HomeMy WebLinkAboutAFS between Kittitas County and AtWork!11
Kittitas County Public Health
Contract/Agreement Review Form
Today s Date: 07/02/26 Legal Request #: 12583
Fund/Department: 116-Public Health Agenda Date:
Contract/Agreement Information
Contract/Agreement Agency: AtWork!
itas County
Public Health
Department
Contract/Agreement Title: AFS between Kittitas County and AtWork!
Begin Date: 05/01/26 End Date: 09/30/27
Total $ Amount: $12,600.00 Contract/Agreement #: PHMH26-016
Contract/Agreement Summary:
The purpose of this agreement is to provide school -to -work services, per the contractual
requirements of the Washington State Department of Vocational Rehabilitation (DVR) including
but not limited to intake, assessment, job placement along with required deliverables.
Kittitas County Prosecutor and Auditor Review and Comment:
APPROVED AS TO FORM:
Signature of Prosecutor's Office
Signature of Auditof'kOffice
Budget InformatioR-
Revenue Code(s): 105-568.334.04.68
Expense Code(s): HA1000-101/4122
✓I Agency is not suspended/disbarred
Date
7`S/`;�.c
Date
f d�
❑ Not Checked (reason) I
Pass Through Information
Agency to Pass Through
Amount to Pass Through Expense Code:
Sub -Contract Approved Date:
ADMIN I Version: 0 Supersedes: 0 I Date Adopted: 12/01/2024 Modified By: Katie Odiaga Approval By: Chelsey Loeffers
Katie Odiaga
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Order MC27064391
Processed on July 03, 2026 12:13 AM Los Angeles.
Standard plan $20.00
500 contacts
Tax $1.30
Retail Sales and Use Tax
Tax Rate: 6.5%
Tax $0.42
Local Sales and Use Tax
Tax Rate: 1.9%
Tax Rate: 0.2%
Paid via Visa ending in 6560 which expires 05/2030 $21.72
on July 03, 2026
1
7/7/26, 9:33 AM
SAM.gov
ATWO RK! Active Registration
Unique Entity ID CAGE/NCAGE
YZYWSMJX2EY9 1 MUX9
Physical Address
1935 152ND PL NE
Bellevue, Washington
98007-4209, United States
Purpose of Registration
All Awards
Version
[Current Record
BUSINESS INFORMATION
Doing Business As URL
ATWORK!
www.atworkwa.org
Division Name
Division Number
(blank)
(blank)
Congressional
State/Country of
District
Incorporation
Washington 01
Washington, United
States
Owner CAGE Legal Business
Name
Immediate (blank)(blank)
Owner
Highest Level (blank)(blank)
Owner
Entity Information
Expiration Date
Nov 18, 2026
Mailing Address
1935 152ND PL NE
Bellevue, Washington
98007-4293, United States
Registration Dates
Activation Date
Nov 20, 2025
Submission
Date
Nov 18, 2025
Initial Registration
Date
Aug 1, 2001
Entity Dates
https://sam.gov/entities/viewfYZY WSMJX2EY9/coreData?status=Active&emrKeyValue=1551592-1763399404446864® Id=16672901 1 /2
7/7/26, 9:33 AM SAM.gov
Entity Start
Date
Mar 1, 1977
Fiscal Year End
Close Date
Sep 30
Executive Compensation
Registrants in the System for Award Management (SAM) respond to the Executive Compensation
questions in accordance with Section 6202 of P.L. 110-252, amending the Federal Funding
Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is
sent to USAspending.gov for display in association with an eligible award. Maintaining an active
registration in SAM demonstrates the registrant responded to the questions.
SAM SEARCH AUTHORIZATION
I authorize my entity's non -sensitive information to be displayed in SAM public search results:
Yes
ENTITY TYPES
Business Types
Entity Structure', Corporate Entity (Tax
Exempt)
Entity Type Business or
Organization
Profit Structure I Non -Profit
Organization
Organization (blank)
Factors
Socio-Economic Types
AbilityOne Non Profit Agency
Check the registrant's Reps & Certs, if
present, under FAR 52.212-3 or FAR 52.219-1
to determine if the entity is an SBA -certified
HUBZone small business concern. Additional
small business information may be found in
the SBA's Dynamic Small Business Search if
the entity completed the SBA supplemental
pages during registration.
https://sam.gov/entities/viewNZYWSMJX2EY9/coreData?status=Active&emrKeyVaIue=1551592-1763399404446864®ld=16672901 2/2
KITTITAS COUNTY
AGREEMENT FOR SERVICES
PHMH26-016
This Agreement for Services (hereinafter "Agreement") is entered into by and between Kittitas County
(hereinafter "County"), a political subdivision of the State of Washington, and AtWork! (hereinafter "Contractor").
The purpose of this Agreement is as follows: To provide school -to -work services, per the
contractual requirements of the Washington State Department of Vocational Rehabilitation (DVR) including but not
limited to intake, assessment, job placement along with required deliverables.
The term of this Agreement shall be from May 1,2026 through September 30, 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 St Ste 102
Ellensburg, WA 98926
Laurie Holt
Developmental Disabilities Administrative
Specialist
Human Services
Laurie.holt@co.kittitas.wa.us
509-962-7515
CONTRACTOR
AtWork!
1935 152nd PL NE
Bellevue, Washington
98007-4209
Project Contact:
Daniel Harting
Director
danielhl@atworkwa.org
This Agreement includes the following, which are attached hereto and hereby incorporated by this
reference:
Attachment "A": Scope of Work
Attachment "B": Compensation
Attachment "C": Insurance Requirements
Attachment "D": General Terms and Conditions
Attachment "E": W-9 (Contractor must complete and return to the County for payment)
Attachment "F": DVR School to Work Contract with Kittitas County, including:
Exhibit A Data Security Requirements
Exhibit B School -to -Work Guide Instructions, including billing instructions
Exhibit E School -to -Work Billing Checklist
Attachment "G": Student Guide
Attachment "H": School -to -Work Data Report Template
Kittitas County Agreement for Services (rev. 5/14/25)
Page 1 of 22
IN WITNESS WHEREOF, this Agreement has been executed by and on behalf of the parties through their
authorized representatives, effective as of the latest date written below.
KITTITAS COUNTY
BOARD OF COUNTY COMMISSIONERS
Chair
Vice -Chair
Commissioner
Date:
Attest:
Clerk of the Board
Kittitas County Agreement for Services (rev. 5/14/25)
Page 2 of 22
CONTRACTOR
Signature
Printed Name
<."_—&' V
Title
Date: /
ATTACHMENT "A"
SCOPE OF WORK
Provide School -to -Work services to eligible students in three phases including School -to -Work intake and
assessment phase, job placement phase, and employment phase.
Ensure eligibility and complete a student intake process.
o Work with students, student's legal guardian or representative, community rehabilitation
program, and DVR to establish and document student employment goals and tools needed.
■ Complete assessment using Student Guide and/or Job Foundations report to complete the Student Guide
to include DVR required information.
• Work with the students to find and secure meaningful community employment based on goals.
• Work with students to stabilize and maintain meaningful employment.
• Submit required documentation including student guide and billing checklist.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 3 of 22
ATTACHMENT "B"
COMPENSATION
THE COUNTY WILL NOT PROCESS PAYMENT FOR SERVICES RENDERED UNDER THIS AGREEMENT UNTIL
CONTRACTOR SUBMITS A COMPLETED W-9 (SEE ATTACHMENT "E").
All funds must be spent by September 30, 2027. No extension of the funding period will be granted.
Reimbursement Procedures
A. The Contractor shall submit invoices to the county along with the DVR School -to -Work Billing Checklist.
B. For DVR to release payment, contractors must submit the student guide monthly.
C. The Contactor must provide adequate backup documentation to support costs in each invoice per the
School -to -Work Guide Instruction, including billing instructions. For example, the contractor may bill
$2,000 for the School -to -Work Intake Meeting and must complete team building and information along
with team contacts, roles, and responsibilities to release payment.
D. Failure to submit required documentation as outlined in School -to -Work Guide Instructions may result
in delayed reimbursement payments or denial of invoices.
E. Kittitas County will retain 10% administrative fees per School -to -Work Activity Billed. Administrative
fees for Kittitas County will include the following for activities billed:
a. Intake Meeting = $200
b. Assessment = $300
c. Job Seeker Tools = $100
d. Job Offer = $200
e. Employment Verification = $100
f. Stabilization = $500
g. Total administrative costs to Kittitas County per School -to -Work student will not exceed $1,400.
In no event shall payments under this agreement total more than $12, 600 per School -to -Work student to the
contractor.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 4 of 22
ATTACHMENT "C"
INSURANCE REQUIREMENTS
Contractor shall secure and maintain in effect at all times during performance of work under this
Agreement such insurance as will protect Contractor, its employees, and agents from all claims, losses, harm,
costs, liabilities, damages and expenses arising out of Contractor's performance under this Agreement, including
but not limited to personal injury (including death) or property damage.
All insurance shall be issued by companies admitted to do business in the State of Washington and have
a rating of A-, Class VII or better in the most recently published edition of Best's Reports unless otherwise approved
by the County. If an insurer is not admitted, all insurance policies and procedures for issuing the insurance policies
must comply with Chapter 48.15 RCW and 284-15 WAC.
At a minimum, Contractor shall maintain and provide proof of the following selected options:
® Commercial General Liabilitv Insurance
■ Coverage limits not less than:
• $1,000,000 per occurrence, for all covered losses
• $2,000,000 general aggregate
• $1,000,000 products & completed operations aggregate
• $1,000,000 personal and advertising injury, each offense
• The policy must be endorsed to include the County and its officials, employees and agents
as additional insureds.
® Commercial Automobile Liability Insurance
■ Automobile Liability for owned, non -owned, hired, and leased vehicles, with an MCS 90
endorsement and a CA 9948 endorsement attached if 'pollutants' are to be transported.
• Coverage limits not less than:
Is $1,000,000 combined single limit
❑ Excess or Umbrella Liability
■ Contractor shall provide Excess or Umbrella Liability coverage of $5,000,000. This Excess
or Umbrella Liability coverage shall apply, at a minimum, to both the Commercial General
and Automobile Insurance policy coverages. If used to meet limit requirements, coverage
must be at least as broad as specified for underlying coverages, and must cover those
insured in the underlying policies.
■ This requirement may alternatively be satisfied through Contractor's primary Commercial
General and Automobile Liability coverage, or any combination thereof.
■ The policy must be endorsed to include the County and its officials, employees and agents
as additional insureds.
• Coverage shall be "pay on behalf", with defense costs payable in addition to policy limits.
• There shall be no cross liability exclusion precluding coverage for claims or suits by one
insured against another.
® Workers' Compensation & Employer's Liability
■ Contractor shall provide Workers Compensation and Employer's Liability insurance on a
state -approved policy form providing benefits as required by law with employer's liability
limits no less than $1,000,000 per accident or disease.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 5 of 22
C Professional Liability/ Errors and Omissions Liability
• Coverage limits not less than:
• $1,000,000 each claim
• Contractor must provide evidence of this coverage on a policy form appropriate to
Contractor's profession.
Contractor shall furnish to the County a Certificate of Insurance, with endorsement where required above,
as evidence that policies providing insurance required by this Agreement are in full 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.
Contractor agrees to provide notice to the County at least thirty (30) days prior to cancellation, or any
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 Contractor, or Contractor's agents, employees,
suppliers or contractors, as well as 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: Notwithstanding any other provision(s) of this Agreement, no contract shall form under this Agreement
until and unless the following are provided to the County: (1) a copy of the Certificate(s) of Insurance 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. 5/14/25)
Page 6 of 22
ATTACHMENT "D"
GENERAL TERMS AND CONDITIONS
1. Scope of Contractor's Services: Contractor agrees to provide to the County services as set forth in
Attachment "A". No materials, labor, or facilities will be furnished by the County, unless otherwise provided
herein. All work performed under this Agreement shall comply with applicable laws and regulations.
2. Accounting and Payment: Compensation to Contractor for services rendered under this Agreement
shall be as set forth in Attachment "B". Where Attachment "B" requires payment(s) by the County, payment shall
be based upon billings, supported unless provided otherwise in Attachment "B", by documentation of units of
work actually performed and amounts earned, including, where appropriate, the total number of hours for the
month and the total dollar payment requested. Unless specifically stated in Attachment "B", the County will not
reimburse Contractor for any costs or expenses incurred by Contractor in performance of this Agreement. Where
required, the County shall, upon receipt of appropriate documentation, compensate Contractor, no more often
than monthly, through the County voucher system, for Contractor's services pursuant to the fee schedule set forth
in Attachment "B". In the event Contractor fails to perform any of its obligations under this Agreement within the
time specified herein, then the County may withhold all monies due and payable to Contractor until such failure
to perform is cured or otherwise adjudicated. The County will not process payment for services rendered under
this Agreement until Contractor submits a completed W-9 (See Attachment "E").
3. Taxes: Contractor understands and acknowledges that the County will not withhold Federal or State
income taxes from payments made to Contractor. Where required by State or Federal law, Contractor authorizes
the County to make withholding for any taxes other than income taxes (e.g., Medicare). All compensation received
by Contractor will be reported to the Internal Revenue Service at the end of the calendar year in accordance with
applicable IRS regulations. It is the responsibility of Contractor to make its necessary estimated tax payments
throughout the year, if any, and Contractor is solely liable for any tax obligation arising from Contractor's
performance of this Agreement.
The County will pay sales and use taxes imposed on goods or services acquired hereunder as required by
law. Contractor must pay all other taxes, including but not limited to: business and occupation tax; or taxes based
on (1) Contractor's gross or net income, or (2) personal property to which the County does not hold title. The
County is exempt from federal excise tax.
4. Independent Contractor: Contractor's services shall be furnished by Contractor as an independent
contractor, and nothing stated herein shall be construed to create a relationship of employer -employee or a
guarantee of future employment. Contractor acknowledges that its entire compensation under this Agreement
is specified in Attachment "B", and that Contractor is not entitled to any County benefits, including but not limited
to: vacation pay, holiday pay, sick leave pay, medical, dental, or other insurance benefits, or any other rights or
privileges afforded to Kittitas County employees.
5. Assignment and Subcontracting: and Subcontracting: No portion of this Agreement may be assigned
or subcontracted to any other individual, firm or entity without the express and prior written approval of the
County. The Contractor may only subcontract work contemplated under this agreement if it obtains the prior
written approval of the County. If the County approves subcontracting, the Contractor shall maintain written
procedures related to subcontracting, as well as copies of all subcontracts and records related to subcontracts.
For cause, the County in writing may require the Contractorto amend its subcontracting procedures as they relate
to this agreement, prohibit the Contractor from subcontracting with a particular person or entity, or require the
Contractor to rescind or amend a subcontract. Every subcontract shall bind the Subcontractor to follow all
applicable terms of this agreement. The Contractor is responsible to the County if the Subcontractor fails to
Kittitas County Agreement for Services (rev. 5/14/25)
Page 7 of 22
comply with any applicable term or condition of this agreement. The Contractor shall appropriately monitor the
activities of the Subcontractor to assure fiscal conditions of this agreement. In no event shall the existence of a
subcontract operate to release or reduce the liability of the Contractor to the County for any breach in the
performance of the Subcontractor's duties.
Every subcontract shall include a term that County is not liable for claims or damages arising from a
Subcontractor's performance of the subcontract.
6. Right to Review; Maintenance of Records: This Agreement is subject to review by any Federal or State
auditor. The County or its designee shall have the right to review and monitor the financial and service
components of the work performed under this Agreement by whatever means are deemed expedient by the
County. Such review may occur with or without notice, and may include, without limitation, on -site inspection,
inspection of all records or other materials which the County deems pertinent, and any and all communications
with or evaluation by service recipients under this Agreement. Contractor shall preserve and maintain all records
relating to this Agreement for six (6) years after termination or expiration of the Agreement, and upon request
shall make them available for review by any Federal or State auditor, the County, and/or any persons authorized
by the County.
7. Modification
7.1. This Agreement may be amended by mutual agreement of the parties. Any such amendment
shall be in writing and signed by both parties.
7.2 The County may unilaterally amend this Agreement at any time by written notice ("Change
Notice") to Contractor, to modify the work to be performed under this Agreement, within the general scope of
the Agreement. Such changes may include, but are not limited to, changes in the exact scope of work to be
performed (including modification, substitution, addition, or deletion of required tasks) and changes to the
schedule of performance. If any such Change Notice causes an increase or decrease to Contractor's cost of, or the
time required for, performance of the work, an equitable adjustment in the compensation to Contractor and/or
in the schedule for the performance of the work shall be made by the County to reflect such an increase or
decrease. Notwithstanding any dispute or delay in arriving at a mutually acceptable equitable adjustment,
Contractor shall proceed in accordance with all Change Notices. Within thirty (30) days after receipt of any Change
Notice which, in Contractor's opinion, lacks an adequate adjustment, Contractor must submit to the County a
written statement requesting a' modified adjustment; otherwise, Contractor will forfeit its right to any such
modified adjustment. The County retains the final right to determine adjustments hereunder.
