HomeMy WebLinkAboutFully Executed - FKITTITAS COUNTY AMENDMENT TO:
PHMH26.OO2
Amendment #2
This Amendment ('Amendment") is made as of June 2,2026 by and between Kittitas County
(hereinafter "County"), a politicat subdivision of the State of Washington, and Robin H Read
Consutti ng (herei nafter "Contractor").
WHEREAS, the parties entered into an agreement February 1 ,2026 (the 'Agreement"); and
WHEREAS, the grantee was requested to add additionaI data cotlection around devetopmentaI
disabil.ities retated information;
WHEREAS, the parties desire to amend the Agreement;
NOW THEREFORE, the parties agree as fottows:
1. Amendment
The Agreement is amended as fottows: in the Devetopmental Disabitities Biennial Ptan
2026-2028 Creation, add hosting two listening sessions under data updates in the scope of
work.
Totat contract amount increases by $3,500 to a new contract total of $27,500.
2. No Other Changes
Atl, other terms of the Agreement remain unchanged and in futl. force and effect
lN WITNESS WHEREOF, the parties have executed this Amendment as of the latest date written
below.
Kittitas County Amendment to: lLA, AGS, lnterDept. MOU (8128/25)
Page 1 ot 2
CONTRACTOR
Titte
(b,",7
Date:
0*uvrr
S
Printed Name
KITTITAS COUNTY
BOARD OF COUNTY COMMISSIONERS
ABSENT
CoryWright, Chair
mmissionerLau
oblt b I AbDate
Attest:
trBh
of the rd
-E JulieKjorsvik
! Mandy Buchholz
Kittitas County Amendment to: lLA, AGS, lnterDept. MOU (8128/25)
Page 2 of 2
t
Kittitas County Public Health
Contract/Agree ment Review Form
Kitlitas county
Public Health
Departmerit
Today's Date:03.17.26 ffi rcgat Request #:12183
Fund/Department:116-Public Health ill Agenda Date:
lnformation
Contract/Agreement Agency: Robin Read
Contract/AgreementTitle: AFS Between Kittitas and Robin Read Amendment 1
End Date: 03.01.27Begin Date: 02.01.26
Contract/Agreement #: PHMH26-002Total S Amount: $23,000.00
Contract/Agreement Su mm a ry:
The amendment is established to change the original begin date of the contract from
Upon Signature
to
Q2.01.26
Kittitas County Prosecutor and Auditor Review and Comment:
o 3'21, zc-
DatePl'sSignature
Dateditor's ceof
Bu lnformation
Revenue Code(s)
-lvxqllnl /4lnt -DDD1l+lExpense Code(s):
Not Checked (reason)Agency is not suspended/disbarred
Agency to Pass Through
Expense Code:Amount to Pass Through
Sub-Contract Approved Date
Pass lnformation
Approva LoeffersBy:Modified By: Katie OdiagaSupersedes:0 Date Adopted: l2loLl2o24ADMINVersion:0
KITTITAS COU NTY AMENDM ENT TO:
Agreement for Services between
Kittitas CountY and Robin H Read
Gonsulting PHMH26'002
This Amendment (.,Amendment") is made as of Aprit 7,2026, by and between Kittitas County
(hereinafter "County"), a potiticat subdivision of the State of Washington' and Robin H Read
Consutti ng (herei nafte r "Contractor")'
*HEREAS, the parties entered into an agreement dated March 3,2026 (the "ASreement"); and
WHEREAS, the parties desire to amend the A$reement;
NOW THEREFORE, the parties agree as foltows:
1. Amendment
The Agreement is amended as follows Contract start date to change to February 1 ' 2026
2. No Other Changes
Al.l. other terms of the Agreement remain unchanged and in futt force and effect'
lN WITNESS WHEREOF, the parties have executed this Amendment as of the tatest date written
betow.
Kittitas County Amendment to: lLA, AGS, lnterDept' MOU (8128/25l,
Page 1 of 2
Qt*t(
Printed Name
3o
CONTRACTOR
re
Titte
2-.hDate
LA ,b.*lJ
KITTITAS GOUNTY
BOARD OF COUNTY COMMISSIONERS
CoryWright, Chair
Vice-ChairBrett
Commissioner
Date:
Attest:
of the ard
-E lutie Kjorsvik
tr MandY Buchhotz
SEAI,
7:,
Kittitas county Amendment to: lLA, AGS, lnterDept' Mou (8128125')
Pagezof 2
s
Kittitas CountY Public Health
Contract/Agreement Review Form
A Xr:l;(rt {'uatYIt puntic Health
{
U#'t)if 'ri4:i:
12183legal Request S:01128126Today's Date:
Agenda Date:116Fu nd/DePartment:
lnformation
Contract/Agreement ReadRobinncyAge
and Robin ReadKittitasbetweenle:AFSTirContract/Agreement
Begin Date: UPon Signature tnd Date: 03/31 t14
H26-002P#:HMct/AgreementContratotal 5 Amount: $23,000.00
Contract/Agreement Summ a rY:
The purpose of this Agreement is for the creation of plans.for advisory committees including a 2
vear strategic pran toi'mentat hearth rno ,r-o-:i"n**1"" disorder prevention. an actions pran for
iromeressness an affordabre housing, ".#;;;;e-Joienniar
plin for development disabilities
advisory committee.
