HomeMy WebLinkAboutKittitas County & ElmviewKITTITAS COUNTY
AGREEMENT FOR SERVICES
PHMH26.018
This Agreement for Services (hereinafter "Agreement") is entered into by and between Kittitas County
(hereinafter "County"), a political subdivision of the State of Washington, and Elmview (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 L,2O26 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
507 N Nanum St Ste 102
Ellensburg, WA 98926
Laurie Holt
Developmental Disabilities Administrative
Specialist
Human Services
Lau rie. holt@co. kittitas.wa.us
509-952-7515
Elmview
PO Box 65
Ellensbu rg, Washi ngton 98926
Project Contact:
Sherie Bury
Director
Sherieb@elmview.org
This Agreement includes the following, which are attached hereto and hereby incorporated by this
reference:
Attachment "A":
Attachment "B":
Attachment "C":
Attachment "D"
Attachment "E":
Attachment "F":
Attachment "G":
Attachment "H":
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
Page L of 22
atu re
Printed Name
CONTRACTOR
Title
Date:
KITTITAS COUNTY
BOARD OF COIINTY COM
Commissioner
Date
N
ot(a,tlhu
Attest
S[,AL
\NLy
7
lN WTTNESS 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/L4/25)
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.
r Complete assessment using Student Guide and/or Job Foundations report to complete the Student Guide
to include DVR required information.
r Work with the students to find and secure meaningful community employment based on goals.
o Work with students to stabilize and maintain meaningful employment.
o Submit required documentation including student guide and billing checklist.
Kittitas County Agreement for Services (rev. 5/14/251
PageS 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
Reim bursement Procedures
A. The Contractor shall submit invoices to the county along with the DVR School-to-Work Billing Checklist.
B. For DVR to retease payment, contractors must submit the student guide monthly.
C. The Contactor must provide adequate backup documentation to support costs in each invoice per the
School-to-Work Guide lnstruction, including billing instructions. For example, the contractor may bill
S2,OO0 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 Seeker Tssl5 = $100
d. Job Offer = 5200
e. Employment Verification = S100
f. Stabilizallep = 9500
C. Total administrative costs to Kittitas County per School-to-Work student will not exceed SL,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/t4/251
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
by the County, lf an insurer is not admitted, all insurance policies and procedures for issuing the insurance policies
must comply with Chapter 48.15 RCW and 284-15 WAC.
At a minimum, Contractor shall maintain and provide proof of the following selected options
Commercial General Liabilitv lnsurance
r Coverage limits not less than:
r $1,000,000 per occurrence, for all covered losses
o $2,000,000 general aggregate
. S1,000,000 products & completed operations aggregate
. S1,OOO,0O0 personal and advertising injury, each offense
. The policy must be endorsed to include the County and its officials, employees and agents
as additional insureds.
x 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.
r Coverage limits not less than:
. S1,000,000 combined single limit
!Excess or Umbrella Liabilitv
. Contractor shall provide Excess or Umbrella Liability coverage of 55,000,000. This Excess
or Umbrella Liability coverage shall apply, at a minimum, to both the Commercial General
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 alternatively be satisfied through Contractor's primary Commercial
General and Automobile Liability coverage, or any combination thereof.
. The policy must be endorsed to include the County and its officials, employees and agents
as additional insureds.
r 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.
x Workers' Compensation & Emplove/s Liabilitv
. 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/Ia/251
Page 5 of 22
Professional Liabilitv / Errors and Omissions Liabilitv
. Coverage limits not less than:
. S1,000,000 each claimr Contractor must provide evidence of this coverage on a policy form appropriate to
Contracto/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 full force and effect. Contractor's
insurance policies required above must apply on a primary non-contributing basis in relation to any other
insrrrance rrr 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: (L) 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/L4/25)
Page 5 of 22
ATTACHMENT "D,,
GENERAL TERMS AND CONDITIONS
l. Scope of Contractor's Services: Contractor agrees to provide to the County services as set forth in
Attachment "A". No materials, labor, or facilities will be furnished by the County, unless otherwise provided
herein. All work performed under this Agreement shall comply with applicable laws and regulations.
2. Accounting and Pavment: Compensation to Contractor for services rendered under this Agreement
shall be as set forth in Attachment "B". Where Attachment "B" requires payment(s) by the County, payment shall
be based upon billings, supported unless provided otherwise in Attachment "8", by documentation of units of
work actually performed and amounts earned, including, where appropriate, the total number of hours for thc
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 system, 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 to 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. Contractormustpayall othertaxes,includingbutnotlimitedto: businessandoccupationtax;ortaxesbased
on (1) Contracto/s gross or net income, or (2) personal property to which the County does not hold title. The
County is exempt from federal excise tax.
4. Independent Contractor: Contractor's services shall be furnished by Contractor as an independent
contractor, and nothing stated herein shall be construed to create a relationship of employer-employee or a
guarantee of future employment. Contractor acknowledges that its entire compensation under this Agreement
is specified in Attachment "B", and that Contractor is not entitled to any County benefits, including but not limited
to: vacation pay, holiday pay, sick leave pay, medical, dental, or other insurance benefits, or any other rights or
privileges afforded to Kittitas County employees.
5. Assiqnment and Subcontractins: and Subcontracting: No portion of this Agreement may be assigned
or subcontracted to any other individual, firm or entity without the express and prior written approval of the
County. The Contractor may only subcontract work contemplated under this agreement if it obtains the prior
written approval of the County. 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.5/14/251
PageT of 22
comply with any applicable term or condition of this agreement. The Contractor shall appropriately monitor the
activities of the Subcontractor to assure fiscal conditions of this agreement. ln no event shallthe 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
Su bcontractor's performa nce of the su bcontract.
6. Right to Review; Maintenance of Records: This Agreement is subject to review by any Federal or State
auditor. The County or.its designee shall have the right to review and monitor the financial and service
components of the work performed under this Agreement by whatever means are deemed expedient by the
County. Such review may occur with or without notice, and may include, without limitation, on-site inspection,
inspection of all records or other materials which the County deems pertinent, and any and all communications
with or evaluation by service recipients under this Agreement, Contractor shall preserve and maintain all records
relating to this Agreement for six (6) years after termination or expiration of the Agreement, and upon request
shall make them available for review by any Federal or State auditor, the County, and/or any persons authorized
by the County.
7. Modification
7.L. This Agreement may be amended by mutual agreement of the parties. Any such amendment
shall be in writing and signed by both parties.
7.2 The County may unilaterally amend this Agreement at any time by written notice ("Change
Notice") to Contractor, to modify the work to be performed under this Agreement, within the general scope of
the Agreement. Such changes may include, but are not limited to, changes in the exact scope of work to be
performed (including modification, substitution, addition, or deletion of required tasks) and changes to the
schedule of performance. 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
8.1 This Agreement may be terminated at any time by mutual written agreement of the parties
8.2 The County, by giving written notice, may terminate this Agreement at any time without cause
and without further obligation to Contractor except for payment due for deliverables provided and/or services
performed priorto the effective date of termination. An equitable adjustment in the contracted price for partially
completed tasks will be made by the County, but such adjustment shall not include compensation for loss of
anticipated profit on uncompleted work.