8. Termination
8.1 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 Agreement at any time without cause
and without further obligation to Contractor except for payment due for deliverables provided and/or services
performed prior to the effective date of termination. An equitable adjustment in the contracted price for partially
completed tasks will be made by the County, but such adjustment shall not include compensation for loss of
anticipated profit on uncompleted work.
8.3 If Contractor defaults by failing to perform any of its obligations under this Agreement, or
becomes insolvent, is declared bankrupt or commits any act of bankruptcy or insolvency, or makes an assignment
for the benefit of creditors, the County may, by written notice to Contractor, terminate the Agreement, and at
the County's option, obtain performance of the work elsewhere. If the Agreement is terminated under this
paragraph, Contractor shall not be entitled to receive any further payments under this Agreement until all of its
obligations hereunder have been fully performed, and any extra cost or damage to the County shall be deducted
Kittitas County Agreement for Services (rev. 5/14/25)
Page 8 of 22
from any money due or coming due to Contractor. Furthermore, in the event of termination under this paragraph,
Contractor shall bear the costs of any extra expenses incurred by the County in completing the work, and all
damages sustained, or which may be sustained, by the County.
8.4 Termination of this Agreement by any means provided herein shall not excuse any party's
performance of its obligations hereunder through the effective date of termination, except that the County shall
not be obligated to pay for services that have not been performed or deliverables that have not been provided.
9. Indemnification
9.1 To the fullest extent permitted by law, Contractor agrees to indemnify, defend and hold the
County and its departments, elected and appointed officials, employees, agents and volunteers, harmless from
and against any and all claims, damages, losses and expenses, including but not limited to court costs, attorney's
fees and alternative dispute resolution costs, for any personal or bodily injury, sickness, disease or death, for any
damage to or destruction of any property (including the loss of use resulting therefrom), and for any other claims,
damages, losses, and expenses sustained by the County, which (1) are caused in whole or in part by any act or
omission, negligent or otherwise, of Contractor, its employees, agents or volunteers, or Contractor's
subcontractors, their employees, agents or volunteers; or (2) are directly or indirectly arising out of, resulting
from, or otherwise connected with the performance of this Agreement; or (3) are based upon Contractor's or its
subcontractors' use of, presence upon or proximity to the property of the County. This indemnification obligation
of Contractor shall not apply in the limited circumstance where the claim, damage, loss or expense is caused by
the sole negligence of the County. This indemnification obligation of Contractor shall not be limited in any way by
the Washington State Industrial Insurance Act, RCW Title 51, or by application of any other workmen's
compensation act, disability benefit act or other employee benefit act, and Contractor hereby expressly waives
any immunity afforded by such acts. The foregoing indemnification obligations of Contractor are a material
inducement to the County to enter into this Agreement, are reflected in Contractor's compensation, and have
been mutually negotiated by the parties.
9.2 The County reserves the right, but not the obligation, to participate in the defense of any claim
for damages, losses or expenses, and such participation shall not constitute a waiver of Contractor's indemnity
obligations contained in any section of this Agreement.
9.3 In the event Contractor enters into subcontracts to the extent allowed under this Agreement,
each such subcontractor shall indemnify the County on a basis equal to or exceeding Contractor's indemnity
obligations to the County.
10. Venue and Choice of Law: In the event that any litigation should arise concerning this Agreement,
the venue for such action shall be in the Superior Court of the State of Washington in and forthe County of Kittitas.
This Agreement shall be governed by the laws of the State of Washington.
11. Non-Appropriationof Funds: If the County does not appropriate sufficient funding for this Agreement
for any future fiscal period, the County will not be obligated to make payments for services performed after the
end of the last fiscal period for which sufficient funding was appropriated. No penalty or expense shall accrue to
the County in the event this provision applies.
12. Contractor Commitments Warranties and Representations: Contractor represents and warrants as
follows:
Kittitas County Agreement for Services (rev. 5/14/25)
Page 9 of 22
12.1 Contractor is duly incorporated, validly existing and in good standing under the laws of the State
of Washington, and has all requisite corporate power and authority to enter into and to perform its obligations
under this Agreement.
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.
12.3 This Agreement has been validly executed by an authorized representative of Contractor and
constitutes a valid and legally binding and enforceable obligation of Contractor.
12.4 Contractor holds, or will obtain prior to commencing work under this Agreement, such licenses,
permits and other authorizations from federal, state and local governmental authorities, or from any applicable
industrial or professional certification or licensing bodies, as are necessary for the lawful performance of its
obligations under this Agreement, and will maintain such throughout the term of this Agreement.
12.5 Contractor is not in violation of any applicable law, ordinance or regulation the consequence of
which will or may materially affect Contractor's ability to perform its obligations under this Agreement. Contractor
is not subject to any order or judgment of any court, tribunal or governmental agency which materially and
adversely affects its operations or assets in the State of Washington, or its ability to perform its obligations under
this Agreement.
12.6 Contractor is not presently debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded from covered transactions by any Federal or State department or agency.
12.7 None of the representations or warranties in this Agreement, and none of the documents,
statements, certificates or schedules furnished by Contractor in connection with the performance of the
obligations contemplated under this Agreement, contains or will contain any untrue statement of a material fact
or omits or will omit a material fact necessary to make the statements of fact contained therein not misleading.
13. Ownership of Items Produced: All writings, programs, data, reports, films, recordings, or other
materials prepared by Contractor and/or its consultants or subcontractors, in connection with the performance
of this Agreement, shall be the sole and absolute property of the County. The County will have all rights of
ownership therein, including but not limited to the right to use, copyright, trademark, and/or patent, and the
ability to transfer any or all ownership rights.
14. Intellectual Property Infringement: Contractor will defend and indemnify the County from any
claimed action, cause or demand brought against the County, to the extent such action is based on the claim that
information and/or materials supplied by Contractor infringe any intellectual property rights of any third
party(ies). Contractor will pay all costs and damages attributable to any such claims finally awarded against the
County in any action. Such defense and payments are conditioned upon the following: (1) Contractor shall be
notified promptly in writing by the County of any notice of such claim; and (2) Contractor shall have the right
hereunder, at its option and expense, to obtain for the County the right to continue using the information and/or
materials that are the subject of such claim, provided no reduction in performance or loss results to the County.
15. Use of County Name and Logo: Contractor may not use the County's name, logo(s), trademark(s), or
other identifying information, or identify the County as a current or former client, on its website or in any
marketing or promotional materials without the prior written consent of the County.
16. Disputes: Any dispute between the parties arising under or relating to this Agreement shall be
resolved informally if possible. However, in the event such a dispute cannot be so resolved, it shall be adjudicated
Kittitas County Agreement for Services (rev. 5/14/25)
Page 10 of 22
by a dispute board ("Dispute Board") in the following manner: Each party shall appoint one member to the Dispute
Board, the members so appointed shall jointly appoint an additional member to the Dispute Board, and the
Dispute Board will evaluate the facts, Agreement terms, and all applicable statutes and rules, and make a
determination as to the proper resolution of the dispute. Such determination shall be final and binding on both
parties. The cost of resolution will be borne as allocated by the Dispute Board. Alternatively, if agreed to in writing
by both parties, the parties may forego the option of establishing a Dispute Board to adjudicate the dispute, and
instead pursue arbitration, jointly selecting an arbitrator acceptable to both parties. In the event the parties
choose to pursue arbitration, the parties agree that: (1) the fees and expenses of the arbitrator shall be shared
equally by both parties to this Agreement, (2) each party shall bear its own costs and attorney fees, (3) arbitration
shall be conducted according to the commercial arbitration procedures of the American Arbitration Association,
and (4) the arbitrator's decision or award shall be final and binding on both parties.
17. Confidentiality: Contractor, its employees, agents and volunteers, and any of Contractor's
subcontractors and their employees, agents and volunteers, shall maintain the confidentiality of all information
provided by the County or acquired by Contractor in performance of this Agreement, except upon the prior
written consent of the Kittitas County Prosecuting Attorney or an order entered by a court after having acquired
jurisdiction over the County. Contractor shall immediately provide the County notice of any judicial proceedings
seeking disclosure of such information. Contractor agrees to indemnify, defend and hold harmless the County
and its departments, elected and appointed officials, employees, agents and volunteers from all loss or expense,
including but not limited to settlements, judgments, setoffs, attorneys' fees and costs resulting from Contractor's
breach of this provision. Notwithstanding the foregoing, and to the extent that any information obtained by the
Contractor hereunder is required to be shared with others by the explicit terms of the Scope of Work, this
provision shall not be construed as prohibiting such sharing, provided there are no applicable laws or regulations
prohibiting same.
18. Notices: Written notices required or permitted to be provided by one party to the other party under
this Agreement may be provided by personal delivery, legal courier service, or certified mail, postage prepaid and
return receipt requested. Notice may be provided by regular first-class mail if simultaneous notice is provided by
email. Notices given by Contractor shall be provided to the County's point of contact listed on page 1 of this
Agreement, at the address there listed, and to the department head of the county department for which services
under this Agreement are rendered. Notices given by the County shall be provided to Contractor at Contractor's
address listed on page 1 of this Agreement.
19. Prevailing Wage: Where labor to be performed under this Agreement is considered "public work" as
defined in RCW 39.04.010, Contractor shall pay the prevailing rate of wages to all workers, laborers, or mechanics
employed in the performance of work under this Agreement in accordance with RCW 39.12 and the rules and
regulations of the Washington State Department of Labor and Industries. The schedule of prevailing wage rates
for the applicable locality or localities is determined by the Industrial Statistician of the Department of Labor and
Industries. It is Contractor's responsibility to verify the applicable prevailing wage rate. It is understood that
Contractor is responsible for obtaining and completing all required government forms relating to prevailing wage
and submitting same to the proper authorities. Disputes regarding prevailing wage rates shall be referred for
arbitration to the Director of the Department of Labor and Industries. The arbitration decision shall be final and
conclusive and binding on all parties involved in the dispute as provided for in RCW 39.12.060.
20. Standard of Care: Contractor shall perform its duties hereunder in a manner consistent with that
degree of care and skill ordinarily exercised by members of the same profession or industry as Contractor currently
practicing or working under similar circumstances. Contractor shall, without additional compensation, correct any
of its services not meeting such a standard.
21. Nondiscrimination:
Kittitas County Agreement for Services (rev. 5/14/25)
Page 11 of 22
21.1 In the performance of this Agreement, Contractor will not discriminate against any employee or
applicant for employment on the grounds of age, race, creed, color, national origin, citizenship or immigration
status, sex, sexual orientation, marital status, honorably discharged veteran or military status, or the presence of
any sensory, mental or physical disability or the use of a trained dog guide or service animal by a person with a
disability; provided that the prohibition against discrimination because of such disability shall not apply if the
particular disability prevents the proper performance of the particular worker involved. Contractor shall ensure
that applicants are employed, and that employees are treated during employment, without discrimination
because of their age, race, creed, color, national origin, citizenship or immigration status, sex, sexual orientation,
marital status, honorably discharged veteran or military status, orthe 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. Such requirements
apply, without limitation, to the following: employment, promotion, demotion, transfer, recruitment or
recruitment advertising, layoff or termination, rates of pay or other forms of compensation, and programs for
training, including apprenticeships. Contractor shall take such action with respect to this Agreement as may be
required to ensure full compliance with local, state and federal laws prohibiting discrimination in employment.
21.2 Contractor will not discriminate against any recipient of any services or benefits provided for
under this Agreement on the grounds of age, race, creed, color, national origin, citizenship or immigration status,
sex, sexual orientation, marital status, honorably discharged veteran or military status, or the presence of any
sensory, mental or physical disability or the use of a trained dog guide or service animal by a person with a
disability.
21.3 If any assignment and/or subcontracting has been authorized by the County, said assignment or
subcontract shall include appropriate safeguards against discrimination.
22. Waiver: The waiver of any default or breach of this Agreement, or the failure of a party to enforce
any provision hereof or to exercise any right or privilege hereunder, shall not be deemed to waive any prior or
subsequent default or breach, the enforcement of any provision hereof, or the exercise of any right or privilege
hereunder, unless otherwise stated in a writing, signed by the parties hereto.
23. Headings: The headings of sections and paragraphs of this Agreement are for convenience of
reference only and are not intended to restrict, affect, or be of any weight in the interpretation or construction of
the provisions of such sections or paragraphs.
24. Survival: The provisions of paragraphs 2, 3, 4, 6, 8, 9, 10, 13, 14, 15, 16, 17, 19, 20, 22, 24, and 28 of
these General Terms and Conditions shall survive the completion, expiration, termination or cancellation of this
Agreement for any reason.
25. Complete Agreement: This Agreement constitutes the entire agreement between the parties and
supersedes any and all other agreements, understandings, negotiations and discussions, oral or written, express
or implied, regarding the work to be performed hereunder. The parties agree that no other representations,
inducements, promises, agreements, orwarranties relating to this Agreement, oral or otherwise, have been made
between the parties. Except as provided elsewhere in this Agreement, no modification or waiver of this
Agreement shall be valid or binding unless in writing and signed by the parties.
26. Severability: If any term or condition of this Agreement or the application thereof to any person(s)
or circumstances is held invalid, such invalidity shall not affect other terms, conditions or applications which can
be given effect without the invalid term, condition or application. To this end, the terms and conditions of this
Agreement are declared to be severable.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 12 of 22
27. Time: Time is of the essence in the performance of this Agreement unless otherwise agreed between
the parties in a signed writing.
28. Construction: This Agreement lias been mutually reviewed and negotiated by the parties and should
not be construed against the drafter.
29. Agreement Not for benefit of Third Parties: This Agreement is entered into solely for the benefit of
the parties hereto and vests no rights in, nor is it enforceable by, any third parties.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 13 of 22
ATTACHMENT `rE"
FormW. Request for Taxpayer Give form to the
Rev. March 2024) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service Go to tvtvw.irs.gov/FormW9 for instructions and the latest information.
Before you begin, For guidanau related to the purpose of Form W-9, see Purpose of Form, below.
1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's ra,ne on !ine 1, and enter :he business/disregarded
entity's name on line 2.)
2 Business name/disrogarced entity name, it different from above,
3a Check the appropriate box !or federal tax classification of the entity,/indmdual whose name is entered on line 1. Check
only ono of the following seven boxes,
❑ Individuaysolo proprietor ❑ C corporation ❑ S corporation ❑ Partnorshio ❑ Trust/estato
❑ LLC. Enter the lax classification (C = C corporation, S = S oorporation, P = Partnership) ,
Note: Check the "LLC" box above and, in theAfllry fiWe, enter the Hppraprlate code (C. S; or P) for" UK
classification of the LLC, unless it is a disregarded crdity. A disregarded entity should instagdchock rV I MOPriato
box 'Or -he tax classification of its owner.
❑ Other (see instructions)
3b if on line 3a you checked "Pannership" or "Trustlestate," or checked "LLC" and entered "P" as As tax classification,
and you are providing this lore to a partnership, trust, or estate in a-hich you have an ownership interest, check
this box if you have any foreign partners, owners, or beneficiaries. See inslructlons . . . . . . ❑
Address (number, street, and apt or suite no ). See instructions.
6 Ciry, state. and ZIP code
7 Last account number(s) here (optional)
Identification Number
4 Exemptions (codes apply only to
certain entities, not individuals:
see instructions on page 3):
Exempt payee code (if any)
Exemption from Foreign Account Tax
Compliance Act (TATCA) reporting
code (if any)
(Applios to accounts maintained
outside the United States.)
Requester's name and address (optiona)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
I P
"
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, It is your employer identification number (EIN). If you do not have a number, see How to get a
or
TIN -later,
Employer identification number
Note: If the account is in more than one name, see the instructions for line 1. See also What Name and
Number To Give the Requester for guidelines on whose number to enter.
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer Iden1'Ification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Intemal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out ilern 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have fal!ed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement flRA). and. generally. payments
other than interest and d+vitlendfa, you are not mats ed to sign the certification, but you must provide your correct TIN. Sea the instructions for Part 11, rater,
Sign Signature of
Here U.S. person Date
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs_gov/FormW9,
What's New
Line 3a has beer modified to clarify how a disregarded entity completes
this line. An LLC that is a disregarded entity should check the
appropriate box for the tax classification of its owner. Otherwise, it
should check the "LLC" box and enter its appropriate tax classification.