n
Pass lnformation
Su b-Contract APProved Date :
Date
6 LLL
J 3'p
Review and Comment:Kittitas CountY Prosecutor and Auditor
Signature of
Date
itor's Offlce
Revenue Code(s):- 001-1654101I01o1l411H000H010l41HS2000Expense Code(s):
Not Checked (reason)isbarredAgency is not su spended/d
AgencY to Pass Through
Expense Code
Amount to Pass Through
Loeffers
DateVersion: O 0ADMIN
J
1/28126, 1:19 PM
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zJS
KITTITAS COUNTY
AGREEMENT FOR SERVICES
PHMH25.OO2
ThisAgreementforServices(hereinafter,,Agreement,,)isenteredintobyandbetweenKittitasCounty
(hereinafter "County"), a political subdivision of it't" State of Washington' and Robin H Read Consulting
(herei nafter "Contractor")'
COUNW CONTRACTOR
1301 N Main Street
Ellensburg, WA 98926
ThepurposeofthlsAgreementisasfollows:creationofplansforadvisorycommitteesincludinga?-year
strategic plan for mental trea'ith and substance use disorde, pr"u"ntion. an ac;on plan for homelessness and
affordable housing, and an updated biennial pt,nlo'developmental disabilities advisory committee'
The term of this Agreement shall be from the date of execution through March 31' 2027' unless the
Agreement is terminated ""-'ly
o' its term is extended as provided herein'
Theparties,addressesandpointsofcontactfortheadministrationofthisAgreementareasfollows:
507 N Nanum Street Ste 102
Ellensburg, WA 98925
Kasey Knutson
Human Services Manager
Kittitas County Public Health Department
Kasey.knutson@co.kittitas'wa'us
509-962-7sLs
Robin Read
Owner, Robin H Read Consulting
robinhread@gmail'com
509-607-1375
This Agreement includes the following, which are attached hereto and hereby incorporated by this
reference:
Attachment "A":
Attachment "B":
Attachmerit "C":
Attachment "D":
Attachment "E":
Kittitas County Agreement for Services (rev' 5/14/25],
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 r/ contractollt "i inaiuiaual' as opposed to a corporate business
entitY)
ATTACHMENT "A"
SCOPE OF WORK
tltol| oF |%MENTAL HEATTH AND CHEMICAL DEPENDENCY ADVISoRY BOARD - CREATION OF A 2 YEAR
STRATEGIC PI.AN
Pre-work
o Review Kittitas County Behavioral Health assessment results
oResearchandreviewbehavioralhealthplansfromothercounties
o Attend committee meetings
Dats Collection
oCreateinterviewquestionsandinterviewcommitteemembersandstaff
oConductStrengths,Weaknesses,opportunities,Threatsanalysiswithcommittee
o Compile and present feport of data collection results
o Analyze services funded for duplication
o Analyze perforrnance data for people served and cost per person
tn person strategic planning meetings
o Create vision, mission, and value statements
o ldentifY new name of committee
o ldentifu 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 na! Strotegic Plan Dacumentation
o Complete final strategic plan document
o Create presentation slides for communication of plan
Quarterly uPdotes
o Prepare quarterly updates on plan progress
o Attend quarterly public health study sessions to present updates
7-2-hour workshop on facilitation
o Meetings with staff far feedback on content
o Development af content and activlties
o Provision of workshoP
a
a
I
a
o
HOMELESSNESS AND AFFORDABLE HOUSING ACTION PLAN CREATION
Pre-work
o Review Kittitas County Homeless Housing Plan
o Meet with Hope5ource to identify strategies they will lead
o Observe HAHC meeting
rrior;tizffiand
conduct prioritrzation exercise with HAHC to identify strategies they want to work on
e 2026lmPlementotion.Plan
Kittitas County Agreement for Services (rev' 517a125)
Page 3 of 19
ATTACHMENT "B/
coMPFNSATIoN
THEcouNTYWILLNoTPRocESsPAYMENTFoRsERVIcEsRENDEREDUNDERTHISAGREEMENTUNTIL
CoNTRACTOR SUBMlrs A coMPLETED W-9 (SEE ATTACHMENT "E")'
Kittitas County Agreement for Services (rev' 5114/25'
Page 5 of 19
As full compensation for satisfactory performance of the work described ln Attachment "A"' and within
thirry (30) days of receiving Contractor's itemizJ inuoi.", the County shall pay Congactor the following amount(s)
plus any applicabte tr*", i, detailed in contractor's invoice: $24'000; Contractor will bill $150'00 per hour'
Unless otherwise provided herein, contractor shall be solely responsible for ContractotJs 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 local tax 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 wiil notifi the contractor immediately if financial forecasting or actuals
indicate such a circumstance.
All funds must be spent by Maich 31, 2027.Noextension of the funding period will be granted'
Re imbursement Procedures
A.Thecontractorshallsubmitinvoicesforservicesdueonceamonth'whichshallbeemailedtoKatie
odiaga, Kittitas County Public Health Department, at katig,g(|iaga@c9'kiltita '
B. Att invoices must be submitted oy the Lnd of the month tottowing tne catendar month in which
services were detivered and witl. be reimbursement-based payment, on[y.
