrn io Aufn*ine vrhelher the FATCA esde and/or ex€mp! payea
code should be completed-
Line 5
Fntpr vour address lnrrrnber' str€el. and apartment or suita number|'
;il;;J;;;;;;i"oGi "r this Form lAi'e vrrll mail vourinfomation
iii'rir".]iini, Iioois aitt"o fronr rhe sne rhe requesler atready has.on
;j;:"i"; ;iiiw;itt" t"p- lf a new addrss is provided' there is sdll a
"iiiol rir* oia aadress wilt be used unbl the payor changes your
address in {heir records.
Line 6
Enter your city, slste' and ZP code'
Part l. Taxpayer ldentification Number (TlN)
Entgr vour TIN in the appropnate box' ll you are.a 'esidenl alien and
;;;l;J;;i it""u. *a are not'etgbte to get' an SSN' vour TIN is vour
ilid ilt'i;;i;;li ; in- *rw spJce ior tie social securitv nrrmber' lf vou
do not have an fflN, see How to get aTlNbdow'
lf you are a sole prcprietor and you have an EIN' you may enter either
your SSN or ElN.
lf vnr, ere a srnol*memb€r LLC that rs drsregarded as 'm
gnlity
.";#i" ;;; n.iiunti. *ntet ths ovrne''s SSN (or EIN' if lhe o*ner has
;ffi i' fi
'il ii& "r;;;iia'; ;
"arpsration
or partnershrp' €nt€r lhe
entity's ElN.
Note: Se€ Wha{ lr/arre and rYuftb€r
'o
GtvE ffe Reqrresfer' latet for
furlher clarification ol name and TIN combinallons'
I'low lo {Iel a Tlil- ll vou do not hav+ a nf't. appty fo' one rm-mediately'
;;;;;1"'6 ;" bsll. ier Form ss-5. Apprcation ror a soctal secunly
cit-d?ti'* yort local -SSA office or gel lht$ lorm onl'ne at
paav .S-$A-oov. You mav also qei lh;s fotm by €lliflg 600, 7?2- 1213' Uss
i'-- iI-; I"ori""tion ior IRS-lndividual Ta:<payer ldentifcation
i"ilL;;.',; J#i;ioi nn nrnr. or Form SS-'t hp'plcat'o n- to.r Em plov*r
il;;ircat;;iffi;r. to applv bran EIN' You can apptv foran EIN
"].lr^"
[u "l"i*"ing
rh€ lRb'v;bsile al tYivrr'ts govl61v" Go lo
;;#;.,;l;;;F;;'o vle'e ao*ntoao' ot pnn! F;rm w'7 and'/or Form
SS-J- or. vou can qo io ? nv.,i $i5detForms to place an order utd
t oua Form W-z anl/or Form SS'l mailed to you vnlhu'l l 5 buslness
days.
lf vou are asked !o compl'Bts Form W-9 bo! do not hsve 3 Tlftl' apply
f";'.'i;N;;;;;i;';aoplfo For rn {he space lor th*.Ilsl' sign and date
il;;e.#,;; qG ir ri'*re recuester' Fbr m!€r€51 and divrdend
guvr*ni*, *ti ""r!an
paytnene tnade vilh resF+ct ioreadily tradable
;:i;;;;;;ilil;n si"e'.tv have 60 davs to ser.a rll'l.a'td sive n rc'
the requestJb€fo re l')u ue zub1ecl to backuo \{lhimldrng on
,i* *"-ir-.. itt* oo'ia'v tule does hot apply io oth+t types ol paymentsHv;;;;;t;";;i;tio'uacttup wrnnolirngi on atl euch pa'/manrs unril
you provide your TIN to the tequester'
Note: Enlenno "Applie<l For" means lhal you havc alr+ady appfued for a
i,;i;;;il;;;"" int!-nJro "ppfu
for one goon s4€ alsoEsrtbtshns u's
;il'l;;#;r,p#; ii "tiF,iii e-ia chapat rvtithhotdrns' +artier rot
il;;;;;;"i;r*ac u"'sull*cr to \urthholdrng uncnr chapter 3 or 'l of
the Code.