New line 3b has been added to this form. A flow -through entity is
required to cornplele this line to Inoicate tW It has direct or indirect
foreign partners, owners, or beneflciarles when it provides.the Form W-9
to another flow -through entity in which R has an ownership interest. This
change is intended to provide a flow -through entity with information
regarding the status of its indirect foreign partners, owners, or
beneficiaries, so that it can satisfy any applicable reporting
requirements. For example, a partnership that has any indirect foreign
painers may be required to complete Schedules K-2 and K-3. See the
Partnership Instructions for Schedules K-2 and K-3 (Form 1065).
Purpose of Form
An individual or entity (Form W-9 requester) who is required to rile an
information return with the IRS is giving you this form because they
Cal, No. 10231X Form W-9 (Rcv. 3-2024)
Kittitas County Agreement for Services (rev. 5/14/25)
Page 14 of 22
Fcfm d -9 Mev 5-2Rc4)
must ohfan youreorred taxpayer idenfficaWn number (TIM. which
may be y vx s c of `eprsty rxmnbef (SSM. mdviduai taxpayer
idersk katon nvnber iITIM, adoption taxpayer identification ri umber
(A lNj_ ar =mpk7ff identdica;iofr nurk*r (Ellli,. to repent on an
Wonrialcn return bw arrrckm paid to yo�.r. or otf oer amount fepc r le
on an ir*rmatoa reirin- Exarnp4,s of rdarma, reiurT - irtadie, but
are not limited ta, the following,
• corm 1099-1W 4iztetest earned or pads.
■ To rt Tp'994YV (freidands. mchuding those from stocks or mat A
il: .t
• Porm Tp39AMC {various types of income. prizes, wards. or gmsa
P
■ Form Mq@-NEC I.norestOoye,,, compensatiori}_
• corm TC49-8 (SAS or rnutW hard sales and oertan after
transactions by brokersj.
• term T S (prooeeds from real estate, i orGlL
• Form tfjg9-K (merc*ant card and thard•yparty rtetmrk s�actrsrs;�
• Form 1099 i'home morly intemstt, IDSG ` Qauda It loan interest,.
arid 10545-T MAoo).
• Ferro 1099-G :canceled debt)-
• scorn l w3 -A jaMuA;bon or aba rdorment of secured propert jl
Use Form la-9 only if you are a U.S. person Cmcixxting a rtlidenf
aiieni.:a pnynde your conect TIN_
Cautimt: If you don't rerun Fora W-9 to the toga vAth a TDI. you
mfghl be subject to backxV witfrholdia% Sue Ma! is beckLP
rm�ng, later.
By signing the filed -cut forth, you:
1_ Gertify that the TIN you'are diving s correct (err you are wailing far a
n amber to he issued):
2. Certify &tat you are not subject to backup wahhoki . or
$- cairn exernpwa from biwkoup withhaldmg it you ate a U-S_ exmPl
payee: and
s. Certiy to your non -foreign sta1US for purposes of v% tthold-mg cruder
chapter a or 4 of tie Code fit appliceWe� and
5. thai FATCA code(s) entered on this form (0 amri indicaarr
that you are exempt kmn ft FATGA reporting is correct. 'See f.'iftat fs
FATCA "q. later, fartatherinformation.
Note: If you are a U.S. person and a requester gives you a form other
;parr Form M-9 to request your TiN. you must use the requesters iorrrt 9
h,, is subst fy similar to this Form N-9_
Defrndmn of a US. person. Fix- federal taut purposes, you are
cones a UZ- person H you are
-An, ind[Mdual whor is a U-S. citizen or U.S. resident alien:
• A pare•>xs . mrpor-tan, company. or assooiabon asated or
organized in the United States of under the haws of the United States
• Art estate joihear t�an a foreign estate): or
• A domestic trust has defined in Regulations section 301.7101-7y
€stabFshurg US. status for purposes of chapter 3 and chapter 4
withholding. payments made to foreign persons, including cet3in
dsstrilwdons allocations of iriovrne, or transfers of sales proceeds. may
be sLt4ed to wtihhokfrtg under chapter 3 or ehaplef 4 of toe Code
pe tons 1 t31-1474j. Under those rules. ff a Farm W-9 or other
cartfnic of norr-far gn status has not 1 received. a wiftoidirg
agent, thane eeff-. or paAn—hip (Mn4 9e-e-* appi- pres mToon
Mies th-t may rt gwnr the pwy to withhold appiicaFale tax from tt*
ra*ett ouaK. tray y eror. or partner fpayeej. Sea Pub_ 515.
n*Mthholdltng of lac on Nonresident Aliens and Foreign Fntities_
The-i Vlawing persorss must proride Form W-9 to the pea for
pu'Ws,es of establishing its run -foreign sitilus.
• [n the case of a disrec,arded entity svitft a U_S_ o+.vnen, the U.S_ er orrer
Of ti : drsre-garded entity and not the disregarded entity.
• in the case of a grantor Lust wM a U.S. grantor or Other U_S- ornrrrr.
generaly. the 1AS- grrdw or other U.S. owner of the grantor trust aid
not the grantor truss_
• in the case of a U.S. trust (other than a grantor trust). the U.S_ trust
and not the beneficiaries of the trust
See ruin_ 515 for ni_,m infonratim on providi g a Farm W-9 or a
catificat m of rrx fnndgn status to avoid vathhafdir S
Kittitas County Agreement for Services (rev. 5/14/25)
Page 15 of 22
Foreign persm fd you are a foreign person or the U.S. branch of a
foreign bank that has elected to be treated as a U.S, parson (undx
R_gu1;Ao7r8 section 1, 1441-1(b}E2i{iY} or otter appflcable section for
du3pt:r 3 cr 3 purposes. do next use Form IN-9. Instead. use the
appmprk= Fenn ►" or Farm Sett Nee Pub. 5M tf ym are a
qual bed far� persiori laid urKW Raguialmy. seacri or
a parrersfrip that is wholly owned by qualified foreign pefzson funds,
that is *N%iad as a non foreign person for purposes of SBCb[frr 14-45
withhokimg. do not use Form W-9. Instead, use Form Yl-8> %P for other
cefnik_ t at n0*4bre gn stead
Nosuesidera aken who becomes a resident afierc Generally, ar+ftr a
ncrxes rsk alert inlividuak may- use the nerrrrs of a tax treaty to reduce
,or aflminate U.S. tax on pertain typs of income- tdavrever, rhos tart
treo,es asnt�rn a grcvi*ion known as a saving clause. Exceptions
spacified in samlg clause may permit an exemption from tax to
continue fur cx_rtain types of mcoma even afief the payee has othermse
became a J_5 resident alien for tax pusposLn-
V yuu are a'U.S. resident alien olio is relying on an exception
aon»d in the saA a claim of a tax yeti to clam an exemption
frorn UIS, m- x on oartain types of income. you must attach a stat4ment
to Form W-9 that specifies tw% folovAng five items.
t_ The treett county-y, C-�nerally. this must be fire saune treaty under
which you chaired exerription from tax as a norxesident afren.
The treat• ar5de addressing the income.
3. The arli de, number Ior kcabonj in tftr tax linty that contain; the
saving clarase and its exceptions.
4, lire type and amount of income that qualifies for the exemption
tram tML
S_ Suffi6esrt facts to justify the exemption ham tax under the terms of
the txeal-I article.
Ecwr4 te. Article 20 of the U.S. Civr*a Omme Tax treaty allows en
exemption Isom tax lot scholarshp income received by a Chrtese
s,-L�iertt J,>MporaftTy present in the United States. Under U_S. law. this
shAent veil b-corne a resident aken for tax purposes if the r stay in the
United Sw s ezaeeds 5 calendar }sans F- "Bever. paragraph 2 of the
first Pvokcwl to the U_S.-China treaty (dated Ancl 3o, 19&) Mows the
peveisrorrs of Amefe 2010 aontrwe to apply even after the Chinese
sal c�a becomes a resident alien of the United States. A Chres-1
saxient who quari5es for this excepbon (under paragraph 2 of the fast
Protocol) and is relying an this exception to claim an exemption fmm lax
an t>ar schabirship or felowshap Ttconte mould attach to Form W-9 a
saaternert;l Sleet indudes the information d_scritkd above to support 1KA
If you are a noreesidstt alen or a foreign Entity. gil-te *w requeste f the
4Foro13ria7e sic mpletxi'.crin -S or Form Sett.
Backup WMholding
What is backup withhokfmg? Persons mooing certan payments to you
must under certain condiaorrs r9ii-Wd and pay to the CpS 24% of such
pa}mrerft Ties is ca.1--d'ba tufty wW iWding.' Payments that may to
sLtjec•I m2 backup vrithMiding include. ttr rt are not Iirnifed to. interest-
tax-ar- rrV irn=rest dridends. braker and Starter exchange
trarsac-tians. rents, r aMes. nonemployee pay. payments made in
seet)ercent of payTTient card and trim p" rfetwofk tmrsartions. and
oerlain parrfsevis tram fishing boat operators Real ,a mate transactsons
are not subject to backup wAhcldrtg.
You era nA b�_ sLiblecct to backup withholdrt^3 on payments you recevre
if you give tfre "_ Tue ter your corrW'nW. make the proper conficamions.
and r_-pon all yew taxable infest and dhidends on your tax return.
Payrnertts you receive will be subject to backup withhoidmg &
T_ You do not furnish your 11N to The requester.
2. Ya r da riot certify your TiN %Awn required {see the rrstructons Ior
Part I l for dewilsa
3. The IRS leis the requ ster that you Purr isheet an incorrect TiN:
4 The 196 tafs you that you are subject to backup withhokkig
becaus_: yxs dud not report all ymu interest and drvidends on your tax
ra:utrrr fur reportable rrtereest and dividends only): or
5. You do not certify to tip requester that you are rat subject to
bacMQ wilt iold+ng. as described in dem 4 under `By siguing &,e Wed-
out,brrn' above tfor repotiabie arterest and dvidend axounts uNried
after T9W only}_
Form W-9 iF ev. 3-2424)
Certan payees and payrmerrts ai e exempt from backV w&jhdd-,g-
See Exempt payee code. later, and the separate Ins--rx6ors 5Dr the
Requester of Form W-9 for mare infortrtaturi
See also Fst ditF W us sraLw for pcapasas oecftapor3and
cuter d wrthhokfMg, ex'Fer.
What Is FATCA Reporting?
The Foreign A£,aunt Tax Compliance Act tPA]-CA, r- r res a
participating foreign firkv c institution to report alt U.S, ataour'd
Holders that are sgea5ed U.S. persons. Certain pays am exempt fmrrt
FATCA reporting. Sea Fxernp6on [roar Ff TUA repafWW code. UX-r, and
the Instructions far the Requester of Form W-9 far more infzmratiN-�
Updating Your Information
You must provide updated information w wry person to whom yoc
claimed to be an exempt payee if you are no brger an exempt payee
and anticipale receiving reportable payments in the, f>rhre ir,,- this
pemont For example. you may need to provide updated inlionnation if
you are a C corporation that ekwft to be. an S mrporcdon, of iF {ou are
no longef tax exempt. in addition. you must famish a new Form er 4 if
the name or TIN changes for the acootxtt for example. iF the grantor ae a
grantor trust dies.
Penalties
Failure to furnish TIN. If you Fart to furnish your correct TIN to a
rectaester. you are subject to a Wally of 60 for each such W1-i e
unless your failure is due to reasonable cause and mat to wiM, neghect.
CiO penalty for false information with respect to withholding. If yrsa
make a false statement with no reasonable trans turd. vest is in no
backup withholding, you are subject to a S5W penaitg.
Criminal penalty for falsifying information. Willfully Wsitrvrg
certficatons or afEnnations may subject you to crimmal penalties
indudng fines anWor in prisonmertt
Misuse of T1Ns. If the regnresler drsdoses or uses TIUs in 4iWoo a
federal law. the requester may be subject to chit and awl inal penat'a�.
Specific Instructions
Line I
You must enter one of the following on this line: do not feat tls Wr
blank The narne should snatch the rrarne on your lax reams.
IF this Farm W-9 is For a joint account (other than-i an aaxu #
mamtainecd by a fcfaign financial institution i RFi tSt first and&;ern
circle, the nanne of the person or entity whicise number roe entered in
Part I of Form W-9. IF you are providnq Form W-9 to an FFI b document
a joint aooaunL each holder of the account that is a U.S. pe'son rrffst
provide a Form W-9.
• IncHviduaF. Generaly, enter the name shown co year tax return. If you
have changed your last name without informing the Soaarl Securty
Adrninistraton (SSA) of the name change. enter fast name. ffna law
name as shorm ore your social 9,-m fity card. arc} +.,new last name.
Note for MN applicant: lister your inndsidual manse as n rras entered
on your Form W-7 application, lime 1a. This should also be the same as
the name you entered on the Farm 1046 you iced voh y" applica on.
• Sale proprietor. Enter your indivdual fray as shiawn cup yoau Farris
14=11 on !ne 1. Enter your business, trade. or "doing business as O&N
mama on line 2.
• Partnembip. C corporation. S corporation, or LLC. o#wr than a
disregarded entity. Enter the errlitys tame as sh ovin on the entity's. tax
return an line 1 and arty business. trade. or D13A nitre an line 2
• Other entities. Enter your name as shown on required U-S_ fadesaI man
documents on Fine 1. This name should match the. name shown on tt a
charter or other legal document creating the entity. Enter any busi,r.--
trade, oe DBA rtarne on trte 2.
• Disrsgirde l entity. In gmetal, a business aamity that has a single
owner. including an LLC. and is rmt a corporatiom is disregarded as an
- ity separate from its owner (a dsregarded erttisy}. Sea Reguialions
section 301.Tftl1-2(cKZt. A disregarded entity st oLk ctiedx 1-e
appropriate box for the tax classifcation of its o%Tw. cErfter the owrreds
r%3rma on tine 1. The name of the owner entered on line 1 should rw%w
be a disregarded entity. The name on lira3 l should be ttra name shown
on the income tax return an which the inane should be sported. For
Kittitas County Agreement for Services (rev. 5/14/25)
Page 16 of 22
P39t3
example. tf a foes p LLC dat is treated as a died an ilv bar U-S.
federal lax purposes has a srrale owner flat is a t4.S, persona ft L.S.
awn"- Is name is miclured to be praw.rxd on fine 1_ of the cirect Owner d
the. ernity is also a t%egarded entry. enter tta irs;,saner tftw is rn:
disregeced for federal tax ptrpzes. En-r the dmrgwdcd a sbityrs
name on urae 2- H the IYAYPV ai Ile d+s*egard--i entity Is a farsgn p
the owner rmist compta�,- an appropr4te Farm IN-6 irsWead of a Frm
W-a This is the tie %-en it ttfe irxayn person tress a U.S. Tft
Line 2
It ti h3ve a lupines name. trade To". MA narm or disregarded
aiitky name, enter it an fire 2-
Una 3a
Check the appropriate box an fine 3a for the U.S. federal ta-tti
classftaboo of the person whose name is entm-cl ar fsrr- 1. F. hxi, cc*
acne box an line 3a.
IF the enthyiutdvidual on fine d
T KEN check the box for ...
isaN---
• Corporati , n
Carpordhov-
• Individual ar
Irtdviduai sde proviewt.
• sa4a proprietorship
• LI-C dassiFed as a par tip
13nvted hablitir conpareyr and
fur U.S. federal tax purposes or
enter the appropi ate tax
• LLC lhat has filed Form M32 or
dass�ati;om
2553 6-acting to be taxed as a
P = Fartnemshp.
corporal iarr
C = C co poralxvk or
S = S oorpCrahcrL
• Partrrer5tsp
Rar��n'srrip.
• Trusflesta[e
Trusts�tate.
Line 3b
C heck this bmx if you are a p&uwr I* [i cluding an, LLC clxmliW as a
pa tfcrslip for US_ federal tax p.uposes}, trust or s"a lhaa has arrr,
foreign partraers. -ArKn. or bezaficianes, and you are prcrrixdiii g t1�
form to a partnership-1r"t or estates in which �cu ha%* an ownership
interest You must dxxc* She box on b-* 3b i= you n3cei a3 a Farm W4
for dmurrar"ry, 2Videncel imm any partrw. owner. or ben iary
establishing foreign staffs or H you recekea Form W-9 ism arty
partner, owner. or beneficiary that has checked this box an fete 3b.
Note: A parrnership that provides a For n IM-9 and cineclxs box 3b may
be required to complete S�hedules K-2 and K-3 (F-w-m 1L'65L For mom
in7fornVhan, see the partnership heir=fixes for Sdrzdxdes K-2 and K-3
[Farm IM.t.
Id you ate reWred to tample�* lint 3b but i al to do so. you may riot
naa -.a the infamtation necessary to file_ a comEcl infotmaitio n return with
the PS or famish a o=e t payer s=er neat to gear partsrers ar
beneficiaries. See. for exaample. sec dons 66M 6722."672s for
+A may apply.