1
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 expendlture
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-payroti""p"nrus must include a copy of the receipt or payment
invoice. Payments to subcontractors must be listed as a specific line item per subcontractor'
D. All invoices must include involce date and an invoice number'
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 (generalfund), and the Kittitas county Developmental Disabilities plan 2026-2O28
F. lll'llt"t":1", must atso be accompanied by an updated contractor Spending Form, as provided bv Kittitas
County, to ensure that billing record keeping matches County records'
G. Kittitas county is not llable ror ru*i.", plouia*a unless the invoice is received on time or prior
arrangements are agreed to in writing signed by the County'
lnnoeventshallpaymentsunderthisagreementtotalmorethans24,000.
comply with any appricabre term or condition of this agreement. The contractor sharl appropriatery rnonitor the
activities of the subconir".,o' to assure fiscar conditions of this ugre"*ent- rn no event shall the existence of a
subcontract operate ,o-r*L"a* or reduce the riabirity of the contractor to the county for any breach in the
ffj;'Tffff"Tjr ilffT:nT:''i
o,:t';."nrt
county is nor riabre for craims or damases arising from a
tuo.b"[".liJ;1:X:il'J:;:lil"""'i$fii;*: rhisAsreemenr.is subjectto review bv.anv Federaror state
auditor. The county oiitio*.ignee sha, nilTr.,e rigtrito review ani monitor the financiar and service
components of the work performed unout.thil-ig'*t**t by whatevei means are deemed expedient by the
county. Such review rnay occur with or *,rn""r'i"o,i*, and ,.nay include, without llmitation' on-site inspection'
inspection of all records o, o*,", materials which the county deems pertinent, and any and all communications
with or evaruation by service recipients unoer this Rgreement. contracioi shail preserve and maintain all records
relating to this agru"t.nfioiri* fof yu.r, 'fttit"rlmination
or expiration of the Agreement' and upon request
shall make them available for review by any Federal or state auditor, ttr" coun,y, tna/ot any persons authorized
by the CountY.
7. Modificatiil
7.7.ThisAgreementmaYbeamendedbymutualagreementoftheparties.Anysuchamendment
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
Norice,,) to conrracror, to modify the work a;;;;;;;;eiund.er trris nfre"ment, within the general scope of
the Agreernent. Such changes may include, U'i t'" not limited
'o'
tn''ig*t in the exact scope of work to be
performed (including modiiication. sunstitutioi, ,Jaiaion, o, a"r"tion oirequired tasks) and changes to the
schedure of performance. rf any such change t,roiice causes an increase or decrease to contractor's cost of' or the
time required for, performance of the work, an equitaure adjustment in the compensation to contracto r andlor
in the schedule for the performance of the woii shall be made by the county to reflect such an increase or
decreaEe. Notwithstanding any dispute or .delay
in arriving at,a. mutually acceptable equitable adjustment'
contracr,or shart proceed in l.roioun." with arr iiJnee woticei. within ttrirty {:o) days after receipt of any change
Notice which, in contracto/s opinion, t".L, an uJJquate adjustment, coniractor must submit to the county a
written statement requesting a modified 'oiu'it""t; otherwise' coni.uttot wlll forfeit its right to any such
modlfied adjustment. ittu iolrn,v retains the riitr tigr'i to determine adjustments hereunder'
g' Termlnation
LL This Agreement may be terminated at any time by mutual written agreement of the parties'
8.2 The county, by giving written notice, may terminate this ABreement at any time without cause
and w*hout further obrigation to contracto, ;-;;;; f;, payment due for deliverables provided and/or services
performed prior to tne e;ective date of termi;il;. Rn equitabre adjustment in the contracted price for partia'y
compreted tasks wi, be made by the county, but such adjustment sha, not incrude compensation for ross of
antiiipated profit on uncompleted work'
g.3 lf contractor defaulr:s by failing to perform-any.of its c,bligations under this Agreement' or
becomes insolvent, is declared bankrupt or .orniriii any act of bankruptcy 'r' iisolvency' ot makes an assignment
for the benefit of creditors, the county ,nrv,'iv *iirren notice to coniractor, terminate the Agreement' and at
the county,s option, obtain performance or iil"- *orr, ersewhere.
-rf
the Agreement is terminated under this
paragraph, Contracto. ,hall not be entitled to receive any further puyt"ntt inder ttris Agreement until all of its
obligations hereunder nru" O"un fully perforrned, and any extra to" o' damage to the County shall be deducted
Kittitas county Agreement for Services (rev' 5/741251
Page7 of L9
L2.1, contractor is duly incorporated, validly existing and in good standing under the laws of the state
ofWashington,andhasallrequisitecorporatepower.andauthorityto-enterintoandtoperformitsobligations
under this Agreement.
12.2 Contractor has the authority to execute this Agreement' to make the representations and
warranties set forth herein, and to perform its obligations hereunder.
L2,3ThisAgreementhasbeenvalidlyexecutedbyanauthorizedrepresentativeofcontractorand
constitutes a valid and iegally binding and enforceable obligation of contractor'
L2.4Contractorholds,orwillobtainpriortocommencingworkunderthisAgreement'suchlicenses'
permits and other authorizations from federar, itate and locar governmentar authoritiet 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 *aintain such throughout the term of this Agreement'
!2.5 Contractor is not in violation of any applicable law, ordinance or reSulation the consequence of
which wirr or may materialry affect contrac,"r', .iiriiv-,o perform its obrigations under this Agreement' contractor
is not subject to any order or judgment or rny court,'tribunal or goiernmental 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-
Lz.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'
L2.7 None of the representations or warranties in thls Agreement' and none of the documents'
statements, certificates or schedules furnisrreo by contractor in cJnnection with the performance of the
obrigations contemplated under this Agreemeni, .on,.in, or wit contain any untrue statement of a material fuct
or omits or wi, omit a materiar fact necessary to make the statements of fact contained therein not misleading'
13. Qwnership of lterns produced: All writings, programs, data, reports, films, recordings' or other
materiars prepared oy dJnlrr.t* ,nd/or its consurtanti or subcontractors, in connection with the performance
of this Agreement, shall be the sole uno ,nroiutt fl.op"ny of tn" countv' rr'" County w.ill have atl rights of
ownership therein, including but not limited to the right to use' copyright' trademark' andfor patent' and the
ability to transfer any or all ownership rights'
14.lntellectualPropertylnfrineement:contractorwilldefendandindemnifytheCountyfromany
claimed action, cause or demand brought acai;; the county, to the extent such action is based on the claim that
information and/or materiars suppried by contractor infringe any intelrectuar property rights of any third
party(iesl. contractor *irr p"v all costs and damages attributable to any such claims finally awarded against the
County in any action. Such iefense una p"vi"^i' are conditioned upon the following: (1) Contractor shall be
notified promptly in writin8 by the county of any notice of such cla.im; and (2) contractor shall have the right
hereunder, at its option and expense, to obtainJor the county the rlght to continue using the information andlor
materialsthatarethesubjectofsuchclaim,providednoreductioninperformanceorlossresultstotheCounty.
