HomeMy WebLinkAboutKittitas County & AbilityKITTITAS COUNTY
AGREEMENT FOR SERVICES
PHMH26.015
This Agreement for Services (hereinafter "Agreement") is entered into by and between Kittitas County
(hereinafter "-ounty"), a political subdivision of the State of Washington, and Ability (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 CONTRACTOR
This Agreement includes the following, which are attached hereto and hereby incorporated by this
507 N Nanum St Ste 102
Ellensburg, WA 98926
Laurie Holt
Developmental Disabilities Administrative
Specialist
Human Services
Lau rie. holt@co. kittitas.wa.us
509-962-75L5
Attachment "A":
Attachment "8":
Attachment "C":
Attachment "D":
Attachment "E":
Attachment "F":
Attachment "G":
Attachment "H":
Ability
L212 N. washington st. #L24
Spokane, Washington
9920t
Project Contact:
Ty Lingo
Director
tlingo@abilitvem Plovment. net
so9-242-3758
reference:
Scope of Work
Compensation
lnsurance Requirements
General Terms and Conditions
w-9 (contractor must complete and return to the county for payment)
DVR Schoolto Work Contract with Kittitas County, including:
Exhibit A Data Security Requirements
Exhibit B School-to-Work Guide lnstructions, including billing instructions
Exhibit E School-to-Work Billing Checklist
Student Guide
School-to-Work Data Report Template
Kittitas County Agreement for Services (rev.5/7a/251
Pagetof22
CONTRACTOR
Signature
Printed N
3oa
6
e
Title
Date:
<i )p,rtT
KITTITAS COUNTY
BOARD OF COUNTY
Commissioner
ISSI
c
Attest:
r,/nr -0u f
Date:0s(0q lhu
x
\\)tt ty
S^E,AL
tN WITNESS WHEREOF, this Agreement has been executed by and on behalf of the parties through their
authorized representatives, effective as of the latest date written below.
Kittitas County Agreement for Services (rev.5/7a/25)
Page2 of 22
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'
o 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.
o Complete assessment using Student Guide and/or Job Foundations report to complete the Student Guide
to include DVR required information.
o Work with the students to find and secure meaningful community employment based on goals.
o work with students to stabilize and maintain meaningful employment.
r Submit required documentation including student guide and billing checklist.
Kittitas County Agreement for Services (rev.5/74/251
Pagel of 22
ATTACHMENT "8"
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. FUr DVR Lu release payment, contractors must submit tho student guide monthty'
c. The contactor must provide adequate backup documentation to support costs in each invoice per the
school-to-work Guide lnstruction, including billing instructions. For example, the contractor may bill
52,OOO for the school-to-work lntake 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 lnstructions 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. lntake Meeting = 5200
b. Assessment = 5300
c. Job SeekerTesl5 = $100
d. Job Offer= 5200
e. EmPloYment Verification = S100
f. Stabilization = 5500
g. Total administrative costs to Kittitas County per School-to-Work student will not exceed S1-,400'
ln no event shall payments under this agreement total more than S12, 600 per School-to-Work student to the
contractor.
Kittitas County Agreement for Services (rev.5/La/251
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 Vll or better in the most recently published edition of Best's Reports unless otherwise approved
bytheLounty. lf an insurer is not admitted, all insurance policies and proceduresfor issuingthe 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:
x Commercial General Liabilitv lnsurance
r Coverage limits not less than:
. 51,000,000 per occurrence, for all covered losses
r $2,000,000 general aggregate
o $1,000,000 products & completed operations aggregate
o $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 Liabilitv lnsurance
r 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.
I Coverage limits not less than:
o $1,000,000 combined single limit
Excess or Umbrella Liabilitv
r Contractor shall provide Excess or Umbrella Liability coverage of 55,000,000. This Excess
or Umbrella t-iaUility coverage shall apply, at a minimum, to both the CommercialGeneral
and Automobile lnsurance policy coverages. lf 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 aliernatively 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 insu reds'
. 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
insu red against another.
Workers' Compensation & Emplover/s Liabilitv
r Contractor shall provide Workers Compensation and Employe/s Liability insurance on a
state-approved policy form providing benefits as required by law with employer's liability
limits no less than S1,000,000 per accident or disease'
Kittitas County Agreement for Services (rev.5/74/25)
Pagei of 22
Professional Liabilitv / Errors and Omissions Liabilitv
' Coverage limits not less than:
r $1,000,000 each claim
r Contractor must provide evidence of this coverage on a policy form appropriate to
Contractor's Profession.
Contractor shallfurnish to the County a Certificate of lnsurance, with endorsement where required above,
as evidence that policies providing insurance required by this Agreement are in fullforce 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 lnsurance with all
required endorsements, properly completed and in the amounts required, and (2) where requested by the county,
a copy of the required insurance policies, including all required endorsements.
Kittitas County Agreement for Services (rev' 5/14/251
Page 6 of 22
ATTACHMENT,,D"
GENERAL TERMS AND CONDITIONS
t. Scooe of Contractorrs Services: Contractor agrees to provide to the County services as set forth in
Attachment ,,A". ruo rrt"r'otr, trUor, 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 pavment: Compensation to Contractor for services rendered under this Agreement
shall be as set forth in Attachment "B". Where Attachment "8" requires payment(s) by the County, payment shall
be based upon billings, supported unless provided otherwise in Attachment "8", by documentation of units of
work actually performed and amounts earned, including, where appropriate, the total number of hours for the
month and the total dollar payment requested. Unless specifically stated in Attachment "B', the county will not
reimburse Contractorfor 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 syitem, for Contractor's services pursuant to the fee schedule set forth
in Attachment ,,8,,. ln the event contractor fails to perform any of its obligations under this Agreement within the
time specified herein, then the County may withhold all monies due and payable to Contractor until such failure
to perform is cured or otherwise adjudicated. The County will not process payment for services rendered under
this Agreement until Contractor submits a completed W-9 (See Attachment "E")'
3. Taxes: 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
theCountytomakewithholdingforanytaxesotherthanincometaxes(e.g.,Medicare)' Allcompensationreceived
by Contractor will be reported io the lnternal Revenue Service at the end of the calendar year in accordance with
applicable IRS regulations. lt 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 ,tt other taxes, including but not limited to: business and occupation tax; or taxes based
on (1) Contractor,s grosi or net income, or (2) personal property to which the County does not hold title' The
County is exempt from federal excise tax'
4. lndependent Contractor: Contracto/s services shall be furnished by Contractor as an independent
contractor, ,nd nothing ,tut"d l',"r"in 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 ,,8,,, 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 unv otft.r inaiuidu+ firm or entity without the express and prior written approval of the
County. The Contractor may only subcontract work contemplated under this agreement if it obtains the prior
written approval of the County. lf the County approves subcontracting, the Contractor shall maintain written
procedures related to subcontracting, as well as copies of all subcontracts and records related to subcontracts'
For cause, the County in writing may require the Contractor to 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/La/251
PageT of22
comply with any applicable term or condition of this agreement. The contractor shall appropriately monitor the
activities of the Subcontractorto assure fiscal conditions of this agreement. ln 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. tt " County - it, d"rignee 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 slx (6) years after terulrirral.iurr or expiration of the Agreement, and upon rcqucst
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.t. 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 io 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. lf any such change Notice causes an increase or decrease to contractot's cost of, or the
time required for, performance of the work, an equitable adjustment in the compensation to Contractor and/or
in the schedule for the performance of the work shall be made by the County to reflect such an increase or
decrease. Notwithstanding any dispute or 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
g.1 This Agreement may be terminated at any time by mutual written agreement of the parties'
g.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.
g.3 lf 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. lf 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/La/25)
PageS ol 22
from any money due or coming due to contractor. Furthermore, in the event of termination underthis 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'
g.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 no1 b""n performed or deliverables that have not been provided'
9. lndemnification
g.L 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 clarms, damages, losses and expenses, lnclutlilrg bul. rrot linrited 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 Contractot's
subcontractors, their employees, agents or volunteers; or (2) are directly or indirectly arising out of' resulting
from, or othenruise 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 lndustrial lnsurance Act, RCW Title 51, or by application of any other workmen's
compensation act, disability benefit act or other employee benefit act, and contractor hereby expressly waives
any immunity afforded by such acts. The foregoing indemnification obligations of Contractor are a material
inducement to the county to enter into this egre".ent, are reflected in contractor's compensation, and have
been mutually negotiated by the parties.
g.Z 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 ln the event Contractor enters into subcontracts to the extent allowed under this Agreement,
each such subcontractor shall indemnify the County on a basis equal to or exceeding contractor's indemnity
obligations to the County.
10. venue and choice of Law: ln the event that any litigation should arise concerning this Agreement,
the venue for such action shall be in the superior court of the state of washington in and forthe county of Kittitas'
This Agreement shall be governed by the laws of the state of washington.
11. Non-Appropriationof Funds: lf thecountydoes notappropriatesufficientfundingforthisAgreement
for any future tir..t p"riodjr* 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/!a/25)
Page9 of 22
LZ.I 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.
L2.2 Contractor has the authority to execute this Agreement, to make the representations and
warranties set forth herein, and to perform its obligations hereunder.
I2.3 This Agreement has been validly executed by an authorized representative of Contractor and
constitutes a valid and legally binding and enforceable obligation of contractor'
I2.4 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 perforrnance of lts
obligations under this Agreement, and will maintain such throughout the term of this Agreement'
L2.5 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.
I2.7 None of the representations or warranties in this Agreement, and none of the documents,
statements, certificates or schedules furnished by Contractor in connection with the performance of the
obligations contemplated under this Agreement, contains or will contain any untrue statement of a material fact
or omits or will omit a material fact necessary to make the statements of fact contained therein not misleading'
13. Ownership of ltems produced: All writings, programs, data, reports, films, recordings, or other
materials prepared uy c*trr.to r and/or its consultants or subcontractors, in connection with the performance
of this Agreement, shall be the sole and absolute property of the County. The County will have all rights of
ownership therein, including but not limited to the right to use, copyright, trademark, and/or patent, and the
ability to transfer any or all ownership rights'
L4. lntellectual propertv lnfringement: Contractor will defend and indemnify the County from any
claimed action, cause or demand brought ,g.ir,rt 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 paymeni, "r" 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 riBht
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'
L5. Use of Countv Name and Logo: Contractor may not use the County's name, logo(s), trademark(s), or
other identitying intorrrtion, * id"ntify 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'
LG. 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/M/25)
PagetO 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. ln 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.
L7. Confidentialitv: 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.
1g. 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 regularfirst-class mailif 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.L2 and the rules and
regulations of the washington state Department of Labor and lndustries. The schedule of prevailing wage rates
for the applicable locality or localities is determined by the lndustrial statistician of the Department of Labor and
lndustries. lt is contractor's responsibility to verify the applicable prevailing wage rate. lt is understood that
contractor is responsible for obtaining and completing all required government forms relating to prevailing wage
and submitting same to the proper authorities. Disputes regarding prevailing wage rates shall be referred for
arbitration to the Director of the Department of Labor and lndustries. The arbitration decision shall be final and
conclusive and binding on all parties involved in the dispute as provided for in RCW 39.12'050'
20. Standard of Care: Contractor shall perform its duties hereunder in a manner consistent with that
degree of care ,nd ,t ilt orain'rrily exercised by members of the same profession or industry as Contractor currently
practicingorworkingundersimilarcircumstances. Contractorshall,withoutadditionalcompensation,correctany
of its services not meeting such a standard.