Caution: A disregarded U.S. entity ttrat has a foreign owner must use
the approPtiale Form W€-
. Faymenls
be reported
over $600 requi.ed to
and direct sales o!'er
. Payrnents made in settlement
payment card ot.lhrtd-perty
nehroti( lrarrsacllons
1 See Form 1099-M|SC, Miscellaneous lnformation, and itis instructions.
I Hovrever. lho follosiing payments mad+ to a corporation and
reoorlable on Form 1099-&tlSC ate nol ex+mpl lronr Dackup
rrfifrft Jai" g, medical afl d heallh care. psyme.nts, etlome ys'.le.es' g ross
oroceeds data to an aflomey rePonable under s*ction 60'r5(f)' and
payments-{or services paid by a federal executive sqency'
Frenrolioc fronr FATCA reporting code' The follorving codes id*lrlify
;;;;;! lh"l ;;xempt ftom reportrng under FATCA' Th"-se codes
5;il;#;;;; iuom'n;ng thii formJor accounts maintained oulside
;iiil U;A-Si;r"" uv &ti"i^ forcisn financial institutions' Therefore' if
J"r rr""onfu ti,t*,nin'q th,. lorm (o/an account you hold in the Unrted
3irt".. vor't"y reauelhis lreld blank Consult vith lhe p€rson
,*rlin'no this lorm il you ate uncedain if lhe frnancial rnstiluton ts
."ii*iio"ritut" teQurrements. A request€r may rndicals lhat a code is
il;l*q"; Ly proiioing vo, vith aForm w-o vrrtn 'tlot Appiicable'' (or
;;;;;i;;;;iliion1 en-tdtea on the 'ine
for a FATCA exempuon code
A-An otaanEation ex+firpt {torn iax unde{ section 501 (al of any
rndividual t"iit"tent plan as defined In seclon Tiol{a)(37}'
8-The United Slales or any of its agenciee or insfumentalities
C-A state, the Disfict of Columbia. a U'S' commonwealth or
t"nitory, or any of their political subdivisions or inslrumentalrtes'
D - A corparation lhe slock ol \rhrch Is regtrlalty kaded on-one or
mJre estabiished securitres rnarkets' as descobed in ResUlations
section 1.1 472-1(cl(1)0.
F -A comration that !s a rr,ernber of the same expande<J affilialed
gt;p';;;;;tp.iation descnued in Regu'ations sectran 1'r'!-/2-1 {c}(l)('}
Kittitas County Agreement for Services (rev' 5/!4/25)
Page 15 of 19
Paqe 5
Fom W-9 (Bev. 3-2024)
Part ll. Certification
To establish to lhe r.tithholding agent lhat you are a U S' person' cr
;;;"^t;;*, siqn Form w-s]vdu may be requested to sign bv tlre
rrilhholding age,it euen il item 1, d. or 5 bslow indicJtes othenvrse
For a iorot accouot. only the pelson vthose Tlhl is shoi'Jn rn.Part I
nr'oirJiion-turtten teqr,t""cl. ln'the oa$s of a disregaded onlity' lhe
i-*"^,al"rin"u on line I must sign' Exernpt payees' see €xemptpayee
8.
this of account:
€ntily mt ,v/cad b'/ nn The omer
Give and ol:
code, eatlier.
Signature requirements-
itemslthrough5below.