15.UseofcountVNameandLogo:contractormaynotusethecounty'sname'logo(s)'trademark(s)'or
otheridentifoinginformation,oridentifotheCountyasacurrentorformerclient'onitswebsiteorinany
marketing or promotional maierials without the prior written consent of the County'
16'Disputes:AnydisputebetweenthepartiesarisingunderorrelatingtothisAgreementshallbe
resolvedinformallyifpossible.However,intheeventsuchadisputecannotbesoresolved,itshallbeadjudicated
Kittitas County Agreement for Services (rev ' 5lLa/25)
Page 9 of 19
zl,tlntheperformanceofthisAgreement,Contractorwillnotdiscriminateagainstanyemployeeor
applicant for employm*n, "n it'. grorna, oi;, r'cl, treed' color' national origin' citizenship or immigration
status, sex, sexual orientation, marital status, nJiorrurv 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 wlth a
disabirity; provided that the prohibition againsr discrimination because of such disabirity shall not apply if the
particular disability pr"u.n,, ih" prop". p"*or*,ntu of the particular worker involved' Contractor shall ensure
that applicanB are employed, and ,nr, "rpiov"", ,r" treated during employment, without discrimination
because of their age, race, creed, color, national origin, citizenship or immigration status' sex' sexual orientation'
marital status, honorably discharged veterrn o. n,,ititJ'y 't"tu',
or the presence of any sensory' mental or physical
disability or the use of a traineJuog guide or service animal by a person with a disability' such requirements
apply, without limitation, to the following: "tprov*"nr,
promotion' demotion' transfer' recruitment or
recruitment advertising, layoff or termination, ^,Jt * pay or other forms of compensation' and programs for
training,includingapprenticeships.ContractorshalltakesuchactionwithrespecttothisAgreementasmaybe
required to ensure futt complianie with local, state and federal laws prohibiting discrimination in employment'
21.7 Contractor will not discriminate against any recipient of any services or benefits provided for
under this Agreement on the grounds ol age,,,t", J'""0, color' national origin' citizenship or immigration status'
sex, sexual orientation, marital status, honorably discharged veteran o|. tilittry 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.
2L.3 lf any assignment and/or subcontracting has been authorized by the county' said assignment or
subcontract sha ll include a-ppropriate safegua rds 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 frivitege 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 |."rtri.t, ur"ct, or te oiany weight ln tll interpretation or construction of
the provisions of such sections or paragraphs'
24. survival: Theprovisionsof paragraphs2, 3,4,6,8,g,ro,L3,14,15, 16' !7'!g'20'22'24'and28of
these General Terms and conditions shall survive the completion, expiration' termination or cancellation of this
25' Complete Agre-ement: This Agreement constitutes the entire agreement between the parties and
supersedes any and all;fr;G-ruuments, understandings, negotiations and discussions' oral or written' express
or implied, regarding the worito 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
between the parties.
'eicept as provided elsewhere in this Agreement, no modification or waiver of this
Agreementshallbevalidorbindingunlessinwritingandsignedbytheparties.
26.Severabilitv:lfanytermorconditionofthisAgreementortheapplicationthereofloanyperson(s)
or circumstances is held invalid, such invalidity ,lrri not affict.other terms, conditions or applications which can
be given effect without the invalid term, coniition or application' To this end' the terms and conditions of this
Agreement are declared to be severable'
Agreement for anY reason
Kittitas County Agreement for Services (rev' 5/14/25t,
Page 11 of 19
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Unde( penaltiee of periery l cenirl lhst;lor 4 numbel lo be rs3ugd to me): rnd
1 The numEEr sncwn on thrs form js my torrecl :up:Y€'denlrlication cumoer ior I am'vallil)9
2 ! am not subject :o oacklp wilnholdrnE beau'se {aj I am axempt irom csckup niiht"olding, or ib)i nave.al been nolifed oY :he !niemal le-/BnuE
SeFJrce (lFS) lha t I am sublect io:aGlaip !'ithholdiirg s 3 iFlrlt of a isilure lo lepor{ 3ll in(lrgsi or oi'/rdeods, or lc) the IFS nas
flg longer sublst lo tlackuD &ilhhclding; $d
or olher U.S person ideiinsd oelowi: and
4. The FqTCA code{s)entered on :his iorm {ii 3n-v) ir\diqxling rhal I atrr axempt kom FATCA 'epodi'g s corecl
C€rtilicstion insrtuciloN. You must cros out itm 2 Boove il /ou \ave ba)n ^clltied
btrausa you have lailed io report rl intetasl md crv,dsds cn Ycur lil ietum For lgal
scquisition or abadonmsnt of ssuted ProP9fiY'cacellatioo ai iebl,conriibdions lo
ihM intalo$l and.J lnB
Sign
Here
SbnabrE ol
U.s. p96on
noljfled 'lr-3 lFal I am
3 lemaUS.;itizen
?re not 'fil rc'J:o
Dat€
Generai lnstructions
Sslion'eltrences are lo lhe lnlemal Aevenue Code tnle:s o(her{i*
noteC.