8.3 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.5/14/25l.
PageB of 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.
8.4 Termination of this Agreement by any means provided herein shall not excuse any party's
performance of its obligations hereunder through the effective date of termination, except that the County shall
not be obligated to pay for services that have not been performed or deliverables that have not been provided.
9. lndemnification
9.1 To the fullest extent permitted by law, Contractor agrees to indemnify, defend and hold the
County and its departments, elected and appointed officials, employees, agents and volunteers, harmless from
and against any and all claims, damages, losses and expenses, including but not limited to court costs, attorney's
fees and alternative dispute resolution costs, for any personal or bodily injury, sickness, disease or death, for any
damage to or destruction of any property (including the loss of use resulting therefrom), and for any other claims,
damages, losses, and expenses sustained by the County, which (1) are caused in whole or in part by any act or
omission, negligent or otherwise, of Contractor, its employees, agents or volunteers, or Contractor's
subcontractors, their employees, agents or volunteers; or (2) are directly or indirectly arising out of, resulting
from, or othenruise connected with the performance of this Agreement; or (3) are based upon Contractor's or its
subcontractors' Ltse 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 Agreement, are reflected in Contractor's compensation, and have
been mutually negotiated by the parties.
9.2 The County reserves the right, but not the obligation, to participate in the defense of any claim
for damages, losses or expenses, and such participation shall not constitute a waiver of Contractor's indemnity
obligations contained in any section of this Agreement.
9.3 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.
LO. Venue and Choice of Law: ln the event that any litigation should arise concerning this Agreement,
the venue for such action shall be in the Superior Court of the State of Washington in and for the County of Kittitas.
This Agreement shall be governed by the laws of the State of Washington.
11. Non-Appropriation of Funds: lf the County does not appropriate sufficient funding for this Agreement
for any future fiscal period, the County will not be obligated to make payments for services performed after the
end of the last fiscal period for which sufficient funding was appropriated. No penalty or expense shall accrue to
the County in the event this provision applies.
12. Contractor Commitments, Warranties, and Representations: Contractor represents and warrants as
follows
Kittitas County Agreement for Services (rev.5h4/25l.
Page 9 of 22
L2.L Contractor is duly incorporated, validly existing and in good standing under the laws of the State
of Washington, and has all requisite corporate power and authority to enter into and to perform its obligations
under this Agreement.
I2.2 Contractor has the authority to execute this Agreement, to make the representations and
warranties set forth herein, and to perform its obligations hereunder.
L2.3 This Agreement has been validly executed by an authorized representative of Contractor and
constitutes a valid and legally binding and enforceable obligation of Contractor.
12.4 Contractor holds, or will obtain prior to commencing work under this Agreement, such licenses,
permits and other authorizations from federal, state and local governmental authorities, or from any applicable
industrial or professional certification or licensing bodies, as are necessary for the lawful performance of its
obligations under this Agreement, and will maintain such throughout the term of this Agreement.
I2.5 Contractor is not in violation of any applicable law, ordinance or regulation the consequence of
which willor may materially affect Contractor's abilityto perform its obligations underthis 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.
L2.7 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 by Contractor and/or its consultants or subcontractors, in connection with the performance
of this Agreement, shall be the sole and absolute property of the County. The County will have all rights of
ownership therein, including but not limited to the right to use, copyright, trademark, and/or patent, and the
ability to transfer any or all ownership rights.
L4. Intellectual Propertv lnfringement: Contractor will defend and indemnify the County from any
claimed action, cause or demand brought against the County, to the extent such action is based on the claim that
information and/or materials supplied by Contractor infringe any intellectual property rights of any third
party(ies). Contractor will pay all costs and damages attributable to any such claims finally awarded against the
County in any action. Such defense and payments are conditioned upon the following: (1) Contractor shall be
notified promptly in writing by the County of any notice of such claim; and (2) Contractor shall have the right
hereunder, at its option and expense, to obtain for the County the right to continue using the information and/or
materials that are the subject of such claim, provided no reduction in performance or loss results to the County.
L5. Use of Countv Name and Logo: Contractor may not use the County's name, logo(s), trademark(s), or
other identifying information, or identify the County as a current or former client, on its website or in any
marketing or promotional materials without the prior written consent of the County.
16. Disputes: Any dispute between the parties arising under or relating to this Agreement shall be
resolved informally if possible, However, in the event such a dispute cannot be so resolved, it shall be adjudicated
Kittitas County Agreement for Services (rev.5/La/251
Page LO 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 ( )the arbitrator's decision or award shall be final and binding on both parties.
17. 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.
18. Notices: Written notices required or permitted to be provided by one party to the other party under
this Agreement may be provided by personal delivery, legal courier service, or certified mail, postage prepaid and
return receipt requested. Notice may be provided by regular first-class mail if simultaneous notice is provided by
email. Notices given by Contractor shall be provided to the County's point of contact listed on page 1 of this
Agreement, at the address there listed, and to the department head of the county department for which services
under this Agreement are rendered. Notices given by the County shall be provided to Contractor at Contractor's
address listed on page L of this Agreement.
19. Prevailing Wage: Where labor to be performed under this Agreement is considered "public work" as
defined in RCW 39.04.01O, 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.L2.060.
20. Standard of Care: Contractor shall perform its duties hereunder in a manner consistent with that
degree of care and skill ordinarily exercised by members of the same profession or industry as Contractor currently
practicingorworkingundersimilarcircumstances. Contractorshall,withoutadditionalcompensation,correctany
of its services not meeting such a standard.
2 L. Nondiscrimination:
Kittitas County Agreement for Services (rev. 5/14/251
Page LL of 22
2L.L 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, orthe presence of
any sensory, mental or physical disability or the use of a trained dog guide or service animal by a person with a
disability; 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 advertising, layoff or termination, rates of pay or other forms of compensation, and programs for
training, including apprenticeships. Contractor shall take such action with respect to this Agreement as may be
required to ensure full compliance with local, state and federal laws prohibiting discrimination in employment.
27.2 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.
2L.3 lf any assignment and/or subcontracting has been authorized by the County, said assignment or
subcontract shall include appropriate safeguards against discrimination.
22. Waiver: The waiver of any default or breach of this Agreement, or the failure of a party to enforce
any provision hereof or to exercise any right or privilege hereunder, shall not be deemed to waive any prior or
subsequent default or breach, the enforcement of any provision hereof, or the exercise of any right or privilege
hereunder, unless otherwise stated in a writing, signed 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: Theprovisionsof paragraphs2,3,4,6,8,g,LO,!3,L4,15,16,L7,L9,20,22,24,and28of
these General Terms and Conditions shall survive the completion, expiration, termination or cancellation of this
Agreement for any reason.
25. Complete Aereement: This Agreement constitutes the entire agreement between the parties and
supersedes any and all other agreements, understandings, negotiations and discussions, oral or written, express
or implied, regarding the work to be performed hereunder. The parties agree that no other representations,
inducements, promises, agreements, or warranties relating to this Agreement, oral or otherwise, have been made
between the parties. Except as provided elsewhere in this Agreement, no modification or waiver of this
Agreement shall be valid or binding unless in writing and signed by the parties.
