HomeMy WebLinkAboutFully Executed AgreementKITTITAS COUNTY AMENDMENT TO:
Agreement for Services between Kittitas
County and Peers Rising PHMH-018
Amendment 1
This Amendment ("Amendment") is made as of March 1,2026 by and between Kittitas
County (hereinafter "County"), a potiticaL subdivision of the State of Washington, and Peers
Rising (hereinafter "Contractor").
WHEREAS, the parties entered into an agreement dated January 1,2026 through
December 31, 2027 (the'Agreement"); and
WHEREAS, the parties desire to amend the Agreemenq
NOW, THEREFORE, the parties agree as fottows:
1. The Agreement is amended as fottows:
ln Attachment B, Compensation, add the foltowing language:
The purchase of suppties, equipment, and materiats for daity general
activities, inc[uding but not Limited to arts and crafts, games, food, and
suppLies for recreationaI activities are not atlowabte'
Any uses of these funds outside of the l,isted atl'owabte uses must be
approved by Kittitas County in advance of the expenditure, in writing' The
Contractor must contact the contract manager in advance for review and
approvat of any purchases of unctear atl'owabil'ity'
ln Attachment B, Compensation, under Reimbursement Procedures, add the
fol,towing [anguage:
Contractor must submit the Non Payrol,t Expenses lnvoicing Temptate with
invoices that inctude non-payrot[ expenses'
Add Attachment I to inctude the Non PayrotL Expenses lnvoicing Temptate (attached)
2. No Other Changes
Al,t other terms of the Agreement remain unchanged and in fut[ force and effect.
Kittitas County Amendment to: lLA, AGS, lnterDept' MOU (8128125)
Page 1 ot 2
lN WITNESS WHEREOF, the parties have executed this Amendment as of the I'atest date
written betow
Kittitas County Amendment to: lLA, AGS, lnterDept. MOU (8/28/25)
Page 2 ol 2
CONTRACTOR
Signature
Printed Name
Date:
,l
Titte
KITTITAS COUNry
BOARD OF COUNTY COMMISSIONERS
ABSENT
CoryWright, Chair
ith, Vice-Chair
of the B
La
Attest:
rd
Date D4 l
Commissioner
2-t lza
kuti)OTSVIeKj
y Buchhotz
*
Kirtilt; a{)un{Y
Kittitas CountY Public Health
Contract/Agreement Review Form
Public Health
I)epsrlaieilt
12085Legal Request #nl1al2025Today's Date
Agenda Date
Fund/DePartment
Contract/ment lnformation
B lnformation
Revenue Code(s)105 560.313,4000
Expense Code(s)
Pass Thro
RCOKCPrevlousrseeRislyPtngnntraAgency:Co ct/Agreeme
ct/Agreeme
Ris nPeersnd gCouKittitasntycesbetweenServforentTitlentContraAgreem
End Date: 1213112027
Begin Date: O1lUl2A26
ct/Agreement 1-0 BHPHMContraTotalS Amount: See Exhibit B
li
Sumnt m aryntrcct/Co Agreeme
kiS SdanLifeenceResCSSlnWelndaWarmthRrSdsnPeersrngfucesrforviSEreementThendaagHealthntaleMIofo//oII0th1ethdndemebyASctrecomroPConuntyJeKittitasSupport
rdBoaAddenvrsorycalDemthencycpe
U
Review and Comment:Kittitas CountY Prosecutor and Auditor
/).12.2s*
Date
F?,HCHIVEESignature of rosecutor'
Date
Signature of Au ditor's Office
Agency to Pass Through
Expense Code
Amount to Pass Through
5ub-Contract APProved Date
Version:0
lnformation
LoeffersApprovaI Bv:Modified BY: KatieDate AdoPted: 1-2lO1Supersedes: OADMIN
SAM.gov12l15/25.3:18 PM
Unique EntitY lD
CY39Z6JRAL25
PEERS RISING Active Registration
CAGE/NCAGE
(blank)
Entity lnforrnation
i.',,:!;..!i;''.
ry17,7 7, ?0?i
Physical Address
2II W3RDAVE
Ellensbu rg, Washington
98926-3026' United States
Purpose of Registration
Federal Assistance Awards OnlY
Version
Current Record
BUS{ N TSS I N FORIVIAT'CIN
Mailing Address
110 West 6TH Avenue
Pmb ll8
Ellensburg, Washington
98926, United States
Reglstration Dates
Activation Date
May 8,2025
Subnrission
l-\ a fa
May 7,2025
lnitial Registration
Date
Feb 1,2024
Doing Business As
(blan k)
Division Name
Peers Rising
Congressional
District
\lr-- L:- -a^- novvaslllllgl,ull vq
Owner
lmmediate
Owner
URL
(blank)
Division Number
(blank)
State/CountrY of
lncorporation
Washington, United
States
CAGE Legal Business
Name
(blank)(blank)
HighestLevel (blank)(blank)Entity Dafes
httpg://5am'gov/entitieslviewlcY3g26JRAL2Sl@reData?status=Aclive&emfKeyvalue=21736408.1746623032347606
1i2
1U15125,3:18 PM
Owner
SAI/lgov
EntitY Start
Date
Sep 29, 2021
FiscalYear End
Close Date
Dec 25
RegistrantsintheSysiemforAwardManagement(SAM)respondtotheExecutiveCompensation
questions in """oro"n"u
with section 6202 of i..r. lto-tsr, amending the Federal Funding
Accountability and TransparencyAct (p.t. rce-zi'zf ir'is intormationls not displayed in SAM lt is
senttoUSAspending'govfordisplayinu,,o"i"tionwithaneligibleaward.Maintaininganactive
registration in SAM d#onstrates the registrant responded to the questions'
SAM SEARCH AUTFIORIZATION
I authorize my entity's non-sensitive information to be displayed in sAM public search results:
Exec utive Com Pensation
ENTITY TYPES
Business TYPes
EntitY Structure Other
Socio-Econornic TYPes
Check the registrant's Reps & Certs' if
;;;;i'unJJr rnn 52'2i2'3 or FAR 52 21e-1
il;;l;il;; if tne entitv is an sBA-certiried
,
iiu"ii-t"" ttalI business concern Additional
ttiiiur't-i^".i information may be found in ..
iil sie''= ov"arnic Smatt Business Search if
iirl ;*ty ;;Pt"t"o tnu sBA suPPlemental
pages during registration'
Yes
Entity TYPe
Profit Structure
Business or
Organization
Non-Profit
Organization
Organization
Factors
(blank)
https://sam.gov/entities/viewcY3926JRAL25/coreData?status=Active&emrKeyvalUe=21736408-174662303?347606
2t2
KIfiITAS COUNTY
AGREEMENT FOR SERVICES
PHMH-018 (Prev KCRCO)
This Agreement for services (hereinafter "Agreement") is entered into by and between Kittitas county
(hereinafter "County"), a political subdivision of tne State of Washington' and Peers Rising (hereinafter
"Co ntra cto r" ).
The purpose of thls Agreement is as follows: Peers Rising will expand youth prevention and recovery
services in Kittitas county through peer-red youth support groups, famiry rife skiils workshops, and winter wellness
supply distribution. This project reduces stigma, strengthens resilience, and improves access to free behavioral
health support for youth ages 12-25 and their families'
The term of this Agreement shall be from JanuarY Tt,2026, through December 31't' 2027' unless the
Agreement is terminated early or its term is extended as provided herein'
The parties, addresses and points of contact for the administration of this Agreement are as follows:
COUNTY
507 N Nanum Street Ste 102
Ellensburg, WA 98926
Kasey Knutson
Human Services Manager
Human Services
Kasey. knutson @co. kittitas.wa. us
(s09) 962-75ts
refe re nce
Attachment "A"
Attachment "8"
Attachment "C"
Attachment "D"
Attachment "E"
Attachment "F":
Attachment "G"
Attachment "H"
Kittitas County Agreement for services (rev' 5/]'4125)
Page L of 24
coNTAACJOR
1-10 W 6th Ave, PMB 118
Ellensburg, WA 98926
Brandi Amundson
Executive Director
brandi @Pee rg r isinLwa' o rg
(sog) 312-8041
This Agreement includes the following, which are attached hereto and hereby incorporated by this
Scope of Work
Compensation
lnsurance Requirements
Reporting
General Terms and Conditions
W-9 (Contractor must complete and return to the County for payment)
RetirementStatusForm{ContractormustcompleteandreturntotheCounw
for payment f Contractor is an individual, as opposed to a corporate business
entity)
Subco ntracting
rN wrrNESS *HERE'F, this Agreement has been executed by and on behalf of the parties through their
authorized representatives, effective as of the latest date written below'
KITTITA5 COUNTY
CONTRACTOR
BOARD OF COU ONERS
Signature
Printed Name
Vi
Title
0 ,202u Date
Date
Attest:
rd
Kittitas County Agreement for Services (rev' 5/Mlzsl
Page2 ol 24
ATTACHMENT,.A"
SCOPE. OF WORK
rn addition to providing ail materiar and rabor, the contractor shail perform the foilowing activities as indicated in
your performance tndicators and Evaluation Workbook for the Warmth & Wellness: Resilience and Life Skills
Support in Kittitas County project:
r Facilitate workshoPs
r Expand youth Programs
. SuPPort grouPs
r lnvolvement and coordination of community events
r Develop advocacy and awareness campaigns
r Hire additional staff
r Expand available services in our three Peers Rising hubs
o Staff training and DeveloPrnent
o coordinate community outreach, engagement, and promotion
r Provide referrals for behavioral health screenings
r lmplementingearlyintervention programming
e Partner with healthcare providers
c Expand availability of crisis services
o Hire Peer SuPPort SPecialist
r Winter suPPlY distribution
r Direct aid distribution
r Evaluation and rePorting
Kittitas CountT Agreement for Services (rev' 5/1'4/25],
Page 3 of 24
ATTACHMENT "8"
coMPENsATloN
THE COUNTY WILL NOT PROCESS PAYMENT FOR SERVICES RENDERED UNDER THIS AGREEMENT UNTIL
coNTRAcroR suBMlr;;tott'-ttuo w-9 (sEE ATTA.HMENT "F")'
As full compensation for satisfactory performance of the work described in Attachment,,A,,, and within
thirty {30} days of receiving contractor,s itemized invoice, the County-srratt pay contractor the foltowing arnount(s)
prus any appricabte taxes as detaited in contrr.tois invoree: suot,aJt '"
uiJ,lir" to g125,754
'emaining
from the
terminared conrracr, *,nui ,.ornrs bired *,rougl., that conrrac, o;;;;;;mination for the months of october'
November, and December 2O25'
Arowabre direct expenses incrude, b-ut are not rimited to, sararies, wages, benefits' direct client servlces'
promorion, outreach ,ri,"iill ,rppries, professionar deveropnrent ani trainin!, equipme.nt' and subcontracts' All
expenses must be n".*ruo and directry ,..rui"J io rhe scope "f *";;';;;;iii""i i" Attachment A' contractor will
refer to their approved budget documenr ,r;;;J tirorgn the funding request process.for line-item expenses'
Any changes or updates to tne budget *";;'l;;;'ouu-d uv riti'tl'?o""tv through the appointed contract
.rn"g", in advance of the expenditure' in writing'
unress otherwise provided herein, contractor sharl be solely responsible for contracto/s travel and
related exPenses'
Any uses of these funds outside of the risted ailowabre uses must be approved by Kittitas county in advance of the
expenditure, in writing'
A, funding is based on rocar tax and fee revenue. rf rocal economic conditions resurt in insufficient funds to
compensate at the stated revers, the county reserves the right to renegotiate funding amounts to remain within
available revenue barances. The county wit notifo the contracto,' rrr""di.t"ly if financial forecasting or actuals
indicate such a circumstance'
Allfunds must be spent by December 3L't'2027 Noextensionofthefundingperiodwillbegranted
Reimbursement Proced ures
A.TheContractorshallsubmitinvoicesforservicesdueonceamonth,whichshallbeemailedtoKatie
od iaga, rittita s ;"; "it
pubtic Hea lth o"o. r,t"n,, at &I!-e'odiisp @cg-k41i
B. At|. invoices must be submitted by the iast day ot tt'* tffitililGt'r'e calendar month in which
services were detivered' r--..d^-+, 'r each invoice' This
c. The Contactor must provide adequate backup documentation to support costs ll
includes a general leclger from the tlnanciar acccunting ur*** det"ili*g t'ansactions and expenditure
dates for allowable activities witnin tnl periou oi pe'formance' PayrOtf exFenses rnust show employee
names, hourly rate, nurnbe, o, nourr, ,o,.t ouu, ,no pr*i1Jt ,oo*' iu**rltscan be one line item but
shoutd include project code. Non-p;r;,;;;;r"s murtinctud" " topy of the receipt or payment
invoice'Paymentstosubcontr,..o,,,',,.belistedasaspecificlineitempersubcontractor.