Fjlut€ d€volclments Ftl lhe;alosi ni4rmal;nf :tbult Ceveloorents
r*liiJ i. i"i.i:irlg md lls inslruclidr's' 3!ctr :g iegirtlatian ?n3cted
;;;;;"; ;,. psbrisned. go io'a\A't 'G'!ov/Fumvv9'
'ilhat's Ne''v
rJI" Ja ai:i 1a{. ftodiliea to ,iatrh/ noiv r l'SrsglrCid,:',ltriitornplotes
'ts. ll^p nn I I l: !Fa: s 3 j'5rgqRdsd t^llly thn\rlc :hecH l'o
:-:j,.;".;.;'- l.r :ho ux sloisillcatron ?l l$ ottnet Oller'v'so' 't
lffi ;il ; ; ; k l;-''L -c-" ooi i'ia rnr t: tl s app'E or r!" lax cl43s'lica(or''
Nevr tlns Jb has o96n sddod lo lhs tgm '\ fiot'lnl{ugh tolity i$"
,-rr.r:r{ t" -e" l, lit lll. i iil'c :o ;'g'-il:r''l tl I )'l' :' :il Jt I citl:;l
;;';:;'."t;:;;,r";;'r:t': :' r+r''tt'c''r'e! xr"s' : :ro'rd"5'l1cr-rn1 w'r
to ltrnr':it k'. 'tt')t.41' :'rlx'r r.'rrln-i;'':i il'i"r:rrJnip llt'1"j!l rh's
l].""on,t nio.ouu :c 5rc?rds a llow'through cnli(y ?llh;nlorrnallcn
;,;,;:;';; ilo tts,"t rr rls r'{:rr&t 'o'L'lgn 3 't'r";ni oilrrjr' cr
:;f;i,. .i. *s. ro rn.t it aa!' j.rrsF/ ar'l iDp,,.;ru''itr+r:'ta
;;;.;;;".'s;;. Fot it.lrrrrls' f, rnr:rr':r'rhiD'rdl ^ rt lt '? ':i':'t*ct :r)'rrit'
;;;;i:.;";;";'.,1,,r',': ro cc'rl'rr't S:'*'c'J 1' il :l x-1 54e lho
;il;;f;;,; i';;'.";,ons ror Scnedurgs x'? ent x'? i itriil ic65i
Purpose of Fofin
dJr indl'/tdua' or e^ll:v iForm ''V-9
nlomaocr] rellri eilh thJ IAS;s
r?quesicr) flno rs icqulraC :o rllg ln
qrvi.9 /ov lnis ioca :ccluse lnEY
t:m lV-3 ?.ev i ?cz't;
'..a1 jtc ll:2] .4
Kittitas CountY Agreement for Services lrev' 5/14/25]'
Page 13 of 19
6nll.no ol lh! lollofl ig sv"n boras
fl lndi/rououwlo proo.l4tor I c cctporrlon I s ccrporalon i] Pantu:Ehia
tr LLC:nlc.lhqltr!:lalsrlicallonlC1Ccoriomllil s''3l4ipeftrllo^ P:gril'cltlt'o'
Iqtq: Cn{Ck US ,l.r.i)- t9r rbove xrj. {l '",'1r, rt'r:" n:lfi 'f" rlilrrlntls 'irhr lc s f i;
'",'.-.itic,ltlonlithrlL-C.untesriris'r'iiiv"+!':''r rrlrli '\ l a' 'r::l'rirryrhc
lrntl'lD'r"
hx loa :ho l& clsilHllon cl rB t\vner
I r Tirrsuoslal0
: i ,r 'rtlnrl6Al[
f] olho.iss inskucl'ons)
gnl,Yed tn t rle 1 Chtrkdl ,nd en!l/lnrl, rrdunl 'rhov! iarn'f r9
f,r C\xk lho:lpgrcPtralo ecz /s lxlBrtl ia: chgn'ic,llion
rficationfPdrt I
Pase 3
Fom W-9 (Fev 3-2024)
Ccrlain payees snd Paylnents are "';a;5p1
fiot:t bachup v;thholding'
s.Ii.ilaiffii"o coio"later. and the seidrats Inslruclions lor rhE
Fuqr.ttei oi eor- W'9 for more inlormatjon'
ses afso FslEb/rbftiag 0'S' status /or pwpases ol chaptar 3 aod
chapter ! tvilhholding, ?arnar.
What ls FATCA RePorting?
The Foreign Accouni Tax C,omPlianc€ Act {FAiCA} requires a
r;'*Fil:.:l'+l*r #f#il#rh{s*ir#il* 'lr;
;f;'ff#;;;;i;itlt*ieq,i"ster ot Form w-e for mom infonnsrion'
Updating Your lnformation
You must provide updBted intormadon lo any person to whom you
^'l;"ii^ t r - examot oavee if you ate no longe' an exernpt Payec
#;a;;;idt;"eivrn! rip6rtauli oavmenrs in tfie futur€ rrom rhs
^o,snn For tranrole, vou may neiiil riio"i<l+ upaarx rnformalion rf
;;;;;;;E ,to.porEriou that ilects lo be an s €orporalion' or rl vou dte
no lonc€r lai excmpl. tn aOO'rron' yorr nrue t furnish a nerr.Form'i'l-9 rl
lii";#;; "iiiri "iiinqt=
r". n" iico'nr' ror +'(rrnPtr'' i{ rhe sr3nrur tl a
grantor trust dies.