What Name and Number To Give the Requester
For this tyPe of account:cive name and SSN of:
9. A valid ItuI, esttle. ot peEion tslEt
to. Cnnromtion or LLC ettcting corpffite
sbhE on Fm 8&i2 or Fm 2553
11. Assciatim. club, elfuirus. chlitable'
eduatiomj, or oths td€xmPl
orgmiation
1t. Pottni/sh,p tr mullr'nrmbrr tlC
13. A broker or eg'etercd nminee
14, nf,trmt sith the Oeparunill of
Aoialhre h the mrne of a Public
en]tity (srcfr s a stde or lmal
ioue-ttimer,t scfiml dstia' or priwn)
that Eerve agricultiral Progm
payrnats
15. Gnntor ttlst 6tng Ftrtn 1o'll o'
mder the OPtional Fding Mefro'd 2'
rmuirino Fom 1OS (se Regulati're
"4rion i.671 -4(bx2)0€))-
tUst firsi and circle the name of lhe person whose number You fumish'
lf only one Person
must'be furnished.
on a ioint account has an SSll, that Person's number
2Circle rhe mino/s name and fumish the minor's SSN'
) You must shorv your rndividual name on hoe 1 ' and enter your bugness
"ibblliii,i.fiiinv, ci' Lnea Y;iimav use e'tner vour ssN or Elt'l fl
y6u have on*l. but fie IRS encoursges you lo us€ your DDI!'
{ Ust lirst and circle the name of lhe trusl' eslate' or pension trust' (Do
noG.i"n rc ff N of the personal rePresentative or. trustee unless the
legal entity itself is not designated in the account mle')
'liote: The grantor must also provide a Form W-9 to the lnrstee of the
trusi.
" For more information on optional filing merhods for grantor trusts' see
the lnstructions for Form 1041.
Note: lf no name is circled wheo more than one oame is lisled' the
ir"-ir#r tiili o. ;nsidered to be that of lhe first name listed'
Secure Your Tax Records From ldentity Theft
ldenuw thefl o€curs |.Jhen someone tls;s your pe'sonfll rnfofmstion'
;;t;;;;; ;;;;. SSli" or olher rd*nbfvns 'nfcrmalion' 1'rilhoul vour
o"r*tatrirn to commrt {raud or other crimes Art identlty thr$,may use
|i;;;'itil ;;;4" i"-t o, *uv hle a rax retrirn usins vour ssN ro ree*ive
a refund-
To reduce Your dsk
. Proteet your SSN,
. €nsure your employer is protecting your SSN, and
. Be careful vrhen chooGrilg a tau €tum prepatef'
ll vour lax aecoads ar€ aftected by rdenn'ty thefi and you rec€N€ 3
r";J;;;;i;;"-'R5, respone ngnt irvav ro ih+ nanre and phone numb€r
pnnted on the lFlS nouce or letler'
ll vout tax recorejs are rlot cuncnUy atfected by rdenllty thett but 'Youtn"liilrTi*'uit."r. cu" io i to.t ot itolen p'ts"'':t vrallel' questionable
;;ilIJJ';i;;t* oi a qu"-srionabls credit t4pori' contac'l-the IRS
i#;t-ft;fuiline at a0o-soa-{'le0 or submtt Form 1'103E'
For more rnforrnation. s€e Pub. 5q2?. fdenlrt'/ Thglt lnformatlon lor
Taxpayers.
Complete the c€dificalion as indicated in
Legat entjbl
The caporation
The *gaizaiion
The partraship
The broks or nominee
The public enlitY
lletud
l. lnteresl, dividend, and bader exchange accounts opened
t.i"t f Sga anO broker accounts conside?ed active during 19[B'
iil;-r;Gi"; t;uiconect TIN' but you do not have to s;gn the
cerdfieation.
2. tnterest, dividend, broker, and barter exchange €ccounts
#;;;;fi;; rbrii "nj brokcr accounts considered inaclive during..