2L. Nondiscrimination:
Kittitas County Agreement for Services (rev ' 5/M/25l.
Page lL of 22
2t.t ln 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, 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' Such requirements
apply, without limitation, to the following: employment, promotion, demotion, transfer, recruitment or
recruitment advenislng, layoff or termlnatlon, rates of pay or uLlrer fuillrs uf culilpettsation, and progranrs 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.
2t.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 lf any assignment and/or subcontracting has been authorized by the County, said assignment or
subcontract shall include appropriate safeguards against discrimination'
22. Waiver: The waiver of any default or breach of this Agreement, or the failure of a party to enforce
any provision trereof 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 bythe 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, g, !O, L3,14, \5, L6,17 , !9,20,22,24, 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 anO all other agreements, understandings, negotiations and discussions, oral orwritten, express
or imptied, regarding the work to be performed hereunder. The parties agree that no other representations,
inducements, promises, agreements, or warranties relating to this Agreement, oral or otherwise, have been made
between the parties. fxcept as provided elsewhere in this Agreement, no modification or waiver of this
Agreement shall be valid or binding unless in writing and signed by the parties.
26. Severabiliw: lf any term or condition of this Agreement or the application thereof to any person(s)
or circumstances is held invalid, such invalidity shall not affect other terms, conditions or applications which can
be given effect without the invalid term, condition or application. To this end, the terms and conditions of this
Agreement are declared to be severable'
Kittitas County Agreement for Services (rev.5/L4/25)
Page t2 of 22
Zl. Time: Time is of the essence in the performance of this Agreement unless otherwise agreed between
the parties in a signed writing.
2g. Construction: This Agreement has been mutually reviewed and negotiated by the parties and should
not be construed against the drafter.
29. Aereement 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/L4/251
Page L3 of 22
ATTACHMENT'E"
o.,,,,llU'9 Request fol TaxPaYer
ldentification Number and Certification
Go lo ww.its.govlFormYlg lor instructions and the lalest information'
Give form to the
requester. Do not
sond to the lRS.ill€v. March 2924)
fleparllnont o{ tlrs TPasury
o
o
co
otr*8
OT:4
tl'oE
oo
o-q
oo
!.1)
Belore bsqln. For relaied to tho oi Form sBa of bsio}J.
I Nsme ol entity'/ltdlvldual. r'ln entry i5 Gquired'
F!l/'9 rama on 'ine 2 l
iFor a sle proprielor or disregarded sitit'/. enter the o\,/ne/s .ame on li*e 1, and enter ih€ business/dlsreqsCed
2 8u$i!i9$ namc/disroqa.dod olltity naFc, it diflsrentirem sbovc
4 ExomFtions {codos aPPiY mlY to
sertain entiti6, not individuals;
9e ingttrlcli€as on Psge 3):
Erulul pdyw rug, (ll .ltiy)
Fxffiptlorr from itrolgr\ Acc@nt tax
Comp'iancs Act iliATCAi r€porlifig
cod6 (d uy)
(Appli6s lo accetnL, tHifitainsd
dtside ihr uniled stslos,)
Feqr€sler's nsme itFd addFss (oplionai]
7 L,st eo@nl nornber(si here {aphqral}
Tax
Ent€r yoor TIN in the approp.iate box. The TiFl Provided .nust match the naFe given on line 1 to avoid
backup withholding.For individual8. ihrs is qenorally yotlr social security nilrnber (SSN)' llows'/er, for a
re$id6nt ali€n, $ole Proprialor or dl$rugarded entity, $oe the inslrirction$ for Part l, lafor. For othot
entitiBs, it is your amPloyer identitication nulnber (ElNi lf you do not have a ndrnbet, tea Haw to gel a ot
lJ^,r. laier.
Noto: lf the account is it.l morg than one :lame, 9ee the in8tnlctions for lilre '1. see also what Naft|e and
Numbor To Qive the Requeslsr for glidollnes on whosa ntfitlor to m{tr-
Under penatties of perjury, I csrtif'/ that:
1 ,
-rh€ number shown on this fom is my corract iilpaye. identification numbo' {ot I em waiting ior a number to D€ issued to me}; and
2. I am noi subjeci to backuF withholding bocause {ar) I am exempa froa t}ackup leithhofding, or {b} I havo.ot b€en notified b'y ihe internfll Ret/anro
seru'ce (lFlS) tha! I am subject ,. ou"riup *i*'noroing as a result ol a lailure to report ail inle.eet or divid€nds, of ic) the iRs ils$ rlotiJied rne that I ar)
no ionger subiect to backup wiihholding; and
3, I am a U.S. cilizen or other U S. person idefined bolow). ancl
.1. Tho FATCA code(s)ontered on th;s forn 0f any) indicaling thal I am exempt from FATCA rQporting
'5
corrst'
certmcafion imtr:rctbn3. You must closs out item ? above if you have been nolifled by the IRS lhat you are currently subject to backuP withholdhg
b€cause you have tatlgd to teport all intorest and divid€nds on Your tax rsturil. For raal estale i.ratlsaclions' item 2 doss no{ apply. Fot mort?age ifllerast paid'
acquisition or abandonm€nt of gecured property,canc€llation of dobt,contributions to an individuai
othor inttr*t and dividonds.ara r€t io lhs carlifitaiion, but .nu6t
$ign
Here
Signablrc ot
U,S, pdson Date
General lnstructions
Section references ale to the lntemal llevellue Code unless otheruise
noted.
Future doveiopmants. For lhg :alesl infotrnal:on aboul dev€lopmenls
rciated to Forrn W-g anrl its instructions' st,ch as legislatlon enacted
atter they were published, ga lo vvww-irggovlFamw),
What's New
Lrne 3a has beeE mod|lied to clarity hovr' a dis'regarded eatity completes
thrs lino. An LLC that is a disregarded entit, should chosk tho
appropriate box for ihe lax claisification of lts ownel Othsr#ise' it
sirorlit check the "LLc" bor and enter its approprate tax classification'
Now line 3b has bson added to this fom. A flow-through enlily is
required to eo{nplete this line lo indicale that,t has direet or indirect
totLign pa.iners, ovtners, or beneticiaries whetr il provides the Fonn W-9
io an"otner ttow-inrough enllty in which it has an own€rship intorest This
ciranqe is intanOeU to'provide a flow-through enlity with lnfotrnation
reoardrno lhd staius of 'ts lndirocl fo/oign padners, dwttors or
oe-neficrides. so lhat it can sattsfv any applicablo reporting
requiremants. For example, a partnorship that has any ndrrec-t ro'elgn
onin"t" -oy ba required to complcte Schodules K-2 atrd K-3 Sse the
Farrnonhip instruction* for Schcdules K-2 and K-3 {Forrn 1C65)'
Purpose of Form
An individual sr entity (Form W-9 requaeter) who i3 requited :o lile an
ir'rforrnation return w;ih the IBS is giving you tllis lorm because they
only ono of lho followrng 6ovar boxg
n individuatsle propristor ! C c*poration ! S corporation fl Partrorshlo ! TnrsVostatc
E LLc- Entct tha tor cldssili$llon 1C -' c {;orPomllon, 3 = S rorposlion' P = Pattntrship}
Notc: chsk lh€ "LLc" frox abov€ ird, [r lhs entry space, enter the appropilale code (C' $' or P) lor ihe tax
ctmstficalon ot th6 Lic, untasa ttiJa;ir8iugur,il'oiirtv. A dismgartoi emiry shoitd i6$t66.J chd:k li4 aopropfiJ{'
bd lorthe tax classificalioa of ilg ownei-
n Oth* {sq inAtructioil$}
vhqse naile i$ srl€rsl on liris 1 - Chwk3a Ch&k lhe sopopriala box {or tfrleE{ l6x ciasslicalron o{ lhe flrlttyrnd;vidr4l
classiication.ontqtdilid iu:ischeckadd''TruBv€teto,olit3blino0n3a"Pann€6h;P"checkedy0u chtrkints€i,an own6r5lpha!eostategwhichformlbiElatrust,Youparinsghip,ileed providingyou
SeelFnellclarlos.:nEltitllonsofboxlhigparhgF,yot,arly lorelgn
Add.ess (numbet, str4t, and Fpl. or suite no ).5 See inctruclions.
6 City. stato, aod z,P code
numbeaPart I
Cfr iltoystaer.trncmionnumber
Part ll
Cal- No. 1tl231X
Kittitas County Agreement for Services (rev.5/Ia/25')
Page L4 of 22
Fcrn lAf-9 lFcv. 3-202'll
Pase 2
Fomr W-g inev. 3-202'$
must obtain rr'orr conect lai(Fayer idsntification nurnber {Tft'l}, which
iruu Ue vour'so"lal security liunrber {SSN). indlidual laxpayer
iJ#t-f ."rion number (tTlNi. adoption taxpayer identification number
rATIM. or emolover id€ntification numb€r {ElN}. to lepott '$ an
intoi*"tirn return the amount paid to you, or other alnoun-t reprrtable
on an intonlation retum' Exarnpleg o{ informalion rehrns include' bul
are not lirnited to. the following.
r Form 1o99-fNT {interesi s€med ot pa;dl.
. Form 10e9-OM idi'ridends' including those ftlm stocks $r r*xtual
tunds).
. Form 1099-MISC {vs'ious types of income, pxizes' aurards' or gross
praceeds).
. Form 1099-NEC {nonemployee compensationi'
r Form 1099-8 (stock or mutual fund sales and ce{tain other
transactions bY brokersi.
. Form lD99-S lproceeds ftom real estate transaclions)'
. Fomr 1099-K (nrercilant card and thir+party nelwork Fansaclionsi'
. Form 1098 {home nrortgage ifllerest}. 1os8-E (student loan interesl}'
and 1098-T (tuition).
. Form 1099-C (canceled debt).
. Form 1o99-A (acquisition or abandonment o{ secured propeny)'
Use Form W-9 only if you are a U.S- person $ncluding a resid€d
alien), to provide Your conect TIN-
caulion: lf vou don't retum Form $/-9 to tie reguester lYilh a TIN' you
rniqht be .ub1*t to backup withholding. See l{hal r's backup
withholding, laler.