Line 4 Exemptions
if you are exempt frorrn backup w+thhoidnc an for FATCA reparLng-
e:tLer in the appropriate s- r e fxt Inca a w%y crxleiya tiraLnray apply to
SOU -
Exempt payee code.
• indrAduals [Including sale propnetamsy are dal exempt irar n
bad-j-p vAtbolding.
• Exeepi as provided beho H_ oorporadons are exempt moan teckW
v ihho]dng for certain payrr-nun, incItAirag rnttres t and dyid,2nds.
• Corporations are Trot a xempt from backup w.-- dioidirx3 for payrTeffts
made in satSfefnefntof pa?,me tt card or Ord -party rnatauufk tr.iore_
Corporaticos are not exerrxpt tram backup wiftd ding Ywatr re%,ect to
atfomeys fees or grass proceeds pad to aHornays, ar4 corprrabcrfs
that provide medical or health care services are no-[ exempt wft respect
to pafr>- reparh Ue on Form tO99-MISC.
Th-- loiawing cades identity payers that era exernpi from backup
-Ai thholdng- Fnter the appropriate code in the space on fine 4-
1 — Ar orgarnzz_atio n exempt tam tax under section 501 tag any 04A or
a Custodial account under section 4R3tvX-A id ttre account satisfies the
mcluiremants of section -W MS(
Farm W9 t%la v. 3-2M4)
2-The United States or arty of iu agerra� or irsavmertaf teis
3-A state. the D ivt id of Cotambia. a U.S. axrrnormaaft or Mrmoga
or any of their pditicd s:.�s cr ors n ens ies.
3 -A foreign government or any of its paivocai suLdivsiens. N
or instru mentalities.
5-A corporation-
6 -A dealer in securities or o xnmcdtes required to register in the
tlnhad States, the Distnzt of Cokurbia. or a U.S. commonwealth of
terrhory-
-A futures commission mercharx mg�tered nith tha Ce+mmodty
Futures Trading Carrion-
S-A real estate investment trust_
9-An entity registered at ad byres dx" the taco Year LrKW fire
tnvestm0nt Comparry Act o: 1940
10-A common trust fiend operated by a bank tinder section 583{a}_
11-A fnarx irm4hition as deitroed under section 561.
12-A middleman kite m in the iRw�`tmient community as a nominee ar
custodian.
13--A trust exe..mpi from tax under secular 664 or described in section
4947.
The iokaing chart shows. types of payments that may be exempt
from backup withholding. The chart apc& s to the exempt payees fisted
above, 1 through 13_
IF the payment is for...
THEN the payrnens is exempt
for.--
• Interest and dividand payments
.All exempt payees except
for 7.
• Broker transactions
Exempt payees 1 t rmigh d and 6
through 111 and all C corporations.
S corptraliors mtisi not enter an
exempt payee code because they
are exempt only for cabs of
noncovered sec-urrags acquired
prior to 2012.
• Barter exeharxe transactions
Exempt payees 1 trough 4.
and paVoriage dividends
• Payments over SCM regiired to
Gwerallly„ exempt paye�,—,
be reported and drect safes over
1 ttrrc t* 5.'
S5,uo0'
• Nyments made in settlement of
Exempt payees 1 >frrvugn 3,
payment card or third -party
network tranw.rions
iSee Farm 1o99-lAISO. Misc--naneouslnfanrmW&m asd its irstruc6ons.
ZHorsa!ver. the 101lovring paymems made to a carpomton and
reportable on Fenn TOgg-MISC are notev-vVfrom bacl
viithholdiing: medical and heWzh care payrnenls, attornays lees. grass
proceeds paid to an attcrr y reportable under section 60-1-S 3. and
payments far servic*m paid by a federal executive e agency.
Exemption from FATCA reporting coda. The fabmrng codes identify
payees that are exerwo from reporting under FATt k These r "-
apply to persons submitting this form !kr amounts. ma ritaiirred outside
of the Merited States by certan leceign financial instim1horts. Thwefore. if
you are only submang this fcrrn Tor an amount vnu hold in tfsa United
States, you may leave this feid blank. Coruvb with Ihie persm
req resting Ihs form it you are unozr-ain if the 5namial instihAon is
subfect to these requrernerts. A requester may indcafe that a code is
not required by providing you with a Ferrrt'Al-9 with "Not Apphtabte" Or
any swrxfar irtdi attornj artera!d on the line for a;WGA exemptiaet code.
A -An ergari ation exempt from tax under section 5WW or any
iridvidual retirermerit pia r as defined in section 7701W4
B-Tile llnft-ed States or any of its agencies or insbumetrtaiities.
C-A slate. the District at Columbia. a U.S. cornmonwealtti or
territory. or any of their Political sibdivsiorrs or nstrum+entalities.
U-A corporation the stock of which is regularly traded on one or
more established sea3ftes markets, as described in Regutaauns
section 1.14.72-1(c)(1) aii
E--A corporation that is a men -her of the same expanded affiliated
group as a corporation described h R-,grlatans section 1.1472-1(cX1)@-
Kittitas County Agreement for Services (rev. 5/14/25)
Page 17 of 22
P.94-4
F-A dealer in s2CW>ti- a3mr cr der Calve Inatnciai
irismmertts tirK:kidwq rao3ocal pnmpal m fusses. %�ards
---d opborrsp that is regstered as sLch urrdar We lanes of the V 1nred
or atrry state.
G-A reall estate rnVSt rertt trua,
H -A regulated xNesi Twi aar4sh _- dshried in sedw $51 or an
entity ragrsterod at all t r mas dm3 the tax x-ar und=s lire kn estment
Compairl Act of 1940_
I -A common trust hind as deed in section 564*
J-A bsnk as da5ned irr secti.-rr asT-
K-A broken
L--A trust exempt horn tax under s€-bon Sac- ed in sec op
hi -A lax -exempt trust under a section 4400:r pbn or sewn 457 ra
purl
Note: You may viish to corsuft with the fimiinciai irrstftboe requesting
this iorrn to determinewbedtar the FATCA coda ar.6ar exerrm payee
coda shodd be completed
Line 5
Enter your address (number. street. and apartment or site mtmberi.
This is vrbere the requester o i des rcnn W-9 ,rill mail yaur information
reAsrrs. If this addrrs difiars fr vm ti_ oxre tt* requee%,er already has on
fife. enter `NEVr at the tap_ If a ms'a address is pro%i&.tL tilers is still a
char the old address rnill ba used utbl tee page drai-Ves yver
address in their records.
Line 6
Enter yotr citystate. and ZIP coda
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the ,WW*priate box.11 you are a feside!rt aban and
you da not have. and are rot efiobli to 9---L an SS,$L your TTN is your
IRS rT:N_ Enter it in the entry, space far tf'te Social: securfsy nt7rber. If you
do not have an MM. sea W4! M to net a Flo.` beiov►.
tf }vu are a sole lxopm-w and you brave an DR, as u may enter either
your SSN or RN.
tf you are a singe_ -member LLC does rS disregarded as an enr ty
separate from its owner. ens the owners %K Sox IN. c Sire i7mrw has
one}. If tie LLC is classified as a corporation ar partnersHP. enter th8
entity's, EINL
Note: Cs�e May Name ard,%V76ar To Gue Me Rea;6-scerlater. for
h v#w cIe<riaeatioai of name and TIN o: rr radxs.
How to get a TIN. If you dD not rear&- a TIN. apply for are irnmediately.
To apply for an SSN, gat Form SS-5- k-PI catia't Rv a Social Security
Card. fram }vur local SSA o€ e. or gel ?kris form drGue al
www.SSA goe. You may also get this farm by cat" M-772-1213. line
Form'aal`--7. App€icabion for M frRkmdtW Tapayer Ider0cation
Number. to apply for an VW or Form SS-i. Appiicatiora br ErWayw
Identification Numri._,r. tc apply for an EIR Yaw can ap#ily for an ON
online by acoesssx idea !ire webew al r►mrr93-9W971. Go to
w%-.v.)mgov1Far m to view. dcnrload or prier- f orrxr LY-7 andrLor Form
SS-s. or, you vwk go W wurmvr F sass fArcierFrlrr.^s W pW a an Vden anal
have Form W-7 an&or Form SS = mailed to you 15 iecsiness
It you are asked to complete Form'R-9 bva de rot trawz a 11N. appiY
for a TIN and enter `?Applied ForI in ttie space or tare Tiff_ sign etrd data
the forum, and give it to the requestUL For inler�at ani *Adend
payments, and certain payrnerds male -with re c to readily "dabps
instrument_ y ou wil pen erailly have W days to gAt a TI N and give it tr3
the requester bdyre y;ar are subject la backap z&14 nbderg on
payments. The 6"�Y� nle does not applyla ulthar types xr payments.
You ailf be suL*t to backup wdhlralhrig an all' such payments until
you provilE! yc rr TIN to the rec}.rster_
Note: Entering "Applied Fcc mears them you hie a h-ady applied for a
TIN or Inat you intend tot apply for one soar See also €srab4153 .-g U 5
sfaws brpwposes & U.Iap _r3 a d cftapW1 i+itPorZpd nq- smiter, for
when you may insteed be stbiect to siitf'hddirg order OWAer 3 or 1 of
the Coda.
Caution: A disreparded U.S. err*.ity oral tss a aomign owner must use
the appropriate Fom 6•l-8_
Farr dr'-s Imo• 3-=4)
Part II. Ceril#ication
To establish to the withholding agent that you are a U.S. P rWc, or
resident afim sign Fo an l,V--9. You may be ruled to sign by the
wit-hofdirg agem 9ton if item 1. s. or 5 below indicates ati�
For a font a..'^^a.mt, only the person whose TN is shown rn Pad u
should sign 1Fahen m qi-zredy. In the case of a disregarded entity. the
persen idenbhed on line 1 mast sign. Fxempt payves. see &emptpayee
cede. earlier
Signature requirements. complete the certification as irxVoAa -d in
itd T thrltagh 5 balo:Y.
1. interest. dEri Wmi, and barter exchange accounts opened
before 19" and broker accounts considered active during 1981
You must gke yraer vorrect TIN, but you do not have to sign the
certifir- t .
2 Interest. dividend, broker. and barter exchange accounts
opened after IQW and broker accounts considered inacbve during
ISM, You must sign the certification or backup. withholdmg "it apply. IF
you are subject 10 hacivap►Yithholding and you are m,-rety providing
your correct TIN to thna requester. you must cross out item 2 in the
c tiFicatian before siglinnig the form.
3. Real estate transactions. You must sign 1he certifcaton. You map
cross out item 2 of the certification_
d_ other payments. You must give your cornet TIN, but you do not
Fa%--�, to sign'the cartification unless you have been notified that you
have preriou* ghren an mcorrect T1K 'Other payments' include
payments made in the co wse of the regvastEes trade or business for
rents, rayatties. goods (other than bills tar merchandnse). medical and
heotth care sL-vices hroduding payments to corporations}. payments to
a non —employee, :or services, payments made in settlement of payment
card and third -party m wprk transactions. payments to certam fish
boat cr'aty members arnd fisharmen. and grass pros, cis paid to
attorneys tnctuding pa• ments. to cotporattcns�.
S_ Mortgage interest paid by you, acquisition or abandonment of
secured property, canceNation of debt, quaGTied tuition program
payments (under section 529), ABLE accounts [under section 529A).
IRA, Coverdet! ESA, Archer MSA or NSA contributions or
di etribufitms, and pension cGstributilons. You must give your correct
TIN. but vau do rx+thare to sign the cerffcation,
What Name and Nurnber To Give the Requester
For this type of account:
Give name and SSN of:
1. In"iduat
The india:*-i
2 Two or mere iry S idbak quint occoumth
The actual owner of the account or,
e6w char, an accaurit maintained by
it crmlbimed fiends, the find inditiduad
an FRI
on the account'
3. Two or move U.S. persor's
Each holder of the account
faint ao=untmmialtaired by in FFtf
3. custodLd acomnt at a miner
The minor=
Rhdcmn G& to FArrors Act)
5. a The usual., a,7 6e srrrergs trust
The grxtcr-husk"'
4ga'rtar is also ftswo
h. So-called trust account tat is not
The actual owner'
a legal ar vaW trust urdle' slate lawn
aSaieProPrietord pordisregarded
TheVV.TW1
en* aniseed by an irxiviAd
T. Grantor trust Ring under Optimal
The g7rror'
FiGN Yettnod t ode Pegratitirrs
section 1.671-'at13t'2''0QA9"
Kittitas County Agreement for Services (rev. 5/14/25)
Page 18 of 22
PzKr- 5
For tfus type of account&
Give name and EIN of-
a- Disregarded _rroty not vaned by an
Time a,r*nw
li diwidual
4_ A talit' brut. elat& or persi in tnEt
LAo sty r
tfl. Corpwabon or I.LC decinngowVaiaw
T*e carpraliarr
sus an Fame E MP or Fare
11 _ Associaticm, dtu, rams d`vhzb�.
THre cegcreati n
-wail''. am 06-M .irt-1!%eM ti
12_ P'ahnership a muil:HTsunben LLG
The pa t P
t3_ A brdvE r or r egestoesd na rinee
Die trake, or nominee
td. Acnaund mid tl,e DqD rri- era at
The puddle c rt .
AWxxftre intlxnon'readapubic
arm b zld as a or load
y
gaueviirnara. adlocl d"ehra#. ST wisor p
drat receives arp`tlhural prGg'a'n
pnrne nt3
t5_Giraindwtint fiFM%TnIC1411orr
The trust
under the Optional Fang Me>td 2-
requiring Form taesfsee-Rr><1 aEun®
section tZ 11-4boM 8ti"
List Intern and circle the nacre of he pawn -how rm irnber y% Furnish
tf only arse person are a Faint account has an SSN_ that perso s number
must be Fur *d—*--3
Circle lFre mgrmes name and fvari*h the minoes SSN.
'You must show your irdnmktai name art fine 1, and enter business
or DBA rune. if arj} on ine 2_ Ycu may use either your S� ELN Of
you have orrek but the IFS aicourages you to use your SSN.
`list first and circle roT a of the UW, tea. or pension bust. [Do
not iEraish 11be TIh1 of the persanat representative Gr trustee unless the
legal sty itself m not design iW in t-re visit trtla.y
' Note- The gramor must also pirrode a Fwm :V-o to tine tor, ae of the
trust_
.. For mm inforrvubon anopojae a! filing methods for grantor crisis- see
the lnstru, 5or ram 1 Ca1.
Note: tt no name is ceded atr3n more ihim one narne is listed, the
ncmber .all be wnszdered 1n lac ttzl of the first rare Ii t--d.
Secure Your Tax Records From Identity Theft
klen*y thart ca:curs -M!en sosnacna use )vur Wen , U111r-10rnnaboit
suds as your na'raa, SSN. or titer iderttiil" inform5tion. withatA ycLr
pamussion to comra fraud at odrer entree An ida rtty thief may l%F_
your SSN to ge5 a Icnk or may file a tax return usiN lair SSN to rvor--y a
a ref.wd.
To reduce your risk
• Prol-�o your SM.
' Enst— your emplayer is protecting yct.rr SSN. and
• Be cereM wrhen cueing a tax tear im praparzr.
tf your tax records are allecW by i 1encity thieft and you recein,e a
notce from Use IRS. respond rigE,,i a*--p to &-e narn and plane ntxrti+d
printed on the IPS not3:�e air lec-fe'.
If your Sex reCc+rcf, ate raas cuirerroy aFf .cted by idenMy d-*tl but you
think you are at rise: due to a tars cr --wen purse or waineL qu'ntionable
credit card gift iiri. or a orrelxla cre& report contract the IRS
ksenthy Theft Fx ne-_ as er*-3t)tLU9D ar shall Porn S. 4M-
For more etlormaticr t see R&L 5= bdenVyThett In.amaton fir
Taxpayers.
Famm ii-9 Rev. 3-2024)
Victims of identity theft who we exWnenang economic harm or a
systemic problem or are seeking help in reso, ng tax pratrkms tkhk
trace not been resolved thro'xh nourel chwmek% ma_v be ebglote fbr
Taxpayer Advocate Service (TASl assistance. You can reach TAS by
eallim g the TAS tot -free case intake, Ime at aZ-7Tr-4i`M orTCY-MM
SM-M-4059_
Protect yourself from suspicious ernails or phistting schemes.
Phishing is the creation and use of email and websites designed --3
mimic legitm3te businms emails and wrebsneLs. The most ccM- m n act
is sending an email to a user falsely claiming to be, an est kiislied
legitimate emtegXr--e in an attempt to scam the usFr into aurrar61htg
pr v3% information tfrat %vill be used for identity then.