25. 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/Ia/251
Page L2 of 22
27. Time: Time is of the essence in the performance of this Agreement unless otherwise agreed between
the parties in a signed writing.
28. Construction: This Agreement has been mutually reviewed and negotiated by the parties and should
not be construed against the drafter.
29. Agreement Not for Benefit of Third Parties: This Agreement is entered into solely for the benefit of
the parties hereto and vests no rights in, nor is it enforceable by, any third parties.
Kittitas County Agreement for Services (rev.5h4/25]
Page L3 ol 22
0",,,' Ulf'9
ATTACHMENT'E"
Request for TaxPaYer
ldentification Number and Certification
Go to ffi.,-rs.gov/Formwg lor instruciions and the latest information.
Give form to the
requester. Do not
send to lhe lRS.
(llef. Mf,rch 202.1)
Dcp,'n'nort ol lhd lroaiury
lntonal Rcvcnuc Scryicc
Before you begin. For quidarree rolilied to :ho of For[r !V-9, $eo ol beiou.
t Nalne of entjty/irdivid!{1. An enlry is tequired. lFor a soie proprietor or disrega.d4d e,ltity, entcr the o\t/ne,'e ramc on line 1, and entcr :hc b!eiIc:sldisreqarded
enrity's na,ne on he 2 j
2 glrsi':csa ra,nc/disrcqorccd ontily tarrc. ;l dificrcnt trorn abovc.
o
uo
4
6
u8q6
z6.!i
Io
oooq
oo6
4 Zxornpt:ons (corjos
.€rtain entilieg. not
appiy only to
irdividLrals;
see irslnr(droas on pilJs 3):
Exencl payoe codo lil nFyi
Fxa*nptkrr fao4l ao:ei(D A6.0unl Tilt
CoinFl;nnca Aet iF^TCA] roporla'r!l
cocjo iit ily)
(Applios la nccau)ls ltaitlaiDad
drts;de the Unifod Slales.j
Hflll.pcler's nHft:c HI (: ,r,irtIP$s ioolIrr]i,i
7 i sl nccorill ,rrnrtFr{si here i'optoraf
Ta
Elrter your TIN in th€ appropriate box. The TIN provided rnust rnatch the ratre qivelr orl lirle 'l to avoicl
tlackup lvithholciirg. For rndividrrals, ihis is gonerally your social sor;trrity nurnhr:r {SSN}. l'iowe'/ar, for a
r{}sidcfit nliorl. sob proprietor, or di$.cga'ded onlily. $ee tho inslructions lor Par! l,
'ater.
For Qiher
entities, rt is your erilployer idertiiicatior ilut:roer (ElN). lf you do not have a nunlber' see How lo get a
IIN, later.
Note: ll the accoult !s in lnore thalt orle tame, see the instrlictrorts for line 1. $ee also What Name and
Numher To Qive tln Rcq)esler tat gilillolincs on whoss nunrher lo oni"r'
Slgnaturc of
[J.S. porson Dato
or
Certilication
Under pefralties ol perjirry. I cerlify that:
1 I he number snoutn oD this tonr ts my correci ldpayDr rdortiflcation rumbcr for I am lvailing tor a ntlmbe r to be tssued lo lnei; and
no 'onger srDitrt to backup withholding; and
:J. I am a U.S. citizcn or other U.S. ocrson {defined belolrl: and
4. The FATCA codc{s} efiteru:d on this forn tif rny) indic.tting thal I arn exerul)t frotrr FnTCn reporlirg iti corrod.
btrailse y6o nave ialied to teport all interest and divid€nos on your tax.6turn. For raai estaie lrarsaciions. iterr 2 does lloi appiy. For rnodgage lrl',eresi paid.
acqtrisition or abandonrnetrt ol smured propedy. cancellation ol Cebt, contribriions to an individual rel:rement arrangernent [lHA). and. generally. paymenls
otl'ar than irtorast and d'vidends. to(r il.o |ot to tho cBrli{icati0n, cut *{ist yoLir correcl TlN. See tho instructions for part ll, later
Sign
Here
General lnstructions
Section refere|ces are to lhe ltlenral llevehue Code L,rlless oihemise
notod.
Futurs dovelopmonls. For the lateei iftormalion abo(rt dcvelof)rnonls
related !o Fonn W-9 ard it$ irrstrilctions. stich as legislatiot enacted
alter they vrele publisned. go to Mtrw.l6.9ov/!'armlry9,
What's New
Ljne 3a il€ls been rnoditied to clanty horT a drsregarded entity cornpletes
this line. An L.L.C lhat is a rlrsregarded cntity shottld check tne
apfJropriatc box for lhe tax classificnlion of :is owrter. Olhr:ruise, it
siro.lld check lhe "LLC" tlox 3|d eFlelts aplrropr;.rte lax classiiicalion.
Now lioc :lb ha1: becn adcier! to lhis fonil. A flow-through enlity i:;
.eqilired to cor'rlpiete thig lire to indicate that it has d;rmt or ir)direcl
foreiqn padners, o\,./lreis, or berleticiaries Yrherl it provides the forln !V-9
to anolaler flow-throrigh ettity tlt wnich it has alr ownclship ;ntefcst. lhls
chang;e is intended lo provide a llol'r ll'rough e|r!rty',vilh inforniltion
regarditg lho slalus dt its ilrdireci iorcigff oartncrs, 6r'Jrler$, or
cenelicia/aes, so iirat it ca,r sai,sfy any applicable reporting
req[irsrnents. For exafi]ple. a parlnersnip that has any indirect ioteigrl
partners may bo required io complete Schedlules K-2 and K-3. Sae tho
Parlnarsbip lr$lruclions for $chcdules K 2 ard K-3 iFonn 106ii).
Purpose of Form
An iflrjivitlual or eltily {Forrn !V-9 rcqueslcr) who is rcquirod to lilc arl
lnforrnation rst.rrn w,th the lfls is giving yot; this torrn because lhay
3s Olrg,k lhe Hl)Drrpriale rox tr ferlerii lax {:iasSrfjcilon ol Ihe e'rLlyllnll !(ilal el()is nalrre ig 9rler{l orI l:ile L fjhe(:i(
orrly ono oi tl'D fo,lolvi,rg sovoa box{i.
fl ,ndilirlilnl'/.nin Frnnrietor ! n norF,nrion ! S rnrpn.nt;np f] sadnrrchin f] Trltt/f stahl
[ [LC. Enkri ihc tax llassilicalion lC '. C ft)rF:orrllorr, S ' S.orF)r.rlkt]' P = Ptrr1!)crshrl!]