By signing the filled-out form. You:
1 . Certify that lhe Tlt{ you are gii4ng is conect {or you are waiting for a
number to be isg.red);
2. Certify thai you are not subiect to ba€kup wtthholding; or
3. Claim exenrption from backup withholding ii yr:u are a U-S' exempt
payee; and
4- Certifv to vour nonJoreign Btalus ior purposee of Trithholding under
chapter 3 irr -t
-of the Code [t applicablei: and
5 Certifu that FATCA codeisi entered qn this farnr ff any! indicaling
tn"i vou "ie
*""tpt from the FATCA reporting b cctrect' See l'Vhat Is
FATeA Reporting. later. for further infomration'
Note: lf you are a U.S. person and a requsster gives you a fcrm other
inan po#'.nj-s to request yourTll\'1. you must use lhe requester's Ic'rm if
it is substantially similar to ihis Form liv-g'
Definition of a U.S. person' For federal tax purposes- you are
considered a U-S. Person il You are:
. An individual rvho is a U S. cilizen or U-S. resident alieu
. A nartnershiD. corDoration. company. or association created or
,rgiitexl in ne United States or under the larts of fte United Statm:
. An eslate {olher than a foteign estate}: o{
. A don'lestic truet {as defined in Regulations section 3o1 -7701 -/J'
Establishing U.S. statls tor purPo3es of chapter 3.and chapter 4
withholdinq-. Pavments mad€ l'l fore'gn p€tsons" including certan
itliriuittii"i, all#ations of income, oitrinsfers ol sales prcceeds' tnay
u. i"Oi*.r td wilhholdinq under chapter 3 or chapter 'i of the Code
{*chons 14.11 -1474). Under those rules, tf a Form !V-9 or otfier
t"rtin""tiot ol non-foreign status has oot been recei'red, a wilhholding
Ii"ni, Gn*t*t ",
or par&rership (payorJ generally applies presumption
*i** frrt *"V t*iu;ri ttre payor tb *'itnnotd appicaU'te- tax from tl"e
rmiolenl olvner. iansferor, or partner (payee! See Pub' 51 5'
WrfltoUinq of f axon Nonresident Aliens and ForeiSn Entities'
The follor,ving p€rEons must ptovide Form !V-9 to lhe patlor tor
purposes of es-tiblishing its nofl-foteign 3ta1us'
r ln the case of a disregarded entity rvith a U-S' ol"'ner' the U'S- crvner
of the disregarded entiiy and not th+ disregarded entily-
. tn the case of a grantor lruGt w;ih 1 U.S. granlo.r.or other.U'S' orcner'
#;;lt, th; U.iig[ntor or otier u.B. oriner # the grantorlrust and
not the grantor ltust.
. ln the case of a U.S. trust {olher than a grantor trus0, lhe U S' trust
and not the benejiciaries of the trusl'
See Pub. 515 lor rnore information on provrding a Form l!'-9 or a
certification cf non-foreign status io avoid $ithholding'
Foreion t)ersott. lf lou are a f'orergll pers{'{l or tfie U-S' br3ftch of a
i."J; ;5;ili; n# Jt*t"o to ui t'eatec as a u's person iurder
h-*ri"t"ti" .*tion 1.I a4l -libj[2]$?l or othe( applicaHe section for
cha'nter 3 or 4 oumosesi do not use Fo{m W-9' lnstBad, us€ the
aootoriate foim tfi-s sr Form &233 {see Pub 51 5} lt you are a
"Iiin[J-f*"ion oension h.rnd under Fegulations section 1'8971t-1(d)' or
r'i-ri""Ji"-it ,ii is '.'ntrotly ownea by qialifisd loreign pensron tunds'
Glt ," u""t;o as a non-ioreign persin lor purposee D! p191 1415
;ilhh;ldilg;a;"ot u** rottn'yi-g. lnsleaci. u& Form uJ-eE(P {iratler
certification of non-foreign status).
Nonresident alien who becomes a resident alien' Generally' only a
"r"roia"ni"fi"^ individlal rnay use tie t€rmg of a tan lreaty to leducs
oi ii*n"t" U.S. iax on cerlain types o{ htc'llte'. However' rr}osl tax
trealies cpntain a provision kno|n as a saving clalse' Excepllons
."."m"C in the savinq clause may permit ar exemption from tax iD
;5;;;;;i.;;'an tfres ot irnoftb even afier lhe.pavee has otherurise
become a U.S, resident alien for tax purpag€a'
lf 'rnu arc a I I S rFsidpnt alicn wtrn is ralyrng on an excepthn
*nt|inJ in in" saving clause of a tax treaty tb claim.an exernption
i;;; U.S. t*;" tertai"n types of income, you must attach a stalement
to Form W-9 that sPecifi€s the foilorving five hems'
1. The treaty coufltry. Generally, flli3 must be ths.s€me treaty urder
which you claimed ex6mption from tax as a nonresident ali€fl'
2. The treaty article addressing the inconre'
3. The article number (or location) in the tax tl€aty that centains the
saving clause and i1s 6xceptions.
4. The type and amount of income that quali{ies for the exemption
from tax-
5. Sutficienl facts to iustify lhe exemption lmm tax under the tenns of
the tre.aty arbcle.
Exanale. Article 20 of the U.S.-China income tax beaty^allows an
.ri*.ii5n itorn iaxlor scholarshrp income received by a Chinese
;i;;;ii;p;t;ry pres€nl irr the United States under u S' lavr' this
=i"O""i *if f b*.me'a resident alien for lax purposes if lheir stay in the
U;;;-Sl;i; ;"eeds 5 calendar years Houever' paragraph.2 oi the
n*iFioi*or to tte U,S.-China lreity (dared April 3-0 198'li allours the
orovisions of Article 20 to conlinue to appiy Bvefl atter tne unlnese
iiua"ni o""o^o a resident alien of the United States' A Chinese
ri rJ""i *ht q""lifies lor this exception (under paragmph 2 of the first
pr"i"""fi
"^O
l" relvinq on this exception to clain an exernption hom tax
ild;;3;h;l"bi[ oit"ito*"hip iniome *ould attach to.Form w-s a
"Lt"'"""iinJ i^iiudes the inlomation degcribed above to support lhal
exemplion.
lf vou are a nonresident allen or a foreign enlity, give the r€quester tfie
appropnate completed Form W-8 or FDml 8233'
Backup Withholding
What is backup withholtling? Percons makrng certain Faym.ents to yolr
**f unJ*t ""ti"tn
condidon! withhold and pay to the IRS 2'1% of suctr
""^r"i". ftti" ii called "backup wirhholding.i Payments that may b€
!r6i*t t" backup witiholding include, but ate not limiled to inierest'
i*lexemot interesL divrdend!, brpker and barter exchange
i;;"il"t,;;"G.toy"itm. nonemployee pay, payments made in
;-fi;;;i;i p;ymeni c€ru and third-pirty netlork tansactions' afld
""rt"" ".tt"J"6 {rom fishing boat operators' Real estate ttansaclicfls
are nol su'biect t,r backup rvithholding.
You will not be subje€t to backup withholding on Payments you rmeive
il vou oive lhe requester your cofiect TlN lnake lh€ p(Dper sBrlifications'
"ria
r"-pott utt you'r taxaOt-e inlerest and dividends Gn your ta:< retum-
Paym€nls you receive will be subject to backup withholding il:
1 - You do not fumish your lIN to lhe requeslef;
2,You do not cerli{y yourTllrl when required {see the instructions {or
Part ll for de-tailsf;
3. The IRS talls the requesier that you furnished afl inconect TIN;
4- The IRS tells )'ou tfial you are subiect to backup withholding
because you did not repori all your interesl and dividends Gn yourtax
retum fioi reportable interest and dividends only); or
5. You do not certifrl to the requesler tiat you are not.sublect to
#il;;"ithil;;;, ds Jescriueb ln itenr 4 rjnder "Bv signing the filtaa'
,"t iti-: Joi" (f;; reportable inieresl and dividend accounts opened
aftsr 1 9s3 onty).
Kittitas County Agreement for Services lrev' 5/U/25)
PageLS of 22
Fsse 3Fom W-9 {Rev. 3-?024)
Certain payees and payments are exempt hom backup wilhhalriing'
See Exernlr irayee code,-laier, and the separate lnstructions for the
Requeoter of Form W-9 for more information.
See als,o Fsfab/lsfting U.S. sfafus forputposet of chapter 3 and
clwtet 4 r,vithhatding, euliet.
What ls FATCA RePorting?
The Foreign Account Tex Compliance Act {FATCA) requires a
participating foreign financial instiluiion to report all U.S. ac€ount
hotUerL *aiare specffied U.S. persons. Certain payees are exempt from
FATCA reporting.'See ErenrpU6n fom FATCA repofting code. later' and
th6 lnstru;tion$-for the Requester of Form W-9 for more in{ormation.
Updating Your Information
You must provide updated information to any peBon to whom you
claimed to be an exempt payee if you are no lcnger an exempt payee
anrl anti^ipela rmciuing rolnrtahto leymmtc in thc fi rh rm from lhis
person. for examp{e, ybu may need td provide updated information if
vou are a C corporation that elects to b€ an S corporation, or if you are
io longer tax exempl ln addition, you must fumish a new Form W-9 if
the nale or TIN changes for the aicount, for example. if the grantor ol a
grantor trust dies.
Penalties
Failure to funrish TlN. lf you fail to fumish your conect TIN to a
requester, you are subject to a penalty of $50 for each such..fuilure
unless youi fail.tre is dle to reasonable cause and not to willful neglect'
Civil nenaltv for false information with respect to withholding' lf you
nrake a fal# statement lvith no reasonable bbsis that results in no
backup vrilhholding, you are subject to a 5500 penalty.
Crinrinal penahy for falsifying itrformalicn. Willfully lalsi{ying
certifications or affirmationi may subiect you to criminal penafties
including fi nes and/or imprisonment.
Misuse of TlNs. lf the requester discloses or uses TlNs in violation of
federal law, lhe requester may be subiecl to civil and criminal penalties'
Specific lnstructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your lax retum.
lf this Form Ui*9 is for a ioint account (other than an account
maintained by a foreign financial instiMion {FFI}), list first. and then
circle, the name of the p€Eon or entity whose number you entered in
Parl I of Form W-9. H you are providing Form W-9 to an FFI to document
a joint accounl each holder ol the accbunt that is a U.S. person musl
provide a Form W-9.
. hrdividual. Generally, enter the name shcwn on your tax return. lf you
have changed your lait name withor:t informing lhe SocialSecurity
AdministrJtion 1SSA) of the name change, enler your first name, the last
name as shorvn on your social security card, and your new last name.
Note for tTlN applicant: Enter your indlvidual name as it was entered
on your Form W-7 application, line 1a This should also be ihe rame as
the name you entered on the Form 10"to you filed wilh your application'
. Sole proprietor. Enter your individual name as shown on your Form
1 040 o; lin-e 1 - Enter youi busine€s, lrade, r:r "doing business as" (DBA)
name on line 2-
. Parlnershirr, C corporation, S corPolation, or LLG, other than a
disregardetl entity, Enterthe enlity'd name as shown on the entity's lax
refum on line 1 and any business, trade, or DBA name on line 2'
. Other entities. Enter your name as shown on required U"S' federal tax
documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. Enter any business,
trade. or DBA name on line 2.
. Disregarrled entity. ln general, a businets entity.thaf has a eingle
owner, including an LLC, anO is not a corporation, is disregarded as an
entitv separate irom its owner (a disregarded entity). See Regulations
sectibn iot .zzot -2(c)(2). A disregarded entity should check the
aoorooriate box for thb tax classification of its owner. Enter the owneds
nlin" bn line 1 , The name of the orvner entered on line I should never
be a disreoarded entiW. The natne on line 1 should bs the name shown
on ttr* in"6** tax retuh on which the income should be reported' For
lF rhe en{tYilntllvldual oft llh€ 1
isa(n| ...
THEN ch+ck the b,}r lor
r Corporation Corucration"
. lndivkluai or
r Ssle propristorsltip
lndl4duaLrssie p{Oprietor.
r LLC classified as a pathershiP
for U.S, federal lax PUrPose€ or
. LLC that has filed Form 8832 or
?553 et€cting to be tsxed as a
corporalion
Limited fiabtity cornpanY and
enter lh* appropriate tax
elassificatiDn:
P = Partrrership.
C=0corporatio{r.or
S = S corporation.