The IRS does root initiate contacts dith taxpayers via emaas At= the
IRS does not request personal detailed inform ati n through email or ask
taxpayam for the PIN numbers, pssssvords, or similar secret a
information for their credit card. bark or other financial accounts.
if you receive an unsolicited emal dairnwV to be tram the RSx
forhard teas message to phdslling+Dimgov. You may also report mi!s%r
of the, IRS nacre. logo, or other IRSpmperly to the, Trmsuryr bsspector
General far Tax Administration (TIGTA) at W, You can
forward suspicious ema Is to the Federal Trade Commission at
spa rtartaa.gav or report them at www. Ac.gavfiorraptairrt. You can
contact the FTC at mrw.t3c.govlydtheR or 977-FDTHEFT OT7-438-4M,
If you have been the victim of identity theft, see wwwJd4rrtll7fe4 gov
and Pub. 5027.
Go to www.imgovildenatyThefr to learn more about identity theeitand
haw to reduce your risk
Kittitas County Agreement for Services (rev. 5/14/25)
Page 19 of 22
Cage- 6
Privacy Act Notice
Secrkn rat•39 of Irnemal %rserk]e Code requires you to provide ,otF
car,xi-nm is perms 2irv3ujng f+3deral agencies( ^7m are required la
6h= anbrmatim W xns'mtn the, IFM to r<eptrt "erest, chidends, ct
eftact L,&w inoctrre gaud w ycu rrxrfgage irderest you paid; they
acquiswt oe abWK5WMM of secuVEd prWertyr. the, CancellatOn od
debt ur oonhtwhons you made w an JRk Archer TASk cr MSik The
pamon calfectirrg this foam ton tfae in9orr+►a[kn cc the Them to We
iron r8turrs vh& the IWS, mpvrtirg tie ab m* informaticxx
Rmake u6ns of dis Won tatim irmkKle giaim it to ire f]evtmW of
Justice for civil and ais, kk at €i'6921150aa acid to dies, siadas, tl19 llistrict of
G44ffba. aril U.S- corrrruvx9dft and h-rritsari` tr use 'sr
admiristerirg their itt+ars The to kwmabon may also be, disclosed to other
countries w,,der a treaty. to federal cad st� agues to enforce o',a
and csrq. rW farts or w federal Fear enforcement and htteFGg me
agenci s to combat terrorism You mLm provide ycw TIN whed e'r or not
you are regWed to Tale a tax rakm Under sxEan 3X& occurs mxt
gerneraly a ilaroid a perm of taxable interest~ dividemis, and
certain cdww pa)mwt s to a payee %+ft does naf gip- a TiN to the Pa r.
Certain penabes May also apply for PVLKirg false or *audrtl tat
inforru4czm
Attachment "F"
LWashington
DSHS Agreement Number
State
COUNTY PROGRAM AGREEMENTDepartment
of Social
V
2663-70974
7&Health Services
School -to -Work Direct Service Pilot
Transforming lives
Contract
This Program Agreement is by and between the State of Washington
Administration or Division
Department of Social and Health Services (DSHS) and the County identified
Agreement Number
below, and is issued in conjunction with a County and DSHS Agreement On
County Agreement Number
General Terms and Conditions, which is incorporated by reference.
DSHS ADMINISTRATION
DSHS DIVISION
DSHS INDEX NUMBER
DSHS CONTRACT CODE
Division of Vocational
Division of Vocational
1225
850OCC-63
Rehabilitation
Rehabilitation
DSHS CONTACT NAME AND TITLE
DSHS CONTACT ADDRESS
Austin Diaz -Munoz
4565 7th Ave SE
Contracts Specialist
Lacey, WA 98503
DSHS CONTACT TELEPHONE
DSHS CONTACT FAX
DSHS CONTACT E-MAIL
(564) 200-2812
Click here to enter text.
Austin. DiazMunoz@dshs.wa.gov
COUNTY NAME
COUNTY ADDRESS
Kittitas County
Kittitas County Court House
205 W Fifth St Room 211
Ellensburg, WA 98926
COUNTY FEDERAL EMPLOYER IDENTIFICATION
COUNTY CONTACT NAME
NUMBER
Kasey Knutson
COUNTY CONTACT TELEPHONE
COUNTY CONTACT FAX
COUNTY CONTACT E-MAIL
(509) 962-7090
509 962-5883
kasey.knutson@co.kiftitas.wa.us
IS THE COUNTY A SUBRECIPIENT FOR PURPOSES OF THIS PROGRAM
ASSISTANCE LISTING NUMBERS
AGREEMENT?
No
PROGRAM AGREEMENT START DATE
PROGRAM AGREEMENT END DATE
MAXIMUM PROGRAM AGREEMENT AMOUNT
05/01 /2026
09/30/2027
Fee For Service
EXHIBITS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into this
County Program Agreement by reference:
® Exhibits (specify): Exhibit A - Data Security Requirements Exhibit B - Student Guide Instructions, Exhibit C -
Student Guide, Exhibit D - School -to -Work Student Data, Exhibit E - School -to -Work Billing Checklist
❑ No Exhibits.
The terms and conditions of this Contract are an integration and representation of the final, entire and exclusive
understanding between the parties superseding and merging all previous agreements, writings, and communications, oral
or otherwise, regarding the subject matter of this Contract. The parties signing below represent that they have read and
understand this Contract, and have the authority to execute this Contract. This Contract shall be binding on DSHS only
upon signature by DSHS.
COUNTY SIGNATURE(S)
PRINTED NAME(S) AND TITLE(S)
DATE(S) SIGNED
DSHS SIGNATURE
PRINTED NAME AND TITLE
DATE SIGNED
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 1
Special Terms and Conditions
1. Definitions
a. "Authorization for Purchase (AFP)" means the formal DVR fiscal document that officially identifies
and authorizes a DVR Contractor to deliver a specific service.
b. "CRP" or "Community Rehabilitation Program", means a provider which provides vocational
rehabilitation service to individuals with disabilities to enable those individuals to maximize their
opportunities for employment.
c. "Contractor' means Kittitas County.
d. "County" means the political subdivision of the State of Washington, named above, performing
services pursuant to this Program Agreement and includes the County's officers, employees, and
authorized agents.
e. "County Coordinator" means the official developmental disabilities program coordinator or their
designee.
f. "DDCS" means the Developmental Disabilities Community Services, formerly known as the
Developmental Disabilities Administration (DDA).
g. "DVR" means Department of Social and Health Services, Division of Vocational Rehabilitation.
h. "DVR Counselor(s)" means the Vocational Rehabilitation Counselor(s) assigned to the School -to -
Work Student through the DVR eligibility process.
i. "Individual Plan for Employment (IPE)" means a DVR form that documents important decisions
about vocational rehabilitation services for a Student as defined in WAC 388-891-1115. The
decisions documented on the IPE include, but are not limited to:
(1) The employment outcome the Student plans to achieve;
(2) Each major step needed to accomplish the employment outcome;
(3) The Student's responsibilities in accomplishing each step of the plan;
(4) DVR's responsibilities in assisting the Student to accomplish each step of the plan;
(5) Vocational Rehabilitation (VR) services needed to complete each step; and
(6) Terms and conditions the Student and the DVR Counselor agree are required for
continued support from DVR.
j. "Intensive Training Services" means individualized, one-on-one job skills training and support
provided at the supported employment job site to enable a Student to:
(1) Attain Job Stabilization in on-the-job performance, with job supports;
(2) Meet the employer's expected level of work productivity; and
(3) Transition to Long -Term Services when stabilization is achieved.
k. "Job Foundation" — The Job Foundation process is intended to engage students earlier in targeted
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 2
Special Terms and Conditions
employment planning and connection; increase partnerships with school staff to complete student's
Job Foundation report with actionable next steps; and increase the number of students completing
transition programs with a job or secondary education connection.
(1) The Job Foundation report and process may be a source of information for the
Assessment in determining an employment goal for the Student.
I. "Job Placement" means locating, securing, and placing a Student into competitive integrated
employment that is mutually agreed upon by the DVR Counselor, the Contractor, and the Student
or the Student's Team.
m. "Job Stabilization" means the Student, the employer, the DVR Counselor and the Contractor
mutually agree that a Student placed in a Supported Employment position has demonstrated and
maintained satisfactory on-the-job performance and has the quantity and type of long-term
employment supports available to them that are needed to maintain satisfactory on-the-job
performance.
n. "Long Term Services" means ongoing support services provided by an entity other than DVR after
the Student obtains employment and exits DVR School -to -Work services.
o. "Monthly Progress Report" means progress reports that are to be filled out on a monthly basis and
shared with the Student's Team to demonstrate progress towards employment and summarize
monthly work being done with and on behalf of the Student.
p. "Assessment" means
(1) Identify a Student's unique work interests, abilities, and any competitive employment
barriers related to communication, mobility, work skills, work tolerance, self -direction
(cognition and learning), and interpersonal attitudes, skills, behavior, or self -care, etc.;
and
(2) Identify the nature and extent of support(s) and accommodations needed for the
Student to obtain and maintain competitive integrated employment.
q. "School -to -Work" means a program that supports a seamless transition for students with
intellectual/developmental disabilities from school to adulthood through employment services and
connecting students to the necessary resources for success.
r. "Service Delivery Outcome Plan (SDOP)" is a written plan jointly developed by the Student, DVR,
DVR Counselor, and CRP representative for obtaining School -to -Work services. The details of the
agreement are tailored to the unique needs of the Student and documented.
s. "Student" means an individual with an intellectual/developmental disability age 20 to 22 who is in
their high school transition program.
t. "Student Guide" means a guide designed for a Student and/or parent(s)/guardians to house School -
to -Work related documentation, information, assessments, activity logs, and notes. This guide is a
Student's 'road map' to ensure key activities and milestones are completed and organized.
u. "Student's Team" means any combination of people, including, but not limited to; educators, CRPs,
the Student's Legal Representative or Guardian, County Staff, DVR Counselor(s) who support a
Student as they move towards Job Placement and Job Stabilization.
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v. "Subcontractor" means a Community Rehabilitation Program that the Contractor has separately
chosen to perform all or a portion of the duties and obligations that the Contractor is obligated to
perform pursuant to this Contract.
w. "Youth Extended Services" means ongoing support services and other appropriate services
provided to support a Student with a most significant disability in employment as a means to bridge
employment support between stabilization and long-term services.
2. Purpose. The purpose of this Contract is to represent a collaborative effort between community,
educators, caregivers and providers to support Students with comprehensive training and experience
that will lead to paid, integrated employment by graduation.
3. Period of Performance. The period of performance for this Contract shall begin May 1, 2026 and end
September 30, 2027. Contractor will determine their specific program timeline within the period of
performance.
4. General Requirements. The Contractor must perform the minimum expectations below in conducting
the services of this Contract:
a. Provide all services of this Contract in a manner and setting(s) that meet the requirements of
Washington State DSHS Administrative Policy 7.02.
b. Arrange and be responsible for all costs associated with communication interpreter services, as
needed, to provide disability -related access per the Americans with Disabilities Act (ADA) unless
the cost involved would cause an undue hardship (significant difficulty or expense) for the
Contractor. Determination of what constitutes an undue hardship will be made on a case -by -case
basis, relative to the Contractor's overall resources.
(1) If an undue hardship does exist, the DVR School-to-Work/Transition Program Manager
or their designated representative may authorize paying for interpreter services and/or
translation services apart from the contracted fee for service.
(2) Provide and be responsible for the cost of providing services through alternative
formats, methods, and languages, as needed, for Students who have Limited English
Proficiency (LEP) as per the Civil Rights Act of 1964.
c. Contractor is responsible for addressing cultural, language, and technological accessibility for all
Students to the best of their abilities when performing the services under this Contract.
d. Eligibility: Students must meet the following criteria:
(1) DDCS-eligible.
(2) DVR-eligible.
(3) Enrolled in a school district educational program that may include, but is not limited to:
(a) High school;
(b) Home school;
(c) Technical college, by exception approved by the DVR Transition Program Manager or
designated representative;
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(4) Higher Education, by exception approved by the DVR Transition Program Manager or
designated representative. Student starts School -to -Work services as of May 1, 2026 or
later, as determined by the Student.
(a) School -to -Work is a wrap -around service that's only available one (1) time per Student.
i. Students who choose to participate in this cohort may not participate again under a
different contract covering a different cohort. Should the Student change their mind on
the cohort they choose to participate in, the Contractor is responsible for communicating
with DVR to ensure there are no duplicate payments.
ii. Should a Student move from one School -to -Work County to another, or pause services,
due to individual circumstances, it is determined by the DVR Transition Program
Manager or designated representative, whether School -to -Work services will continue,
and if so, at one point in the process.
(b) Students must apply for DVR to start School -to -Work services no later than January 31,
2027. Students who intend to start services after January 31 may only do so with prior
written approval from the DVR School -to -Work Transition Program Manager or their
designated representative.
(5) Between ages 20-22. Students who have been identified to start services at age 19
may do so with prior written approval from the DVR School -to -Work Transition Program
Manager or designated representative.
(6) Have an Individualized Education Plan (IEP)
(7) Establish a DVR Individual Plan for Employment (IPE) with an employment goal that
requires Youth Extended Services as needed and Long -Term Services in order to be
achieved. This requirement must be completed by the end of the School -to -Work Intake
and Assessment Phase per section 5, Statement of Work.
e. Meetings must be held in the format best suited for the Student. If all parties are not able to attend
meetings in person, use of telephone or video conferences is encouraged to complete the process
in a timely manner.
f. Contractor must keep all Students enrolled in School -to -Work through the duration of this Contract,
regardless of outcome and/or Stabilization, unless Student chooses to exit the program of their own
volition or due to unforeseeable circumstances.
(1) Should a Student exit early for any reason, Contractor must document the departure in
Exhibit D — School -to -Work Student Data. See Section 6, Deliverables for further
instruction.
g. Service Delivery Agreement: The Contractor's delivery of VR services specified in this agreement
will begin upon the completion and signing of the agreed upon SDOP.
h. Service Delivery Payment: The Contractor will be paid upon completion and submission of the
required documentation demonstrating completion of each of the three phases for each Student as
outlined in Section 5, Statement of Work.
i. Service Delivery Method: This Contract utilizes Exhibit C - Student Guide as a reporting tool and all
associated activities outlined in Section 5, Statement of Work shall be carried out using the Student
Guide. Exhibit B — Student Guide Instructions offers instruction on how the Contractor may use the
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Student Guide.
& Statement of Work. The Contractor shall provide a program to provide the services, staff, resources,
and otherwise do all things necessary for, or incidental to the performance of work, as set forth below:
Services shall be sorted into the following three phases:
Intake and Assessment Phase.
Job Placement Phase.
Employment Phase.
a. Intake and Assessment Phase. The intent of this phase is to ensure the Student and the Student's
Team collaborate to determine if enough information is available to establish an employment goal,
establish the employment goal, and build an individualized roadmap of the Student's transition from
their education to meaningful community employment. This shall be accomplished through the
following objectives:
(1) Intake
(a) At a minimum, the Contractor shall work with the Student, the Student's legal representative
or guardian (unless they are their own), the CRP, and the DVR Counselor to:
i. Complete intake forms as needed, including the SDOP.
ii. Outline how assessment will occur, including additional meeting time.
(b) The employment goal is established and documented.
Determine what Job Seeker Tools are needed for the Student's employment goal.
(2) Assessment
(a) Through the assessment process, the Contractor will collect information about the Student's
strengths, skills, and supports needed for success on the job. This information will be based
on the Student's school, home, and community work -related activities, interviews with the
Student, family, school personnel, and others who are familiar with the Student. This
information may be obtained from Job Foundation report, work -based learning, school
assessments, etc.
(b) At a minimum, the following criteria must be addressed -
History of school attendance and reliability;
ii. Behavior support or potential strategies;
iii. Student Communication skills;
iv. Student learning preferences;
v. Student's personal hygiene;
vi. Potential job safety concerns;
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vii. Student stamina/endurance;
viii. Student social skills;
ix. Demonstrated skills and task performance;
x. Transportation needs; and
A. Work preferences and interests.
(c) Based on the above criteria, the Contractor must determine recommendations regarding
appropriate and attainable job goal(s) that align with the Student's:
i. Skills and interests;
ii. Desired work environment;
iii. Desired schedule;
iv. Ability to travel to/from work within a reasonable length of time; and
v. Accommodations and supports necessary to achieve identified goals.
b. Job Placement Phase. The intent of this phase is to provide the Student with the tools they will
need to find and secure meaningful community employment based on their employment goal. The
Contractor shall provide all services necessary to locate, secure, and place a Student into
competitive integrated employment that is mutually agreed upon by the Student's Team. Specific
placement expectations shall be outlined on the DVR SDOP for Job Placement and Intensive
Training.