Note; Ct'stk tre "l,l,i)" box above a,rrj, ir lhe eillry spdce, errler ll€ al4rropriale.jorle (O, :i, or lJ) {d lle lRx
r:laesiijclti.rr i)r lh{, I i.C, u'losa it is a .liBre-{raej({l orlily. A disf.,gnrdfll rr[!1y rl'ouid insload cirsk !ilo dopft4tialo
box {or il,o iu claSsilication of iic orvDe,.
n Other{sc.o i.strk:tiorrs)
3b rf on litla 3a you chscted "t'anf,crsh;p' or ' l,let/oslate, o. ilccksd "LLC" rild ettcred "P' as ils tax cias$iircation.
atnd yau.lre provrdirg llag lora lo a par1ne.shrp, laust, or 9sl;rle rn wiich you hale an o\'J.iefgrip interesi, check
Itr,s lxrx rl /(,., liilv{ ilr'y tleigrr l:arl lafi, r)v lPrs, rY iic' el'( l{r'es :;Fe rr.lr',r::rnrs n
5 Addreis lnrlrrber, elreet, aad irpt. ot srrie no.J. See i.slndions.
6 City, state. ind Z:P codo
number
Part I
numbet
Part ll
(lil.
^k].
ItJ23iX
Kittitas County Agreement for Services (rev.5/M/25l'
Page L4 of 22
Forrr W-9 {ncv : aoz.l}
Fm t&9{Fee.3-2€t4l Pase2
nr{rsl*tain your conpct taxpayer identification number (IXN}, rvhich
may be ysLtr social E€curity number iSStl). irxfuidual taxpayer
irJe$fificalioo mcnber {FllN}" adoption taxpayer identificatlcn number
[AT1$, or emploler idenlificalion mnt€r FIN], to report on afl
infonrsticn refurn ths amount paid to yonr, or oltrer arnount reportable
o{l irn *rfumatiofi aeturn- Exarnpfes of infonnalion retrrns brc}de. but
are r:ol limited to. &e fdlowing,
. Fom i0gg$lT lhterest earned o; paidl.
r Fsrmr trogs$lV {diuid€nds, including those from stocks or rnutud
frudsl-
. Fsm i099-[tdl5C {varicus types of incams. prizes. att ards, or grqss
prBceedsl-
r Fcnn 10€9-NEG {nonernployee comp€{tsation}.
o Furn tr0€9€ {staclc s rnutual firnd sales ard certain other
transactiar* by brokersl.
r flqrn tr0!19€ (txocceds hom rrd 6trtGtrnsactimsl.
c Fonn 109$X {rnerchant card and third-party nelwo* Fansaclions}.
r Fsrn tffla {horne rnortgage inleres{. -109s-E {sfudent loan intelestf
ard 1098-T$nr6'l].
. Fsrn 1O99{ {canceled debtl-
o Farm tolEl-A {acquisitron or abandonment ol secured property}.
t}se Form l/V-9 only ifyou are a U,S. person fncluding a resident
aFenl, to p{ovde your conect TlN.
Garnioru lf 1"oU don't retum Fom W-9 ta the tequester wirh a TlN, pu
rnight be sutisr:t to backup withholding. See Whatts bac&up
rtrrtffioldirgr, later.
By signing lhe filled-orrt forrq you:
I. Certifu tral lh€ TIN you are giving b correct {or you are waiting for a
number to be iss:edh
?. Gertity illaf yo{j arB not subiect to backup wilhholding; or
3. #airn exernplbn from backup withholding il you are a U.S" exempt
payeq and
4. Certiry b yaur flon-foreign status for prposes of lvirhholding nmder
shapter 3 or 4 sf tfie Co,6 $f appficable); and
5. kjfri diar FATGA cod{s} enlered on ftis fenn (if arry} irdicating
tfut 1ou are exempt {lam lhe FATCA reporting rs c-crrect- See W}tat ls
FAIC,4 Eqportidg. later. for further informatian.
Note: ff you are a U.S" penon and a requesler gives you a iorm other
lhan furm tlr-9 ro request yourTlN, you must use the requeetefs {orrn if
it is subelantially similar to lhie Fotrn W-9,
Definitbn of a U.S. person. For federal tax purposes, you are
considered a U,S. petson if you are:
. ful lndi'riidud r.rho is a U.S. cilizer or U.S. resident allefi
. A pd'tnersftip, cotporalion, cotrlpany" or association creat€d ar
organizecl in the Uniled States or under the laws of the United States;
. ,fin €state {other lhan a foreigrr eslale}; or
o A donrrestic lnrst {as defined in Regulations sectian 3O1-Iru1-4.
Esrabtshing U.S. stalus lor purposes of chapter 3 and chapter {
witl*roldng. Payments rnade to foreign persong induding certain
distibofions. dloealions cf incornq ortransfers ol sales proceeds, rnay
be striect to silkrholdng under chapter 3 or chapter 4 ol the Code
{ireclions 1.{41-14?4}. Under t}lcse njles" il a Fonn W-9 or oiher
cerlification of non-foreign siah-rs has not been received" a withholdng
agent" aareferee. or partnership {payor} generally applies presttmption
rules tlnat r.nalr require the payor to '.dthhold apflicable tax ftorn &e
resaplsnt osrn€r. trarelero.r, or padner {pay€€i. See Pub. 515,
ltlil!fioldr:ng ol Tax on Nonresident Aiens and Foreign Entities.
The tdilowing persons must provide Form W€ lo the payor fur
prrposes of estab&stung its non-foreign status.
o ln the case of a disregarded gnlity with a U"S. ot'mer, the U.S. awner
of ltre disragarded entity and nat the dlsregsrded enlity'
' ln the cqse of a granlor tru€t wi{h a U-S. grantor or olher U-S. ovnrer,
generd$, iltre U"S- grantor or olher U.S. otmer oI the granlor trust dld
rnot the grantortrusL
o ln tle case of a U.S. trust {other tfnn a grantor trustl. fhe U.S. trust
ard not the beneficiari€€ of the bu8l.
See ft.db" 5-[5 tor more information on providing a Forrn lT-g or a
certificalim of non-^fBreign slabs to avoid 'Irithholding.
Kittitas County Agreement for Services (rev. 5/7a/251
Page L5 of 22
Foreign person, ll you are a breign person or the U.S. branch o{ a
fore6n Airnt< that has dected !o be, keated as a U.S. person {under
@rIaliorn *eotiur 1"1aa1-1p){![iv] or olher appficaHe seclian fo;
ctlapts 3 or 4 trryoGcsl. do rlo! us Form W-9, lnstead. trge tlp
apprnpiate Forrn til-8 or Fofin Hig {see Pub,. 515}. ll }tou sre a
q{jaf{i€d formbrr Frr€iorntund rnder BeguHions section 1"897fl}tr{d}, or
a perlnership ihalis t'rftdlyowned byqualified forelgn pension furds.
lhat is teded as a non-Iwe*gn person lor purposes of section 1445
sithholdng" & rrof use Fcnn $f-9. lnstead, use Form W-8E(P {or other
carlificatiofi of noif}@fi stausi.
ilcnresidert aften rho b€Gomes s resident alien. G€neratly. or{y a
nonrcsidqnta*en iindr*fual nrEt use th€ terrs ol a tax lrreaty tro tedu{e
or eliminate U.S" ts6( ur certain typ ol inoome" Howeler, frrost tax
fealiee contair: a pra'risim ltre'..rn as a saving clause. Exceptiors
spcified in lle sanirg cb.rse rnay permll an exetnplion frorn bx lo
cbntirnre fior cerbin types o{ ircome euen afbr the peyee has otf}ert ds€
becorne a Lj.S. resident dien for tsx puryce.
lf yor.r are a U"S" nesider:t dbn nhe is relying on an exceplirn
eantained ln tle sariig dause ot a tax rea$ to claim an exemplion
Jrorn U.S- tax on certain tiipee ol income, you musl attaci a stal€ment
io Fonn !V-9 that specifies the {ollouing fve items.