I lli:'lil;:=;::lff:*:::*;*f,T:l;::,;:.::-1?lJ..o.sp"naing
Form' as provided bv Ki'fti'ias
F Fl,Li.Y;l",imi:ml,l*":l;;in;!x':::ilTi""'T:l'l;fi:1';""chmentA:
scope orwork mav
result in delayed reimbursement payments or denial of invoices'
Kittitas County Agreement for Services (rev'5/La/25l,
Page 4 of 24
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'
October, November, and December 2a25
Kittitas County Agreement for Services (rev' 5/14/25)
Page 5 of 24
c
ln no event shall payments under this agreement total more than $346,309 in addition to s125'754 remaining
from the terminated contract, minus amounts biiled through that c'ntract priorto termination for the months of
ATTACHMENT "C"
IIJSIJIIANCE R Equ I REMENTs
contractor sha, secure and maintain in effect at a, times during performance of work under this
Agreement ru.i, inrurunc" a, wirr protect contrr.tor, its emproyeJs-, ,"a .?**r f1om,1ll claims' losses' harm'
cosrs, liabitities, damages and expense, uririnc';'itJtont"tio''t ;;;;;;nte und"' this Agreement' including
but not limited to p""'o*n"i injury (including death) or property damage'
A, insurance sha, be issued by companies admitted to do business in the State of washington and have
a rating of A-, ctass vlt or better in the most .."i."ou o'olished editionT;',*";; ti;F:-Y::*t otherwise approved
by the county. rt an inzure, is not admitted, at inrurance poricies and procedures for issuing the insurance policies
must comply with Chapte r 48'15 RCW and 284-15 WAC'
Ataminimum,Contractorshallmaintainandprovideproofofthefollowingselectedoptions:
Comrnercial General Liabilitv lnsurance
--'-Tou"rage limits not less than:
t $r,OOo,0OO p"' occurrence' for all covered losses
r $2,000,000 general aggregate
' 51,000,000 products & completed operations aggregate
' S1,00;;;io i"'*n'rand advertising injurv' each offense
n The pof l.V rrril" endorsed to include ai" io'nty and its officials' employees and agents
as additional insureds'
fa
' Automobile LiabilitY for owned, non -owned, hired, and le ased vehicles, with an MCS 90
endorsement and a CA 9948 endorsem ent attached if 'Pol lutants'are to be transPorted
Coverage limits not less than:
r $1,000,000 combined single limit
J Excess or Urnbrelia Liabilitv
rcontractorshallprovideExcessorUmbrellaLiabilitycoverageofs5'000'000'Th'isExcess
or Umbrella r-ianitity coverage si,arl apprv, at aminimuT:]: l"'n the Commercial General
and Automobile lnsurance policy.ou"i"g"r. lf used.to meet limit requirements' coverage
must be at least as broad as specified ior underlying coverages' and must cover those
' T,i: :""i ffi "ilT 1; :f; #ff : rv b " ::i':r ::i::::*;::-:,'ff l?::iii
m a ry co m m e rci a I
General and Automobile Liability t";;;;;' or any combination thereof'
. The pori.y |.nrrl i" undorr"d to incrudeiie'county and its officials' employees and agents
as additional insureds' .:tL /ar^6ca.nctq navable in addition to policy limits'
' coverag" 'n'ir
i" "pay on behalf" with defense costs pay
. There shall be no cross liability exclusion precluding coverage for claims or suits by one
tr
limits no less than S1,000'
Kittitas County Agfeement for Services (reu ' 5/M/25)
Page 6 of 24
insured against another
Em
Contractor shall Prov ide Workers ComPen sation and EmPloYe r's LiabilitY insurance on a
state-aPProved PolicY form Providing benefits as required bY law
000 Per accident or disease
with ernPloYer's liabilitY
Coverage limits not less than:
r $1,000,000 each claim
contractor'u,.p,.ouioeevidenceofthiscoverageonapolicyformappropriateto
Contractor's Profession.
contractor shall furnish to the county a certificate of lnsurance, with endorsement where required above'
as evidence that poricies providing insurance required by this Agreemeni are in fut force and effect' contractor's
insurance policies required above must apply on a primary non-contributing basis in relation to any other
insurance or self-insurance available to the County'
contractoragreestoprovidenoticetotheCountyatleastthirty(30)dayspriortocancellation,orany
material alteration or non-renewal, of any of the above-required insurance coverages'
contractor shall assume full responsibility for all loss or damage from any cause whatsoever to any tools'
machinery, equipment, or motor vehicles owned or utilized by contiactor, or contractor's agents' employees'
suppliers or contractors, as wellas to any temporary structures' scaffolding and/or protective fences'
contractor shall have sole responsibility for ensuring the insurance coverage and limits required herein
are also obtained by any subcontractors'
NoTE:Notwithstandinganyotherprovision(s)ofthisA8reem.ent,nocontractshallformunderthisAgreement
until and unless the following are provided io tne County: (1) a copy of the Certificate(s) of lnsurance with all
required endorsements, properly completed and in the amounts required, and (2) where requested by the county'
a copy of the required insurance policies' including all required endorsements'
Kittitas County Agreement for Services (rev' 5/M/25)
PageT of 24
AtrAcHMFNT "p-
REPORTING
contractorsha, provide quarterry progress reports usingthe temprate provided. prease submit progress reports
to the clerk at healthan4humanservices@go'ki$itas"wa'![l'
. Quarter 1 (January-March) report due on the last day of April'
. Quarter 2 (April-June) report due on the last day of July'
. Quarter 3 (July-September) report due on the last day of October'
r Quarter4 (October-December) report due on the last day of January'
The report shall include, at a minimum:
L. A narrative of project activities during the reporting period, incruding progress on the activities outlined
in your Scope of Work (Attachment "A")'
2. A narrative of project successes during the reporting period'
3" A narrative of project challenges during the reporting period'
4.AdatasummaryofthefollowingoutputsasindicatedinyourPerformancelndicatorsandEvaluation
Workbook (submitted in application process):
a.Numberofuniqueindividualsexposedto/numberofpubticawarenesscampaignsandmessages
b.Numberandpercentageofuniqueindividualswhohavedemonstratedimprovementin
knowledge,attitudes,orbeliefsrelatedtopreventionand/orpromotion
c.Numberofpoliciesdevelopedandimplementedasaresultofthegrant
d' Number of organizational changes made to support improvement
e' Number of new staff hired
f.Numberofuniqueindividualstrainedinpreventionorbehavioralhealthpromotion
c.Numberofuniqueindividualstrainedintrauma-informedcarepractices
h. Number of unique individuals receiving or participating in evidence-based behavioral health-
related services as a result of the grant
i-Numberofuniqueindividualsscreenedforbehavioralhealthorrelatedinterventions
j.Numberandpercentageofuniqueindividualsaccessingservlcesafterreferra|
k.Numberofuniqueindividualsreferredtocrisisorotherbehavioralhealthservicesforsuicide
risk, ideation' or behavior
t. Number of unique'individuals trained in suicide risk assessment as a result of the grant
m.Numberofuniqueindividualsscreenedforsuicideideationasaresultofthegrant
n.Numberofuniqueindividualsscreenedfortrauma-relatedexperiencesasaresultofthegrant
o. Number of organizational changes made to support improvement
P. Number of new staff hired
q-Numberofuniqueindividualstrainedinpreventionorbehavioralhealthpromotion
r.Numberofuniqueindividualstrainedintrauma-informedcarepractices
Kittitas County Agreement for Services lrev' 5/14/25].
PageB of 24
The county retains the right to request crarification or additionar information of the applicant as needed to assess
prfect progress and/or appropriate use of funds'
Fairure to submit the required reports may resurt in derayed reimbursement payments, denial of invoices' or
contract termination.
Contracts, reporting, and invoicing documentation issubjectto public disclosure' Please refrain from using
individual names in these documents. These documents may be posted to the Kittitas county Public
Department,sWebsiteatanytimetoprovidetransparencyintheuseoftaxfunding.
Kittitas county Agreement for Services (rev' 5/L4/251
Page 9 of 24
ATTACHMENT.,E"
L.scopeqfcontractor'sServices:contractoragreestoprovidetothecountyservicesassetforthin
Attachment .,A,,. trto rn-aterials, labor, o,' rr.ititi", will be furnirnJi ov tn" County' unless otherwise provided
herein. All work performed under this ng,u";"nt shallcomply with applicable laws and regulations-
2. Accounting and Pavment: compensation to contractor for services rendered under this Agreement
sha, be as set forth inrttacnment ,,8,,. where Attachment "a,' ,,uquir", payment(s) by the county, payment shall
be based upon birings, supported unress provided otherwir" in nitrcnment "B'i, by documentation of units of
work actually performed and amounts earned, including' where "oot"p.'"t"'
the.totallumber of hours for the
month and the totar dorar pavment ,"qr"r,-J. Unless specificaty stated in Attachment "8"' the county will not
reimburse contractor for any costs or expenses incurred nv contrr.to. in performance of this Agreement' where
reguired, the county snatt, upon receipt of appropriate document"tion' compensate co.ntractor' no more often
than monthry, through the county uou.n"r ryiJ"mlror contru.,or', ,"*i.es pursuant to the fee schedule set forth
in Attachment ,,8,,. rn the event contractor r.ir, ,o'p".rorm any "r it, ouig"tion, undu. this Agreement within the
time specified herein, then the County ,ry *i,nhotd all monies a* ,nJpuyable to contractor until such failure
to perform is cured or otherwise adjudicated. The county witt not ir-o'c"r, p"yr"nt for services rendered under
this Agreement until contractor submits a completed W-9 (See Attachment "E")'
3.Taxes:Contr'Ct0runclerstancJ:andacknrrwleclgesthattheCountywillnotwithholdFederalorSla|e
ineome taxes from payments made to conrru.tor- where required iti,ur* or Federal iaw, Contractcr authorizes
thecountytomakewithhordingforanytaxesotrrerthaninrometr-"Jt*'*.'*edicareJ .AIi
compensationreceived
by contractor wi, be reported to the rnternul-R"runr* service ,r ai" ""i"f the carendar vear in accordance with
appricabre rRs regurariorrs. rt is tne responsibirity of contractor to make its necessary esti:-nated tax pa'Tments
throughout the year, if any, and contractor ir'rot*ty riabie for any tax obrigation arising from Contractor's
performance of this Agreement'
TheCountywillpaysalesandusetaxesimposedongood.sorservicesacquirerlhereuncJerasrequiredby
raw. contractor m ust pay a, other taxes, i".irJi.g irt not rimited to: business and occupation tax; or taxes based
on (1) Contractor's gross or net income, or (Z) plrsonal property to which the County does not hold title' The
County is exempt from federal excise tax'
+,@:Contractor,sservicesshallbefurnishedbyContractorasanindependent
contractor, and nothing stated herein sha, be construed to create a relationship of .emproyer-emproyee
or a
guarantee of future u*lroyrnunt. Contr.actor acknowiedges that its entire c.mpensation under this Agreement
is specifieci in Atiachfnent,,B,,, arrd that contiacto,. is not entitrea ,o-u* county benefits' including but not limited
to: vacation pay, holiday pay, sick ieave pay,-medical' ciental' "t ;;;; insurance benefits' or any other rights or
Oriuit"gut afforded to Kittitas County employees'
5' Assienment alrd Sultgnllallinq: and Subcontracting: No portion of this /\Sreemenl may be assigned
or subcorrtracted to any otrrer individuat, firm or entity without the express ancl prior written approval of the
county. The co.tractcr may onry subcontract *ork conrempratea under thrs agreement if it obiains the prior
Kifiitas County Agreement for Services (rev' 5/74/25)
Page 10 of 24
written approvar of the county. rf the county approves subcontracting, the Contractor sha, maintain written
procedures rerated to subcontracting, as wet'as'copies of a* subcontrJcts and recorcls reraied to subcontracts'
For cause, the county in writing may require the Contractor to amend its subcorrtracting procedures a5 they relate
to this agreement, proniu,a the contracto," t,o,.n subcontracting with a particular person or entitY' or require the
contractor to rescind or amend a subcontract. Every subcontract shail hind the subcontractor ta follow all
appricahre terms of this agreement. The contro,,to,. is responsibre to the county if the subcontractor fails to
complywithanyapplicableterrn0rconditionofthisagreement.TheContractorshallappropriaielymonitorthe
activities of the gubcontractor to assure fiscar conditiors of this agreement. rn no event shall the existence of a
subcontract operate to rerease or reduce the riabirity of the contractor to the county for any breach in the
fffi'Tffi;:jf ilff"lTilT:t:i:iff that county is not riabre ror craims or darnages arising rrom a
t'o'"'*;:'1il;?;T:[il:;;lj["n"*$'*T"';*, ,h:,,o.s,-1.i:nr is subject to review bv anv Federar or state
auditor. The county or its designee sna, have the right to review ani monitor the financiar and service
components of the work performed under tii' ng'*"t*' ny whatever means are deemed expedient by the
county. such review may occur with or without n"nri.*, and may incrude, without rimitation, on-site inspection'
inspectionofallrecordsorothermaterialswhichtheCountycleemspertinent,andanyandallcommunications
with or evaruation by service recipients under this Agreemeni, contractor shaf r preserve and maintain all records
rerating to this Agreement for six (6) years after termination or expiration of the Agreement' and upon reqilest
shail make them avairabre for review by any Federar or ritate ,uortor, itre county, and/or any persons authorized
by the CountY.