. Parhership Partriasltip-
. Trustlestate Trustiestate.
examole. if a foreion LLC that is lr:ated a a dis'egard*d entity for U'S'
fedet tar putpoG* has a srnEb owner the.t is a U'5- person. the U'S'
or$nefs na;re is required to be prodd+d on lin'ra 1- l{ tie dirEct owner of
the entity is also a disregrarded entilu' enter fie frr5t owner that is nol
Aisregarled for federal tax trspcsei. Enier tfle distegarded entity's
namJon line 2. lf tfie ownsof ttre disregar# e*t-ly is a foreignperson,
tie onner must complete an approFrhte FDlTn U{-6 instead-ol a Form
W-9. fhis is lhe cas,] e'ren 'f the forelgn person has a U.S- TIN'
Line 2
lf you have a business nafils. lnrJe nanre' DBA nsre, or disregarded
entity name, enter it on lfue 2.
Line 3a
Check the appropriate box sn line 3a fc,r the [J-S" federal tax
classificalion of tir. per*on whose flame is efi1er€d an line 1 ' Check only
one box on line 3a.
Line 3b
Check this box if you are a partnership lincluding an LLC classjfied as a
parfrership for U.'S" feaeral tax purposeGl" ttust" or estate that has any
ioreign partners, owners, or beneficiaries. and 1"ou are providing this
iom"to a oartnersftio, trilst. ,]t estate- k whiclr loU tiaue an ownership
inteet. You must iheck the box on Une 3b if 3"sir receir€ a Form W€
{or documentary evidenceJ frotr, any Partftef. owner' or beneficiary
eslablishing foreign status or il you receive a Form W-g frotn any
partner, ovjner, oi benefr:iary that has chetked the box on line 3b'
Nate: A partne.ship that pror,'ides a Form Yd-B anrd checks box 3b may
be requiied to cornplete Schedules K-? and K-3 {Form 1065}' For more
information, s€e the Pattnerchip lnstn cticns for Schedulee K-2 and K-3
(Form 1065i.
H vou are teouired to complete line 3b but faittD do so. you may not
receiJJtne intormation neceisarytc file a r*nec.l in{ormatieft retum wilh
fhe IRS or fumish a csnect payee stalBff€nt to ]€ur Fiarbr*rs or
benei:ciaries. See. for erample, se{{iofls 6699. 6.7?2, uld 6724 lor
penafties that nray a$PlY.
Line 4 Exemptions
lf you are exempt &cfi] baakup wi*thlldng an:lror FATCA r€Forling,
eril.s irr the appiotrxiate spacri on firw { arly eo"J*isl tiral illay appiy ts
y0u.
Exempt payee code'
. Generally, indivirftrals {inctuding s'r{e prrupnetorsl are not exempt {rorn
backup rvithholding.
. Except as pmvided belol'r' corp'c'ratiofls are Firsrnpl ftom backuP
withhaliing fix certain payrnents' inoludirq interes! and dt'idends-
. Corrorations are not exe{nFt frgrn backup u*iihhddiftg for paym€ntg
maae in setttement of paymeit card or third-party net'vcrk transaciions'
. C{rporations are not exemPt {rtm bskup rvi{htrolc{ing with resPect ts
attomeys' fees or groes proc6'eds paid to attornel'q and rorporutions
rhat orovide med&i or treahh cari ser'rbe6 are nctt sxempt !'rith respect
to piyments reportable ofl Fonn'[89&fu11ffi.
The follor',,ing codes idenliflr p*ayeee {hat are *tempt lrom backup
withhr:lding. Enter the appropriate cc'de in tlre space on flne 4'
1-An organization exempt fronr tax under se-ction Soliaf , any IRA' or
a custodiaiaccount ufld€r aection 403tb)tr1 lf the accc'unl satisfies the
requirements of ssctior ao1 if1{2}-
Kittitas County Agreement for Services (rev' 5/L4/251
Page L6 of 22
Pos* 4
Ftrm !V-9 {Bev.3202.+)
2-The United Siates Dr any of its agencies or instrumentalities'
3-A state. the District of Columbia a U.S' commonwealth or tarritory'
or any of their political suHivisions or instrumenlalities.
4-A foreign govemmenl or any of its political subdivisions, agencies,
or instrumenlalitie6.
5-A corporation.
6-A dealer in securities or commodities required to register in the
United States, lhe Distict of Columbia. or a U.S' commonwealth er
teriiory.
7-A futures commission merchant registered with the C,ommod;ty
Futures Trading Commission.
8-A real e€tate investment trust-
9-An entity registered at all times during the tax year under the
lnvestment Company Act of 1 940'
10-A common tust futnd opsrated by a bank under section 584(ai'
1 1 -A financiai rnstituton as defined under sectan 581.
1?-A middlenran known in the investment community as a nominee or
custodian.
13-A trust exempt from tax under section 664 or described in section
4947.
The following chart shows types o{ payments that may be exernpl
from backup witnholding. The';hart aiplies to the exempt payees listed
above, 1 through 13.
lF the payment is for THEN the payment is exempt
lar..,
r lnterest and dividend payments All exempt payees excapt
for 7
. Broker Exempt payees 1 through 4 and s
through 1 l and all C corporations.
S corporalions must flot enter sn
exempt payee code because theY
are exempt only for sales of
noncovered securities acquired
prior to 2O12-
r Barter exc transactions Exempt payees 1 through 4.
and
. Payments over $600 reqtrired to Generally, exemPt PaYees
be reported and dirsct sales over 'I through 5.?
s5,000'
. Payments made in settlernent of Exempt payees 1 through 4.
payment card or third-PartY
neh'/ork transactions
l See Form 10s9-MlSC, Miscellaneous lnformation. and lts instructions'
2 However, the following payments made to a co-rporation and
reportable on Form 1 og-g-Mi8C are not exempl from backup
tr-lthholding: medical and health care payments, attomeys'fees, gross
proceeds idd to an attotney reportable under seciion ro45{0' and
payments for services paid by a federal executive agency
Exemption from FATCA reporting code. The following codee identify
payee! *tat are exempt from reporting under FATTJA These cods
"pply
to p"t"ont submitting this lorm for accounb matntained outside
o? it''e Uriir"o States by certain foreign financial instiMions. Therefore' if
vou are onty submittin'g this form foian account you hold in the United
btates. yoLr may leave this field blank' Coreult with the person
requesling this-form il you are uncertain iJ the financial inslitution is
"ub!*t to-the"t requirements- A requester may indicate that a code is
not reouired bv providinq vou with a Form W-9 with 'Not Applicable'' (or
iny srriritar indic'ationJ en-trired on the line for a FATCA exemption code'
A-An organizaton exempt from lax under section 5o1 {ai or any
individual retirement plan ag defined in se€tion 770-l{aX37}.
B-The United States or any of its agenciee or instrumentalities-
G-A state, the Dislrict of Columbia, a U.S- commonweaith or
teritory. or any of their political subdivisions or instrumentalities'
D-A rorporation the stock of which is regularly traded on one or
more estabiished securities markets. as described in Regulations
section 1.1 a72-1 {c){1 }(i).
E-A corporation that is a member of the sarne expanded alfiliated
groilp as a corporation describecl in Flegulations section 1 1 'f72-1{c}{lHi}'
Kittitas County Agreement for Services (rev.5/7a/25)
Page t7 of 22
F-A dealer in securities. coorrncrjities, or deriraiive financial
in;hr;eflts $ncludng notional pnindpal cantracis, tutur-e€' ty-e'
and optionsl"lhat is ftistered as such r,rnder ihe la*€ of lhs UniH
Slates or any state.
G-A real €€tata inlrestment ttttst'
H-A requlated ire'esbnent r.ompaft9 as defined in so{tion 851 or an
entity regis-tered at an firnes durirq th* lar yeff under the lnvesBnefit
Company A6t ol 1348.
l-4. common trust fr.nrd as 'lefrned in section 544{a}.
J-A bank as defined in secdon 58tr "
K-A broker.
L-A trust exernpt from tax under sectiofi $6"t or d€sctihed in *ction
4e47{a}{1}.
lvl-A lax-exempt trust under a s€{tion 403ib} plan or B*etiofi 457b}
p,an.
Noto: You mny rvish to oonouit wilh the finonsiol inotiMion roquimting
thls fomr to deieruine lvfiether the FATCA code andor exernpt payee
code should be cornpleted.
Line 5
Enter your eddress {number. sbeet afid apartrnent or suite.n-tmber)'
Tlris is wtrere the requeter ol this Form W-9 will mail your.informaiion
retums. lf this addreis differs lrom the one the rEqusster already has on
fite, enter "NEV\I" at the top" lf a new addres is provided' lhere is still a
chance the old address ltill tle used until ihe payor changes yulr
address in their reoards'
Line 5
Enter your c!ty. state, and ZIP cade.
Part l. Taxpayer ldentification Number [tlN]
€nter vour TIN in the appropriale box- !f you are a residenl alien snd
you dd not have, and ari not eligibie ts get, an,SSN, y+ur TIN is yaur
inS fftN. Enter it in lhe entn' spa,;e for the -social security number' lf yoil
do nol have an fflN, see lfor'l to get a IIrtJ below-
lf ynl are a sole proprietor and 1nu hate an ElN, you may enter eitlrer
your SSN or ElN.
lf you are a sing{e-rnember LLC tfrat rs drsregardTl..as.y. efltttt'
*oamte from its owner, enter the ol'tne/s SSN {or Ell'|, il lhe owner has
""Ei iiG" LLc is classified as a corporalian or partnenhip, enter the
entiiy's ElN.
Note: See l{hat ftlame and ljurn&er Io Gire ifie Hsquester. lalsr, for
{urther clarification of name and TIH cornb*hatiocls.
How to get a TlN, lf you do rot hate a TlFl, apply {or one immediately'
To applyior an SSN, get Form SS-5. Appli'catim for a Social S€cildty
Cani^ frilm your lccal SS'& offtce Dr get lhis fcmr lnline at
mvr*.SSA&v. You rnay alse get this {elrn by calling 600-772-1313- Use
iom W-r-loolication for |Rs-lntrniduaX Taxpayer tdenlilicatbn
Nunrber, to jpply tor an IflN. or Fcrm SS-:r- ,Apdicaiion for Em$yer
ldenfif catior'Fiwnber. lo apdy f*r an Ell'{' You can apply for an EN
onllne by acce*sirg tfne 1ft5 website at r*':ow"ns"gorr,iEJlJ. Go to
wtv'lv.irs-.grlFanti to vie,;r'. dorryntoad or p*int Farm W-7 srd/or Form
SS+. Olyuu orl gt [o w1'sls-]ts'.Sur',rCqderFtnrru lu-gfacearr older altd
have Fo# W-z anir'c,r Fonn SS-4 rnail€d tc you lvithin 15 bosiness
dale
l{ vou se asked to c+mr,lete Form W-g hut do fiot have a Tll'1, apply
ior a'Ttt't and enter *Appfied Fof in the space tcr tfie-TlN' sign.and date
the form. and giw it t6 itre rBquester' For rnlerasl and druiderld
payrne*is, andcertain paynrents rnade I'lith resp€ct ql-readiFt tradabie
int**"nb, yo* *m g#eralh'have 60 days to ge-i.1Tl1'land give il to
ihe reque8tei before vau are suniea to backrrp '.'rithholding on
oavnrents. The 60-dav rule do€s not ryp{f ts orher types of pa}rynenls'
Voir vell ne subject to backup witiholdB-lS sn alf such payrnenis until
you prorride 1"our Tll,l to the req.rsler.