.!
" The treaty carrrty" Generally, this must be lhe same b€ty under
wtrirlr you cbimed exenrplion from tax as a nonresidcnt aliefi.
2" The beaty a;tide addressing the income.
3. The arMe ffirnbs {or localion} in the tax treaty that cootains the
eaving clause and Rs exceptims.
4" The typ,e and amount of income that qualifim lor the exemption
{rom ta,L
5- Sulficient facts ts i$tfy lhe exemption lrom tax under lhe terms of
the trealy ariicle,
Erample. i{rtisle 20 of the U.S.-China income tax treaty allolvs an
exernptidn {rom bax lor s€fro}archip income received by a Chinese
student lstsoftrily pre€€nil in the United States. Under U.S. latir, lhls
siudent wil! b€c€el* a rcsident alis for iax purposes if lheir stay in lhe
Ur*ted Siaies exoeeds 5 calerdar years. Horruever, paragraph 2 of tfte
firsl Rrstocol t6 tfre U-S.-6hina lreaty fdated April $0, '1984) a[ows the
provisbns of.Arlielb E0 to conlinue to app$ even after the Chinese
studert h€dm€s a rcsident alien ol the United States. A Chinese
student w*ro qralifie fior. this exception {under pangraph 2 of lhe firs!
Proloco{ ard is rdyirq on this exceplion to claim an exernplion from lax
on their io*r*brslrif 'rirunw*rip iniorne wolld attach to Form ltf-9 a
slatenrent that incl'udm the inlornatbn descdbed above to support lhat
exernpliron.
lf you are a nonreside':t alen or a forei;n entity, giue the requester tfte
app*apriate oorSted Form W-a or Fofin 4233,
Backup Withholding
What is hackrp wilfthnl&rg? Petsons making cerlain paymeflts to yoll
rnust unds certd*r condtlions wriltSpld and pay to the IRS 2496 of such
paym,mts. This ib caled -bas'ltup
'.'iithho$ding." Payrnents that msy be
3r-&)isct to ha6*qp wi$rlmlding inc,lude, hrt are not limited to, intercst,
lax-exempt irqtere€L dicideirrds, boker and barter exchange
trarsactidns, renrts, rqpalties, nonernphyee pay. payrnents made in
setilernent ol paynrent card and lhir&party netvcrk lransaclions, and
eertain paynnsrG kom fistring boat aperators, Real eslate lransactions
are flot $Jbie€t to backup ltuiilhholding.
Yqr uiI nrt be sr$ecli to badkUp withhalding on Pailrxxlts you recelve
i{ you gi're lhe reqre$el yoon coned Tll'1, nuke lhe proper r:ertifications,
and report dl yo:r tar.ahb interest arrd diuidends on yor.lr tax retutn.
Paym€nls you receiw will be subject lo backup withholding if:
-!
- Y6u do not furnislh yots TIN to lhe requeste4
2" You do rrot cedi{y luurTlN '.yhen requhed {sbe the inslnrclians lor
Fan lilforde{ailslq
3' fhe IRS tefls the .equest€{ that you fumished an inconect TIN:
4" The IRS te[s pu t]rat yo.r are subiect to backup wilhholdtng
because you did not .Bport all F!*rr interest and dividends on your lax
rcturn ffor reportable i'r,rlerest and dividends only|; or
5' YolJ do rnt c€{riftr' lo t}le requesler tfiat yorl are not sublecl to
backup '.'ritfrrMdngl as deccribed fn kern 4 under "fly signtng lfte /?fed-
outfwnr" alnove fior rryrtaHe inleresl and dividend accounts opened
aller1983 on|yl'-
Fm lqt-S {Fev.3-20?4)P-ssF3
Certain payees and payments are exemp! frorn baclap lvitlithdiding,
See Eremptpayee code, laler, ard the separate lnstuctions for the
Requesler of Form W-9 for more infannalicn.
See also Fstat/islrling U"S. status forpurpoces afcftapterg and
cfiqpler 4 witfrhddi4g, earlier.
What ls FATGA Reporting?
The Foreign Accornl Tax Compliance Acl {FATCA} teqdres a
participating foreign fnancial institution lo report dil U.S. affount
trolders that are speolfied U.S" persons. Cerlain payee* ae eramFt frmr
FATGA. reporting. See F,ternpfion frorn FAICA repordfig code, later. and
the lnsructiafls fior the Requesler of Form W-9 for more informalionr
Updating Your lnformation
You n:usl provide updated infiormation to any pe*i{rn t{}whom you
clairned to be an exempt payee if you sre no lonq€r an erempt pa|lee
and anticipale receiving ruportable payments in tie futxe foorn ttds
person. For example, ybu may need lo provide updated information ifi
you are a C corporation thal elecls to be an S corporalion" or ff you are
no :onger lax €xempl ln addition, you musl fumish a nevi Form W-9 if
lhs name orTlN changes for the accornt, for exanph. if lJhe gmntor of a
gnntor lrust dies.
Penalties
Failure to fumish TlN. lf you iailtc fumish yourcor€ctTlN to a
r€quesler, you are subject lo a penalty ol $5{} lor each ssrch fui}ure
unless ycur lailure is due to reasonable cause and nol to willft-d neglect"
Givil penalty for fulse information with respect to withholding. Ilf yottr
make a fulse statemenl rvith nc reasonable basis *rat resllts in no
backup withholding, 1lou are subject to a $500 pendty,
Criminal penafty for lalsifying inlormalion. Wiltfully laHlying
certifications or affinnations may subjecl you to criminal penaities
including fi nes and/or imprisonment
Misuse of TlNs. lf the requester discloses or uses TtNs itr lriolation of
lederal law. the requ€ste. may be subiecl to ciuil and crimirnd penal{ies.
Specilic lnstructions
Line 1
You musl enler one of the following on this line; do not leave ltris line
blank" The name sftould match the name on your tax reftjnr"
lf lhis Farm W-9 is for a joint account {olhe: than an account
maintained by a foreign financial inslihrtion {FFt}}, list frrsl. and &en
circle, the name af the person or entity whose rnumfueryour enlwed in
Part I of Form W-9. lf you are providing Forrn W-9 to an FFI tD document
a loint accounl each holder of the acc-ount lhat is a U-S. person mud
pruvide a Farm W-9.
. lndividual. Generally, enter the name shown on yaw tax rsftJl'n- [f ytHrl
have changed lour last name witftout infonning ttte Sochl Securitty
Adminislration {SSA) ol the name change, enter your first name" lfrte lmt
name as shown on lour social security card, ard your ne*l last natne-
Note lar lTlN applicant Enter ycur indiuidual name as it wa€ eritered
on your Form W-7 applbation, line 1a. This sho.uld also be lhe same a:
lhe name 1ou entered on tft* Form 1040 you filed witfrt yuur ap$icatiorn"
' Sole proprietor, Enler your individuaf name as atlstln on yaur furrn
184-S on line 1, Enter your business, trade, cr "dbing business as" [lEAi
name on line 2.
r Partrrership, c corporfrtion, S corporalion. or LLG. ollpr than a
disregarded entity, Enter the enlity's name as shot'*n on lhe €ntit!'s tax
retum on line 1 and any business, trade ar DBA name orn line 2.