7. Usddlsglo!
7..)'.ThisAgreementmaybeamendedbymutualagreementoftheparties.Anysuchamendment
shall be in writing and signed by both parties'
7,2 The County may unilaterally amend this Agreement at anv time by written notice (,,Change
Notice,,) to contractor, to mocify the work to ue performed under thi' og'"nt"nt' within the general scope of
theAgreement.suchchangesmay|nclude,butarerlotiimitetJto,changesintheexactscopeofworktobe
perfarmed (including nrodificati'n, suilstituiion, addition, o' oetetion oireqLrired tasksi and changes to the
schedure of perforrnance. rf any such Change Norice carises arr increase or erecrease to ccrltractclds cost of' or the
time required for, performance of the work, an equitable adiustment in the compensatiorl t0 contractorandlor
intheschedulefortheperformanceoftheworkshallbemadebytheCountytoleflectsr:chanincreasecr
decrease. Notwithstanding any dispute or deray in arriving at a nutuary acceptabie equitabte adjr"rstment'
contractorshailproceedinaccordancewithailChangeNstices-
withinthirty(30] daysafterreceiptof anychange
Notice which, in coniractor,s opinion, lacks an ad&uat" adjustment, contractor must submit to the county a
wriiten statement requesting a modified adjustment; ott,''",*',u, contractor will forfeit its right to any such
modified adjustment. The county retains trte tinut right to determine adjustments hereunder'
8. Termination
S.lThisAgreementmaybeterminatedatanytimebymutua|writtenagreementoftheparties.
S.2TheCounty,bygivingwrittennotice,nlayterminalethisAgreemerrtatanvtirnewithcutcause
and without further obligation to contractor except for payment cir.re for deliverables provided and/or services
performed priorto the eiective date of termination. Arr equitabre acijustment in the conrractecr price for partially
compreted tasks wi, be made by the county, but sr-rch adiustment shat not incrude compensation for loss cf
anticipated profit on uncompleted work'
Kittitas County Agreement for Services (reu ' 5/14/25)
Page lL ol 24
S.3lfContractordefaultsbyfailingtoperform.lny,o,itsobligationsunderthisAgreement,or
becomes insorvent, is decrared bankrupt "r."a'i,ir.ny
u.t of bankruptcy or insorvency, or makes an assignment
for the benefit of creditors, the county rrv, iv *ritten notice t" i"li"ti"r' term]:lt;e- the Agreement' and at
the county,s option, obtain performance oi ,r," work elsewhere' lf the Agreement is terminated under this
paragraph, Contr..ror rt-,att n,lt be entitled tolecuiue any fLrrther pu'*un" inder thisAgreement until all of its
obligations hereunr,er ;;;; ;"*,, fully performed' and any extra t"n'o'd'*'g* to the County shall be cledrrcted
frorn any money dr:e or coming ciue to contra.tor.' Furthermore, in ,t "
*uun, oiterminarion under this paragraph'
contractor sha, bear the costs of any "*,r, uio"nres incurred uv rir* i"u"tv in compreiing the work' and all
damages sustained, or which may be sustained' by the County'
S.4TerminationofthisAgreementbyanymeanS-providedhereinshallnotexcuseanyparty,s
performance of its obrigations hereund*r,n,.orgr, ,ne effective date of termination, except that the County shall
not be obrigated to pay for services ,nr, n.uJno', been perfor*ua orl"riuerabres that have not been provided'
9. lndemllifigetion
9'lTothefullestextentpermittedbylaw,Contractoragreestoindemnify,defendandholdthe
county and its oup".tr"nts, elected ,"d 'p;;;;Ju oriciats' "to;*;;ents
and volunteers' harmless from
and against any and ril.tr,rr, damages, 1",':;;;l exp€lnses' intr'iinei'i not limited to court costs' attorney's
fees and alternative dispute resolution 'o"'' *""v pt*onur-o,. r"lirv i"i"w' sickness' disease or death' for any
damage to or destruction of any property tin.rrains the ross of "r" ,Jrr,t'"t therefrom)' and for any other claims'
damages, losses, and expenses sustained ov,r," c-ornty, which ttlltl tt"-d in whole or in part by any act or
omission, negligent or otherwise, of Contractor' iti u*ptoyul'' o**n" or volunteers' or Contractor's
subcontractors, their employees, agents o,, uotun""'s; or (2) u."1',."t'[ or inclirect{y arising oui of' resulting
from, or otherwise ."nn".,"0-*irr, ,n" performance of this agru*nr;'ni, o,. (r) uru basecr upon coniractor's 0r its
subcontractors, use of, presence upon or proximity to the prope.tvoitr,*county. This indemnification obligatiort
of Contractor sha, not appry in the rimitea .,rir-r,."ce where the craim, damage, ross or expense is caused by
the sore negrigence of the county. This incremnification o'oligation oi iontrr.tor sharl not,be limited in any way by
the washington State rndustriar rnrrrancu Act, RC\rv Titre 51,- oi"n' lppri.ution of any other workmen's
compensation act, disabili{ benefit r., o' otn"-,. "mptoyuu
n"'''"ntlct' ";. cont'acto' hereby expressly waives
any immunity affordel ;;,,; acts. The.;;";";;; indemnification outisations of contractor are a material
inducement to the county to enter into this Alr-euient, ,r" ,"tl".i"Jin iontraao/s compensation' and have
b""n rnu,u"lly negotiated by the parties'
g.2TheCountyreservestheright,butnottheobligation,toparticipateinthedefenseofanyclaim
for damages, rosses or expenses, and_such pu.ti.ipation snat not constitute a waiver of contractor's indernnity
olf
'rrt'o,i,
contained in any section of this Agreement'
g.3lntheeventContractorentersintosubcontractstotheextentallowedunderthisAgreement,
each such subcontractor sha, indemnify ti" iorntv on a basis ;r;i1" or exceeding contractor's indemnitv
obligations to the CountY'
to.Venueand!-bgt9e-o!!a]^J:-lntheeventthatanylitigationshouldariseconcerningthisAgreement,
the venue for such u.tion ,n.rt be in the superior court of the st.tu'-oiil"'nington in and for the county nf Kittitas'
This Agreement shall i"" *"""tn"d by the laws of the State of Washington'
11,Non.A'propriationofFunds..ll,h"CountyclcesnotappropriatesufficientfundingiorthisAgreement
for any future tin.or pJroaF" County,nritt not be obiigated ,o "iJu payrlrenrs for.services pe.forrneci after the
endoftherasttiscarperioJforwhichsufficientfunding*uruoorof,rir;-i.
Nopenartyorexpenseshallaccrueto
the County in the event this provision applies'
Kittitas County Agreement for Services (reu ' 5/14/25)
Page1-2 of 24
12.Lcontractor is duly incorporated, validly existing and in good standing under the laws of the state
of washington, and has arr requisite corporate power'and authority to enter into and to perform its obligations
under this Agreement.
l,T.2ContractorhastheauthoritytoexecutethisAgreement'to
warrantiessetforthherein,andtoperformitsobligationshereunder'
1'2.3ThisAgreementhasbeenvalidlyexecutedbyanauthorizedrepresentativeofContractorand
constitutes a valid and'iegally binding and enforceable obligation of Contractor'
L2.4 cerntractor hoids, or will obtain prior to commencing work under this Agreement' such licenses'
permits and other outhorizations from federar, state and rocargovelnmentar authorities' or from any applicable
industrial or professional certiflcation 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'
r2.5 contractor is not in violation of any applicable law, ordinance or regulation the consequence of
which wiil or may materiaily affect contractor,s abiliiy ro perform its obrigations under this Agreement' contractor
is noi subject to 3*y orcJer .r jucJgment of any court, tribunal or go'le.nmental agencY which materially and
adversely affects irs operations cr assels in the state cf washington,ir its ability to perform its obligaticns under
this Agreement-
T2.6Contractorisnotpresentlydebarred,suspended'proposedfordebarment'declaredineligibleor
voluntarily excluded from covered transactions by any Federal or state department or agency'
t2] None of the representations or warranties in this Agreement' and none of the documents'
statements, certificates or schedules furnished by Contractot in cJnnection with the performance of the
obligations contemplated under this Agreement, contains or will contain any untrue statement of a material fact
or onrits or will omit a material fact necessary tO rnake the statements of fact contained therein not misleading'
l3.OwnershipofltemsProduced:Allwritings'programs'data'reports'films'recordings'orother
materiars prepared uyTontr".tor and/or its consurtants or subcontractors, in connection with the performance
of this Agreement, shall be the sole and absoiute property of the counly- The County will have all rights of
ovunership therein, including but not limited to the right to use, copyright, trademark, andf ar patent' and the
ability to transfer any or all ownership rights'
1'4-lntellectualPropertYlnfrin*ernent:ContractorwilldefendandindemnifytheCountyfromany
claimed actton, cause or demancl brought ug'i*'the County' ts the extent such actiOn is based on the claim that
information and/or materiars suppriecr br7 contractor infringe any intelrectua{ property riglrts of any third
partyiies).Contractorwillpayallcostsandclamagesattributabletoanvsuchclaimsfinallyawardedagainstthe
county in any action. such defense and paymenl, ,ru conditioned upon the following: (1f contractor shall be
notified promptty in writing by the County;i;.y notice of such cta.imi u"O !i] to.T-':".t'ot shail have the right
hereunder, at its option and expense, to obtain ior tne county the right to continue using the information and/or
materials that are the subject of such claim, provided no reduction in parformance or loss results to the C'Unty.
follows:
Kittitas County Agreement for Services (rev' 5174/25)
Page 13 of 24
L2
make the rePresentations and
15-UseoLCounwNarnean'dLogc:.contractormaynotusetheCounty'sname'logo(s)'trademark(s)'or
other identitying inrorrn-rton, or identify the county as a current or former client' on its website or in any
marketingorpromotionalmaterialswithoutthepriorwrittenconsentoftheCounty.