Note: Efltering "Applied For' means tfrai yau fute akeady applie'C for a
itttt or ttrat vo"u iniend to appl'r' fer one soon. See also Estabi'stlring U 5
it"i* fJrputp*es of ctuli#e a'rd efxqpler4 wttfiiufdiog, eartier, for
*nen you'*"y insread be subiect to u'iifflsgding under chapler 3 or tl of
the Crrde.
Caution: A diveganJed U-S- efltitl that tlas a {oreign o!'Jner must use
lhe appropriate Form W-8.
Pcsa 5Fom W-9 (nev- 3'2024)
Part ll. Certification
To establish to the withholding agent that you are a U.S. person' or
resident alien, sgn Form W-e. you may be requesled to sign by the
rvithholding agenit even if item 1, 4, or 5 below indicates olhersrise'
For a joint account, only the person lvhose TIN is shown in Part I
should sign (when required). ln lJre case of a disregaded eltit-v, &e
person idlntified on line 1 musl sign. Exempt paye€€, see Flernptpagee
code, eadier.
Signature reqrlirements' Complete the certi{ication as indicated in
itemsl through5below.
L lnterest, cJividencl, and barter exchange accounts op*necl
belore {984 and broker accounts considered active during 1983"
You must give your correct TlN, trut you do not have to sign the
certification.
9 lnterest, dividend, broker, and barter exchange accounts
onrncd aftni {q&? and hrnkpr ancnttnls ccnsider*d inaclivs drrrhcl.-
i6rie iou must sign the cerlification or backup witrholding will apply' lf
you are subject to-backup withholding and you are mgrely providing
your
"oneci
TIN to the requester, you must cross or.rt itern 2 in the
certification before signing lhe form.
3. Real estate transactions' You must sign the certification. You may
cross out item 2 of the cerlification'
4. Other paynrerrts' You must give your conect TlN, but you do not
have to sign the certification unless you have been notified that you
have orev6uslv oiven an inconect TiN. "Other payments' include
oavm'ents .ade"in tttt course of the requester's trade or business {or
rerie, royalties, goods (other than bills for merchandise), medical and
heafth care serviies {including payments lo corporalions}, payments to
a nonemplovee for services, payments made in settlement of pa1merd
card and thiid-party network transactions, payrnents to celtain tlchlng
boat crew members and fishermen, and gross proceeds paid 1o
ettomeys (including payments to corporalions).
5. Mortgage interest paid by you, acquisilio-n or abandonment r:f
cecured *oberw. cancellation of debt, qualilied tuition progratn
paymenti {uhde; section 52S}, ABLE accbunts{under section 529A}'
iRA, Coverdell ESA, Archer MSA or HSA conklbutions or
distributions, and pension distributions' You must give your corecl
TlN, but you do noi have to sign the c€rtification.
What Name and Number To Give the Requester
' List first and circle the name of the persofl
lf only one person on a ioint accounl has an
must be fumished.
:Circle the minor's name and fumish the minor's SSN-
rYou must show vour individuaj name on line 1. and enter-your business
"i bEn n"i"-i. ii
"nv.
on iine z. You may use eLther your SSN or EIN {if
you have one), but fre IFS encourages you lo use y'our SSN'
r List firc1 and circle the name of lhe lrusi. estate. or p€fision 1rust' (Do
not iumish the TIN of the personal representative or truslee unlsss tfie
legal efltfty ibelf is not de€ignated in the account title'l
- $ole: The g::ntor must also prcvide a Form !T-g to the truslee of the
irust.
"'For more information on opticnal fillng rnethcds for granlot tusls' see
lhe lnstructions for F0rm l o4-1.
Note: l{ nr: name is cirded when more than sne nane is listed' &e
number ,.'rill be considered to b€ lhst of lhe tirst name listed'
Secure Your Tax Fecords From ldentity Theft
lclentitv theft c{curs rvhen someone usff }'DUr personal rn{ormation'
such ai your name. SSN, or other tdentifying information xilhcul your
oermlssion to commit fraud or otfrer crinm. An identrbg thiet may use
iour SSN to get a iob or may file a ta-l, raturn usng your SSi'l to recerve
a refund-
To reduce your risk
. Prutect your SSN,
. Ersure your employer is prote*ting pur SSN' and
. Be careful when choosing a tax retum Freparcr-
lf vour lax records ate alfecled by ideniitf rheft and you recerve a
notiie from the lRS, respond ng#rt away to the name and phone number
printed on the iRS notice or letter'
It vour tax recorrb are mt cunenfly affected by rdenhty thelt bxl ygtl
tfrini vou are at risk due to a losl or itden putse oI rvallet, questionable
credit card activity. or a queslionabl'e credt report, conlact lhe lFlS
ldenrify Theft Flotine at S0O-90&44SO c,{r 3r$ftit Fsrm 14t}39'
For more infonnation, see Pub' 5O2?" ldefltitl'Theft InJormalion for
Ta:rpayers.
For this of accounl:
s- Ubreqard€d *titY not ovrn€d bY ffi
iodividml
s" A lalid :rust. state, tr Pffiim trust
'lO- Corporo{on w tl.G €Hinq Espscte
stntus an Fm 8332 or Fm ?553
11 , A:s*iatiffi, club, elfuirc, choitable'
edmtisnal. or oilwr td-eampt
orgnniaiioo
12- Pst*eEhip or mullimmberLLC
1 3- A broker or registeed rwine
I*. Acmmt with the DePartrn*i of
Asridture ir ihe ffi ol a PuUic
",itit'o
is"ch s r shte or led
qloffimt. *hml dbbict or Prismi
drat rcdvw ogriculh:ral Program
Fnynflis
15. GMto.tretfilirg Fm to'l| d
mder ihe Optiond Filing Method 2'
requiring Fom t@9 {ffi ReguhtbB
setion 1.s7'l -4{b}{2xi}tB}'"
Give nanre and €lfl aft
T[ewns
LeErJ slit'J4
Tte crFoalion
The wgmiratico
lte peuarslip
Thebrckrywnmiree
lte pu$ic mtily
Tle:Nt
rvhose number you fumish'
SSN, liat person's nutnber
For this type of accorrnt:
z,Two or more tndividusls {cinl mcouni)
other thil m ncmuni maintained bY
an FFI
3. Two or moc U-S pems
fioint accout maintained bY m FFI)
.1. Cwtodia.l asount o{ a mhs
(Unifom Gift to Minm Act)
5- a. The wual revwable mvings trwt
(grulx is also trustee)
b. Sealled trust accryni that is not
a legal ry vatid tnst mds state layr
6. $ole proprietomhip c dimgcded
stity offied by m hdividual
7. Grantd 1r6t fitrng under Optioaal
filing hlethod 1 (sw Flegulatioru
sFtiod 1.671 -4(bX2Kl{4)}"
Give name and S$N ot
The indMdual
The actual oruer of ih+ Hfrnt cr.
if mmbined tunds, the fist individud
on the ac@untl
Eactr holder of ihe rccant
The minod
The gratJr-trusiqel
The actual omsr
The ovmef
The grmtor'
Kittitas County Agreement for Services (rev ' 5/M/251
Page 18 of 22
Fus* 6
Form W-9 (Flw.3-2024)
Victims of identitv theft who are exp€riencing economic-harm or a
r";iil;o*bl#,-iriaiJseeking hdi: in resolvrng tax proHems that
[;;;;;i 6*" resolved through-normal channeb, may be eli$ble for
i""p"v", nauo""te Service [=AS] assistsnce" You can reach TAS by
"Jfilg th" iAS toll-free case intake line a|877 -777 4778 or TTYITDD
800-gz9-4059.
Protect vourselt from suspicious emails or phishing schemes'
Fir"f ing'b lhe creation and use of email and websites designed to
mimic tfritimate business emails and websites' The mssl cornmon act
i" ".^Ut"o
an email to a user falsely claiming to be an establbhed
il"iiit"iJ*i"-.piEein an attemptio scam fre user into surrendering
private information that will be used for identity theft'
The IBS does not initiate contacts with taxpayers via emails' Also' the
tRS Ooes not request perconal detailecl information through enrail or ask
taxoavds for the PIN irumbers. passwords, or similar secret access
ir*&niation for their credit card,'bank. or other finqncisl accounts'
lf vou nrcaivc an unsolioitcd omoil oloiming no bo from tho lFlS'
torwfi tnis message to phrbhrngr@rmgov. You may also rePort misuse
of the IBS name, loio, oi other IRS property to the Treasury lnspector
General for Tax Adftinistration (TIGTA) at 800-36H484' You can
fonvard suspicious emails to the FederalTrade Commisston at
."""-or"".6on or re@rt them alwww,ftc.govlcomplaint' You can
i!"i""r u""irc
"
r iwn'ftc.govlidrheft or b77-IDTHEFT {87.7-4:}8-4338)'
f f i""iti"it O*t the victim it iaentity *,"n, see www-ldentityTheft'gov
and Pub. 5027.
Go to www.ris.govltdentityTheftto leam more about identity theft and
how to reduce Your risk.
Privacy Act Notice
Section 61ff} of lhe tntemal Rever.r* Co'de equiree you lo pro'Jide your
;;lnN ; ;;ns {irrtuding fiederal aeqciiesl wfro. are reQuired to
file information retume wilh lhe IRS to rEport interBst' 'lluden{ts' or
;;;;id;idme pajd to votr; rYwrtgige inlere€t vc'u patd: lhe
;ilffi;;; "btt'ddnment
itsecurea prnper$ tf'e cfflcdlation ol
;il;;;;b'rti"ns you made to an tee, ercrr'er usg' or FIS'{- The
oelon collectin this furm uses tlre inlormalion ':n Sr'e icrrn tr: file
lili.i"irt "ii ,-ttfrt" *i*t tt " ms' reprxtirq *re aboue info*rnalion'
if"Liii--"*" ii ttet information inalude s-i'JErg il to the Departrnent of
l*ti* n"i .iril -J criminal tiligation arJ to citjes, slares" tF District ol
Columbia, and U.S. cornmonwedths and teratones l.or rse ln
,,i"i;"i"i"i1""-t * ta,vs" ttp intormation rftay atso be disclosed to other
il;ffiilil;ii*r{ to t*a** and state-ageraies to.enlorcs ciuil
and rriminal laws, or to federal laur eniorcernent and lntelllgence
;;;6";;6"t terrsrism. You must provide your TIN trhether or not
viu are resuiled to file a tax relutrl Uflder sectian 3{06'.psYors must
[!i#,iri-ililiilt"ti;-+;;nt"s" "f ta.catie interest di$idends' and
E"rt"in ,ittte. p"y*erits to a payee who does not, gir'e a TlN.lo tfie payor'
C"triln p.t"fti"i may abo app\'for providing false or fraudulent
iniormation.