Placements less than 10 hours: Job placement goals that are less than 10 hours per week shall be
approved in advance by the appropriate DVR Vocational Rehabilitation Counselor in consultation
with the Student's Team.
(1) Job Seeker Tools
(a) Contractor shall create tools based on individual need, such as a resume, cover letter,
videos, PowerPoint (or comparable applications), and/or portfolios.
(b) Contractor may also develop other materials as it pertains to the Student's individualized
pathway to employment such as a letter of recommendation, create and/or update Linkedln
page or other social media, etc.
(2) Job Offer
(a) If the Student received the job offer, Contractor must provide details of the job offer including
the following:
i. The Student's Employment Goal;
ii. Job Title;
iii. Start Date;
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iv. Job Duties;
v. Expected Weekly Hours;
vi. Starting Wage;
vii. Location;
viii. Transportation Consideration;
ix. Benefits Package; and
x. Potential Training Services and Date/Additional Info.
(b) If the Student rejected the job offer, Contractor must provide the reason(s) why the Student
rejected the job offer. Details must include how the job did not meet their individualized
employment goal, as well as the criteria in (2)(a).
(c) If a Student has a job goal that is 10 hours or more per week, but receives a job offer fewer
than 10 hours per week, the Contractor shall request approval from the DVR Counselor in
consultation with the Student's Team should the Student want to accept the offer.
c. Employment Phase. The intent of this phase is to verify, stabilize, and maintain meaningful
community employment.
(1) Employment Verification
(a) Contractor shall submit the following method of verification of employment after Student's
first day of employment:
i. The Employment Verification page of the Student Guide.
(2) Intensive Training Services
(a) Intensive job training expectations shall be outlined by the Student's Team. The Contractor
shall provide individualized, one-on-one job skills training and support at the supported
employment job site that will enable a Student to:
i. Achieve job stabilization in on-the-job performance, with job supports and services, and
a fading plan;
ii. Meet the employer's expected level of work productivity; and
iii. Transition to Youth Extended Services as needed and Long -Term Services.
(3) Stabilization
(a) Stabilization is achieved when the Student's Team and their employer agree that the
Student has demonstrated and maintained satisfactory on-the-job performance and has
long-term supports in place.
(b) Job stabilization is determined for each Student in supported employment based on their
unique circumstances. The DVR Counselor determines that the Student's work performance
is stabilized with input from the Student, employer and extended service provider when:
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i. The Student has reached the agreed -upon goal for the number of weekly hours worked,
unless the Student and the DVR Counselor agree that the job represents substantial and
suitable employment.
ii. The Student has reached a maximum level of on-the-job employment and meets
employer expectations.
iii. The supports available are adequate for the Student to maintain stable employment and
meet the employer's expected level of work productivity.
iv. The Student has long-term employment supports available or in process and is able to
transition to these services to maintain job stability.
(c) Once achieved, a Stabilization Report and supports on the job the Student may need, must
be completed for the Student as outlined in the SDOP and must include:
i. Detail and summary of how the placement hours were met (or if the job represents
suitable employment); and
ii. Detail, descriptions, and summary of how the DVR Counselor, CRP, and the employer
agrees that the employer's expectation have been met; and
iii. Detail and summary of how long-term supports have been set up and will occur; and
iv. The strengths the Student brings to the job; and
v. The Student's fading plan, including how they will remain stable on the job; and
vi. Additional training, services, and supports the Student may need.
(4) Stabilization needs to be achieved by September 30, 2027. However, exceptions may
be made on a case -by -case basis through the end of the calendar year (December 31,
2027) with approval from the DVR Transition Program Manager or their designated
representative. Youth Extended Services.
(a) DVR shall provide Youth Extended Services needed by the Student until DDCS funds are
available, in accordance with WAC 388-891 A- 1060.
i. Should Youth Extended Services reach six (6) months, the Contractor and DVR shall
collaborate to determine next steps which may include additional Youth Extended
Services or other options as needed.
(b) Youth Extended Services funded by DVR shall be outlined on the DVR Youth Extended
Services SDOP.
i. Maximum 26 hours per month at the hourly rate of $105.00
(A) If more than 26 hours per month are needed for a Student, the DVR Counselor must
document the requirement for more service hours and staff the case with their
supervisor to request an exception to this maximum.
(B) Exceptions may be made on a case -by -case basis and must be reported to the DVR
School -to -Work Transition Program Manager or designated representative.
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6. Deliverables. The Contractor shall demonstrate completion of activities for payment through the
following reporting methods. Submissions should be written in language that directly addresses the
Student and shall continue for 90 days beyond the Student's stabilization, or until DVR case closure.
The Contractor shall submit the required Monthly Progress Report to the assigned DVR Vocational
Rehabilitation Counselor for each Student who is served by this Contract.
a. Student Guide
(1) The Contractor shall submit a copy of the Student Guide to the Student's Team at the
end of each month demonstrating the progress of the Student's transition year via
completion of the Monthly Progress Reports section located on the front page and the
back of the Student Guide.
(2) The Contractor shall submit Exhibit E - School -to -Work Billing Checklist to the DVR
Counselor upon completion of payment points for each Student as demonstrated in the
Student Guide.
(3) Contractor shall submit a minimum of three (3) School -to -Work Billing Checklists for all
payment points for each Student.
(4) The Student Guide is a living document that comprises the following activities:
(a) Intake — Signed SDOP & Roles and Responsibilities of the Student's Team.
i. Roles and Responsibilities of the Student's Team will include;
(A) Team member's role.
(B) Team member's contact information including name, email, and phone.
(C) Team member's responsibility to the Student.
(b) Assessment — Comprehensive assessment demonstrating how an Employment Goal is
reached and established.
(c) Job Seeker Tools — Such as Resume, Cover Letter, Video, PowerPoint, Portfolio, etc.
(d) Job Offer — Documentation/Details of a Job Offer as stated in Section 5 — Statement of
Work.
(e) Employment Verification — Documentation/Details of a Job Start as stated in Section 5 —
Statement of Work.
(f) Stabilization — Stabilization Report.as stated in Section 5 - Statement of Work.
b. Data Sharing and Reporting - DVR is tracking the progress and success of the School -to -Work
program to ensure the program is available to all Students who meet eligibility requirements across
the state. In order to accomplish this, the Contractor must submit Exhibit D — School -to -Work
Student Data.
(a) Exhibit D incorporates the following required data elements:
i. Number of Students identified as eligible for School -to -Work in county or counties
served. If the Contractor coordinates services for more than one county, the Contractor
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shall submit data for each county.
ii. Number of Students enrolled with DVR.
iii. Number of Students employed.
iv. Number of Students who exited School -to -Work early.
v. Reason for Student exiting early.
vi. Number of Students who exited School-to-Work/DVR employed and transferred into
Long -Term Services with DDCS.
vii. Number of Students transferred into Adult Services or Job Placement with DVR.
(b) Exhibit D must be submitted a total of three (3) times to the DVR School -to -Work Transition
Program Manager or their designated representative throughout the course of the 2027
transition cohort following the below schedule and with the appropriate tab completed:
i. The "Aug 31, 2026" tab shall be submitted on August 31, 2026, or upon execution of the
Contract, whichever is later.
ii. The "March 31, 2027" tab shall be submitted on March 31, 2027.
iii. The "Sept 30, 2027" tab shall be submitted on September 30, 2027, or at the conclusion
of the Contractor's program, whichever is sooner.
(c) If the above dates fall on a State -recognized holiday or weekend, Contractor may submit
Exhibit D on the nearest workday prior to the due date.
7. Monitoring.
a. The Department of Social and Health Services, Division of Vocational Rehabilitation is required to
maintain a contract administration system which ensures that Contractors perform in accordance
with the terms, conditions, and specifications of their Contracts. DVR manages and monitors its
contracts through conducted risk assessments and monitoring plans. Authority to conduct such
reviews is provided by Title 2 of the Code of Federal Regulations (CFR), 34 CFR 80.36, OFM
SAAM Policy 16.20.55, DSHS Administrative Policies No. 13.11 and 19.50.30.
b. Progress Meetings: DVR School -to -Work Transition Program Manager shall work with Contractors
to plan meetings which allow discussion of program progress and support methods to ensure
Students are receiving adequate services to obtain employment. In addition, Contractor may invite
DVR partners to attend local County -initiated service provider meetings. DVR partners may include
local DVR Counselors, supervisors, and School -to -Work staff.
8. Subcontractors.
a. All Subcontractors utilized by the Contractor in delivery of direct services described in this Contract
shall hold a current DVR Community Rehabilitation Program (CRP) contract in which they provide
the following services:
(1) Community -Based Assessments; and
(2) CRP Job Placement; and
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(3) CRP Intensive Training Services.
b. Subcontracts
(1) Copies of proposed subcontracts between the Contractor and subcontracted CRPs
shall be provided to DVR School -to -Work Transition Program Manager prior to the start
date of this agreement; OR
(2) Within seven (7) calendar days of Contractor signature on this agreement.
(3) All subcontracts must incorporate this Contract by reference and include all of this
Contract's requirements.
9. Consideration. Total consideration payable to Contractor for satisfactory performance of the work
under this Contract is up to a maximum of $14,000 per Student. This is a comprehensive rate for each
service and takes into account the administrative costs associated with operating the program as well
as the actual costs of each service, and shall be based on the following:
a. Intake and Assessment Phase —A total payment of $5,000 per Student shall be paid to the
Contractor when the individual Student has completed the following activities:
(1) Intake Meeting: Paid upon receipt of a School -to -Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $2,000 per
Student.
(2) Assessment: Paid upon receipt of a School -to -Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $3,000 per
Student.
b. Job Placement Phase — A total payment of $3,000 per Student shall be paid to the Contractor when
the individual Student has completed the following activities:
(1) Job Seeker Tools: Paid upon receipt of a School -to -Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $1,000 per
Student.
(2) Job Offer: Paid upon receipt of a School -to -Work Billing Checklist and a written report in
the Student Guide. The total billable amount for this activity is $2,000 per Student. A job
offer is payable once upon receipt of the offer regardless of whether or not the Student
accepts the job offer.
(3) If a Student with a placement goal of 10 hours per week or more accepts a placement
for less than 10 hours per week, an exception for payment may be granted with
approval of the appropriate DVR Supervisor. This approval shall be in consultation with
the team including the Student, Student's Family (as applicable), DVR Counselor, CRP,
and County staff.
c. Employment Phase — A total payment of $6,000 per Student shall be paid to the Contractor when
the individual Student has completed the following activities:
(1) Employment Verification: Paid upon receipt of a School -to -Work Billing Checklist and a
written report in the Student Guide. The total billable amount for this activity is $1,000
per Student.
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(2) Job Stabilization: Paid upon receipt of a School -to -Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $5,000 per
Student.
10. Billing and Payment
a. The Contractor shall submit no less than three (3) separate original School -to -Work Billing
Checklists to the assigned DVR Vocational Rehabilitation Counselor for each Student who is
successfully served by this Contract.
(1) At a minimum, one School -to -Work Billing Checklist per phase as outlined in Section 5,
Statement of Work.
(2) School -to -Work Billing Checklists may only be submitted to DVR upon the successful
completion of an activity outlined in the SDOP.
(3) School -to -Work Billing Checklists must be submitted within sixty (60) days of service(s)
having occurred or within sixty (60) days of the completion of each phase.
b. Payment shall be considered timely if made by DSHS within thirty (30) days after receipt and
acceptance by the designated DVR Counselor of the properly completed School -to -Work Billing
Checklist. Payment shall be sent to the address designated by the Contractor on page one (1) of
this Contract.
c. DSHS may at its sole discretion, withhold payment claimed by the Contractor for services rendered
if the Contractor fails to satisfactory comply with any term or condition of this Contract.
11. Insurance - Self -Insured
a. DSHS certifies that it is self -insured under the State's self-insurance liability program, as provided
by RCW 4.92.130, and shall pay for losses for which it is found liable.
b. The Contractor certifies, by checking the appropriate box below, initialing to the left of the box
selected, and signing this Agreement, that:
(1) ❑ The Contractor is self -insured or insured through a risk pool and shall pay for losses
for which it is found liable; or
(2) ❑ The Contractor maintains the types and amounts of insurance identified below and
shall, prior to the execution of this Agreement by DSHS, provide certificates of
insurance to that effect to the DSHS contact on page one of this Agreement.
Commercial General Liability insurance CGL — to include coverage for bodily injury, property
damage, and contractual liability, with the following minimum limits: Each Occurrence - $1,000,000;
General Aggregate - $2,000,000. The policy shall include liability arising out of premises,
operations, independent contractors, products -completed operations, personal injury, advertising
injury, and liability assumed under an insured contract. The State of Washington, DSHS, its elected
and appointed officials, agents, and employees shall be named as additional insureds.
12. Investigations of Contractor or Related Personnel
a. DSHS may, without prior notice, suspend the Contractor's performance of the Contract if the
Contractor, or any partner, officer or director of the Contractor, or a subcontractor, or any employee
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or volunteer of the Contractor or a subcontractor, is investigated by DSHS or a local, county, state
or federal agency regarding any matter that, if ultimately established, could either:
(1) Result in a conviction for violating a local, state or federal law.
(2) In the sole judgment of DSHS, adversely affect the delivery of services under this
Contract or the health, safety or welfare of DSHS Students.
b. DSHS may also take other lesser action, including, but not limited to, disallowing a staff member,
employee, or other individual associated with the Contractor or a subcontractor, from providing
services, or from having contact with DSHS Students, until the investigation is concluded and a final
determination made by the investigating agency if inconclusive or unsubstantiated.
13. Removal of Individuals from Performing Services
a. In the event that any of the Contractor's employees, subcontractors, or volunteers who provide
services under this Contract do not meet qualifications required by this Contract or do not perform
the services as required in this Contract, DSHS may require that Contractor remove such individual
from providing services to DSHS Students under this Contract.
b. DSHS shall notify the Contractor of this decision verbally and in writing and the Contractor shall,
within 24 hours, remove that individual from providing direct services to DSHS Students. Failure to
do so may result in a Corrective Action Plan.
14. Compliance with Corrective Action Plan
In the event that DSHS identifies deficiencies in Contractor's performance under this Contract, DSHS
may establish a Corrective Action Plan When presented with a Corrective Action Plan, Contractor
agrees to undertake the actions specified in the plan within the timeframes given to correct the
deficiencies. Contractor's failure to do so shall be grounds for termination of this Contract.
15. Order of Precedence in DVR Process
In the event of any inconsistency or conflict between the Terms and Conditions of this Contract and the
DVR Service Delivery Outcome Plan (SDOP) and the Authorization for Purchase (AFP), the
inconsistency or conflict shall be resolved by giving precedence this contract in its entirety. Terms or
conditions that are more restrictive, specific, or particular than those contained in this contract shall not
be construed as being inconsistent or in conflict.
16. Disputes
When a dispute arises over an issue concerning the terms of this Contract, the following process is
used to address the dispute:
a. The Contractor and DVR shall attempt to resolve the dispute through informal means between the
Contractor and the assigned DVR Counselor. For those contracts where a DVR Counselor is not
assigned, the Contractor shall attempt to resolve the dispute with the contact person identified on
the first page of the contract.
b. If the Contractor is not satisfied with the outcome of the resolution with the DVR Counselor or
DSHS contact person, the Contractor may submit a request for review of the disputed issue, in
writing, for review within thirty (30) business days of the outcome to:
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DVR Director
DSHS/DVR
PO Box 45340
Olympia WA 98504-5340
c. The Director may appoint a designee to review the disputed issue.
d. A request for dispute resolution shall include:
(1) Name of the requester.
(2) Contractor's name, full address, phone number, and email.
(3) Contract number.
(4) Description of the issue in dispute.
(5) A statement describing the requester's position on the issue in dispute, including any
documentation that supports this position.
(6) Steps already taken to resolve the dispute.
e. The reviewer may request additional supporting documentation from either party to assist in
reaching a fair resolution.
f. The Director shall issue a written decision to the Contractor within thirty (30) business days of
receipt of all information relevant to the issue.
g. The dispute resolution process described above is the sole administrative remedy available under
this Contract.