;ffii."iJ;;1, fr;ii;;e'i;n;ti"^ or backup wiihholdins rvilla.pplv' lr
"i" i*-t"oi*, toiackup rvithholding and vou are merely providing
i""i."t."i nru to the requester. yoi must cross out tleft 2 in the
certification before signing the form,
3, Real estate transactions" You must sign the certification' You may
cro*s out ilem 2 of the certification'
it- Olher oavtnents. You must give your coftect TIN' but you do not
rrave to sion llie certification unless you hav€ baen nolifted that you
i'ir. "i*i""=r" oiven an inconect TiN. 'Other payments" include
li-*!l,t-'"t-"J"T" inl
"our="
ol lhe requester's tiade or business for
i.'i;:;;"lii;;,;ooJs otner rnan bills fbr merchandise)' medical and
ttr"firt #" t"*[*s 0ncluding payrnents to corporalions]' pa^yments to
. *ir*Jou* {or services' pdyments made ill settlemenl of payment
3jtllii'uill-ptttv n*r-oti 'trin*"tions' paymenls to cedarn fishing
;;;;il.b*; and fishermen' and gross proceeds paid to
"tro*ayr
(including paytnenls to corp€raliong)'
5. Mortgage interest paid by you, acquisiliot or abandonmenl of
"o"uiud o"ro-nertv, c:tnc-ellatlon of debt, qualified ttrilion Program. -.;:;;;;!i;;;7;;;ii;;i s2e). ABLE eictunrs {tin<rer secrio. 520A}'
ihf,- cover.tett ESA' Archer MSA or HSA conlribulions or
iiiiluril.*. and pension distributions' You must give your conecl
TlN, but you do noihave to sign the cerlification'
1.
2. Trvo or more individuals fioint acmunt)
other thm m acmunt maintained bY
m FFI
3- Two or more U.S. Pemre
[oinl atrount maintained bY a FFI)
4. Custodial aeount of a minq
(tjnifom Gifi la Mhrors Act)
5. a- The mud rcvo€able svings uusl
(grmtor is also Eustee)
b- Sqcalled tEt accwnl lhat is not
a lega, o{ valid tsr6t unds state lav/
6. Sole orcprieto6hiP u diwgarded
trlity ovned bY m individual
7. Gnnlor tnsi filinq under OPtional
Filing fulethod 1 (see Regulations
*mn t.671 -4{bl{2x0(A)}"
The actual owner of the account or'
il combined tunds, the frst individual
on lhe ac@unir
Each holder of the account
The minor2
The grantor-lret€r
The actual omerl
fie ovmero
The orantor'
Kittitas County Agreement for 5ervices (rev' 5/A125)
Page 17 of 19
Page6
Victims ol ldenlity (heft who arE exp€riencing economlciafin ot a
.";;;;;;6iil.'6r are seeting helir in resoliing tax ptoblems lhst
;lilffi ru;;;;ttuJ iltmusn i'ormal channels' tnav bs eligible for
r;;;,;;;;; b" ti"" rr'esl ass isranc e' You-cal f a-clles u v
iJriigifi" fnS loll-free case inla'ke line at 877 -f 77 -4778 ot ITY/TDO
800-829-4059.
Prolecl voursell fronr suspicious entails or phishirrg schemes'
;;;;";;;t""iion tn,j use of emarl and websites designed to
-rrii"'iJ"'itiitiri'ouiine; amaits and websltes' The most common acl
;ru;#iil;;il i; ; ,;;' ralserv ctaimins-to be an esrablrshed
il;;;i;;;Ftri.e ln an aftemptio scam -ure user into sr'rnendering
jn*vate mfonnarion that will be used lor identity th€fi'
The IHS does not initiate contacts with taxpay€rs via ematls' Also' the
lRs;;;-#;"qu""i p.oond detailed informaton through email or ask
i;;;; i;; td PIN humbers, passlvords' or srmilar.s:cret acc€ss
i"iii#"lon toi rtleir credtt card,'bank, or other tinanciat accounts'
tt vdu rec€iv& afl unsoliciled email ctaiming to bs fiom lhe IRS'
nrr-E:ni*a:::lln:r''-et#:;fi lffi ill}ff'*#:'tr
Cenea for ia* itdriinisration filGTAl at 800-3q64dq4 You uan
tiiirlJ suspiiious emails to lhb Fedenal rrade Co*.tiTig."t
i"rn&uu.iou or rePort them al ffiv\v'ftc'govlcampta'n1' You can
i".iii.itldi-rc ar thvw. fr c. govt idlheft or 677'IDTHEFT (877-'r38'4338)'
i#ffi .;"i ;-" ir," ui.iiri''-oila"ntitv ten. see rvrvw'ldenrtvTh ert'g ov
and Pub. 5o27.