Kittitas County Agreement for Services (rev . 5/Ia/251
Page t9 of 22
Attachment "F"
DSHS Agreement Number
2663-70974COUNTY PROGRAM AGREEMENT
School-to-Work Direct Service Pilot
Gontract
Washlngton State
Department of Social
& Health Services
Transforming lives
Administration or Division
Agreement Number
Cou nty Agreement Number
WashStatetheofndabetween ingtonramrsPThisbyAgreementrog
identifiedCoutheDSandandealthHntyServicesofrtment(HS)SocialDepa
OnDSHSandwithnctionAgreementarsstsinueduandCountylowbeconJ
rence.referatedbyichwhonsConditiermsTandeneralG
IN DEX NUMBER
1225Division of Vocational
Rehabilitation
Division of Vocational
Rehabilitation
oSHs corurRncr coDE
8500cc-63
AND TITLE
here to enter text564200-2812
CONTACT
Austin
4565 7th Ave SE
ACT AD
wA 98503
FAXCONTACT
Austin Diaz-Munoz
Contracts Specialist
DSHS
Ciick
COUNTY ADDRESS
Kittitas CountY Court House
205 W Fifth St Room 211
wA 98926
COUNTY NAME
Kittitas CountY
RAL EMPLOYER IDENTIFICATIONCOUNW FEDE
NUMBER
kasev.knutson@co.kittitas.wa.us
Tour.n'Y coNTAcr E-MAILCOU]tW CONTACT FAX
(509) 962-5883
COLJI.ITY CONTACT TELEPHONE
(509) 962-7090
NUASSISTtvt
AGREEMENT?
No
MAXIMUM PROGRAM AGREEMENT AMOUNT
Fee For Service
PREiGRAM AGREEMENT END DATE
09t30t2027
PROGRAM AGREEMENT START DATE
05t0112026
County Program Agreement by reference:
XiiiioiJ (speci-ity): Exhibit A - Data Security Requirements Exhibit B - student Guide lnstructions, Exhibit c '
student Guide, Exhibit D - schoot-to-work student bata, Exhibit E - school-to'work Billing checklist
No Exhibits.
the following Exhibits areEXHIBITS. \Nhen the box below is marked with an X,and are incorPorated into this
DSHS
ustveexclandentirethefinal,ndanarethisofContract representationtermsTheconditionsintegrationand oralunications,and commentsallagreemwritingsandprevlousthebetweenmergrngsupersedingpartiesunderstanding andreadhavethattheybelowTherepresentpartiessigningofmatterContract.thisrditheorotherwise,rega ng subject DSHSonbindibeContractThis onlyshalContract.this ngexecutetohtheaveandthisauthoritynderstandContract,u
DATE(S)SIGNED?RTNTED NAME(s) AND TIrLE(s)NTY SIGNA
DATE SIGNEDD TITLENAMDSHS SIGNATURE
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017)Page 1
1
Special Terms and Conditions
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. "Contracto/' means Kittitas County.
d. "County" means the political subdivision of the State of Washington, named above, performing
services pursuant to inis 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 Ad min istration (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. "lndividual Plan for Employment (lPE)" means a DVR form that documents important decisions
about vocational rehabilitation services for a Student as defined in WAC 388-891-1 1 15. 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.
k.
"lntensive 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.
"Job Foundation" - The Job Foundation process is intended to engage students earlier in targeted
DSHS Central Contract Services
601 7CF County Program Agreement (10-31-2017)Page 2
SPecial Terms and Conditions
employment planning and connection; increase partnerships with schoolstaff to complete student's
Job Foundation repoi 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.
l. .Job placement" means locating, securing, and placing a Student into competitive integrated
employment that is mutually agieeO upon-Oy the DVR bounselor, the Contractor, and the Student
or the Student's Team.
m. ,,Job Stabilization" means thc 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*6"-1ob performance and has the quantity and type of long-term
employment supports Lvailableto them that are needed to maintain satisfactory onthe-job
performance.
n. ,,Long Term Services" means ongoing support services provided by an entity other than DVR after
the diudent 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) ldentify 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) ldentify 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/developmentat oisaoitities from schoolto 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{o-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 lo 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 documentition, information, assessments, activity logs, and notes' This guide is a
Student's,roadmap'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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Special Terms and Conditions
v. ,,subcontractor" means a Community Rehabilitation Program that the Contractor has separately
chosen to perform all or a portion otine 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 mostlignificant disability in employment as a means to bridge
employment support between stabilization and long-term services.
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.
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.
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
needeld, 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) lf an undue hardship does exist, the DVR School-to-WorUTransition Program Manager
or their designated iepresentative 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
desig nated rePresentative;
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Special Terms and Conditions
(4) Higher Education, by exception approved by the.DVR Transition Program Manager or
designateJi"pr"i"rit"tive. Studeni 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 di*erent cohort. Should the Student change their mind on
the cohortihey choose tJparticipate 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 Oo so-witn prior written approvalfrom the DVR School-to-Work Transition Program
Manager or designated representative'
(6) Have an lndividualized Education Plan (lEP)'
(7) Estabtish a DVR tndividual Plan for Employment (lPE) with an employment goalthat
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 lntake
andAssessmentPhasepersection5,statementofWork.
Meetings must be held in the format best suited for the Student. lf 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.
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.
Service Delivery Agreement: The Contractor's delivery of VR services specified in this agreement
will begin upon inegompletion and signing of the agreed upon SDOP.
Service Delivery payment: The Contractor will be paid upon completion and submission of the
required documentition demonstrating completion of each of the three phases for each Student as
outlined in Section 5, Statement of Work.
service Delivery Method: This contract utilizes Exhibit c - student Guide as a reporting tool and all
associated activities ouflined in section 5, Statement of work shall be carried out using the Student
Guide. Exhibit B - student Guide lnstructions offers instruction on how the contractor may use the
t
g
h
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Special Terms and Conditions
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:
lntake and Assessment Phase.
Job Placement Phase.
Employment Phase.
a. lntake 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, anO buitd an individualized roadmap of the Student's transition from
their education to m'eaningiul community employment. This shall be accomplished through the
following objectives:
(1) lntake
(a) At a minimum, the Contractor shallwork 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. Oufline how assessment will occur, including additional meeting time.
(b) The employment goal is established and documented'
i. 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' '
strengtns, 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 miy Oe obtained from Job Foundation report, work-based learning, school
assessments, etc.
(b) At a minimum, the following criteria must be addressed:
i. History of school attendance and reliability;
Behavior support or potential strategies;il.
iii
iv
V.
vi
Student Communication skills;
Student learning Preferences;
Student's personal hYgiene;
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
xi. 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 empioyment based on their employment goal' The
Contractor shall provide all services necessary to locate, secure, and place a Student into
competitive inteEjiaieJ employment that is muiually agreed upon by the Student's Team. Specific
placement expectations shall'be outlined on the DVRSDOP for Job Placement and lntensive
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 em'ptoyment such as a letter of recommendation, create and/or update Linkedln
page or other social media, etc.
(2) Job Offer
(a) lf 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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Special Terms and Conditions
iv. Job Duties;
v. Expected WeeklY Hours;
vi. Starting Wage;
vii. Location;
viii. Transportation Consideration;
ix. Benefits Package; and
x. PotentialTraining Services and Date/Additional lnfo'
(b) lf the Student rejected the job offer, Contractor must provide the reason(s) why the Student
rejected the job bffer. oetails must include how the job did not meet their individualized
employment goal, as well as the criteria in (2Xa)'
(c) lf a Student has a job goal that is 10 hours or more per week, but receives a job offer fewer
than 10 noursfer we"i, the Contractor shall request approval from the.D.VR Counselor in
consultation *itn tn" Student's Team should the Student want to accept the offer.
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
flrst day of emPloYment:
i. The Employment Verification page of the Student Guide'
(2) lntensive Training Services
(a) lntensive job training expectations shall be outlined by the Student's Team. The Contractor
shall provide individ-ualized, 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 onthe-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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Special Terms and Conditions
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
agreesthattheemployer'sexpectationhavebeenmet;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 thiough tne end of the calendar year (December 31,
2027)witn appiov"t tior 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 388-891A-1060'
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.Maximum26hourspermonthatthehourlyrateof$105.00
(A) lf 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-Wori Transition Program Manager or designated representative'
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601 7C F County Prog ram Ag reement (1 0-31 -201 7 )
Special Terms and Conditions
Deliverables. The Contractor shall demonstrate completion of activities for payment through the
following reporting methods. Submissions should be written in language that dire-ctly addresses the
Student and shall continue for 90 days beyond the Student's stabilization, or until DVR case closure'
The Contractor shall sunmit tne 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 ine progress of the Student's transition year via
completion of the Monthly Progrjss 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
Counsetor 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) lntake - 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) Stabitization - 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 prog-ram is available to all Students who meet eligibility requirements across
the state. ln order to accoriplish 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. lf the Contractor coordinateJ services for more than one county, the Contractor
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SPecial Terms and Conditions
shall submit data for each countY'
ii. Number of Students enrolled with DVR'
iii. Number of Students emPloYed.
iv. Number of Students who exited Schoolto-Work early'
v. Reason for Student exiting early.
vi. Number of Students who exited School-to-WoTUDVR 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 lttrn"g"r or their designated representative throughout the course of the 2027
transition conot following the bllow 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) lf 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'
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
w1h 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 provideJ by Title 2 of the Code of Federal Regulations (CFR), 34 CFR 80.36' OFM
SAAM Policy 16.20.5-5, DSHS Administrative Policies No. 1 3' 1 1 and 19'50'30'
b. progress Meetings: DVR School-to-Work Transition Program Manager shallwork with Contractors
to pian meetings-which allow discussion of program progress and support methods to ensure
Students are receiving adequate services to ob.-tain employment. ln addition, Contractor may invite
DVR partners to attend locai County-initiated service provider meetings. DVR partners may include
tocat bVR Counselors, supervisors, and School-to-Work staff.
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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Special Terms and Conditions
(3) CRP lntensive 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 requ irements,
Gonsideration. 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. lntake 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) lntake Meeting: Paid upon receipt of a School-to-Work Billing Checklist and a written
report in the Siudent 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 Studeni GuiOe. 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 individualstudent has completed the following activities:
(1) Job Seeker Tools: Paid upon receipt of a Schoolto-Work Billing Checklist and a written
report in the Student Guide. The toial billable amount for this activity is $1,000 per
Student.
(2) Job Offer: paid upon receipt of a Schoolto-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) lf a student with a placement goal of 10 hours per week or more accepts a placement
for less than 10 hours per wee:k, an exception for payment may be granted with
approval of the appropriate DVR Supervisor. This approval shall b_e 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 individualstudent has completed the following activities:
(1) Emptoyment Verification: Paid upon receipt of a School-to-Work Billing Checklist qq a
written report in the Student Guide. The total billable amount for this activity is $1,000
Per Student.
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SPecial Terms and Conditions
(2) Job Stabilization: Paid upon receipt of a Schoolto-Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $5,000 per
Student.
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 onlybe 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 sna'it Oe 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'
lnsurance - Self-lnsured
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) n The Contractor is self-insured or insured through a risk pool and shall pay for losses
for which it is found liable; or
(2) n The Contractor maintains the types and amounts of insurance identified below and
sha1, prior to the execution of this Agreement by DSHS, Orgvlle certificates of
insur#ce to that effect to the DSHS contact on page one of this Agreement.
Commercial General Liabilitv lnsurance (CGL) - to include coverage for bodily injury, property
damage, anO contr"ctu"l li"Oitity, witn tne tottowing minimum limits: Each Occurrence - $1'000'000;
GeneratAggregate'$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
ano appointed officials, agents, and employees shall be named as additional insureds'
lnvestigations 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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'|.4.
15.
16.