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Exhibit A — Data Security Requirements
1. Definitions. The words and phrases listed below, as used in this Exhibit, shall each have the following
definitions:
a. "AES" means the Advanced Encryption Standard, a specification of Federal Information Processing
Standards Publications for the encryption of electronic data issued by the National Institute of
Standards and Technology (https:Hnvipubs.nist.gov/nistpubs/FIPS/NIST.FIPS.197-upol.pdD.
b. "Authorized Users(s)" means an individual or individuals with a business need to access DSHS
Confidential Information, and who has or have been authorized to do so.
c. "Business Associate Agreement" means an agreement between DSHS and a contractor who is
receiving Data covered under the Privacy and Security Rules of the Health Insurance Portability
and Accountability Act of 1996. The agreement establishes permitted and required uses and
disclosures of protected health information (PHI) in accordance with HIPAA requirements and
provides obligations for business associates to safeguard the information.
d. "Category 4 Data" is data that is confidential and requires special handling due to statutes or
regulations that require especially strict protection of the data and from which especially serious
consequences may arise in the event of any compromise of such data. Data classified as Category
4 includes but is not limited to data protected by: the Health Insurance Portability and Accountability
Act (HIPAA), Pub. L. 104-191 as amended by the Health Information Technology for Economic and
Clinical Health Act of 2009 (HITECH), 45 CFR Parts 160 and 164; the Family Educational Rights
and Privacy Act (FERPA), 20 U.S.C. §1232g; 34 CFR Part 99; Internal Revenue Service
Publication 1075 (https://www.irs.gov/pub/irs-pdf/pl075.pdf); Substance Abuse and Mental Health
Services Administration regulations on Confidentiality of Alcohol and Drug Abuse Patient Records,
42 CFR Part 2; and/or Criminal Justice Information Services, 28 CFR Part 20.
e. "Cloud" means data storage on servers hosted by an entity other than the Contractor and on a
network outside the control of the Contractor. Physical storage of data in the cloud typically spans
multiple servers and often multiple locations. Cloud storage can be divided between consumer
grade storage for personal files and enterprise grade for companies and governmental entities.
Examples of consumer grade storage would include iTunes, Dropbox, Box.com, and many other
entities. Enterprise cloud vendors include Microsoft Azure, Amazon Web Services, and Rackspace.
f. "Encrypt' means to encode Confidential Information into a format that can only be read by those
possessing a "key"; a password, digital certificate or other mechanism available only to authorized
users. Encryption must use a key length of at least 256 bits for symmetric keys, or 2048 bits for
asymmetric keys. When a symmetric key is used, the Advanced Encryption Standard (AES) must
be used if available.
g. "FedRAMP" means the Federal Risk and Authorization Management Program (see
www.fedramp.gov), which is an assessment and authorization process that federal government
agencies have been directed to use to ensure security is in place when accessing Cloud computing
products and services.
h. "Hardened Password" means a string of at least eight characters containing at least three of the
following four character classes: Uppercase alphabetic, lowercase alphabetic, numeral, and special
characters such as an asterisk, ampersand, or exclamation point.
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 16
Special Terms and Conditions
i. "Mobile Device" means a computing device, typically smaller than a notebook, which runs a mobile
operating system, such as iOS, Android, or Windows Phone. Mobile Devices include smart phones,
most tablets, and other form factors.
"Multi -factor Authentication" means controlling access to computers and other IT resources by
requiring two or more pieces of evidence that the user is who they claim to be. These pieces of
evidence consist of something the user knows, such as a password or PIN; something the user has
such as a key card, smart card, or physical token; and something the user is, a biometric identifier
such as a fingerprint, facial scan, or retinal scan. "PIN" means a personal identification number, a
series of numbers which act as a password for a device. Since PINS are typically only four to six
characters, PINS are usually used in conjunction with another factor of authentication, such as a
fingerprint.
k. "Portable Device" means any computing device with a small form factor, designed to be transported
from place to place. Portable devices are primarily battery powered devices with base computing
resources in the form of a processor, memory, storage, and network access. Examples include, but
are not limited to, mobile phones, tablets, and laptops. Mobile Device is a subset of Portable
Device.
I. "Portable Media" means any machine readable media that may routinely be stored or moved
independently of computing devices. Examples include magnetic tapes, optical discs (CDs or
DVDs), flash memory (thumb drive) devices, external hard drives, and internal hard drives that have
been removed from a computing device.
m. "Secure Area" means an area to which only authorized representatives of the entity possessing the
Confidential Information have access, and access is controlled through use of a key, card key,
combination lock, or comparable mechanism. Secure Areas may include buildings, rooms or
locked storage containers (such as a filing cabinet or desk drawer) within a room, as long as access
to the Confidential Information is not available to unauthorized personnel. In otherwise Secure
Areas, such as an office with restricted access, the Data must be secured in such a way as to
prevent access by non -authorized staff such as janitorial or facility security staff, when authorized
Contractor staff are not present to ensure that non -authorized staff cannot access it.
n. "Trusted Network" means a network operated and maintained by the Contractor, which includes
security controls sufficient to protect DSHS Data on that network. Controls would include a firewall
between any other networks, access control lists on networking devices such as routers and
switches, and other such mechanisms which protect the confidentiality, integrity, and availability of
the Data.
o. "Unique User ID" means a string of characters that identifies a specific user and which, in
conjunction with a password, passphrase or other mechanism, authenticates a user to an
information system.
2. Authority. The security requirements described in this document reflect the applicable requirements of
policies and standards of the Washington Technology Services Agency
(https://watech.wa.gov/policies?coiiibine=&field categories target id=80&field type target id=Al1),
and of the DSHS Information Security Policy and Standards Manual. Reference material related to
these requirements can be found here: htts://www.dshs.wa. ov/falkee in -dshs-client-information-
private-and-secure, which is a site developed by the DSHS Information Security Office and hosted by
DSHS Central Contracts and Legal Services.
3. Administrative Controls. The Contractor must have the following controls in place:
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 17
Special Terms and Conditions
a. A documented security policy governing the secure use of its computer network and systems, and
which defines sanctions that may be applied to Contractor staff for violating that policy.
b. If the Data shared under this agreement is classified as Category 4, the Contractor must be aware
of and compliant with the applicable legal or regulatory requirements for that Category 4 Data.
c. If Confidential Information shared under this agreement is classified as Category 4, the Contractor
must have a documented risk assessment for the system(s) housing the Category 4 Data.
4. Authorization, Authentication, and Access. In order to ensure that access to the Data is limited to
authorized staff, the Contractor must:
a. Have documented policies and procedures governing access to systems with the shared Data.
b. Restrict access through administrative, physical, and technical controls to authorized staff.
c. Ensure that user accounts are unique and that any given user account logon ID and password
combination is known only to the one employee to whom that account is assigned. For purposes of
non -repudiation, it must always be possible to determine which employee performed a given action
on a system housing the Data based solely on the logon ID used to perform the action.
d. Ensure that only authorized users are capable of accessing the Data.
e. Ensure that an employee's access to the Data is removed immediately:
(1) Upon suspected compromise of the user credentials.
(2) When their employment, or the contract under which the Data is made available to them, is
terminated.
(3) When they no longer need access to the Data to fulfill the requirements of the contract.
Have a process to periodically review and verify that only authorized users have access to systems
containing DSHS Confidential Information.
g. When accessing the Data from within the Contractor's network (the Data stays within the
Contractor's network at all times), enforce password and logon requirements for users within the
Contractor's network, including:
(1) A minimum length of 8 characters, and containing at least three of the following character
classes: uppercase letters, lowercase letters, numerals, and special characters such as an
asterisk, ampersand, or exclamation point.
(2) That a password does not contain a user's name, logon ID, or any form of their full name.
(3) That a password does not consist of a single dictionary word. A password may be formed as a
passphrase which consists of multiple dictionary words.
(4) That passwords are significantly different from the previous four passwords. Passwords that
increment by simply adding a number are not considered significantly different.
h. When accessing Confidential Information from an external location (the Data will traverse the
Internet or otherwise travel outside the Contractor's network), mitigate risk and enforce password
and logon requirements for users by employing measures including:
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 18
Special Terms and Conditions
(1) Ensuring mitigations applied to the system don't allow end -user modification.
(2) Not allowing the use of dial -up connections.
(3) Using industry standard protocols and solutions for remote access. Examples would include
RADIUS and Citrix.
(4) Encrypting all remote access traffic from the external workstation to Trusted Network or to a
component within the Trusted Network. The traffic must be encrypted at all times while
traversing any network, including the Internet, which is not a Trusted Network.
(5) Ensuring that the remote access system prompts for re -authentication or performs automated
session termination after no more than 30 minutes of inactivity.
(6) Ensuring use of Multi -factor Authentication to connect from the external end point to the internal
end point.
Passwords or PIN codes may meet a lesser standard if used in conjunction with another
authentication mechanism, such as a biometric (fingerprint, face recognition, iris scan) or token
(software, hardware, smart card, etc.) in that case:
(1) The PIN or password must be at least 5 letters or numbers when used in conjunction with at
least one other authentication factor
(2) Must not be comprised of all the same letter or number (11111, 22222, aaaaa, would not be
acceptable)
(3) Must not contain a "run" of three or more consecutive numbers (12398, 98743 would not be
acceptable)
If the contract specifically allows for the storage of Confidential Information on a Mobile Device,
passcodes used on the device must:
(1) Be a minimum of six alphanumeric characters.
(2) Contain at least three unique character classes (upper case, lower case, letter, number).
(3) Not contain more than a three consecutive character run. Passcodes consisting of 12345, or
abcd12 would not be acceptable.
k. Render the device unusable after a maximum of 10 failed logon attempts.
5. Protection of Data. The Contractor agrees to store Data on one or more of the following media and
protect the Data as described:
a. Hard disk drives. For Data stored on local workstation hard disks, access to the Data will be
restricted to Authorized User(s) by requiring logon to the local workstation using a Unique User ID
and Hardened Password or other authentication mechanisms which provide equal or greater
security, such as biometrics or smart cards.
b. Network server disks. For Data stored on hard disks mounted on network servers and made
available through shared folders, access to the Data will be restricted to Authorized Users through
the use of access control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User ID and Hardened Password or other
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 19
Special Terms and Conditions
authentication mechanisms which provide equal or greater security, such as biometrics or smart
cards. Data on disks mounted to such servers must be located in an area which is accessible only
to authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism.
For DSHS Confidential Information stored on these disks, deleting unneeded Data is sufficient as
long as the disks remain in a Secure Area and otherwise meet the requirements listed in the above
paragraph. Destruction of the Data, as outlined below in Section 8 Data Disposition, may be
deferred until the disks are retired, replaced, or otherwise taken out of the Secure Area.
c. Optical discs (CDs or DVDs) in local workstation optical disc drives. Data provided by DSHS
on optical discs which will be used in local workstation optical disc drives and which will not be
transported out of a Secure Area. When not in use for the contracted purpose, such discs must be
Stored in a Secure Area. Workstations which access DSHS Data on optical discs must be located
in an area which is accessible only to authorized personnel, with access controlled through use of a
key, card key, combination lock, or comparable mechanism.
Optical discs (CDs or DVDs) in drives or jukeboxes attached to servers. Data provided by
DSHS on optical discs which will be attached to network servers and which will not be transported
out of a Secure Area. Access to Data on these discs will be restricted to Authorized Users through
the use of access control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User ID and Hardened Password or other
authentication mechanisms which provide equal or greater security, such as biometrics or smart
cards. Data on discs attached to such servers must be located in an area which is accessible only
to authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism.
e. Paper documents. Any paper records must be protected by storing the records in a Secure Area
which is only accessible to authorized personnel. When not in use, such records must be stored in
a Secure Area.
Remote Access. Access to and use of the Data over the State Governmental Network (SGN) or
Secure Access Washington (SAW) will be controlled by DSHS staff who will issue authentication
credentials (e.g. a Unique User ID and Hardened Password) to Authorized Users on Contractor's
staff. Contractor will notify DSHS staff immediately whenever an Authorized User in possession of
such credentials is terminated or otherwise leaves the employ of the Contractor, and whenever an
Authorized User's duties change such that the Authorized User no longer requires access to
perform work for this Contract.
g. Data storage on portable devices or media.
(1) Except where otherwise specified herein, DSHS Data shall not be stored by the Contractor on
portable devices or media unless specifically authorized within the terms and conditions of the
Contract. If so authorized, the Data shall be given the following protections:
(a) Encrypt the Data.
(b) Control access to devices with a Unique User ID and Hardened Password or stronger
authentication method such as a physical token or biometrics.
(c) Manually lock devices whenever they are left unattended and set devices to lock
automatically after a period of inactivity, if this feature is available. Maximum period of
inactivity is 20 minutes.
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6017CF County Program Agreement (10-31-2017) Page 20
Special Terms and Conditions
(d) Apply administrative and physical security controls to Portable Devices and Portable Media
by:
i. Keeping them in a Secure Area when not in use,
ii. Using check-in/check-out procedures when they are shared, and
iii. Taking frequent inventories.
(2) When being transported outside of a Secure Area, Portable Devices and Portable Media with
DSHS Confidential Information must be under the physical control of Contractor staff with
authorization to access the Data, even if the Data is encrypted.
h. Data stored for backup purposes.
(1) DSHS Confidential Information may be stored on Portable Media as part of a Contractor's
existing, documented backup process for business continuity or disaster recovery purposes.
Such storage is authorized until such time as that media would be reused during the course of
normal backup operations. If backup media is retired while DSHS Confidential Information still
exists upon it, such media will be destroyed at that time in accordance with the disposition
requirements below in Section 8 Data Disposition.
(2) Data may be stored on non -portable media (e.g. Storage Area Network drives, virtual media,
etc.) as part of a Contractor's existing, documented backup process for business continuity or
disaster recovery purposes. If so, such media will be protected as otherwise described in this
exhibit. If this media is retired while DSHS Confidential Information still exists upon it, the data
will be destroyed at that time in accordance with the disposition requirements below in Section 8
Data Disposition.
i. Cloud storage. DSHS Confidential Information requires protections equal to or greater than those
specified elsewhere within this exhibit. Cloud storage of Data is problematic as neither DSHS nor
the Contractor has control of the environment in which the Data is stored. For this reason:
(1) DSHS Data will not be stored in any consumer grade Cloud solution, unless all of the following
conditions are met:
(a) Contractor has written procedures in place governing use of the Cloud storage and
Contractor attests in writing that all such procedures will be uniformly followed.
(b) The Data will be Encrypted while within the Contractor network.
(c) The Data will remain Encrypted during transmission to the Cloud.
(d) The Data will remain Encrypted at all times while residing within the Cloud storage solution.
(e) The Contractor will possess a decryption key for the Data, and the decryption key will be
possessed only by the Contractor and/or DSHS.
(f) The Data will not be downloaded to non -authorized systems, meaning systems that are not
on either the DSHS or Contractor networks.
(g) The Data will not be decrypted until downloaded onto a computer within the control of an
Authorized User and within either the DSHS or Contractor's network.
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 21
Special Terms and Conditions
(2) Data will not be stored on an Enterprise Cloud storage solution unless either:
(a) The Cloud storage provider is treated as any other Sub -Contractor, and agrees in writing to
all of the requirements within this exhibit; or,
(b) The Cloud storage solution used is FedRAMP certified.
(3) If the Data includes protected health information covered by the Health Insurance Portability and
Accountability Act (HIPAA), the Cloud provider must sign a Business Associate Agreement prior
to Data being stored in their Cloud solution.
6. System Protection. To prevent compromise of systems which contain DSHS Data or through which
that Data passes:
a. Systems containing DSHS Data must have all security patches or hotfixes applied within 3 months
of being made available.
b. The Contractor will have a method of ensuring that the requisite patches and hotfixes have been
applied within the required timeframes.
c. Systems containing DSHS Data shall have an Anti-Malware application, if available, installed.
d. Anti-Malware software shall be kept up to date. The product, its anti -virus engine, and any malware
database the system uses, will be no more than one update behind current.
7. Data Segregation.
a. DSHS Data must be segregated or otherwise distinguishable from non-DSHS data. This is to
ensure that when no longer needed by the Contractor, all DSHS Data can be identified for return or
destruction. It also aids in determining whether DSHS Data has or may have been compromised in
the event of a security breach. As such, one or more of the following methods will be used for data
segregation.
(1) DSHS Data will be kept on media (e.g. hard disk, optical disc, tape, etc.) which will contain no
non-DSHS Data. And/or,
(2) DSHS Data will be stored in a logical container on electronic media, such as a partition or folder
dedicated to DSHS Data. And/or,
(3) DSHS Data will be stored in a database which will contain no non-DSHS data. And/or,
(4) DSHS Data will be stored within a database and will be distinguishable from non-DSHS data by
the value of a specific field or fields within database records.
(5) When stored as physical paper documents, DSHS Data will be physically segregated from non-
DSHS data in a drawer, folder, or other container.
b. When it is not feasible or practical to segregate DSHS Data from non-DSHS data, then both the
DSHS Data and the non-DSHS data with which it is commingled must be protected as described in
this exhibit.