. Olher entities. Enler your narne as shown on required U"$" ledhral tax
docurnenls on line 1. This name shauld match the narne shown sn tha
charter cr olher legal documenl creating the entity- Enter any busiress..
trade, or DBA name on line 2.
. Disregarded entity. ln general, a bssiness entity lhat has a singfe
owner, including an LLC, and is not a corporation. is dsregprded m an
entity separate from its ownar [a disregarded entity]. See Reguhiors
s€ction 3O1 .7701 -2{c}{2f. A disregarded entity should chec* lhe
appropriate box for lhe lax classification ol its ownet,. Enter the owner's
name on line 1, The name of the owner entered on llne 1 should newr
be a disregarded entity. The name on line 1 should be tie narne slmwn
on lhe income tax retum on rrhich lhe lncorne should be reported. Fo*
Kittitas County Agreement for Services (rev. 5/74/251
Page tG of 22
erande, if a foreim LLC that is trealed as a disreEarded eniitl for U.S.
tederat tar purposes has a sirqle owna tlnt is a t-i.S. persorq Oe U.S.
o'.'r:er's nane is required ro be provided on lirp 1. ]f tlre direr-t ounet of
ttre, enlity b abo a drsregarded entty. enterlhe first o'wris tlat b nct
dwegaded lor fuderal tax ptlrpos€s. Enter lhe dsregaded enti!/s
nsne onr llne ?. lf the owner olthe dsregaded entity is a furdgrn pmoq
th* o.rnat nrust completq an 3pp!'opdiate Form lS-8 irnted of a Form
It-9, This is the cae euen if the loreign person has a U.S- Tlil"
Une 2
lf gou have a businss name. lrade natne. EBrl narTe. ct' discgnrded
el:tit!'nam€, enter it on line 2"
Line 3a
Ctmlt $e apprcpriate box on line 3a for the U.5" lederal ta:t
d*afibatkn of the person rvhoe natn€ b e{rtersd on line' 1" Cfiree*t ady
one box on $ine 3a
Une 3b
Chec* this box if you are a partnershir [iincfutfng an LLC chssified as a
parBrerslrip for U.S, fuderal tax pu.pm€s!" trust* or estate lhat has ilty
lorcign padn€rs. owners. orbeneficiqies, and you are ptoui&lg $tis
{own t6 a partnership, trusE 6r eslala in which yolt have an ownerstrip
iffierEst- You rnust ctreck lhe hox on h.re 3b r you receive a Fotm tfd-g
{or dscumentary evidencel fronr any partner, owner" or benefiikry
eetablistring loreigF stalus or if you reeeiue a Fonn W-9 frarn any
parber, swner, or benefciary that has chscked the b,ox on iine 3b.
Note: A partnership ltrat p,rouides a Fonn 1S-9 and chechs box sh may
be e4nred ro conplete $cheddw K-2 and K€ lForm 10651.. FDr mo{e
ilnforrmatipn, see lhe Paflnership lnstructirns fon Schedies K-Z and K-i
{Form 1065i.
lf you are required tc comSele lin* 3b but {ait to do so, ysil rTEy tlot
neceirre the info*rrration reeessaty lo frle a cqnect infonnation rehtrn wifi
the lFtS or furnish a c(Nreci payee statefi€rit to lqur p.arblers or
herneficiaris, $ee. fr exarn$g s€ctions 669s" 6122' and 6?24 for
penafties fhd rnay apply.
Une 4 Exemplions
ff you a.e exempt frorn backup wilhhrrldng and.for FATCA rryrling,
eri|er in tlre appiopriate spuc+ un lire .t arry cctiu{s} llrat rluy a1tFly tu
$€u..
Exenpt peyee code.
. Gensally. indir,ridtrais {incfuding sole proprietors} are not ex€mpt frtrifln
hockrry '.'ritlfiddng.. b(c€pt as prqvidhd betow, corporalioris are exernpt ftom baclaup
u*irthhoHing for cerrtain payrnents, includt€ intetest and dntitdends-
r Corporations are not exempt lrum backup *itt'thotdrq fur Faltn€nts
nnade ira setdement ol payment card or ttfrd-party netuedk trmsaclirns.
. Corporations ale nst exempt lrorn backup wittthotdng rrith respect to
attomeys'fees or gross proceeds paid to attoffre}ts, and corpqratims
tlrat provide rrnedcal or heallh care ser*bes are not exempt with tsPect
lo, payments reporiahte on Forrn !fit9{lIl5C.
Tlne followling codes idenli$ payees tlut ane exernpl from, backup
wiillirholding. Enterthe appropriate code in tlr+ space on linrc 4.
tr -An organization exempt from tax arnder seetion 5oltal, arry lRA. ot'
a cqstodial $count under secticn 403{Wxl i{ t}F actounl satisfies tfre
nequirennenls of section a.01 fil{zi.
lF l}re entityAnditddual on line I
isa(n|...
TIIEN check the box lor
o Corporatton Corporation-
* lndlvilusl o.
. Sole proprietorship
tndviruelf*ofe Foprietor"
. LLC clmsilied as apartnerdfp
fo. t r.S, iederai tax purposes or
. LLC lhathas filed Form8832 or
2553 d€cting ro be taxed as a
conporation
Limked fiabitily conpany and
eriter rte +propdate rEX
dassifrcation:
P = Parbership,
C=GcorFomliofl.otr
S = S corpcration.
. Partnemltp Partrteship,
Trlrsl'estate Trusbrestate,
Ftrm W-s {Rev.3-:024)Psoe4
Z-The United Stales or any oF its agencies or insbum€nlaflies"
3-A state, the Disldct of Gohrmbia, a U-S. comunorw€dth or tenrtory,
or any ollhdr polilical suMiiisions o. insbwnentalili€s.
4-A loreign govemmefit or any cf ils poltbsl sr&ditieions. agpncbq
or instrumentaliti€s.
5-A corpration.
6-A dealer in securities or comrnodiGm re<$rired ts rregieter in the
Unitsd Srates, lhe Dislrict sl Goh.mbia qr a tr-& csmtncrueeallh sr
tenitory-
7-A {utures cornmission merd\ant regislered wirh fte Commodity
Futures Trading Commission.
8-A real estate investment bllst"
9-An entity registered at all tirnes *rirq the tax year under lhe
[nvestment Company Act ol l9tl0-
1n-A mmnxln ft.lrt furrj ope{atfd hy a bank urdirr re,ction 5e,l{e}.
1 1 -A financial instiMion as defined under s€€tion 581.
'12-A middleman known in lhe investment co,nmudty as a nominee er
custodian,
1 3 - A lrust exempt from tax under sectrm S64 qr d€€cdbed in section
4947.