1,6.Disputeg:Anydisputebetweenthepartiesarisingunderorrelatingtothi5Agreementshallbe
resorvedinformaryifpossibre. However,intheeventsuchaoirputJ'crnnotbesoresolved'itshall
beadjudicated
by a dispute oorru t,,Jspuiu eouru") in tir" toiro*ing rrnn",., r"r' p"tv shall appoint one member to the Dispute
Board, the members so appointed shall ;"'ti'u 'oo"int
an additi-on"t'tt'nu"r to tne Dispute Board' and the
Dispute Board will evaluate the facts, Or'""tt* terms' and all applicable statutes'and rules' and make a
determination as to the proper resorution oiin. i,rpr,e. such d.;.;;;;;;n shat be finar and binding on both
parties. The cost of resorution wi, be borne as atocated by tne oispuie e;ard. Arternatively' if agreed to in writing
by both parties, tne parties may forego trre opiion of estabrishi", ,";;;;;Board to adjudicate the dispute' and
instead pursue arbitration, jointry serecting an arbitrator r.."ptrblio notn parties. rn the event the parties
choose to pursue arbitration, the parties urr"",r,r,, (1) the t""r rnJ ""p"nrui
of the arbitrator sharl be shared
equalty by both p"*i", ,o ,i,is Rgreement, (zj;;;h partv shall ut"lt' "*" t?t]t^T:-T:rnev fees' (3) arbitration
sha, be conducted according to the commerciar arbitration procedures of the American Arbitration Association'
and (4)the arbitratorrl..irion or award shall be finaland binding on both parties'
LT.confidenti?litv:contractor,itsemployees'agentsandvolunteers'andanyofcontractor's
subcontractors and tr.reir emproy"ur, ,r"n,, ,nd vorunteers, ,nat maintrin ,n" confidentiarity of all information
provided by the Counif or r.quir"A by Contractor in performance of this Agreement' except upon the p.rior
written consent of the Kittitas county prosecuting Attorney or an.order entered by a coLrrt after having acquired
jurisdiction over the a"r'"ir. contracto*r,.rii,-ni"aiately provid" ,i" a"r",t notice of any judicial proceedings
seeking discrosure of sucir information con,rr.io. agrees to ino"rnitv, defend and hold harmless the county
and its departmentr, "Li"o and appointed officials, emproyees, agentsand volunteers from all loss or expense'
including but not rimited to settrements, judgments,rsetoffs, attornlys'fees and costs resulting from contractor's
breachofthisprovision. Notwithstanaingti"tor"going,and,o,n"""r"ntthatanyinformationobtainedbythe
Contractor hereunder is required to ne sna-rel *it1 "1n""-:^Y.,ii"'"*o'n't
terms of"the scope of work' this
provision sha, not be construed as prohibiting such sharing, proviaei iiir" ur" no applicabre raws 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 oy p""on't!"liu"'y' legal couriei'"Jt"' or certified mail' postage prepaid and
return receipt requested. Notice may be prouia"u by relurar first clss mair if simurtaneous notice is provided by
email. Notices given by contractor shall o"-prouio"a ti trr" corniy', point of contact listed on page 1of this
Agreement, at the ,aor"r, tr,"re listed, "nd
to'trr" department it"to ort'r'" county department for which services
under this Agreement are rendered. Notices given by the county sirtt oe provioed to contractor at contractor's
address listed on page 1 of this Agreement'
19-PrevailineWage:WherelabortobeperformedunderthisAgreementisconsidered,,publicwork,,as
defined in RCw :s.oq-010, Contractor strat pay the prevairin* ,.r,u of *.c""s to a'workers' laborers' or mechanics
employed in the p".f;;;; of work ,n0",. tnl, Agreement ln accord"ance with RCW 39'L2 and the rules and
regurations of the washington state Depart-m"nt oriruo.. "na
rnorrirres. rhe schedure of prevailing wage rates
for the appricabre rocarity or rocarities.is determined by the rnaurtrirlltatistician of the Department of Labor and
rndustries- rt is contractor,s responsibirity;; ";;t the appricabre prevairing wage rate' rt is understood that
contractor is responsible for obtaining and compt"ting alt requirel gouurn*"n, forms relating to prevailing wage
and submitting same to the proper authorities. Disputes regardirig prevailing wage rates shall be referred for
arbitration to the Director of the oepa,tmeniot ruuo. and tndustriJr. ar'ru arbltration decision shall be final and
concrusive and binding on ag parties invorved in the dispute as provided for in Rcw 39'12'060'
Kittitas County Agreement for Services (rev' 5/M/251
Page t4 of 24
20.Standardof9'ere:Contractorshallperformitsdutieshereunderinamannerconsistentwiththat
degreeofcareandstirtoroinarilyexercisedbymembersofthesameprofessionorindustryasContractorcurrently
practicing or working under similar circumstances. contractor shall' without additional compensation' correct any
of its services not meeting such a standard'
21. Nqgdiscriminatio4
21.I ln the performance of this Agreement, Contractor will not discriminate against any employee or
applicant for employment on the grounds o;;, race, creed, color, national origin, citizenship or immigration
status, sex, sexual orientation, marital status, f'Jno"UfV discharged veteran or militarystatus' orthe presence of
any sensory, mental or physical disability or the use oia trained dog guide or service animal by a person with a
disabirity; provided that the prohibition against discrimination necJule of such disability shall not apply if the
particurar disabirity prevents the proper performance of the particurar worker invorved, contractor shall ensure
thatapplicantsareemployed,andthatemptoyee,aretreatedduringemployment,withoutdiscrimination
becauseoftheirage,race, creed, color, national origin'citizenshiporimmigrationstatus'sex'sexualorientation'
maritarstatus, honorabry discharged veteran or mirita-ry status, orthe presenie of any sensory, mentalor physical
disabirity or the use of a trrin"Joog guide or service animar by a person with a disabirity. such requirements
apply, r,vithout limitation, to the following: emplcyment, promotion' dernotisn' lransfer' recruitment or
recruitment advertising, layoff or" terminatio-n, rates of paY or ather forms of conrpensation' ancJ programs for
training, inciuding apprenticeships. contractor shall take such action with respect to this Agreement as may be
required to ensure fu, compriance with rocar, state and federar raws prohibiting discrimination in employment'
2l..2Contractorwillnotdiscriminateagainstanyrecipientofanyservicesorbenefitsprovidedfor
unrjer this Agreement on the grouncls of age, rate, creerJ,coror, nationar or"igin, citizen-ship or immigration status'
sex. sexuai origntation, marital status, honorairly disc*arged vetersn or military status' or the presence of any
sens0ry, mental or physical disability or the uge of a trained dog guida or service arrir.na{ by a per.son with a
disabilitY.
2l.3lfanyassignmentand/orsubcontractinghasbeenauthorizedbytheCounty,saidassignmentor
subcontract shall include appropriate safeguards against discrimination'
22.Waiver'ThewaiverofanydefaultorbreachofthisAgreement,orthefailure."''.q":.']::]:l1r*
any provision hereof or to exercise any |.igtri ol. privilege hereunder, shall not be deemed to waive any prror or
subsequent default or breach, the enforcement of any provision hereof, or the exercise of anv right or privilege
hereunder, unless otherwise stated in a writing' signed by the parties hereto'
23- Headines; The headings of sections and paragraphs of this Agreernent are for convenience of
reference only and are not intended to restrict, affect, or be of any weight in the interpretation or ccnstruction of
the provisions of such sections or paragraphs'
24.Survival:Theprovisionsofparagraphs2'3'4'6'8'g'LA'13'14'75'16'1I7'19'20'22'24'and28of
these General Terms and conditions shall ,,r*iu. the completion' expiration' termination or cancellation of this
Agreement for anY reason'
25.ComoleteAgreement:ThisAgreementconstitutestheentireagreementbetweenthepartiesand
supersedes any and ariotner agreements, understandings, negotiarions and discussions, orar orwritten, express
orimplied,regardingtheworktobeperformedhereunder.Thepartiesagreethatnootherrepresentations,
inducements, prornises, agreements, or warranties relating to this Agreement' orai or otherwise' have been made
between the parties. Except as provided elsewhere in this ag'.iement, no rnoclification or waiver of this
Agreement shall be valid or binding unless in writing and signed by the parties'
Kittitas County Agreement for Services (reu'5/M/251
Page L5 of 24
25'leverabilitv;lfanytermorconditionofthisAgreementortheapplicationthereoftoanyperson(s)
or circumstances is treilinvarid, such invaridiiu ,1., ,"t affict.other terms, conditions or applications which can
be given effect without the invarid ,"r,n, .onii,ion or apprication- To this end, the terms and conditions of this
oct;"t"na are declared to be severable'
27.Time:TimeisoftheessenceintheperformanceofthisAgreementunlessotherwiseagreedbetween
the parties in a signed writing'
28. constructio|.!: This Agreement has been mutually reviewed and negotiated by the parties, and should
not be construed against the drafter'
29. Agreernent.Not for 8enefit of Third Parties: This.Agreement is entered into solely for the benefit of
the parties hereto tnAG't' no rights in' no' f it "'**ceable
by' any third parties'
Kittitas County Agreement for Services (rev ' 5/].al25),
Page 16 of 24
W-9
ATTACHMENT'F"
Request for TaxPaYer
ldentification Number and Certi fication
Co to lr"^Y.i6.lio v t Formwg f o( instructions and the latest inlormation'
Give form to the
requester- Do not
send to the IRS'';:
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:;;-,W-9:1t):-'2i
Kiiirtas County Agieement for Services (rev 5/1'4/2s\
Page L7 of 74
2
Fom W-9 {Fev 3-?024)
flinds)
. Form I o99-lVllSC {various rypas of income' Ptizas' au'ards or gross
proc*sd3l-
i gorm tosg-tIEC {nonemployee comPtnsaiion}'
. Fotrm lOSg'B (stock or mutr:al rund sales and certain o'jer
B ansactions bY brokers)'
. io- t Onn-S (proceeds from reaj estate tt-ansactioos)
. ,o"" , onr-n [me'Liant ciard and thir4parfJ net'#ori( fansactions]'
, t"* iOnU lnome mortgage interes!' 1o9&E (shrdent loan interest)'
and 1 098-T (tuftion)-
. Form f099-C (canceled debt)'
. Form '! 099-4 (acquisiton or abandonment of-t"ltf
':f:f
I lcp Form W-9 only if you are a U S person (ncluding a reeident
"fiJnl.
Io provide your correct TIN'
l""iio", ,, V* don'i relum Form !V"9 tofhe requesterrzih; Ilt\l' 7ou
;;il;; .uii*, to backup withholding $?P wDa( is ddc^up
wihheldtng, laler'
8y signrirg the fillerl-ott! form' you:
tfertii;lhaltheflllyou"*g'tutg;sconeflioryor'r'lrervailinqiora
number to be issr'red):'"'z*Certfl
that yDU ar3 not sublsci to backup wilhholdingi
,or.
3'ClaJme:(emPtionfrDmbackupY/lthhaldingifyousJeaU'S'exempt
6ra,;ee: ar:tl
"iF*=l?!{:*lff 'r;",ffi ,iir;01*"1.':*:.,1:-"**'
z. t;eit'i lhal sA ICA codglsl inlete{t ']n Uilg rernrii :nt j rndicctln'J
that,/ou .lre eaempt ttom t* tiiie;"p"*nu rs ;on{t' t+e wl'at ls
iirii'n"p"*^g latel rorfudher'nformatron -,--
froi4: rr.ro{r. u+ , ,r : Y':i.'fii,:;il;iff',1'J:il1,iol,;",i.,?i'l;;, ,'
watl ;orn, iri-? l':, eques' Your
n'f, *uiu,-,itq simiiar to lhrs Form ltV-9
n"r,.ition of a U-S- person' For lflltrd iu purposes' ycr'l are
ii"iia.r* a u.S Pereon rf Yort ar+:
. *
'"1*o"n
vrhs is a U-S' citiren or U-S' resrdeot alien:
. A i.arinershrF dorpoftttoo' cofir$rni o( ;Lg-io4(r8ofl u7!::'J' -
,1rqsnr:'*d in fid Unn{d Sral"u ot tnO.-lt'n*:aws r't f +'Jrril'rJ italts;
. en est te {other ltrafi a fo€ign tstata}; or
. O ***rt" tGt {as definEd in RegulaEons section 3O1'7701-7J'
Es r 6b'ish in s u.s " 3r arus r of
^ps'po "_::,f-g*:'rn:illl ; ::ffi -
?ithholding- Payfl4cts nart' to to'iy::I:-jil^ -^r'.lilI'*'"ce*c15.