Go to rvt'*'er'rs-9 ovlldenfityThaft to lsam more aboul identily tfteit and
how to reduce Your risk-
Fom W-9 (Rev.3-20241
Kittitas County Agreement for Services lrev ' 5/14/25)
Page 18 of 19
PrivacY Act Notice
Section 6.109 of the lntemal Revenue Code requires you to provide your
#;iiN i";.t*nsl'ntl,oinq reaeral ageniiesf dho are required 1o
iti"ii#"ti".i*turng wilh rne iRS to repirt inleresl' dividends' ot
:;;i;;;-.-;";*e oad to vou: tongrise interest you pard: lhe::fiilili;;ilr"*; ;ijr*l*;:rg;ffi.r$il1fiil
dedt; or contrrbr.rlions You madr
ffiff *ffi lT#fl'y#fr.Tfr':ffi il:"ltr'ifi 'l{{"rh;;il;;;ihl inio,mation'lnJude slvins it to the Dep.attrn€nt of
:;siic;fffi;'ai.Jcrirninat tlrigarion anol to c--ge.s' stales' the oisrict ot
Coftmbia. and U.S. commongo*lllts and temtone€ !ot.s:tn
Ii'i'i#l"'ls ri';;iii"". rttu inio*uoon mav also be disclosed to olher
cnrrnlries under a lreatv, to reoei"i JnO slute agencies lo.enforce civil
iij'#;;i;*; oi tciieaerat law enforcement and intelligence
:;;;;;;;-b"t turronet' You mr.st provide your TIN t'rhether or not
;;;'ilfi"il roii" ilu" t"tu* undei sectron 3406' pavcrs must
ii#;'hi;iilih"ta a percentage ot taxable rnterest' dividends' and
certain othet paymenls to a payee wtro does nol give a TlN.to lhe payor'
il;;;;;63't"v ar* a'ppiv tor providing tulss or (raudulenl
information.
ATTACHMENT'E"
RETIREMENT STATUS FORM
* * All contractors who are individuals must complete and sign **
SECTION 1: CONTRACTOR COMPLETES THls SECTION:
2'lsContractoraretireeofaWashingtonStateRetirementSystem?
3. Did Contractor retire before age 65 using the 2008 ERF?
I have verified the information above using MRV or by contacting DRS'
COUNTY REPRESENTATIVE (Please Print)
Signature Date:
COUNTY RETAINS THIS FORM
Kittitas County Agreement for Services trev' 5lM/25)
Page 19 of 19
DidyouretirefromoneoftheStateofWashingtonRetirementSystems?
Did you retire before age 65 using the 2008 early retirement factors (ERF)?
Will you be receiving direct compensation for these services?
Will you be receiving indirect compensation for these services?
_Yes -
No
_Yes -
No
*Yes -
No
_Yes -
No
CoNTRACTOR (Full name of contractor as in DRS filings-Please Print):
Signatu Last Four Digits of Social Security No'-. -
SECTION 1: COUNTY COMPLETES THIS SECTION:
[use Member Reporting verification (MRV) to verify the past retirement membership and document belowl
1. Has contractor been a member of a washington state Retirement Systern? -
Yes
-
No
lf yes, which system and Plan?
-
Teachers' Retirement System (TRS) -
Plan 1
-
PIan 2
-
Plan 3
-
School Employees' Retirement System (SERS) -
Plan 2
-
Plan 3
-
Public Employees' Retirement Systems (PERS)
-
Plan 1
-
Plan 2
-
Plan 3
Public Safety Employees' Retirement System (PSERS) -
Plan 2
_ Law Enforcement officers' & Fire Fighters' Retirement system (LEOFF)
-
Plan 1
-
-
Washington State Patrol Retiremeni System (WSPRS) -
Plan 1
-
Plan 2
Judicial Retirement SYstem (JRS)
Plan 2
Yes
Yes
No
No