Penalties
Failure to fumish TlN. ll you iail to fumish your con"Ji TIN io a
.;il;tl;;, y,lu are suul*ci lo a penelF/ of s50 (or':ach such larlute
u"r[. vol,i iuifuto tE dL'? lo reasonabiE crusz end no( to willfrrl neqlecr'
Civrt penalty f,rr (altc trllotrrriiliorr willl retpect to vJilhltoklirrg-;f torr
,rak; a lals€ Slat+menl vlln no r*asonabl+ bass lhat l€4ulls 'n nc
t..iii,i,iinrtiiaing, you are subiect to a 3500 psnaltv'
Crirninal pcnalty for falsitying infotmalion' Wilttully hlsitying. '
J"#iiJtt'iti" ",.
itf rmationi miy subjecr you to criminol penahies
including fi nes and/or imprisonment'
Miouse lf TlNs. lf the requeslor disclosBs or uses TlNs. in-violalion of
iliHil;;,,h;;"qu""t"t'*av u"-st'l;*a to civil a'rd Gritninal p€nallies'
Specific lnstructions
Line I
Ydrr musl enler on€ of lhe following on lhis ling: do notleave thisline
bl;k, The nama should match lhe nam€ on your lar r€rum'
lf this Form W-9 rs ior a joinl acc€unt (other lh8n an accounl
.
,";HfirJ;;; rorign rn'on.,or 'nslihrti;rn rFFll)' ltst hr:l orrd.:hin
dtrcl*. lht rtam€ of tfl* F:rsoll or ':niitr r;hoH' 1ilmb*r yoir inl'jt']d Itr
;;; i ;i i.t;t w'o rr 7o, arc' pr1)w{''r1:l Fr'rrrr ('Y'9 14 arr FFi ta 'rccutrrtiri
t ioirt-rr.o"t', 'rach ii'rlder oi th+ n':ihutrt lhal rs i U'S FF:rs4n nrust
provi<Je a Form W'9'
, tnoiuidu"l. Ganarally, enter he name shown on your tax r+itlrn' lf you
;iil;il;;;'Jili r#i ""rn" "i*'o't
informlne tho Social securitv
n-a.'nJ*iiot is$Al qi the narrc cittrlge' :nt; your iitsl nantt lhe llsi
#;;;J;'liil;;; iour iac,ar :x'rririani rnd'/t)uilt+r r'5t natn+
Note for lTlN applicaol: Enter your individual natnc &B il v'as €ntered
;;;;;'F;r;;t ,/i; appr,carion, lln* I a. Ih's should also b'! rh+ *m+ rs
;r;t#;;;; inru'lioit the Fomr ll)ro Ydu r'ite<l srrh'/out tP{h'ztt')n
. Sole frropnetor. ErllJr'/ou. rtrdi'/idu;l ftaln€ as thosr on yr:ur For;rr
t,ri*, "L riio r. Enrer ioui busi"isr' ttu't't' ot "'Jorng bus"!4s9 a$'to'qAr
nams on lino ?.
' Pintl,Jrsl\ip. C cotpol'rtiolr' S cor;loralion' ot LLC' otlter tlt':tt 't
.r;'ri-iiiiJi-.it"rry tnrer rtre *nttty'i n"t"t 35 sr'it\'n on rhs'lnlril s !a'
;;i;,;i;; h; i ani anv business, tlade' or oEA name on linE 2'
. Olher €ntitiss. Enter your narne as ghown on equired U'S' [:<i*ral tar
;;;;;#ili^u t. lii" n"m" tn*ld match dte nerne show on the
;;fieff;th-e;i"gat document c-reiting the enrii'"' Enler any business'
tradq, oa 0gA nama on lins 2.
c Digroqarded entity. ln general, e buslness enlity.that has d,single
;ffi;:iff;ld;n-lLC,La;' not
"
corporation' is disresarded as an
:ll;:."":;;;; 7,;irr rti ovrn,rr {a disregeri*d eniits/}'.s*+ R:gulattnn:'
i*.r"o^ do I i70 I '?icll:?) A ,Jisregerded *ntily snrNiu €nxK,nY
,;;;;;;r uri lnr'ttt* tex clasiifc.'rron ol 'ls oizng cJller ih*.')Y]nsr'i
ililirli'iri"- i. ti,t ntn.' c( :ht o"lnit {n{*r+d on lin: I strould na'/+r
ir!'rioiurlot,l'td rnlrl-v. lhe narne rn line I shoulrj r']i.lht nam*- 5horsn
on tir* rrlcnm't tax r'jluln'r[ "ttt"tt G" ini"'n* :houtrj u+ r+Por:d For
Line 2
f vou hava a businegs na'Tle, bade oame' DBA name' or disrega'ded
entity nunt", enlet it on lina 2'
Line 3a
check (he sppropriste box on line 3a lor th"Lt's lidurl]tt
^.--,
classificarron oi lhe person vrno-u ii** o" tntttuo on lilt: l' ChEck onlv
ons box on line 3a
lF Ut. *fttyfaEvidual on line I
is a{nf
TIIEN check lhe box {or
lndividual/sole proprielor
' lndividual or
r Sole
" LLC olassffied as a parbtershiP
for U.S- federal tax Purposes or
. LLC thal has filed Form 9832 or
2553 electing to be ia,isd 3s a
corporation
andUmited liabilitY comPanY
€nt€r lhe appmPriale tax
classification:
P = PartnershiP.