The lolbwing cha* shorvs types of paymenls that may be exempt
fiom backup withholding. The chart applies to the exernpt payees listed
above, I 13.
lF ihe payment is for THEN the paymenl is exampt
lor.-,
. lnlerest and dividend payments All exerflpt payees excepl
tor I-
. Brokerlransactions pa.yees I throtrgh 4 and 6
'l 1 ard all C cotpcralions.through
F-A dealer in seouriiies. comnrodities, or dleii{aftte fi$ffqial
irlslrumsrts firdudng nofional pninci$ 6o&ll1aob, futures, fo"wards'
and cptixn) rhat is registered as sudl umder t}€ h^'{s of tlhs thitd
States 0r any slsie.
G*A rd ectate investrnent bust
H-A regulated irwestment somparhy N #fined in smtion s51 or an
entity regbtered at atltimes &riq Sre tax $eal under fte lr*esBn€{lt
Company Act ol 19.ltl.
l-A c.o{runon bust fund as defirsed in sectian 5${{ql.
J-A bank c de$ned in sectim $81.
K-Abmker.
L-A *ust exempl Jrorn tax q.:nder ection 664 o.r desryibed in secfion
4e47{al{l1.
M-A hx-exempt kust under a s€cdcn aog{bif @t or s€cext 4-5f{gf
phn.
l{ote: You may wish to @nsult wiih llre filnancial hsldution rerpesting
this form to delermine whelher the FATC,A code and'ror exernpt payee
code should be ccmfleted.
Line 5
Enter youn oddress {nu.nber. sb€et and apartrnrent 6r suite nurnhe{"
This is where lhe requesler ol t}is Form [{-s slin m,ai! }qur infunnation
relums. tf this address dlfe|s korn the qfie the reques{er alleady has on
{ile, ent€r "NEW" at the top. lf a new address b pru'riided" rhere is s$l a
charne the old address'#ill be wed und lhe paEor **ang* yow
address ln lheir remrds..
Line 6
Enter your dty, state. and ZIP code.
Part l. Taxpayer ldentification Number fflN!
Enter your TIN in lhe appropriate bor lt you are a reaident dien and
you do not haue" and are nol eligiHle to get" an 5S8'1, ytrn IliN b your
iBS mN. Enter it in lhe entry space for lhe $midl secudt!. nunb€r. l{ !to'u
do nol haue an lTlN, see Fble t@ gpi a IllV bdatat-
lf you are a sole prnprietor and 1nr hatre an ElN. 3ou rnay efiiler eitfi€r
your SSN or ElN.
lf you are a sirgl+'rnember LLC that is disregprded m ff entltf
separale fiom its orvner, enter ttre o'.'rnefs SSN {or Ellt{, if lfte or.'nrer liras
one1. lt ttre LLC b classified as a orporation or. partrrerstlip. etlterlle
entitt's ElN.
Note: See WratAlanre arfrd Munrber Io &re tfte ,Fsguesfat. lanEr. for
{urthen clarification ol name and r}t'l aan*iilglftre.
llow to g€t fi TlN, !f you do not hare a TlN. @y for ole ifilrne{fiately-
To app$ lon an SSN, get Fo{rn SS-5. Ap$iration {or a Socid $ecudty
Card. fronr your local SSA office or get fib forrn online at
www.SsA.gor. You nny also g*t thislorrnr by cajling HXFTiE-'r213. Use
Form W-7, Application fror lFtS InduiiChd lia4pa,yer lldhnniftcatirn
Number, to dpp$ Ior an [TlN. or Fofln SS-4, Apdicathn 6nr Ernflbyer
ldefllifisalion Number, lo apply frnr an Ellt{, You tan apply for *t EIR
onllne by acc++sing *re IRS v{€heit* at w*ur irs.gotJFlV. Go to
wl*w,irc.govJForrns to view, downfoad, or gnint Fonn W-T aodiorFotm
S$-4^ &, yuu cut go to mruw.*s.gttn/Ort/erFexlr** [u gilaetr arn q:*der alld
have Form W-T antl,'or Forrn S$rt nnailledito yoEI'sithin l5 hlidroffi
days.
ff }.ou are asked to oomplete Form W€ but do not hate a Tll{, apply
{or a TIN and ente,r 'iApplied Fori" in tlle space for ttre TIN sig;n and date
the fiorm, and give it to the t€quester. For interst ard dtirlend
paynt€nts, and certain paymerts rnrade'^tittr respect to rcadily tradabb
ins$urfients, yoo wi$ generafly haue S ctra3s ta get a Tltl rtd gire it lo
lhe requester before yotr are suk{ect to limcla4p'.'dtldml*tg on
payrnehts" The 6o-day trJe does not apdy to othel tfpes of palm€nts.
You wif! be sut{ect to backup wiErhddng
'{n
al{1 s-uclrr poXrnanb unlil
you prolide your TIN to tt€ requester"
Note: Entering "AFplied For" mears that pu hale already appfied lor a
TIN or lhat yo: intend to apply for one so€{t. See dbo EstabAsifftg l"l'S.
status rbrp0rposes of clqpier'r and cfqprer.l hfr&hoftftgL €tl[er" for
when you may ir*stead be sLfuiect to '.drlfuldlnE rrn&r clepter 3 or 'l sf
lhe Code.
Caution: A disregiarded U.S. €fllity thst lnas a fortign olarmr rnust urse
lhe aFpropriale Form 1ff-8.
lo 2012.
. Barter transaclbns Exempt payees 1 ds-ouEh 4.
and
r Payments over $600 requiredto
be reported and direct sale€ over
$s,ooo'
. Payments made in settlement af
payrnent card or third-partlt
neh'rork lransactions
r See Form 10gs-MlSC, Miseellaneaus lnfonnatbn, and ib insUvctions.
2 However, the lollowing paymenls made 1o a corporatron and
reporlable on Form 1099-Ml5C are not exempt ffrum, bdoup
rvithholding: medical and he,alth care pa.ymeniq, attotnsils fe€s" gross
praceeds pdd tc an attorney reportable und€r serclian fiO45{fl, and
paymenls for services paid by a federal executive agency.
Exemption {rom FATCA reporring code. Ttre fdlsning codeo idenlily
payeeC *rat are exempl frorn reporlirg urnder FATGA Ttrirese codes
apply to persons submitti.ng this {orm lor e,co{trts maintained outside
of the Uniied States by csrtain {oretgn financid instihrtions. Therefore, if
you are only submittin'g this fonn foi an accotmt l,tru hold in the United
Statee, you may le,ave this lield bfank. Corcult tnitft the person
requesting this {orm if you are uncertain il lhe financial inslitution is
su$ect to lhese requiremer{s- A requ€€ter may indcale lhat a code iis
nol required by providing ycu wilh a Fom lff-$ r'rith ''i'lot Appticable".{on
any siririlar indication) en-ttired on ltre line {or a FATCA exernption code.
A-An crganization exelnpt from lax und€r seclisrT 5olial or any
individua! retirement plan as deftned in seotion ?Tolia|Sr].
B-The United States or any of its agenoies or insuurnentalilies.
C-A state, the Dsirict of Golumbia. a U"S. cornmrmwealth or
tenilory, or any rf their political subdvisions sr instrrunnentalities.