""-'idislnbu!4n'. sllncauons 3r rrccfia 'l' lGnsirr: ''f.{al?s. f:lr
br sb,.ct io w'rfiholdng *oJ'ti*pr.:t 3 or f,htPttt t of 'h+ Cod*
iii;it t;at -rliJJ. rj;rjc' tiose rules' rf a F:rmW 9a( olr'?l
Drlrfic)tion ot wFfarglgn ''o'u"'"il'iit "*rl
rec+cr{d' a ralsrodi;tg
;;; i. ;;," (-*. "* - p*n; *-*'llp&'ii"1i#Lto,Hf ff :T, i'"
.riies f,ar .F.!y raqu,.? ft: Pa'l(
t a c I o! eot, +rvne{ trir tFl4tor''lr'u'rrr'r*r ipa}et I i"* n'b; ?,:.:.
fiitiinlr,i'!'"ir* on rlonr':atdent 'trli*rs
aftt Fortrgil Lnlrlre s
Th+ ktllo+twg penitns Iiru<r orouC+ Fornr YJ 9 l':r thr pe'/nt ior
^ .'..).^.*--^t "itih[rhrn4 rlr tror torPltn :lalrts
P'tY,'v-' --'
i^lstvvrrtSl{js.{v,'rne' rlt:Ui o'rrner
, Ifl f ha q&3* 'lt a dbrsqardsd
.lir'l'l'i'r'-.i"lota *nt'i and nct rh€ dsr*larcitd =nfity
' ln lh+ iasg ':i a granl.lr ,n,.I {llh ,|j :,. glanlq( or ]lh+f.lj'3' o''.'n*r'
,rdne rti{y tl re U 3 gra"tor or oiir'Jr' ri's'r,"'inl' it rh* g'anltt ttl'ct'v x {
;ot thE grantor tfllsl
, fn tfr"
"""".
of a U-S- trust (othtr liEn a grantor trust)' lhe U'S- trust
""0 ^o,
tf,u beneficiaries of th€ trust'
ir" 0,," i ) fo' $o(+ fl{utlndltflr 'rn llrovrdrng a Form ''1r + cr il
i=i,i * r",ion lf ".rn- for4qn ;l rlris to lr'Did''?ilhhoidir 19'
Kiititas County Agreement for 5ervices lrev ' 5/14/25lr
otlir1.**
facts to iustjfy the eremption from tax under the terms of
lhe t*av adiels'
llggiffi*ffittffi
**f*t'mt
atulunlont thnt rnclttd;s th* lnl{
""o#;,{t;t:'m*t':;,'ffi1';:11'siveiheeq@st"rtie
BackuP Withholding
*[i*ii*,,iHtriiffi"*H'#ffi '
'*ru"#i:rfflifi{'{#;A
nt#*i -- .
rx,*ifr,q4qffi#Jffi Hffii***ff;:ilH';'ffiffi-o'
"iT,.*fr H*r,&:gqqffi Sffi #,#$:
oiA rtiotr ;!l iour lanabl: nl+
9trnEr*5vnl,(*':*ge,/i||be'{d,i.{(ro$ckrrp+ridr}oltlingil:-i
A"Oo not fumisft yo ur Tltl ttt tm @)eslef:
:- Y*'t Jo lor :{nri1' '1our Tlll then r;qu n'l(l B4 ths in:rttucutrn$ lor
Pattll fuf 'Jelai|e.l..
3- The lFlS lBEr tle4r+-swtv( ioufuminh+d u ncorrect TIN:
.l lh.i lf:S !€f,t /orr ihat vou ar+ 3obl{':'t !o baet 1'9-tr:y'ng
bicaus; 7ou 4rd not raport aj''*t *ii*'t arrd &'iidsnds on Tcur tar
:;;il;l;tr;able 'ni*rcsr
a;d iri^dend' o:Er: or
5.,o'-,do'aatczn'q'9lf -";'#Hfi*i'##'e;"jiil;|;inY*'"
:ll#-Yt?'.,' 3;,"#fi"Jn*";"J-&ia'nu"iovnisopan*d
aft:r 1943 gntr'
Page t8 ol 24
Pa4e 3
Fo(m W-9 {Fl.v. 3-262'll
Cerralnpayeesandpa},mgntsa'ee(cnlolffombacfiuptythholdinq.s;i;;#ip;v". c'oio 'lsre',;n;-rha seiareta lnsrnmtrons ror rh+
ilJi,l*it* oi16^ W e (or rnorg rnforrnation'
See also C:tabris,lng U S tlpt"s lar putps+s of ciapler l f,'l;Li
chapte( 4 rvithhaldng. eadier'
What ls FATCA RePorting?
fhe Forergn Acccunt Tax Comf'ance Art (F'\iCAl teqrlres .r
^-..;.,'.-r;^^ r.vpinn frnancrel,nst,tution to repan ail J S dccdunt
f, :i ffi 1#l ,I lil;ilUb' ; ;-ons o.-'t"n pavT : 3-' :,eli{pr'r'T
cAr.A randrrrno Soeg.*,tordn tion FA1CAniporung cd{'/c' lstcr' an'J
'11',llll5u"l!i":il;.q;;;-; "r
Form w'e iur ntors intamtarior'
Updating Your lnforrnation
Yor: must pr,:vr'le updaled infornratron to rny Per3on lo tlhom. you
"lo*J io U* ir: +,(amFt payee if you are n') lortgff an +i(empt paYea
;;i;;;;;,t rec:i'ring riporrabre pavme''is.in fre rutur--iro;n tnrs
oerson. For +rarnpla. yo' -"y n-uiili providJ upoared'ntormatirrrr ;f
:.,:j,; ;-c i"rtot"rinn rtrar jteas lo be an 5 corpoation -or
rf vor are
H'i.ffi i";"Jffii-i" "iain'^ l'" must fr:mrsh a nerv,Fom w'e rf
iL"-ilil;;in;i,!ng:r fo, rr'e ti"ounr' for *'amplo 't the grantor of a
grantor trust dies-
Penalties
F.rilure to funrish flf{. li vertr farl to (unrsh vour "t1:-."l.lTl 3,"ilul;; yo,, *= *ui"ti to s oenaltv ol S50 far each';uch iadurs
s141ggg 'i6g1 idtlule rs due to ruJonabie cause Jnd rlo( lo rvrilhrl n"'qlecl'
i,*l'p",trftV lor lalse inlornration sJltll respect to witirlr,olrting' li lo t
i"f.'Ju ,"r"i $talJmml ltlh nc reason'lbld basls that r:rtllls ''r 10
iaiti,lirurrhn,:r.ling. you are suqeci io d 55uc lenaliy'
Crirninal Pcnalry for talsiryrng lrlonrraliorl' lllilllir}ly fals!llog
;;;;;;iff- qr iifi*caair'ni sav:rtibiect you i'] tr'mtna! p*nallr€s
{]{{isJlng tltlPg Sntjuo/ !lllorlsrlFmenl'
Mrsuse ol TiN5 lf lh;: rgQsesi4t tlissios*s oi rsl: TlFls in:r<:lat on :i
i:.d':cal iarr'. lh. feqcestrr *^y lt ti'Ul""r lo ct|';l ?trd q4tr{o'li p+cdtr+-s.
Specific lnstructions
Line 1
Yoil !:trl$l ;flt"r try 'lf ii!* ioll'lt'nlJ tQ lht: llfta: {lo noiigala'th'g ir6'
i,Gf. ii .' nanla;hodrj nair:h {l't-i Ra'rr' .1u :Jcur igx rsirrtn
li 0rs Forrlr lvi t .i i{it d !/J6t r'':oilni iolh*r ihi;n *: :cclr'll
*;;;;; !;:t t icr.;4n iinan':'sl tilsutirrior {FFi}!' lisl ri'sl' and-'i"i
crl:0q l&a aam* ri iF: pgflot] u! tnlriy rrhosl lutr''b:r you zcured rt
Psri ici i:+rnr tiV'9. li y';r: art Jruvlr'ttrrQ Furm F/--q to r FFl I/i :k':1!{i1+il1
:il;,?'l;;;i--u"n l*tjt" oitn't actourrl ihi! ir I U i c;ryrn mrsl
pfrero.: a Foan !1-t.
. t.Eiiul,lu"t. (;tn{riY +ttit lht ntfi'l 3ht\':n 'fn ycur ia" €ufi; :: :i'-'''
hEqe ahaft?ad ?oLd lasl ratne rrthoui rnioGnrnQ lh* So'€l ;icuftV
,,fi;;,;J';it; lss'ri'i trt. ndmr ^hanQ+ rrrr: Tour hrsl adnrr'- fi":J3i
;;;;;-.ho",ri lft y4ut ;{}cral ';'-'r'ity-:atd d''d vcsi ti-i""as! fta'1*
Nole to. fllN ap;:lic,rnt: Fntlr ''urir tn(!rllduirl latne b- rI gq: +al*rtd
on ,trrut F o(B i.r,l . ; JpFITC anori. lirrp I a ihis shoqrld slStr b+ !h+ 9inr4 "!"
;i"';;:,t. '; ,r,,"ro-'i ot {h- i4.nr lo-lo you iifq<J viriii i'it( eqqi-^at$r
' Sole,trofrnetcr. frlt;r tot:t t'ldNtduJl oarn-i ?s ;ttc:"n on J')!(r"rl lt
t1)Jo on ttne I EfiiPl 'f4tl{ t'='n*tt t'att* or -deun'; busrn+;:; a;- tl i:'l't
name on lns 2.
, ParlnL'rillll)' U rjotpora!lon' S cot Irotaliotr' nr i-L C' clirat llian :}
drsre<latrlo<l *nirty. tni-r tt *if't'' j ikrllr€ 15 :b]ttn orr !h* ?nni' i lan
I*r-n?'o^t ! :nil lny t'usr'1*ss' iiace' cr oEA r'Jflie':rt lfl; ?'
'Otlrer+ttiitie$,€f;|*f'.]tlrnil]l+Js3h.J1T.i4n.l.],'iill].gd$S'idaGt!;'';;;;;;;;;;t' r trri'= 'a'nt :lrtul(r real'h :he ilant* :horrn on 'h:
;;;;;;;:;ih"t ,!g.rl 'Jncitnrgit !:r?alrnq the tr-ltiti LnI:=' raii b{j"qlt?i
irade, or DBA name on llne 2
. 9is161lat tlerl Blltlty, ll' qqir!'{ -Jt a hu5nrrgs inllty thet has a sind=
;;',:. jn:,1;;;;;,;'r.-ii -. l"a '* "or 3 {"rPoratrorr' rs d'sr"'!l':j':'t at r"
;;i;;; ;ro-r,t ir,nt ,l:' ov,n+r (a 'Jtst v1iltJe4 ctrlilil S+* REgulaxcr''
l,iii",' it r I iot 2(t:,{?}. A rlisi+<lrdtd ird(y drould dh.:i' lh*
#;;;,; tr:, tor th* re' ':l'rssrt':airon cf rl5 o!'Jner' Fniir !h{'r!'nri: i
.liriu'.," t'n* l. [h. nam" 'ri th+ r"'''ogr 6rller{l tn !in* ! Ehsuid rav-r
i- . o,-t-.ltt,l-d +tltiiy Jll-r i'rt!rB ttn iin; I 5!ro'ld be'ihe ndrn* sh'$'''!l
.r! it:e i.rrurr+ ttsi tetutn "u "ttntii itt* 'ntt"i'-" ;tttxki':rt rep':rted i:tr
*r:rnpie. rl c m.eqn LLC l'lat 6 a*alg/' ls a ds'*?qt{erJ *-rtrt"' ft:r L i
te'Jeril tnx tturpo3t€ has a e"dt";';; G;; a dS' p'erson-the'J S -
;;;;;;; trqu:Ed to be f rouilec' on lirur-r ' lf tfte &El.cwn€r oi
il'l:-l,;'ri] "i,'i "
&*e-*; inirr. y:re' tu 6rsr nYDr *a! b rer
d€rsg€tdert (orfudpral l:ry pur*!s' Fr'lrr lh€ 'is(egrrdnd +.tiri l
name on fin+ -]. |i lfi# 'Jrv$?t €t:h* dEtESEC:d enllbl € r
"rsjn
i{rscn
rh. c1'iner.nusi corr-Dltt: * ti"'#'-Ji-lJt iy 3;661'3 'tr'; c re
#;:' ril ;*,4; a.*'r tr'J't-"qn 3d€t,n ftas a u s flil'
Line ?
tf vou ha'r* a bqgr*as tlime- ltaltt sfil!' 0€d nas+- x
unlrry "a,t* ecler it ln ltn+ ?'
Line 3a
Ch*ck ihe appropctt€ ltr' 'ln Dr+ 3a'o< lt:+ U j i*:*rai ":r
^"
cfassifrr:atran of lte p*t-"o* *'l'os* itnit ls tnt*t"e :n 'rr'l i CI::'r ;)lllr'
c I sreg:trrj 9.tr
aoe box 9n iirie 3a-
lF th" "nilt'/lndividual
on line 1
is a(nl
TF{EN cfieck the box lar
prDprietot-lnd'ridualgr:le" lndiviCual or
" Sole
. LLG c(assified as a pattnershiP
ior U-S- federal tax PUrPaGes or
. LLC lhat has filed Fotrn aa32 tr
2553 electing tD tt€ laxed as a
corporalion
x1diJrnited liabilitY comPanY
entet the apprcPtiate t&{
classification:
P = Fartnership'
C = C cor!'aration'
3 = S;orporalion-
or
ftu$/estate
Line 3b
'll,.rj. !h6 bD^ fi jrjtt at+ a 31rr'{irut rr3J:lriding ar -Lil cl:rsii+iJ as I
ladFat:hig iq lj:i iF{re{:Jl ,"" C'Jtf"o-ti lrusi- -' +513i'- i}'].'-ha-'' 1"
ii,"; ;il;: nn,':oi'' :'+'l+{'l' *"tr 'nd itrr re'-ro rlc a ifte
ionr ro 3 ?at142,;h\P t1*i - ==''-tt-".1-'1i.""1 :..*.:*i:ii;fis':
,ntprss i. r' io .n!;i :iH e iil* :a1' ci
;5,;:.. ;;;:-; ; 6*i.=ri a"r
! ai .J+lx:?f il1t' :'rxl;rc+; f'on
*,J,s,^,""-*ll" i't*t* t ;'-s''5''r'+ l:'xr: "v
a it4n-3rv
;;**;;';:*;' ';iet*n'"u' r'irr- has :h*:!'*rJ !h: =*r' : * in*'r1
;{c{e: A t Jrll.{slrF fHi Pr+d+r 'l i *ii:: :'rt i v :1 t!l;'-: s tt t':'-' :t::
::- :-;:;i".ra.rr+u ';:ir-rJ'-'Ls '' : 'itN-
-i lra':*. ',l:::1 ':t ffii?
ritirr{i3lii, <:a i;;; iy.:n;r=iti tt-"'t-t'"'^" 'lt :::'i:lt$i:s /- : 4{\d !' ':
.itm :ttti!