8. Data Disposition. When the contracted work has been completed or when the Data is no longer
needed, except as noted above in Section 5.b, Data shall be returned to DSHS or destroyed. Media on
which Data may be stored and associated acceptable methods of destruction are as follows:
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 22
Special Terms and Conditions
Data stored on:
Server or workstation hard disks, or
Removable media (e.g. floppies, USB flash drives,
portable hard disks) excluding optical discs
Will be destroyed by:
Using a "wipe" utility which will overwrite the Data at
least three (3) times using either random or single
character data, or
Degaussing sufficiently to ensure that the Data
cannot be reconstructed, or
na the disk
Paper documents with sensitive or Confidential Recycling through a contracted firm, provided the
Information contract with the recycler assures that the
confidentiality of Data will be protected.
Paper documents containing Confidential Information On -site shredding, pulping, or incineration
requiring special handling (e.g. protected health
information)
Optical discs (e.g. CDs or DVDs) Incineration, shredding, or completely defacing the
readable surface with a coarse abrasive
Magnetic toe Degaussing, incinerating or crosscut shredding
9. Notification of Compromise or Potential Compromise. The compromise or potential compromise of
DSHS shared Data must be reported to the DSHS Contact designated in the Contract within one (1)
business day of discovery. If no DSHS Contact is designated in the Contract, then the notification must
be reported to the DSHS Privacy Officer at dshsprivacyofficer@dshs.wa.gov. Contractor must also
take actions to mitigate the risk of loss and comply with any notification or other requirements imposed
by law or DSHS.
10. Data shared with Subcontractors. If DSHS Data provided under this Contract is to be shared with a
subcontractor, the Contract with the subcontractor must include all of the data security provisions within
this Contract and within any amendments, attachments, or exhibits within this Contract. If the
Contractor cannot protect the Data as articulated within this Contract, then the contract with the sub -
Contractor must be submitted to the DSHS Contact specified for this contract for review and approval.
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017) Page 23
Exhibit B: School -to -Work Student Guide Instructions
The following is a billing guide forth e Contractor as they work with students by following the pages of the
Student Guide. As the following sections are completed, the Contractor will use Exhibit E: STW Billing
Checklist for Student Guide, provided to the Contractor by DVR.
These instructions will supportguidanceto School -to -Work (STW) contractors as theywork with students
who are participating in STW. To begin the process of STW and to review the STW Student Guide, schedule a
STW Intake and Assessment meeting with the Student and the Student's Team. During th is meeting, the
STW Student Guidewill be shared with the student, goingthrough the process of STW and what the student
should expect in their final year of Transition.
Billing Instructions:
1. Bill $2,000 for the STW Intake Meeting once the following pages are complete:
• Team Building and Information
• Team Contacts, Roles, and Responsibilities
2. Bill $3,000 for Assessment once the following pages are complete:
Assessment pages may include the following pages being completed, as applicable for the student, as
each student mayget to their employment goal in their own way. All sources of information may be used to
determine the parts of the assessment. This may include job shadows, a Job Foundation Report through
DDCS, Work Based Learning through Pre-ETS, or any source to determine the needed information to
establish an employment goal. The student and the student's team will work together to determine this.
The main goal for this section is to get to an employment goal and the next steps for the student.
• STW Assessment
• Job Goal
• Next Steps and Team Actions
3. BILL $1,000 for the Job Seeker Tools once the following pages are complete:
• Job Seeker Tools (determined bythestudent's team and have been completed and shared with the
student and DVR)
4. Bill $2,000 for the Job Offer once the following page is complete:
• Job Offer Details on the page titled "You were offered the job! Way to go!"
5. Bill $1,000 for Employment Verification once the following page is complete:
• Form is completed on the page titled "Congratulations, you are employed!"
6. Bill $5,000 for Stabilization once the following pages are complete:
• Your Supports on the Job
• Job Stabilization Report
Please note there are additional pages in the Student Guide that do not affect the above payments
and are intended to support the student.
00o DSHS
Contractor
Signature
AFP Number
Division of Vocational Rehabilitation (DVR)
Exhibit E:
School -to -Work Billing Checklist
Month and Year
Date of Signature
Student Initials
To be filled out by DVR Staff Only:
Activity Billed
Amount
DVR staff sign and date below to confirm
Billed
items received and to authorize payment
❑
Intake Meeting
$
2,000
❑
Assessment
$
3,000
❑
Job Seeker Tools
$
1,000
❑ Job Offer
$
2,000
❑
Employment Verification
$
1,000
$
5,000
❑ Stabilization
Total Billing:
$
Instructions:
1. The Student Guide is sent monthly to the Student's Team, including the DVR Counselor.
2. The Contractor checks the appropriate box(es) as the corresponding activities are completed in
the Student Guide (one form per student).
3. The Contractor submits this completed form to the assigned DVR Counselor.
4. The DVR Counselor confirms information from monthly submissions of the Student Guide,
verifies activities were completed, then signs and dates the checklist.
5. The DVR Counselor submits for payment.
Notables:
• The Student Guide serves as documentation for proof of completion for the payment / activity
point.
• The Contractor submits no less than three (3) separate checklists to the assigned DVR
Counselor for each student (submitting all payment points separately is also an option).
Any questions, please contact the School -to -Work Team at
DVRSchoolioWork dshs.wa. ov.
Exhibit E: School -to -Work Billing Checklist
DSHS 11-195A (04/2026)
Attachment "G"
School -to -Work
Job seeker:
Month/Year:
STUDENT GUIDE
go DSHS
WASHINGTON STATE
Department of Social
and Health Services
Please check out what is new
in your Student Guide!
Here is the monthly summary of progress made towards your job goal:
No additional steps have been completed this month. Only the Monthly Summary above
to share the progress being made towards supporting you in being employed!
Phase One
L] Team Building and Information F-I Team Contacts, Roles, and Responsibilities
Assessment Information Job Goal Established U Next Steps and Team Actions
Phase Two
Job Seeker Tools Job Offer Details
Phase Three
Employment Verification Supports on the Job Job Stabilization Report
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 2
Welcome'.
School -to -Work Overview
The School -to -Work program is designed to assist you in finding a job before you exit school in June. In this
program, you will work directly with a job coach who will collaborate with you, your parent(s)/guardian(s),
school district staff, County Developmental Disabilities programs, the Division of Vocational Rehabilitation, and
Developmental Disabilities Administration.
This School -to -Work Student Guide
This guide will be updated regularly and is designed to house your School -to -Work related information,
assessments, activity logs, notes, and much more. It will:
• Ensure key activities and milestones are completed and organized effectively.
• Support you in keeping important information in one place.
• Bea great resource to bring to collaboration meetings with your team.
This is a guide for students to ensure key activities and milestones have been completed and organized
effectively. This tool will support students in keeping important information in one place, and it will also be a
great resource to bring to collaboration meetings that occur with support partners and agencies.
School -to -Work Phases
You will be going through three phases for School -to -Work, all moving you toward your employment goal.
The phases are described throughout this guide.
Phase 1: Intake and Assessment
This phase includes bringing your team together that will support and guide you through the program. Key
intake and assessment activities will take place to ensure a positive experience for you.
Phase 2: Job Placement
This phase includes conducting and capturing important job placement activities like employment goals, site
visits, job interviews, and more.
Phase 3: Employment
This phase serves as an exciting step to complete and capture all employment stabilization information like
employment verification information, completion of the first day of work, and much more!
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 3
Next Steps and Team Actions
You and your team will work together to decide what next steps are needed to support you.
Everyone should agree on tasks and actions.
Task • When
Example: Example: Example:
DVR Counselor will connect you Benefits Planner, Student, Family Before job start (and again, as
with a Benefits Planner needed)
Tip: Tasks may be added throughout your School -to -Work year,
or removed if they are no longer something you want to explore.
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 4
Phase 1 Starts: Intake and Assessment
This phase includes bringing your team together that will support and guide you through the
program. Key intake and assessment activities will take place to ensure a positive experience for you.
Team Building and Information
Team Building Date
To -Do -List
1. Introductions / Overview of Services / Strengths and Challenges
2. Assessment Needs
3. Job Goal is Established
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 5
Team Contacts, Roles, Responsibilities
(This list is more than one page.)
You, the Student Name:
(most important
person on the team) Email:
Phone:
Your Parent(s) or Name:
Guardian(s)
Email:
Phone:
Employment Name:
Provider: Your Job
Coach Email:
Phone:
Your County Program Name:
Email:
Phone:
Show Up, Speak Up, and
Share! You are the driver of
your services and without
your voice, the team is not
able to support you with
your goals. Work with your
team to get a job. Services
are person -centered and
individualized.
Supports you in partnership
with school, county, and
state departments to
acquire employment.
School -to -Work CRP/
Subcontractor who
coordinates getting
resources, training, and
supports needed for you to
get a job before you leave
school in June.
School -to -Work Contractor
entity providing local
support for you to find a
job.
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 6
Team Contacts, Roles, Responsibilities
(Continued)
Your Vocational Name:
Rehabilitation
Counselor Email:
Your School Teacher
and/or School Staff
Main Keeper of Your
Student Guide
Other Person on Your
Team
-9TO=
Name:
Email:
Phone:
Name:
Email:
Phone:
Name:
Email:
Phone:
Coordinate with schools,
counties, and other state
departments to help you
get a job. Provide job coach
funding. This could be
the Division of Vocational
Rehabilitation, Department
of Services for the Blind,
or Tribal Vocational
Rehabilitation.
Connects you or your
parent(s) or guardian(s) with
community, county, and
resources for School -to -
Work.
Lead role who edits this
School -to -Work Student
Guide monthly and shares
the most current copy with
each person listed above at
the end of the month and
gathers information from
you and your team to share.
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 7
Assessment: Getting Ready for a Job!
For your team to support you with your job goal, they need to learn more about you. This can happen in so many
ways. Knowing more about you and who you are is key to success!
Information will be gathered about you to get to a goal using multiple sources, such as a Job Foundation report,
job shadowing, or knowing more about your learning style. Your job coach will collect information about your
strengths, skills, and supports needed for success on the job. This information will be gathered through school,
you, your family and friends, and community activities, as well as conversations and observations with those
supporting you.
History of school attendance and reliability:
Behavior support or strategies likely to be needed:
Communication skills:
Learning preferences:
Personal hygiene:
Potential job safety issues:
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 8
Stamina/endurance:
Social skills:
Demonstrated skills and task performance:
Transportation needs:
Work preferences and interests, including: Skills and Interests, Desired Work Environment,
Desired Schedule, and travel to and from work:
Notable Accommodations and Necessary Supports:
Your job goal:
Congratulations! You are on your way to being employed!
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 9
Phase 2 Starts: Jake Placement
This phase includes conducting and capturing important job placement activities like employment
goals, site visits, job interviews, and more.
Job Seeker Tools
Job seeker tools will be developed to support you as you look for a job. You will work with your
team to figure out what you need, which may include the following: online portfolios, cover
letters, video resumes, letters of recommendation, Linkedln pages, and more.
Resume or Media Resume
(Video, PowerPoint, Portfolio, etc.)
Sent to Student: Yes No ❑ Date sent:
Sent to DVR Counselor: Yes ❑ No F, Date sent:
Cover Letter (as determined if needed by you and your team)
Sent to Student: Yes ❑ No � Date sent:
Sent to DVR Counselor: Yes ❑ No El Date sent:
Employer Letter of Recommendation (optional)
Sent to Student: Yes No Date sent:
Sent to DVR Counselor: Yes No Date sent:
Linkedln Page (optional)
Sent to Student: Yes No Date sent:
Sent to DVR Counselor: Yes No Date sent:
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 10
You were offered the Joky! Way to Go!
Did you accept this job offer? Yes C No
If yes, please complete the section below.
If not, please complete the section below and explain why the job was not accepted:
Does the job match your original goal on your DVR plan? Yes No
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 11
Job Goal:
Employer:
Job Title:
Start Date:
Job Duties:
Expected Weekly Hours:
Starting Wage:
Location:
Transportation Considerations:
Benefits Package:
Potential Training Services and Date/Additional Information:
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 12
Phase 3 Starts: Employment
This phase serves as an exciting step to complete and capture all employment stabilization information
like employment verification information, completion of the first day of work, and much morel
Congratulations! You are Employed!
Now what? Please work with your job coach to complete the form below.
Employee's Name:
Employer's Name:
Employee's Job Title:
Employer's Address:
Is this a new job? No ❑ Yes Date Employee Started Work:
Average Number of Hours Worked Per Week:
Rate of Pay or Salary: $
Hourly Monthly Annually
Pay Frequency:
Daily Weekly i Every Two Weeks Two Times a Month
Tips: No �� Yes; if yes, how often and how much?
Commissions: ,� No Yes; if yes, how often and how much?
Bonuses: No L Yes; if yes, how often and how much?
Overtime: �:] No F— Yes; if yes, how often and how much?
Work Schedule (include exact times when possible):
Monday Tuesday Wednesday Thursday Friday
Is health insurance available: No Yes
1. If yes, did the employee enroll in the health plan?: F-1 No Yes
a. If yes, when does the coverage begin?
b. If yes, what is the employee's portion of the premiums? $
Name and Title of Person Who Completed This Page:
Date:
Monthly
Saturday
Sunday
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 13
Your Supports on the Jab!
The strengths you bring to the job
How you will become stable on the job (your fading plan)
Additional training, services, and supports could include
The support you receive on the job from the beginning will be shared
with you and your team in the monthly notes at the end of this guide.
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 14
Job Stabilization Report
You are considered stable on the job when the following things happen:
1. Your desired work hours are met (unless you and your team agree the job represents suitable
employment).
2. Your DVR Counselor, your job coach, and your employer agree that you meet your employer's
expectations (this is verified by your job coach).
3. You are ready for long-term support.
But first...
Did you meet your expected job goal? Yes No
Was your starting wage what you wanted? Yes No
Does the job location meet your expected needs? Yes No
Anything else you want to add about your job?
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 15
Detail and summarize how the placement hours were met (or if the job represents suitable employment):
Detail and summarize how it has been agreed that the employer's expectations have been met. Please provide
descriptions and details as to how stabilization occurred for the employer's expectations to be met:
Detail and summarize how long-term support is set up and will occur:
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 16
Helpful Resources
Developmental Disabilities Administration
• Website: www.dshs.wa.govldda
• DDA Eligibility Information: www.dshs.wa.gov/dda/Consumers-and-families/eligibility
Division of Vocational Rehabilitation, or DVR
• Website: www.dshs.wa.gov 'rivr
• Phone:1-800-637-5627
Social Security Administration, or SSA
• Website: www.ssa.gov
• Phone:1-800-772-1213
Benefit U
• Website: www.benefitu.org
• Benefit U Information: support@benefitu.org
Other Resources and/or Additional Contacts:
Name:
Phone:
Email:
Other:
Name:
Phone:
Email:
Other:
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 17
Optional Documents
Copy of Food Worker Card
Sent to Student: Yes u No El Date sent:
Sent to DVR Counselor: Yes No 1-1 Date sent:
Copy of Current CPR and/or First Aid Certification
Sent to Student: Yes No Date sent:
Sent to DVR Counselor: Yes No Date sent:
Other'
Sent to Student: Yes No E I Date sent:
Sent to DVR Counselor: Yes No n Date sent:
Other*
Sent to Student: Yes � —1 No F-I Date sent:
Sent to DVR Counselor: Yes No F� Date sent:
* Ideas of other items to include could be a person -centered plan, other certifications, and other
job -related documents.
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 18
Monthly Progress Reports
Below is your story of finding a job! As your Job Coach works with you, they will be adding in
their monthly reports that are on the first page of this Student Guide. You will be able to read the
progress made for you ... the story of your journey to a job!
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 19
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 20
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February
Year
March
Year
April
Year
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 22
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 23
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 24
Additional Comments
DIVISION OF VOCATIONAL REHABILITATION I SCHOOL -TO -WORK I PAGE 25
Attachment "H"
School to Work 2026/2027: Graduation Year 2027 or 2028
Leeacv Pilot
# of Students
enrolled in
School to Work
# of Students in
SDOP for
Assessment
# of Students in
SDOP for Job
Placement
# of Students in
SDOP
# of Students
Employed
Asoti n
Benton
Chelan
Clark
Columbia
Cowlitz
Douglas
Ferry
Franklin
Island
Jefferson
King
Kitsap
Kittitas
Lewis
Lincoln
Mason
Okanogan
Pend Orielle
Pierce
San Juan
Skagit
Snohomish
Spokane
Stevens
Thurston
Wahkiakum
Walla Walla
Whatcom
Whitman
Yakima
Total
0
0
0
0
0
*Total enrolled includes students no longer in school, may have moved, not eligible yet, passed away, etc
# of Students # of Students # of Students Comments
# of Students in Transferred to Transferred to Exited STW Add'I Info to Share
Y.E.S. DVR Only DDCS (on CSA) Early Reasons for STW Exit