C=Ccorporation.or
S=S
Trusi.IF-s'.at9-
Line 3b
ajhtEt lh,3 bor 4 you nti' a Fefln'ishro irnclu'Jing tn r-LC :lass'i-id 'Ll :'
)rl;i"rii"p ai u b. i+ue'ar'ra* oumtsrsr' trusl 'rr :sl3ie lhii hils 'rnv
irr.:ign paruers. o'.,'ne.s. r)r oenef,i,an*e . snd 'i'Ju at+ rt:''tlll!ll'*
fomt (o a Plnr:grshlo, t*"' o' u"tol"' i"lt'hn:li1/o:: ha'j:- alr lwnttshrp
inur*-.t'r Du,nusl 4,rPck rh* *rt,'iti i'n" it, ir'lir rac;'v+ d :'lltl lt/'6
il;i'tt;;;;;"4*ntut rto* on/ Parln:r''rv'rer .ot b4rr-Jrcrat/
'-'","Uf'tn,"o l"ri,gn s(etus cr tf you r*eire 3 F'Jrm !v"9 "tT TI.
;il#r]';t:;;'. ';;
L*nr+fi,:,ari 'liai h;s checl'ed rhe trr: on rxle 3E
Nol+: A partn+.shrl: lhai pr':?'xd+s r F'rnn r!'{ and chi':hs.co'; 3b rrat
;;;;rffi; ;'";"ipr!'rr schejul:s K': !n6 i 3 rForm r 06ir' F 'i nrc'=
;;i;;'{i;. ;;lhi Panr:ersnrp ln-srnrcrio"i io' i*hetluie K'? $xt K 3
(Form 1065).
tl you aE r+qurl+d io i,)!npl':l; lirl: 3b bui lal i(' Co so'
"ou
ma'/ noi
reci:iv+ th: oiormadon n*t*nlto niu t t9t-'*"!liLl1xtlui t+ttrri i!(h
ii.liis .l*.Ln a corr€61 payee ilal€ment to your paqifrlr.
ilf'"lliirI""".'i-";JJi"it"pt6' seclions 66es' 6722' a^d 6724 tot
penalties lhat maY aPPIY'
Line 4 ExemPtions
ii v4u ate *i*nrpt iton: backup :Tlllhdtdtrlc rd'or iAlC'A t?FidtnJ
eriter in ih+ aFpropml+ 5pic{ o"!'lf I anl :/'d+}i'i thui flsi iEPl'/ lo
you-
Exempt PaYee code-
. Gen:olt,l. individuals {intiud{r! sole prcpntlor3i aJ; nct::<:mpi lronr
backup vithholdrnq.
. alcept dr Prcvided b+lor"- :'lrporations zr€ i{':mfrt irom berkuF
,-!ilhhr-,lilino loi c*rlailr pny'ttn'= rncludinS;nt:r':€i al:d drutd'-+'rls'
. L.p.rr"i,uns ere noi !-\errlpl itonr backup slhholdrng ior prlot+nls
dradg ;n s+nlenreni ot Palrnent !:il* 'r"J-n"nl
neh'/;ri: lrcniaclitrs
. Cosq6rions ars 0ol sxempl ir<rn: barkup i!;lirlloiding arlh t*sp+:l l!
Allom{r'9 1,!+s ot qrf/ss f}'oce*ot outc t" ddotn?'/s and lolp'oraliuts
lilr?"li'i',r" ;iJ,.""r'oi niottr't 't'* '*t''to t'o aut *'{qnrpl \./rlh rqsF+:f
il;t;;;; reporlable on Fonn loss-tullSc''-
n J rorfo*ing codes identifu.Paves u:ni a're ex€'npl troln backup
*irr.it""iii.l. eit"r the appropri'atd code in llre spac* on line 4'
'i--
in ,,i"n,t"t on €lempt i(orn ta\ uil'l:r se':l'rn 501 (:ll 11):lRA o'
+.aElc,Ji,l[ ac,;ouni'tnde' s+cusn J03lb]:i1 'f 'h? ec'-')urtl $rllisli*s ln?
*qri*ments ot iection aOl(0(?)'
Kittitas county Agreement for Services (rev' 5/ra/25l,
Page 15 of 19
Page 5
oft
Part ll. Certification
fo esbblish lo the !"ilhholdirlg agenl lhat you a'e a U S person'.or
;;?#;i;;. ;ri" i;o'' vlslvol mav be requested to s€n bv-th*
;ilffiffifiili .".n
'r
irtt l"t' or i b''tovi indicates othe^{s+
For a iorit naaor,rt. onty llro p€tson i''hoss flFl is shor"n r0 Patl i
rh;'td'J;;i;"i';; t"qtr'retrl. rrr'rrre casc' of a distegatdt|-o:l'lyil*
il;; it?';tlfi-; on tihe t ntust sign Exempt paye+s' 5e+ exe'npr 6$7;"
code, aetlier.
sion"t,rr" requirements, ComplEte the c€dmcallon as indicaled in
ite-ms t hrough5 below'
r. rnteresr, dividend, and barter ex;LXl?:J::i,:lt "#Ji3".