!i:a{il ar+.*:{Urri 'trJi;3tt:']l;tt'\ri 3l' L'tr ;l' l3 'J+ i+' \'}u G! t-; nti'
:;;5;: tj:i :n'rrltEit.:o lBltJ"*i to '-gt n :'F{i 'fli'll'53iion ":u; ' ;:'il
llr- 1il5 or lsrsa' it:'lc:'l gt'f* t:J:i' cfli : -' u' ita.6+-'t':! '
:;;;;; -*'t*o""tt'on- 5a;t1r-:ttr;*€' ii ? iiJ6;:tr':
)t1-111\4t ih41 fia'g :i}'ri
Line 4ExemPtians
d r* 3l; 4'-Nfi nat ''a:' r[ a:tlr]f'Idl; -: rd'r::r il- --,l t,*t:' .'Q
3r:l:. in r: t ::gpsat'urii t7o"''t' t'i t
"i'1
:t'-l: l t tr't: a' t i z'i?l i vJ
'l{}1}.
ir*xpt P.r;ee cxle'
' {;:<xaqi avt.'.ltidt' 'it\'it-:L!ti;
t'{: --:it]ai?irt: :;; l:;i +'lepi ira
:*cilp rdFrtl'1"C
'2,r4ttvr't'j:4i'ii'.i.Jr,i.f ,7*U1:r:;-::r:T;:r::k*
-!,i jih{:tii..! ic !:{'.-as trrr;1r31
$Jdr.d:,;. .l:*rr:rtt<*'. .tt* r]$i :-1*{}1pl ;:' lf, F r! Jg triht''':t {t'} - lj (. {
*.i-l -oianaiil 't -ilfi:n( ^uc itr 1!,\trl; :?' ' :'l-a"r"'"ft't']t\fr?i
, {:)rFq.?&orr:) v-,"er .rnnp'l ir:r t'a:t''p *'iirf'ot1t:.::! ::!;t",'e59-:r''r
!l
afla.irtri' irli*-.r'q"-ss tr"r-*::;:drl ?':
'ttr'-"t'
4\d :tt';4lt': jna
ia'ai !rr;'.nJ: ,naaaal'rt neal*' '-l'*- qtr'r r" t'i 'rdle ' ' 2'''Li i{f tlg?-a":'
,"'pio* ".,.,f,;'1Jil:P ff : '1q 'i:'lt-'
"(l:ic
ina ,nua, ".o "
:oc:s irf:nail rui --+; rlaa
.
r,-
.--
' +1191 iftm Ita4 iop
*,intlari* iii':r th* asf'rifrtr+: :''1'r r'l ih+ ;'-q;- rtn t "+'
r -.1rr !q#,'-nlliin :a:(nFrt "' "' n' p'!ae iEi:Scn 5'-tt;'r'' vrr {Fl'i- ':r
.1!:ts'x'cll?C,.1ru.1!!'drde's,rla:'!:l]3it]{.!::i:.1J.cci]Iit1.1'd51i'ail1.luiu'n^,*t. 'r {rio'rn lrll{tl :'i
Kittitas County Agreement for 5ervices (rev 5/14/25i
Page t9 of 24
P"g.4
Form \rV-9 iF:v 3-202'{)
above. 1 through 13-
lF the PaYment is for
. lnterest and
transac
. 8ar1e(
and
5 -A corporallon'
' - A dealer n secuntres )l comn\odki4s requirS'l io Ggrs- tet in the
LJnited Stat*s llrs Oistnct ol C"f"^ii' * - 'i d' cornmJnrvsa'th or
t#ritory.
7-AfuluresCommigs.onrnerchantregisteredwlththecommodity
Futr.rres kading Ccmmission'
I -A reai estate investmeni trus''
I** *nu,r r*Stsrerecl s( aU!m*s dunng 1tr* l8x yetr1,nd+r th*
rn-uest;*nr iomlanY Act of t l'to
1o-Acommontruslfundoperatdbyabankundersectrbn5S4(a1.
, i -n fn"n"i.r instrtution as defined under secuon 581 '
12-A middleman knov/n in lhe inYestment community as a norninee or
custodian.
13-A trust axempt irom lax under section 664 or desctibed in sectton
4947.
Ih* folkrrving chatl rho"''s ryoes ol paymenrs lhal may b€ ':rsmg(
iron backup \',rrlhhr)rdrng'
' "- J#^"#;li;;; rhe axernit paveas listed
G-A red FJtate nvesE?rent ar.sg-
x :!*ina'rn ::r;*n af , €( $rj; ffi"JT,T$;;ffi1il''i l[' "]J'''r"'*-r6'iinent
CornPa{r nct af lS'tO"l-llJtn.on *l iurd as d:efir*dis t**'in5&tlal-
J-A i:ank as defined in section 56!'
K-A brok'r- ---.*.-{i
L-A |'lrst4€Jrt'r FaJn lai'' ;'?d*r 5a:f|r'n -F al 6z'<&'.!,dfl1e{'xqft
,1s4t{a}i11. r 5rig}""i i* *--**pt lilg nnd€( r s€€tqli ]#3rt'r Fb* {'t s*let
#Xm,*n6zufr$"$i*.'ffi#;:i?'n;#F[:
Line 5
Flt
chanc6 tfl* old addftss lsll oe
address rn their records
Line 6
Enter vcur tity state' 3nd ZP cod*'
Part l. Taxpayer !denti{ication Number {flN)
Eiller vorrr TIN rn ll:* rpptosriata bol ;l 'cu ac'a tesdert d(an and
;;;J;ihave and "" *t *e'J'' -f:';il31'lf; :lHJ?i,*'
iRS mtr Snterit,n th+ *nlrY t
cio mt ha.e r [rlN' l:+ v6'a ;6 gei a !?ru bi{46n-.
ii vui are a solg pmpnetor ad-';r uhaqe 3nTf"|"#'t *i'i xtlzt 4G1u
TawssN qr EIN' 'I ! tl &31 3 ?'s(eg*d+d aG ar ?",lY
ii 'mu rr* r singl{-n:erib+' tlt T.1 -'-:?ffi;;?nr 'i t" :g:tart 1as
fi [-#"iJild11's**';:'y,';#;ff "?'"'llil'X";'*"-
*nlln.'s:lll. . - - .,,. t,
.;;;;; ,vt*! *!aytt,-vfti ttsmp+r'!': l': iF€ 34t-;i4i'ta:a 'e:
t"#;-'Jr,-ot"t*tn oi rene ard T!!'l :crtuad'ers'
Ftow ri {'.e-'-:Ildil *l tr##f ;,}1#iJ"Tffilil'
l'-ii'l#rii;:lrGi^-- -- -r *'< +'ft trr'€ 4t.l#ril}ffiffrd;ff-iffiff#d;"'"
'##*m
rra;: F+rm Vl' ; tn'Ld* I qtfi
dals ,., n:,, r'/.raths.* 7illi. t6:1
'il1,#,
iiJ i " ttce Y ou( T # t t-o de' +4*+ts
slore: fnlerng -.Appfie"tl ler' 'u*'' 'fi"t irttlz"f-:b:ed'i t*PkEJt}, t
h:#';yil:l:Iry,i#tit*";x;ni^7';#*:;'i"7
vrh:n ''rtn; m,lv '|rtsttad D+ =f,;i;;;;;-h"ldmi:
und+( 1"'4ar4t 3 at 3 al
for
di,ridend Payments All exempt Payees excePt
f,or 7
THEN the Payment 15 exetnPt
io ?O1 e-
tEnsactions Exempt Payees 1 lirough -l'
!6,00.e{irll,ed 19 Generaltl.rxemPt P*/:.t.s
tnd Jrract r:l*-c nva.1 through 5-'
. Payinenls
lle r€P.)t1-'dj
0vel
the code'
Caulion: i\ c!sr-gard'd
lh* 1p/4[jrrate =$m1 r""
U t- efritty d''6€ ila z a ?ari,,gn e:t;s rBtd uta
Kittitas County Agreement for Services lre-v' 5114/75)
Page 20 of 24
5
Fom !V-3 (R-v- 3'292'r,
Part ll. Certification
7o eelablish b lhe mthhordflg agent thet you are : q : po'="tt o
;;ffi1t';;, -,n. io# w-s.-Yi; 'ntv be requested to 'Yn bv r,'
;rruilff LIXd "ri
i'it rrt"i 1.'t' or 5 below-srdrcat€e oth€'rlre.
no, a toit accgunl. only th' person whose ill'l rs sfiorza 'n Farl i
trl"iro igi'(,'rh";t requid!1. lohe casa o{ a dsegarded enliy lhc
i-l*l 11",!n*o on line t #urt tign. Erernpt pay*ec re€ &etnptlrvee
code. eaAier.
Sronature requiromenl3- Comple!; the cerlifrcatbn as indicated in
ite"ms 1 throuqh 5 belo"v
i. interast. a.livi{ttnd, aatJ bnrlel exchang* acco.utrtr op.erred
?:i{'J:S.t*$.:iro:nl,lmft rit*fd*:#',H.'*
certilication,
2- lnlerest, rlividend, broker. sn<l bader €xchange eccrunts
r['il+;T*'::;at:ul*1,"":t"TH:,fl F*",i"':'ffi ',uii$iljl'
;ruffiil;'u."r."p **rt"roog and vou ra rnerBly providing
lil;;#ffiltf' ,h. t"'qtor"t. yoJrntrst roes out item 2 in lhe
lEailicatton b4lore signing lhe form'
3- Real estate lransactions' You must sign the certifcation' You may
cross out item 2 o( tfie certificatton'
rl. otlter p{yments. vrxJ mugt oiva {out cotrecl TtN' but you do not
h '-o rA qi6 lhe cetl't1c6lon unle& you have b€efl noflfied lhal you
;,:JI ;-"ruy Ju*n "o
in""""tt T[u' 'r}tt'er payments- rncltrda
^1,,-6^re trrr.le rn lfie courv! o-t rite,squ":ret's fade or btgnass for
i;'#l.;iil;:sil; ("il']h* b;rs 6r m*'chandsar' rn?dcar and
;:;]ii';# ;;es fincl'ding pavmenis to corpo(aionsl'.FaFnents tn
;;;;;;;;. rror servicas. #vmetrs n'aoe rn sttilernenl ol pavfirent
;ir5;;;I;,t;ttty n-'r"",r uanJJtrons' oavnents to certajn fish'nq
ffij ;;;;-Gri rnd fshernrer=' and gro$s proceerls pild ts
r ttJrn"yt fncluding payrT!€nts to corpontions)'
q Morldice inlerEsl poid by you. ncqql$iltott or aban<lonntettl ol
...;;;;; o1""o.rav. .an"ill"tio^ ol debt' qtrolified itlilton protlranr
lllili",['rrl,l'? section 529],-iiJG-acc'"ii"ts {t'n<ter seclion S?sAl'
irii.'J.*t.t-rigSA Archer MsA or HsA :onlritrutiorts or
:iil;il;t;.; ;;J pe,,siot di$ittbrilions- v:t1trst ii(* vou( tltffiect
Tltl, brrt you <!o not'have tc sign rhi c€rlncalon'
For this sf
e Oin{trdidtdryGl
individud
'Ust firsi and circle the r'arne
9 . A vsrid trust. esiate- # t#il i!6i
l!|. Ciffir;m s tlC l*:'an7'vgr:c- nffi5fonlfJ?rtm)i*
! I . A$€nfiea. --tub' elilirre- cFlebb
aduationaj. or otft a iai:-xfl gi
orgmiatim
l?. ParrwrhrP ry muti'rchs tl.i
13- A brokertr.eg;wd ildffi
l.r A.wnt rr{h Oa Orlrrng r oi
Agiclare * rtrt r*lt r r:u&f
tridtr 6uctr s I rt:c:cbsrj
gfi.;anst schi,l fEF: 69!'.f:
thal r{ei€ rq.icdhsat P${rF
paymtrb
15 G€nlortlst fif4g Fm 164'l s
under tht OolbnJ fe4 LlcSrd -1'
msint fumr I t4':t l*r na7l}'lca
do*
'ottt16l2YgPo''
Gise nrrs and EIN ot
v.lltelws
legi dditr'
th* f,.:rtt:td
r,hr{€#6$a
Ihdsfiddls
lF.e5re!grffirn-
EEe lr$r gcitY
The 5u*
cf the p.=sr:n Trhase fttrnber '7ou fumsh.