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Special Terms and Conditions
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) ln 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 f tnconclusive or unsubstantiated'
Removal of lndividuals from Performing Services
a. ln 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 individualfrom providing direct services to DSHS Students. Failure to
do so may result in a Corrective Action Plan.
Compliance with Corrective Action Plan
ln 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.
Order of Precedence in DVR Process
ln 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, ol particular than those contained in this contract shall not
be construed as being inconsistent or in conflict'
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. lf 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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Special Terms and Conditions
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, fulladdress, phone number, and emall.
(3) Contract number.
(4) Description of the issue in dispute.
(b) 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
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 lnformation Processing
Standards publications for the encryption of electronic data issued by the National lnstitute of
Standards anO fechnology (https://nvlpubs.nist.gov/nistpubs/FIPS/NIST'FlPS.197-upd1.pdO.
b. ,,Authorized Users(s)" means an individual or individuals with a business need to access DSHS
Confidential lnformation, 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 underthe privacy and Security_ Rules of the Health lnsurance Portability
and Accountability Act of 1996. The agreement establishes permitted and required uses and
disclosures of protected health informaltion (PHl) in accordance with HIPM 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
regutalions 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 oy: ine Health lnsurance Portability andAccountability
Act (HlpAA), pub. L. 104-191as amended by the Health lnformation Technology for Economic and
ctinicat Heatth Act of 2oo9 (H|TECH), 45 CFit parts 160 and 164; the Family Educational Rights
and privacy Act (FERpA), 20 U.S.C. 51232g; 34 CFR Part 99; lnternal Revenue Service
pubtication 1075 (https:liwww.irs.govfoub/iri-pdf/p1075.pdD; Substance Abuse and Mental Health
Services Adminisiration regulationl on confidentiality of Alcohol and Drug Abuse Patient Records,
42 CFRpart2; and/or Criminal Justice lnformation Services, 28 CFR Part20.
e. ,,Cloud" means data storage on servers hosted by an entity otherthan the.Contractor and on a
network outside the contr6l 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 oT consumer grade storage would include iTunes, Dropbox, Box-com, and many other
entities. Enterprise clou-d vendors include Microsoft Azute, Amazon Web Services, and Rackspace.
f. ,,Encrypt" means to encode Confidential lnformation 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 Progra-m (see
www.fedramp.gov), which is an assessment and authorization process that federal government
agencies nave-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: Upiercase 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.
j. .Multi-factor Authentication" means controlling access to computers and other lT resources by
requiring two or more pieces of evidence thaithe 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 pn'sicif token; and. something the user is, a biometric identifier
such as a fingerprint, facial scan, or retinat scan. i'PlN" means a personal identification number, a
series of numbers which act as a pasiworo for a device. Since PlNs are typically only four to six
characters, plNs are usually used in conjunction with another factor of authentication, such as a
fingcrprint.
k. ,,portable Device" means any computing device with a smallform factor, designed to be transported
from place to ptace. portable devices a-re primarily battery powered devices with base computing
resources in the form of a processor, memory, stoiage, and network access' Examples include' but
are not limited to, mobile inon"t, tablets, anO taptop!. Mobile Device is a subset of Portable
Device.
l. ,,Portable Media" means any machine readable media that may routinely be.stored or moved
independently of computing devices. Examples include magnetic tapqg' 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 lnformation have access, and access is controlled through use oJa 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 lnformation is not avaii-able to unauthorized personnel. ln 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 OSHS 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 mechanismi which protect the confid-entiality, integrity, and availability of
the Data.
o. ,,Unique User lD" means a string of characters that identifies a specific user and which, in
conjunction with a password, pJssphrase or other mechanism, authenticates a user to an
information sYstem.
2 Authority. The securitY requi
policies and standards of the
rements described in this
Washington TechnologY
document reflect the applicable requirements of
Services AgencY
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
4.
DSHS Central Contract Services
6O17CF County Program Agreement (10-31-2017)
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. lf 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. lf Confidential lnformation 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-
Authorization, Authentication, and Access. ln 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 lD and password
combination is known only to the one employee to whom that account is assigned. For purposes of
non-repudiation, it must aiways be possible to determine which employee performed a given action
on a system housing the Data based solely on the logon lD 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.
f. Have a process to periodically review and verify that only authorized users have access to systems
containing DSHS Confidential lnformation.
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 lD, 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 lnformation from an external location (the Data will traverse the
lnternet or otherwise travel outside the Contractor's network), mitigate risk and enforce password
and logon requirements for users by employing measures including:
Page 18
5
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 lnternet, which is not a Trusted Network'
(5) Ensuring that the remote acce66 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.
i. 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)
j. lf the contract specifically allows for the storage of Confidential lnformation 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.
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 lD
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 accels control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User lD 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 lnformation 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
parigrapn. 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 localworkstation optical disc drives. Data provided by DSHS
on optical disos whioh will be used in localworkstation 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.
d. Optical discs (CDs or DVDs) in drives or jukeboxes attached to servers. Data provided by
ObHS 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 lD 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 accessibleto authorized personnel. When not in use, such records must be stored in
a Secure Area.
f. 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 Uniqle User lD'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' ' porta'Ole devices or media unless specifically authorized within the terms and conditions of the
bontract. lf so authorized, the Data shall be given the following protections:
(a) Encrypt the Data.
(b) Control access to devices with a Unique User lD and Hardened Password or stronger
authentication method such as a physicaltoken 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.
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017)Page 20
Special Terms and Conditions
h
(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 lnformation must be under the physical control of Contractor staff with
authorization tn access the Data, even if the Data is encrypted.
Data stored for backuP Purposes.
(1) DSHS Confidential lnformation 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 uniil such time as that media woutd be reused during the course of
normal backup operations. lf backup media is retired while DSHS Confidential lnformation 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 fart of a Contractor's existing, documented backup process for busine.ss continuity or
disaster recovery purposes. tf so, such media will be protected as otherwise described in this
exhibit. tf this media is retired while DSHS Confidential lnformation still exists upon it, the data
_
will be destroyed at that time in accordance with the disposition requirements below in section 8
Data Disposition.
Cloud storage. DSHS Confidential lnformation 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 wiiting 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 wiil remain Encrypted at alltimes while residing within the Cloud storage solution'
(e) The contractor will possess a decryption !e-y !9r 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
601 7CF County Program Agreement (10-31-2017)Page 21
6
Special Terms and Conditions
(2) Datawill 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)TheCloudstoragesolutionusedisFedRAMPcertified.
(3) lf the Data includes protected health information covered bythe Health lnsurance Portabilityand
Accountability Act (itpnn), the cloud provider must sign a Business Associate Agreement prior
to Data being stored in their Cloud solution'
Syetem protection, To prevent compromise of syslems 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 sofiware 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'
Data Segregation.
a. DSHS Data must be segregated or otherwise distinguishable from non-DSHS data. This is to
ensure that when no totigeineeded by the contractbr, all DSHS Data can be identified for return or
destruction. lt also aids in determining whether DSHS Data has or may have been compromised in
the event of a security breach. As suih, one or more of the following methods will be used for data
segregation.
(1) DSHS Data wiil 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 practicalto segregate DSHS Data from non-DSHS data, then both the
DSHS Data and the non-DSHS data witn wnicn it is commingled must be protected as described in
this exhibit.
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:
7
8.
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017)Page 22
Special Terms and Conditions
Data stored on:Will be destroyed bY:
Server or workstation hard disks, or
Removable media (e.9. floppies, USB flash drives,
portable hard disks) excluding opticaldiscs
Using a "wipe" utility which
least three (3) times using
will ovenrurite the Data at
either random or single
character data, or
Degaussing sufficiently to ensure that the Data
cannot be reconstructed, or
ical the disk
Recycl ing throug h a contracted fi lffi,prov ed the
contract with th e recycl er assu res that the
confidentia of Data will be rotected
Paper documents with sensitive or Confidential
lnformation
Paper documents containing
requiring special handling (e.
Confi dential I nformation
g. protected health
information
On-site shredding, pulping, or incineration
Opticaldiscs (e.9. CDs or DVDs)lncineration, shredding, or completely defacing the
readable surface with a coarse abrasive
Maonetic tape tnctn or crosscut shreddi
9.
{0.
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. lf no DSHS Contact is designated in the Contract, then the notification must
be reported io the DSHS privacy Officer at dshsprivacyofficer@dshs.wa.gov. Contractor must also
take actions to mitigate the risk bf toss and comply with any notification or other requirements imposed
by law or DSHS.
Data shared with Subcontractors. lf 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. lf 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
60 1 7C F County Prog ram Agreement ('l 0-31 -20 1 7 )
Page 23
Exhibit B: Schoot-to-Work Student Guide Instructions
The fottowing is a bitting guide for the Contractor as they work with students by fottowing the pages of the
Student Guide. As the fottowing sections are compteted, the contractor witt use Exhibit E: STW Bil'ting
Checktist for Student Guide, provided to the Contractor by DVR'
These instructions witt support guidance to Schoot-to-Work (STW) contractors as they work with students
who are participating in STW. To begin the process of STW and to review the STW Student Guide, schedule a
STW lntake and Assessment meeting with the Student and the Student's Team. During th is meeting, the
STWStudent Guidewitt be shared with the student, goingthrough the process of STWand what the student
shoutd expect in their finat year of Transition.
Bitting lnstructions:
1. Bitt $2,000 for the STW lntake Meeting once the fottowing pages are complete:
o Team Buitding and lnformation
o Team Contacts, Rotes, and Responsibitities
2. Bi[l $3,OOO for Assessment once the fottowing pages are comptete:
Assessment pages may inctude the fottowing pages being completed, as appticabte for the student, as
each student mayget to their emptoyment goat in their own way. Att sources of information may be used to
determine the parts of the assessment. This may inctude job shadows, a Job Foundation Report through
DDCS, Work Based Learning through Pre-ETS, or any source to determine the needed information to
estabtish an employment goat. The student and the student's team witt work together to determine this.
The main goat for this section is to get to an emptoyment goal, and the next steps for the student.
r STWAssessment
. Job Goa[
o Next Steps and Team Actions
3. Bilt $1,OOO f or the Job Seeker Tools once the fottowing pages are complete:
o Job Seeker Toots (determined bythe student's team and have been completed and shared with the
student and DVR)
4. BiLl $2,OOO for the Job Offer once the fottowing page is complete:
o Job Offer Detaits on the page titted "You were offered the job! Way to go!"
5. Bitl $1,OOO for Emptoyment Verification once the fotl,owing page is complete:
o Form is compteted on the page titted "Congratutations, you are emptoyed!"
6. Bilt $5,000 for stabitization once the fottowing pages are complete:
o Your Supports on the Job
r Job Stabitization Report
please note there are additionat pages in the Student Guide that do not affect the above payments
and are intended to support the student.
wr;,,t*
Division of Vocational Rehabilitation (DVR)
Exhibit E:
School-to-Work Billing Checklist
lnstructions:
1. The Student Guide is sent monthly to the Student's Team, including the DVR Counselor.
Z. The Contractor checks the appropriate box(es) as the corresponding activities are completed in
the Student Guide (one form per student).
3. The Contractor submits this completed form to the assigned DVR Counselor.
4. The DVR Counselor confirms information from monthly submissions of the Student Guide,
verifies activities were completed, then signs and dates the checklist.