?:'f tr":ffi ,:!i,l,Tifi ""if '"*:'mil;H;;i*;;'osisntne
Fom W-9 (Fiev. 3-2024)
What Name and Number To Give the
For fris of account:Give name and SSN of:
ot
stify mt ovmnd b'r' s The oms
e. Dkr€@rdrd
indiuid@l
and
Legal enlit)y'
The uporation
The wgaizalion
The pabxshiP
The broks or nornmee
The Public qtttY
The tust
9. A rdlid l^Eq edda, o' PeEim Fu+
10. Corordtion or LLC otcdng corp-mte'-' .-a't;,s* E* g&3? ot F"mr 2la3
11. Assciatis. club. €ligi4ils' chJ{'lble'
pduatiorul' or oths lsfl sPl
organizlhon
'12- Put LrshiP d muttrnmb'-r LlC
13. A btoker ot€g'BEad nminr
14. a{cr6t Nith the ocpofinenl oI..
arriotnst h tha name ot ! 9lDllc
enritv {srdr s a ct*e orlocal
l,i#tim-ar. :*oot dgorct' o' ptisn)
flral r*crve agdcdhl'nl Progsn
Paymsb
ls Cfflot UBI ilhO io'm lO{l or
mder $ra OPtional Fiing Melhod-2'
.euirino Fom lGft (te Fcgu|omffi
"Cdon
1 .or t -nO)F)flts)l-
2- fr,' or more ndinduab 0ornt ccFUnt)-- ot", ft- m aa-unl mrinllined bY
m FFI
3- Two or moru U.S. Por"oru''
doint .*ount .dnlaned bY m FFI)
{. Cus'todrd 3€ounl ol a minq
{Unrfam Giil to Mincrs Acl)
5. a. The Fual BYoehle svings b-wt
(gr4tor is ars tsusteel
b. S$60ed tEl acc@nt that is not
a legal d vdH twt unds $ate lav'
6- SoJe Frqpnetoship o. disrPgilded
fllrlY olntd bY 4 sdrndual
7- Gfflor trutl frfing under OPtional
filina r\lethod I (sBe Fegulations
a.:ri n 1,67 1 "t(bl(2'{0F))"
trust.llio, .o." inro*ation on opLionai filing melhods for grantor tsusts' see
thglru;hrqti665 {or Form t0'rl '
Note: lf no oame is cilcled when mor6 than one name is lisled' $e
#;#; ;i;;nsidercd to bts lhat oi lhe first narns listed'
Secure Your Tax Records From ldentity Theft
ldrniti,., lnti: .:cturs :,Jhtrt gom+f,3t irses lrollr tPir-{nal rnfolnlaliflrr'
,;;i?;1,;;;;;.W'1,::,11";l::',llX.,l*;"'il*1,'l;'lil;;T'"T,jli'
EEntussr()n ld :omnlll {l tuo cr o
fi;'ii;i'il;;; rot, ,i 'nor
Rl* a iu retur' usrrrii .1cur gsl'l 1.. tec+'!€
a refund-
To reduce Your dsk
. Protecl your S.SN,
" Ensurt you, emPloyer is Prot:cdng your SSN' and
. e* .larnfvl !"hEn cho4s"19 3 ia^ reum pr*p&+r
l, ,ou, ,* recorda' lre aiiected bT tdenltty th*f: attd vcu r*ct!'v: a
J#"i.ff;:-i;i5' *=pontl ngiiJ*ii''o in* nant+ and ph€n; nurrrb€r
pnflted on lhp IRS nouc€ '11
letler'
ll ..'our la.r t:col(J5 a:? not tuf'a^ll" itir':ltt! b' 'dentiv ih+fl tiut yos
th,nh .,nc ar€ at riel: du€ to u totiit dt6ie" f 'lisa'or
v'atter'.ru']slronacle
ctqdri aard aclieiv. oru quttionuur*-"it'tiii r':'pnn corttacl th* lFlS
}',iilt;:ft,"',,'lt ;';irl"i 'ti aco''loa'"reo rr subrnrr Fomr 1'ro3'r'
-
Oo, t,o." infonnattoo. i€e pu9 5c??' l{'*nttt'/ Thgit ln(ornlt}'n i'Jr
Taxpayerg,
The actual own€t of the aq@unt or'
.
if @mbined funds, he first indiudual
on lhe acounll
Fach holder of the account
The minotz
The Erutor'lruster
The actual omerr
The ovrner3
The grmtor'
Kittitas county Agreement for Services (rev ' 5/1'4/25)
Page L7 of L9
ATTACHMENT "E"
RETIREMENTSTATUS FORM
+ * All contractors who are individuals must Gompl€te and sign +*
SECTION 1: CONTRACTOR COMPLEIESTHIS SECTIoN:
Did you retire from one of the State of Washington Retirement Systems?
Didyouretirebeforeage65usingthe2003earlyretirementfactors(ERF)?
Will you n" ,.."iuing direct compensation for these-serv:t",:.t
Will you be receivinB indirect compensation for these services?
Yes No
No
No
No
Yes
Yes
Yes
CONTRACTOR (Fult name of contractor as in DRS filings-Please Print):
Signature:Last Four Digits of Social Security No'
Date:
rrr$T,,[,:-"#]ff9]|lfJ,"T,tlliilT:],n" o"..retirement membership and document berowt
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
-
School Employees' Retirement System (SERS) Plan 2 -
Plan 3
-
Public Employees'RetirementSv't"tntipfni) -Plan
1
-
Plan 2 -
Plan 3
-
Public safety Employees' Re-tirym1nt system (PSERs) - -
Plan 2
* Law rntorcemeni Officers, a rire figf,t"rs' Reiirement System (Leorrt Plan 1 -
Plan 2
_ washington state patrol Retirem"ni svra"r (wspRs) -
Plan 1 - Plan 2
Judicial Retirement Systern (JRS)
2'lscontractoraretireeofaWashingtonstateRetirementSystem?-Yes_No
3. Did Contractoruetiruietore age Si using the 2008 ERF? -
Yes - No
I have verified the information above using MRV or by contacting DRS'
COUNW REPRESENTATIVE ( Please Print)
Signature Date
COUNTY RETAINS THIS FORM
Kittitas county Agreement for Services lrev' 5/l4l25l
Page 19 of 19