S.St{. {fiat Patson's number
lf ody or€ p€.nofl on d iont ac{:ounl h.3s an
mu:t-be ftrnbhed'
What Name and Nurnbe r To Give the Requester
For lhis of eccottnt:Give narne rnd lSl\d cf:
lh"
r Circle the minor's name and frtrdslt tie rilftols SSN
;:*rgyr"n:'##",H:":",il*l#i'?g#T'Hfr F-
yr" ia* ot"f. brrl Ge iFS rrroJt3*:s'taf ig use ycut Jlr'
t !9t first and crrcl,g ihe na..ne tf itl. 1}rr9- esEl]It' or perl-lisn |tusl {Oo
rlot fumrsi! tle nN al lhs p"t=uJrep"*t*ttad"; s/ $Js&l+ 'rnhss |ie
;#;;tq ,ttdi'" *rt *iqiIa?;drn +r F?unt due I
' No!e: ibe ganlos sggl 3ts$ 9'E tdg e F:rm U/-9 {a $'1* r&'sii€ oi ih:
trust.
-- Fof mote ,nfbtmat'qn tn ;p{rorel niit* 'rit'E.(ls
if t gr'inldt itt-isls' 9t:
the lnstuctions fior Fd'rfi lojl
llole: lf nc nama :3 :rctid'{t'}*r r'3r' tlan "* nttn* Ls lt€!*d' the
nornhsr i"fi c* l:f'a{i<*' {* b{ tt}3n ti t1a liGt :aarQ' n{€'J
Secure Your Tax Records Frorn ldentify Thett
ld?nirl.,' lh*f cccuc -'r-'!g1 io{'+'s'c -*s ;ut g+r'otd 'nlolnr0on
;.;;"';;t;;* ssil t rf*'":*-rrhie q 'rdcrraino' aril''rut laj
;;;# ; ;;; Jr*6 5;.^r ;a : ffi +5'b r't-Y *i !F!i'i {Fr' "*
;;;Tsl'i ;;;ir;ob c' r'a''fii+; -:4 -'t!s 6rr€ /ndr ssFl ta t;f,e1''q
a r:nrnd-
To rzdt*z Yav( i{r;
" Frotat your SS|I-
. Enstsg yflJr tqpic'1er t= p<er:cnrrg v>l 56lt ' :rd
- Sa .:arEful {h:n rhc{1stg a'-&\'{-r'tFf,49'alt"'
li rorrr ia .43{lttt uts #t-al{ UI4anii" tea t14';c't '2')t!+ a
""n. il*'',it--, in -,'ry'l 4ht L'3 !' rhe nan+ ]'rt tf'rr; rtJr: ber
tnnred cn ht ,FS eott€* lr iJfi;t-
ll ,raut rar r+cardr sra :r t =En+r[l,
'4f':.{:zrt 1'" dJ1t'ty- fi''it bul -u
,h ;; i ;; ; ; Jlr*''u u *''
=
J' ! * ?6e'lr' rdlsr''?sestrondtt+
i',"*r' i] J''*rr.tt n t * *.G-"e* s&'egl, r' t -ta"1';' e : f€
ffi;';i;ffi ;;i'' 1 fri ne s:o :' rr'aq'r icrrr r'rtjel
ftr iq,)t? ,ni{}rsrif q" ye tab yi13 lt:"ta|]r Jt'{tl-' 'r-}nna!+fi ttr
frtp*1ers-
r 1*,o o{ mcre ndeJdurb ion( Jcc'Mt!- ort':r ths rn rcsrrnt rurirhrrn:d irt
vFfl
J.fwo q moct U $ P+s*
;lornl iccount majntrn:d b'l o FFI
j Custcdial JcEolnl o{ a mrrq
lljnri,Ft G;fl io irlitq; 'Actl
5 r Th" wlt re!ffit{e -vi(gs b'6t
Igrntor is Jls tr6tEl
b. S+aEed fwt rcqunt iJEl {s mr
,tleoal qr vdltd tral '$d"r itatl krv;
o. SolJ propnetwhip tr ii'a*gsdgl
mtitv ovrned bY m indi"iduaj
; 4rantor l-,st ilrng ud€r CtPo9flai
F lht trt'n(4 'ea. Fi'Jfit'd :
:e-- "c^ t,; i I -'trt: :("'tArt-'
Th€ nct€l lranf l:'Jh- s'L-f,rtt r''
ii smf'1 *. i rrr€ rh- ia: roJD'rl'':l
,$ d-* !:;ffi1
Each hqids {i'}.e Eit@t
ihz mmc+l
ih" lrzrtq-rgi-
lh* ci:sl cvrr:r'
Tir: aT.t.{I
Tht ivaioi-
Kittitas County Agreement for Services (rev ' 5/14/25)
Page 2l of 24
Page 6
Fom W-9 iR€v. 3-20211
ho\./ lo reduce Your risk-
Kittitas County Agreement for Services lrev 5ll'a/25)
Page 22 of 24
FrivacY Act Notice
s{€tbl ttss a't d,l. ki*ftld R.rrrr'€ 6ode rlqrrfuel yort lo ptsulde your
ffi 'f;;;';'",'1*%";*#55gt;,ffi ru:Y "
.-
ffi?ts:ffiH$
fffi'ffi t-.;'ry'c'es ocnrorce o'i I
fii;#*t,il ot dt"aettrgt etddE€trenl atd int€-srgenci
srncrci (o.smb3! trrro{isn r6ilJrtol,l" yA-'-yl rvh-ether or nal#ffit '
teilain Penattiss ma! aJso sPP
informalion'
SECTION 1: CONTRACTOR COMPLETES THIS SECTION:
DidyouretirefromoneoftheStateofWashingtonRetirementSystems?
Didyouretirebeforeage65usingthe2008earlyretirementfactors(ERF)?
Will you be receiving direct compensation for these services?
Will you be receiving indirect compensation for these services?
ATTACHMENT'G
SEIISE!4ISI-5IAIUI_EABU
** All Contractors who are individuals must complete and sign r*
2. ls Contractor a retiree of a Washington State Retirement System?
3.DidContractorretirebeforeage65usingthe200sERF?
I have verified the information above using MRV or by contacting DRS'
Yes
Yes
Yes
Yes
No
No
No
No
CONTRACTOR (Full name of contractor as in DRS filings-Please Print): '-
Signature Last Four Digits of Social Security No
Date
SECTION 1: COUNTY COMPTETES 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 System? -- Yes -- No
lf yes, which sYstem and Plan?
Teachers' Retirement System (TRS) -_ Plan 1 Plan 2
-
Plan 3
: fi;;;oi"o*t;o"tiiu*unisvstem {stRs} - Plan 2 -. Plan 3
-
Public Employees' Retirement Systerns (PERS)
-
Plan 1
-
Plan 2
-
Plan 3
--- Public Safety Employees' Retirement System (PSERS) -
Plan 2
-_ Law Enforcement officers, & Fire Fighters' Retirement system (lEOrr) -
Plan 1 -
Plan 2
_ washington state patror Retirement system (wspRs) - Plan 1
-
Plan 2
Judicial Retirement SYstem (JRS)
Yes
Yes
No
No
COUNTY REPRESENTATIVE (Please Print):
Signature Date
COUNTY RETAINS ThIIS FORM
Kittitas County Agreement for Services {rev' 5/14/25)
Page 23 of 24
ATTACHMENT "H"
SUECONTRACTING
The contractor shall subcontract county funding through this agreement to the following subcontractors in the
following approximate amounts. This exhibit constitutes written approval of the subcontracts below'
rf subcontract agreernent s andf oractuar costs change by more than 10%, the contractor must immediately notify
the County, and the County may require an amendment to this agreement'
The county reserves the right to enforce alr parts of Generar rerms and Conditions section 5 of this agreement'
Kittitas County Agreement for Services (rev' 5/t4/251
Page 24 of 24
ntAmou
1,800
Fami PLLCThera
0".- lllf'9
(Fev. March 2024)
Department of lhe Treasury
Give form to the
requester- Do not
send to the lRS.
Go to www.irs.govlForm W9 for instructions and the latest information'
related to the rpose of Form W-9, see of Form, below
An entry is required-(For a sole proprielor or disregarded entily, enter ihe owner's name on line 1. and enter the business/disregarded
2 Business name/disregarded entity name'if different from above
4 Exemptions (codes apolY onlY to
certain entities, not individuals:
s€e instructions on Page 3):
Exernpt paye code (f anY)
Exemption from Foreign Account Tax
Compliance Act (FATCA) rePortlng
code (if anY)
(Appties to accounts maintained
outs/de tig United States'.)
Requester's name and address (optional)
List account number(s) here (optional)
Request for TaxPaYer
ldentification Number and Certification
lnternal Revenue Seruice
Before You in. For
1 Name of enlity/individual-
entity's name on line 2.)
Peers Risi
c.j
o
(!o
co,tooccro>Er(J
oq
EO
o'oE
oo
o-o
0)
0ta
7
Number
Enter you r TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding For individuals, this is generaily your social security number (SSN). However, for a
resident alien, sole Pro prietor, or disregarded entity, see the instructions tor Part l, later' For other
entities, it is your employer identification number (ElN)' If you cio not have a number, see How to get a or
I/N, later.
Notel lf the account is in more than one name' see the instructions for line l See also what Name and
Number To Give the Hequester tor guidelines on whose number to enter'
Certlfication
3. i am a U.S. ciiizen or othei U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating th at I am exempt from FATCA reporting is correct'
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currentiy
For real estate transactions' item 2 does
Under penalties of periury' I certify that:
.1 . The number shown on this form is my correct taxpayer identi{ication number (or I am waiting for a number to be issued to me); and
2. I am norsublect to backup withholding because (a) | am exernpt irom backup withholding, or (b) I have.not.been .,oiified by the lntetnal Revenue
service (lHSi that r am subject to backup withhording as a resurl cf a failure to report att iiierest'or dividends, or (c) the IRS iras noti{led me that I am
no longer sublect to backup withholding; and
subject to backuP wiihholding
not apply For morlgage interest paid,
because you have failed to rePort all interest and dividends on your tax return'
acquisition or abandonment of secured property'cancellation of debt, contributions to an individual retirement arrangement (lBA), and, generallY, Payments
the certiflcation but :/cu must proviCe correct TiN.See the instructions ior Part Il, later
other than interest and dividends,are not to
Sign
Here
Signature ot
U.S. person ,/,;!{,(/&0,t Dare 1/30/2026
General lnstructions
Section re{erences are to the lnternal Revenue Code unless otheruvise
noted.
Future developments- For the latest information about developments
,"rrt.J to rom w_g and iis instructions, such as legislation enacted
atter they rvere published, go lo www irs'gov/FormW9'
What's hlew
Line 3a has been modified to clarify how a disregarded entity completes
ini" f i"". An LLC tnat is a disregarded entity should check the
aoorr-ioriate box for the tax claJsificatlon of its o""'ner Otherwise' it
il;;ti;;";klhe "LLC" box and enter its appropriale tax classification'
New line 3b has been added to this form' A flow-through entity is
l"";;;;;i ;; ;;;Ltt this line to inc'icate that it r'las direcl or indirect
ioreign sartn€rs. owners, or beneficiaries.lvhen It proyifl* ihe Forrn W-9
i" r"ir-* fr"*-itrrcugh entit'l rn
"vhicrr
it i'ras an ownership interest' This
.i""i" i. r;i";decl to"provioe a flow-through entity wrth information
r.uga,'iir,g the siatus of its indirecr foreign panners' owners' or'
be"ne{icia"rres, so lnat it can salis{y nny applicable reporting
."q.rir"nrunt". ftr exanlple' a pa'rne"ii'ip rnqt .nu: ::y indirect ioreign
oatl}e,€may bc requrred to complete sL'hedules K-2 and K-3 See the
i1lll""tt"ip r',tttt,"iiu". for Scireciutes K-2 and K-3 rForm l0d5't
Purpose of Form
Ai individual or entity (Form W-9 :equesier) who.is requirad to file an
rii"i."tirt ,"irt *itF th" IRS is giving you this form because they
only one of the following seven boxes.