5. The DVR Counselor submits for payment.
Notables:
The Student Guide serves as documentation for proof of completion for the payment / activity
point.
The Contractor submits no less than three (3) separate checklists to the assigned DVR
Counselor for each student (submitting all payment points separately is also an option).
Any questions, please contact the School-to-Work Team at
SVRSctr oolT'oWonk(CIdsh s.uta.gov.
Exhibit E: School-to-Work Billing Checklist
DSHS 11-195A (04t2026)
Month and YearContractor
Date of SignatureSignature
Student lnitialsAFP Number
To be filled out bY DVR gtaff OnlY:
and date below to confirm
items received and to authorize
DVR staff signAmount
BilledActivity Billed
2 0 00$I tntat<e Meeting
3 0 00$E Assessment
1 0 00$I .loO Seeker Tools
2 0 00$[ .tob offer
1 0 00$I Employment Verification
$ 5,000I Stabilization
$Total Billing
Attachment "G"
il i 'i, i r ij i''l i.i I r,,' l.l' r. i\ i 1 ',.t irj ;r 1
', t i, i ii : ' I ; li I I ir i'-l
School-to-Ulfork
STUDENT GUIDE
Job Seeker:
Month/Year:
DSHS
WASHINGTON STATE
Department of Social
and Health Seruices
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
Team Building and lnformation
Assessment I nformation
Team Contacts, Roles, and Responsibilities
Job Goal Established Next Steps and Team Actions
Phase Two
Job Seeker Tools Job Offer Details
Phase Three
Em ployment Verifi cation Supports on the Job Job Stabilization Report
DlvlsloN oF vocATloNAL REHABILITATION I SCHOOL-TO-WORK I PAGE 2
Welcorne!
School-to-Work Overview
The School-to-Work program is designed to assist you in finding a job before you exit school in June. ln this
program, you will work d-irectly withi job coach who will collaborate with you, your parent(s)/guardian(s),
schooldistrict staff, County Oevelopmlntal 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' lt will:
. Ensure key activities and milestones are completed and organized effectively.
. Support you in keeping important information in one place'
. Be a 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: lntake 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
"*pioy1n"nt
verification information, completion of the first day of work, and much more!
DtvtstoN oF vocATtoNAL REHABTLTTATION I SCHOOL-TO-WORK I PAGE 3
Next Steps and Team Actions
you and your team witl work together to decide what next steps are needed to support you'
Everyone should agree on tasks and actions.
Task Who When
Example:
DVR Counselor will connect You
with a Benefits Planner
Example:
Benefits Planner, Student, FamilY
Example:
Before job start (and again, as
needed)
, - Tip: Tasks may be added throughout your School-to-Work year,
\g,, o1. i"-ou"d if they are no longer something you want to explore.
DtvlsloN oF vocATloNAL REHABILITATIoN lscHooL-To-woRK lqnce +
Phase 1 Starts: lntake and Assessment
This phase lncludes bringing your team together that wlll support and guide you through the
program. Key lntake anu-asieisment activities will take place to ensure a posltive experience for you.
Team Building and lnformation
Team Building Date
To-Do-List
1. lntroductions / Overview of Services / Strengths and Challenges
2. Assessment Needs
3. Job Goal is Established
Role/AgencyName
DlvlsloN oF vocATloNAL REHABILITATION I SCHOOL-TO-WORK I PAGE s
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.
Name:
Email:
Phone:
You, the Student
(most important
person on the team)
Supports you in PartnershiP
with school, county, and
state departments to
acquire employment.
Name:
Email:
Phone:
Your Parent(s) or
Guardian(s)
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.
Name:
Email:
Phone:
Employment
Provider: Your Job
Coach
School-to-Work Contractor
entity providing local
support for you to find a
job.
Name:
Email
Phone:
Your County Program
Team Member
Role
Team Member
Contact lnformation
Team Member
Responsibility to You
Team Contacts, Roles, Responsibilities
(This list is more than one Page')
DlvlSloN oF vocATloNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 6
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.
Name:
Email:
Phone:
Your Vocational
Rehabilitation
Counselor
Connects you or Your
parent(s) or guardian(s) with
community, county, and
resources for School-to-
Work.
Email
Phone:
Name:Your School Teacher
and/or School Staff
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'
Name:
Email:
Phone:
Main Keeper of Your
Student Guide
Name:
Email
Phone:
Other Person on Your
Team
Team Member
Role
Team Member
Contact lnformation
Team Member
Responsibility to You
Team Contacts, Roles, Responsibilities
(Continued)
DIVISION OF VOCATIONAL REHABILITATION ISCHOOL'TO-WORK IPAGE 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!
lnformation 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, skilL, and ,rppJrt, needed for success on the job. This information will be gathered through school,
you, yiour 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:
Summa ry of Assessment Areas
DIVISION OF VOCATIONAL REHABILITATION SCHOOL-TO-WORK I PAGE 8
Summa ry of Assessment Areds (continuecl)
Stamina/endurance:
Social skills:
Demonstrated skills and task performance:
Transportation needs:
Work preferences and interests, including:Skills and lnterests, Desired Work Environment,
Desired Schedule, and travelto and from work:
Notable Accommodations and Necessary Supports:
Your job goal:
\gi Congratulations!You are on your way to being employed!
DtvtstoN oF VOCATTONAL REHABtLtTATtoN ISCHOOL-TO-WORK IPAGE 9
Phase 2 Starts: Job Placement
This phase includes conducting and capturing importantiob placement actlvities like employrnent
goals, site visits, job intervlews, 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, Ietters of recommendation, Linkedln pages, and more'
Resume or Media Resume
(Video, PowerPoint, Portfolio, etc.)
Sent to Student: Yes
Sent to DVR Counselor: Yes
Sent to Student: Yes
Sent to DVR Counselor: Yes
Sent to Student: Yes
Sent to DVR Counselor: Yes
Linkedln Page (optional)
Sent to Student: Yes
Sent to DVR Counselor: Yes
No
No
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Cover Letter (as determined if needed by you and your team)
Employer Letter of Recommendation (optional)
No
No
No
No
No
No
DtvtStoN oF vocATtoNAL REHABtLITATIoN I sCHooL-To-WoRK I PAGE 10
You were Offered the Job! WaY to Go!
Did you accept this job offer? Ves [] ftf o I l
lf yes, please complete the section below.
lf 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
DtvtstoN oF vocATloNAL REHABILITATION lScHooL-To-woRK IPAGE 11
Job Offer Details
Job Goal:
Employer:
Job Title:
Start Date:
Job Duties:
Expected Weekly Hours:
Starting Wage:
Location:
Tra nsportation Considerations:
Benefits Package:
Potential Training services and Date/Additional lnformation:
DtvtstoN oF vocATtoNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 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 more!
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:
ls this a new job? No Yes Date Employee Started Work:
Average Number of Hours Worked Per Week:
Rate of Pay or Salary: S HourlY
Pay Frequency:
Daily Weekly EveryTwo Weeks Two Times a Month Monthly
Tips:No Yes; if yes, how often and how much?
Commissions:No Yes; if yes, how often and how much?
Monthly Annually
Bonuses:No
Overtime:No
Yes; if yes, how often and how much?
Yes; if yes, how often and how much?
Work Schedule (include exact times when possible):
Monday Tuesday Wednesday Thursday Friday Saturday SundaY
ls health insurance available:No Yes
1.lf yes, did the employee enroll in the health plan?:
a. lf yes, when does the coverage begin?
b.lf yes, what is the employee's portion of the premiums? 5
Name and Title of Person Who Completed This Page:
Date:
No Yes
DlvlsloN oF vocATloNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 13
Your Supports on the Job!
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
v 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.
DlvtStoN oF vocATtoNAL REHABtLITATlON 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, Yorr are ready for long-term support.
But first...
Did you meet your expected job goal? Yes
Was your starting wage what you wanted? Ves !
Does the job location meet your expected needs? Yes
Anything else you want to add about your job?
No
No
No
DtvtstoN oF vocATtoNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 1s
Job Stabilization SummarY
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:
DlvlsloN oF VOCATIONAL REHABILITATION lscHooL-To-woRK IPAGE 16
Helpful Resources
Developmental Disabilities Administration
. Website: www,dshs.wa.qov/dda
. DDA Eligibility lnformation: www.dshs.wa.gov/dda/consumers-and-families/eligibilitY
Division of Vocational Rehabilitation, or DVR
. Website:www.dshs.wa.qov/dvr
. Phone: 1-800-637-5627
Social Security Administration, or 5SA
. Website: www.ssa.gov
. Phone: 1-800-772-1213
Benefit U
. Website:www.benefitu.orq
. Benefit U lnformation:suPport@ benefitu.orq
Other Resources and/or Additional Contacts:
Name:
Phone:
Email:
Other:
Name:
Phone:
Email
Other:
DtvtstoN oF vocATtoNAL REHABILTTATION ISCHOOL-TO-WORI( IPAGE 17
Optional Documents
Copy of Food Worker Card
copy of current cPR and/or First Aid certification
Sent to Student: Yes
Sent to DVR Counselor: Yes
Sent to Student: Yes
Sent to DVR Counselor: Yes
Other*
Sent to Student: Yes
Sent to DVR Counselor: Yes
Other*
Sent to Student: Yes
Sent to DVR Counselor: Yes
No
No
No
No
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
No
No
No
No
* ldeas of other items to include could be a person-centered plan, other certifications, and other
job-related documents.
DtvtStoN oF voCATtoNAL REHABILITATIoN lScHooL-To-WoRK IPAGE 18
Monthly Progress RePorts
Below is your story of finding a jobl As your Job Coach works with you, they will be adding in
their monthly reports that are on the fiist page of this Student Guide. You will be able to read the
progress made for you...the story of your journey to a job!
May
Year
June
Year
July
Year
DtvlsloN oF vocATloNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 1e
August
Year
September
Year
October
Year
DIVISION OF VOCATIONAL REHABILITATION ISCHOOL-TO-WORK IPAGE 2O
November
Year
December
Year
January
1
Year
Dtvt5toN oF vocATtoNAL REHABtLITATION I SCHOOL-TO-WORK I PAGE 21
February
I
Year
March
1
Year
April
1
Year
DlvlsloN oF vocATloNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 22
Year
May
June
"l
Year
July
1
Year
DtvlsloN oF vocATloNAL REHABILITATION lscHooL-To-woRK IPAGE 23
August
1
Year
September
1
Year
DtvtStoN oF vocATtoNAL REHABtLITATtoN lScHOoL-TO-WORK IPAGE 24
Additional Comments
DtvtstoN oF vocATtoNAL REHABtLtTATIoN lscHooL-To-woRK IPAGE 2s
Legacy Pilot
# of Students
enrolled in
School to Work
# of Students in
SDOP for
Assessment
f of Students in
SDOP for Job
Placement
s of Students in
SDOP
# of students
Employed
Asotin
Benton
Chelan
Clark
Columbia
Cowlitz
Douglas
Ferry
F ra n klin
lsland
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
Attachment "H"
Schoolto Work 20261 2O27: Graduation Year 2O27 or 2O28
*Total enrolled includes students no longer in school, may have moved, not eligible yet, passed away' etc
# of students in
Y.E.S.
# of Students
Transferred to
DVR Only
# of Students
Transferred to
DDCS (on CSA)
# of Students
Exited STW
Early
Comments
Add'l lnfo to Share
Reasons for STW Exit
0 0 0 0