I lndivicual/sole oroprietor I C corporation r! S corporation I Partnership I TrusVestate
! ffC. Enter the tax classiflcation (C = C corporation' S = S corporation' P = Partnership)
Note: check the,,LLC,, box above and, in the entry space, snter ihe appfopriato code,(c, S, o' P) for lh'1 iax
classification of tne LLG, unless it is a disregarded entity. A disiegor'reJ enilty shouto instBscl ?heck the appropriate
Non-Profit Orqan ization 501(C) 3
name is entered on line 1. Checktax classification of the entitylindividual whose3a Check the approPriate box for federai
box for the tax classification of its owner
@ otner lsee instructions)
il
classification,ttrentereditsP"asand'LLC"checkedor"TrusVestate,orch€cked PartnershiP"lf3b lineon 3a you checkInterest,orvnershiinhaveanestatewhichoryoutrust,formihis to partnershiP,are providingandyou inslructionsSeebeneficiaries.orowners,if h ave partners,box any foreignthisyou
5 Address (number, street, and apt or suite
110 W 6TH AVE PMB 118
no.). See instructions.
6 City, state, andzlP code
ELLENSBURG WA 98926
numSocialPart I
numbergrnploy€r identification
44292584
Paft ll
Cat. No. 10231X
rorm W-3 (Rev'3-2024\
LIMITSPOLICY EXPPOLICY EFF
YI
INSD WVDTYPE OF INSURANCE
NAIC ''EtNStl
| 17 la::
-5,nAc{}f<f)"\--"'
o11302026
THIS CERTIFICATE IS ISSUEO AS A MATTE R OF INFORMATION O NLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFI CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AME ND, EXTENO OR ALTER THE COVERAG E AFFORDED BY THE POLICIES
EELOW THIS CERTIFI CATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSU ING INSURER(S), AUTHORIZED
REPRES OR PRO DUCER,AND THE C ERTIFICA TE HOLDER.
DITIONAL INSUREO Provis ions or be endorsed'
IMPORTANT:lf the certificate holder is AN ADDITIONAL INSURED,may require an endorseme nt. A statement on
If SUBROGATION lS WAIVED, subject to the terms and conditions
certifi not confer the cate holder i lieu of such e
CERTIFIC ATE OF LIABILITY INSURANCE
CLTi.iTRACT CR OiHER
OATE (MM/DDTYYYY)
REVISION NUMBER:
DOCUMENT .'A/I IH RESPE CT iO Wi-IICH THIS
i\,EJ
"ERSONAL
3 A'V !NJUEY
GENERAL AGGREGATE
P RODII
PRODUCER
f, mpilcan Llnijenr'/rile:3
ni j6 i-i,qior'rllivAY rACofirr\ r^rA eRr0e
PHONE
INSURER F :
2EERS RISING
r i | \l/ 6:H A\/E Pi\"48 118
eLLENSEURG. Vv"A 98926
INSU RED
c OVERAGES
]NPICA
CERTIFICA
: INSR
, LTR
CERTIFICATE NUMBER: 7993548 85 1 9487781 gDC l 3c26T204653
CF INSURANCE LiSTED BE:OVV HAVE BEEN ISSUED TO iH=INSURED NAN1E D ABOVE FCR THE POLICY PERIOD
THIS IS I'O CERTiFY i AT TiiI PCI-ICIES
St.lEO OR N-IAY irEq TAII\] TNE INSURANCE o-r.*O6p gV rFl E POt-lC|ES LIESCRIBED HEREIN IS SUBJECT iO
iXCLUSICi\]S Ai\iD CONDITIONS OF SUCFI PCLICI ES LIMITS SHOWN NlA Y HAVE EEEN REDUCED J'/ PAID .JLAINlS
IANDING ANY REQUI REMEI'IT TERM OR coNDtTloN ctr ANY
POLICY NUMBER
AI,L THE IEA|\IS.
IED NCi\I./!iFiS
TE IV1AY 6: iS
COMMERCIAL GENERAL LIABILITY
:LA,'.1:j vAtrt i c'l'luH
i Ai\IY AI]TC
AUTOMOBILE LIABILITY
DISEAS- - POLICY Lit''1Ii
a r\ii:,
;L j '1:i Ir-\'
H, R: IJ.i , r,l': tll.'1
UIlIBRELLA LIAB
EXCFSS L'AB
SClISDULE'
AUTCS
I'iiill'.J!''j:.::--qr 1199 lfrt
X
!nai!a.JF OI]EnlA
tiO2C3299A iai .3:2a25
'..)t 13r2C25
c!1U2n2a
A
Y/N
AND
oaiic
N/A
I.
Iln EL
ig.;.;rrbe
Ss9 ACORD lC1 lor ad'jilional to'/araEe Cetails
DC2082990
A
DESCRIPTION OF OPERATIONS i LOCATIONS / VEHICLES (ACoRD 101, Additional Remarks Schedule' may be rttached if more sPace is required)
CANCELLATION
CERTIFICATE HOLDER
1,ai 13;an25
SHOULD ANY OF THE AEOVE DESCRIBED POLICIES BE CANCELLED EEFORE
THE EXPIRATION DATE iTT-E-NEOi' NOTICE W!LL BE DELIVERED IN
"iio*o"Hc.
wlrH rHE PoLlcY PRovlsloNS'
?ErRS Rl
'| iC !'J 6r-H
ELL.Ft.ISB!]
Av'E Plv-lg',i l3
rc wA. 9S326 AUTHORIZED REPRESENTATIVE frr*ek
@ 1988-2015 ACORD
,ti
:t
E.L EACH ACCiOFNT
EACH OCCURREi\iCE
AGGR-CA:Eljccllit
CL/\iMS i\4ADE
i?g1al.i iirit{ iDElj
Ni\i
ACORD 25 (2015103)The ACORD name and loqo are reqistered marks of ACORD
CORPORATION All rights reserved.
--,^At:()Rr)*CERTI FICATE OF LIABILITY INSURANCE
DATE {MM/DD]TYYYY}
01t3012026
CATE THISHOLDER,ETH CERTIFIUPONNORIGHTSNFERScoNLNDAoTIONFoINFORMATTERAMA PoLlctESSSEDUASHEBYTISTERDEDAFFOctSERTIFICATHCOVERAGETHETERALOREXTENDATIVELEGAMEND,OR NFATFIRMAIVEL AUTHORIZEDNOTESREINSUDOTEINISSU),R(SGCERTIFICAETHBTETWEENNTRACcoACONSTITUTENOTDOESFUNSRANCEoTEtsTHCERTIFICABELOWtcAFHOLDER.TEETHERTIcNDARoPRODUCER,AENT TIVEREPRES ebe ndorsedorONATItNsLustmhaveREDSUtheONAINpolicy(iesL ontsADDanITholdeAstatementcertificatetfutrenaendorsement'NTAIMPORT n may reqcertaipoliciesoftheconditionspolicytermsandustotheSWANTrOIVED,bjectROGABSUlf suchofleulnholdertocertificatethehtsnotdoesconfercertificatethis
,9 ! Lg 99"" t'tv-!:!l?-l cr
- 99T!9!y-
Nodhcutt, Lavonne
24082
RA:
INSUR€AFFORDING
rl9)i..-..PRODUCER
American Underwriters lns Agcys lnc
6429 South Tacoma WaY
wA 984094004
wA 98926
Taco_ma
INSURED
Peers Rising
J 10 W 6th Ave Pmb 1 18
REVI 201 6-03
COVERAGES CERTIFICATE NUMBER: 01 44906689
TYPE OF INsURANCE
LIMITSUCH
ADDL ,s06R;-
TO THE INSURED NAMEDI-IAVE BEEN ISSUEDE LISTED BELOWE POLICIES OF INSURANCTO CERTIFY THAT TH T OR OTHER DOCUMENTHIS IS OF ANY CONTRACOR CONDITIONNG ANY REQUIREMENT. TERMCATED, NOTWTHSTANDI ES DESCRIBED HEREININDIBY THE POLICIRANCE AFFORDEDMAY PERTAIN. THE INSUICATE MAY BE ISSUED OR BY PAID CLAIMSCERTIFfuIAY HAVE BEEN REDUCEDPOLICIES. LIlilITS SHO\AA]D CONDITIONS OF SEXCLUSIONS AN
ODPERITHEPOLICYFORABOVE
ISTHtcHTOECTWHRESPWITHT
TERMSTHEALt-TOSUBJECTS
A
Prlouuc tl;
000REGA'iE
AGG
*, 1,000,000
s 1,000,000
15.000
1.000.00010i26t2025 10/2612026x x 8KS63980283 s2,
r 2,000,000
OCCURRENC-
GEivi_ /\GGAEGAIE i-llnl: APi!-lqS PE3
!( ,o.,." 111?- X. rcc
X coMMERcIALGENERAL.LIABILITY
t
.-, cLAiMs-i\,1AD: iI ot"'*
10126120258KS63980283A
$ 1,000,000
RY (Pet PErscn) ; 3A U'rO trtoBlLE LIABI LITY
ANY AUTO
.;4I.IED SCIILDULiDi',i,ri rrt, v AIITCSx xffi;;." x l8i',;3'fr',?
1 O I 26 I 2A26' Bo Dr LY rl\r i u RYlry1a:"9"1]r-:,,- - - -:;r-l=i:i'r.F.ii-;ill'fi;e l$
gCDILY iN,jti
AGGRECA
Ul1/IBRELLA LIA'B
FXCESS LJAB
OCCUR
CLqI&IS MA'E
FACFi OCCUP.RENC:
Y1N
i i N/A
1.000.000ELi ltullT
. E L DiSEAS.FA lf.,rPioYie 58KS63980283 - Stop Gap 1O|26DA25 1012612026
WORKERS COMPEI.ISATION
desc.
in NH)
urder
1,!ry!q9 -1,000,000
AND EMPLOYERS' LIABILIIY
AfJYPRCpRIE fOR,'PAR f lrER/E {rC'JTr\l:
oipicenillevgep =XaLi.j DE It
Additional Remarks Schedule' may be attached jf mo.e sPace is lequired)
DESCRIPTION OF OPERAIIONS / LOCATION s / VEHICLES (ACORO 101
"'Prcof of lnsurance^""
TE OLDER CANCELLATIO
o 1988-201s ACORD CORPORA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES.BE CANCELLED BEFORE
THE EXPIRATION DATE TTiC_NE6i,
-HOTICE WILL BE DELIVERED IN
ailon-onr.rce wtrH THE PoLlcY PRovlsloNS'
'a -:/ -:
. .: ?":-|' ..../--
AUTHORIZED REPRESEN TATIVE
Curtis Luken
Peers Rising
110$/6thAvePmb 118
Ellensburg wA 98926
AcoRD 2s (2016to3)The ACORD name and logo are registered marks of ACORD
TION. All rights reserved'
,.drIT',*t
'f;#
$1AT[ *F ]SA5HIN0T0N
Department of Labor & lndustries
certificate of workers' compensation coverage
JanuarY 30,2026
WA UBI No.
L&l Account lD
Legal Business Name
Doing Business As
Workers' ComP Premium Status:
604 817 226
185,334-00
PEERS RISING
PEERS RISING
Account is in good standing'
A;;;;iy rePJrt received and is beins
processed.
Pending current quarter filing
Employer Services Help Line' (360) 902-4817
No
Estimated Workers RePorted
(See DescriPtion Below)
Account RePresentative
Licensed Contractor?
What does "Estimated Workers Reported"
mean?
Estimated workers reported represents the number of
full time position requiring at least 480 hours of work'
per calendar quarter' A single 480 hour position may
be filled by one person, or several part time workers'
lndustrial lnsurance Information
Employers report and pay premiums each quarter
based on hours of employee work already performed'
and are liable for premiums found later to be due'
lndustrial insurance accounts have no policy periods'
cancellation dates' limitations of coverage or waiver of
subrogation (See RCW 5l ' L2'050 and 5I ' i 6' I 90)'
Attachment "l"
Non-Payrotl Expenses lnvoicing Temptate
SG€NGYtllAI{€
ADDRESS
ABOmSS
liltlo
Kinius€auntyPubllt HeEl$ DePanmeor
s?Ntt$rumst,$u[e l0?
Ettee.sburg.WAS26
yl$-sl.t515
trmiccD€tailg
lnvoico Ns:
lft{dcebla:
Flersr miil inloiqs 3ftd backlp docum€nls to lialig.odiigtQoo.l1it{ilis ua'us