D-A corporation lhe stock of tdl;ch rs regillarly lraded on one or
more estat'lished securities markels, as described ir: Regulatibns
section 1. 1 47?-1 (c)fi [i).
E-A corporalion that is a rnernb€r of lhe same expanded alfiliated
group as a corpcration desctbed in Hegutatiions section 1-1412-1{cl{l[l}.
Kittitas County Agreement for Services (rev.5/M/25)
PageLT of22
S corporations must nol ent€r an
exempt patEe code because they
are exempt only {or sales of
noncovered secudt[es acquired
Genemllly. exempt payees
1 ttrruugh 5'?
Exempt p,aye+s 1 thrcugh 4.
Fm W-9 {HEv. }2024}trase5
Part ll. Gertification
To eetablibh to lhe *ilhholdirq qent that you are a U.S. person. on
rEid€fil ali€ri. sign Fonn lT-9. You may be requested to s(]n by the
ruirhho&ding agent evsn if i{ern 1. 4, or 5 below indcates olhenuise.
For a loint aocorrrt" ar$ llire percon rrrhose TIN is shown in Pari {
shouH sign {rruhen reqd{redl- kr tfie oase of a disregarded enlity, tte
person identifted on line I nrxrsl sign. €xempt payees, see Exeoptpdl€e
code. ear*ier-
Signature requitements, Complete the serlilicalion as Irdioated in
iterns I tftrough 5 belor.n
l. lnterest" dividend, and barter erchange accounts opened
before 1984 and broker accorrrls considered aclive during 1983-
Yotr must gire your cerrect Ttrf.l" btrt you do not have io sign the
certification.
2" lnlerest dividen4 hroker, and barler exchange accounls
opsred afier 1983 and broker acounts considered inactive duritrg
108:1. You must sign tfre certifcalion or backup wittholding will apply. lf
you ar€ sutiect to backup withholding and you are mere$ providing
your conecl TIN lo the rcrlr€st€r. yau most cross out ite*n 2 in the
certification belore signing the {orm.
3. Real estate trursacticns. You must sign the cerlificalicn. You may
crws out ilem 2 ol *re cerlificsliron"
4. Other paltrvnnts. You must give your conect TlN, but you do no1
have to sign l}:e cert'fication unless you have been notified lhat you
ha're pranbusly gir.ren an inccrrect TlN" 'Other payments" include
paymenle made in the course ol the requ€sl€r's trade or businees for
renb, rcyalties, gocds (otherlhan blls for merchandise), medical and
heafth care seFriees flncluding payrnents to oorporalisns], paynenls to
a mnerndoyee lor services, pqyrnents rnade in setdement of payment
card and thiitt partry netttlork tmnsactiofls. psyments to certain fishing
boat crea!, members and fishennen, and gross proceeds paid lo
attomeys {inchrding payrnents lo so{porstions}"
5. Mortgage intered paid by you, acquisilion or abandonment of
secured prop€rty, cancellation of debt qualilied tuition program
paymenG (uhdd s€clion 5291, ABLE accounts {under section 529A1,
IRA Coverde0 ESA Arclrer M$A or HSA contributions or
distribulions, and pension distrihulions. You must give your conecl
TlN, but you do rct have tc sigrr the cerlilicatiion"
What Name and Number To Give the Bequester
For lhis of account:Give name md SSN of:
t-The indiuidwl
The actual ow of the rcrwnt d,
il mmbined funds, the ficl indvidwt
on tln armuntl
Each twlder of the mcmt
Tle minors
Thc gretorlffiles:
The actual owrerl
The rvmqi
The grilttr'
Kittitas County Agreement for Services (rev.5/7a/25)
Page 18 of 22
For lhis 6tsccoilnt
8- Oi$eqflrff e{*ilrmtswEd h'}'ff
indieiSEt
S. A sali{ tlEl nsbta, w perntirm bud
lS. CsFomtm d LLC dtdirq cqpsole
etatjs ff Ftm S8flE tr Fm gsf,iJ
t l " Asscistiro" d$. c{briNrs. dnrlh!{e,
edrmtbnd, qqda til€mpt
orq&n{atfoo
12- Prybmftip s mutirun*er tIG
13- A hokw w registered lmiim
1,1- Acsu{ silh lheDepstnemtol
Agri$hnehtheffio*apuUb
miity {sudr u l stde or locd
g$rsm*t, scfml dbhid" {}r p{iwl
that mtim nqrlaltilfil prqgrffi
paylHb
15- tr anto{tnFtfihg Fm !0d1 s
mdenfreOplimat fllirq ltfeilad 2.
€qrid.E Fm 1offl {w meeddirc
setion 1.671-4$lt2{il@1)-
GiYenane and EIN ot
T[em
teErt trtitti
Tlire sspsatim
Ttre oquimlion
llieprtwdrp
f{reM*nmire
lXEtruHilFtiV
?- Two tr mG indiuiJuah lioia* mcwnu
other tfsn m mwl mhtairsd by
on FFI
3- Tm rmre t.!.$- perems
{ioirt amt mojntaired by m FFq
4" Custodial acMt E{ s miiw
{ljnibm Gift ta ldhmArrl
5- a. The usrd msable wgirgs bust
{grv!D( is al$ buste€l
b-Se€Jd twtffifltiltt is rot
a legal m valid twt wds stat€ tnr
6. Sah proprietuslip o disregrded
antirywmd byuhdrffiud
7. GnntqtGt fil[ng wder &ti6ru]
Filhg M,ethod 1 tsgt Fsgdalisn*
wthc i.sil -.u!,1{2.fii1fr{ig-
Th€ klst
1 List lirst and cirde the rmrfie sf lfte person vr'he nrmber you fumi*t.
lf only one person on a itoint a€Eaurit lnas an SSN. that percon's number
mu:i befurnisfied
:Glrcle tfre mina*'s name and frlri$l tlhe nnisrols SSN,
rYou must shoqr vour irdividrd nrne on line 1. and ent€r vour business
or DBA neme" $f ahy, on line 2. Yor.t may use eitkrer yo{r SSN o( EIN (if
you have one), but the lffi encouaqns Xuu to use lnur S'SN.
I Lilt fint arid aircle the nsme of llne lrus, eEEte. or pension rnrst- po
not fumish the TIN of ttn petsond rqnesenhlive or tustee unl€ss tfie
legal enfity lfself is not deeigrmted irn tihe amunt fdle.)
'Nole: The gnantor must alsa prouiCb a Fanm W-9 to the Uustee oflhe
trust
* For nnre infonmatitn on odiofial fifing me{hrds tor grantor busts, se€
the lnslructiors fo,r FoFm 10i4tr"
l{ote: lf no rsne ib circied wtrm nrq,"e iftan cne nsrn€ is lbted, th+
number '.uill he considered Eo he thot of lltre f r,st norne listed.
Secure Your Tax Records From ldentity Theft
ldeotitv thelt oc€urs'.'rt€n sofir€o.r€ uses your penional infonnation'
such e& your nanre, SSF{, or o$let idbntifying infonnatirn, '.'riilr€ut your
permbsbn lo comnit {rarld sr otlref crilne t\n idenlity thiel may use
your SSN to get a job or may i lie a tax return usitq your. SSN to receiw
a refund"
To rcduceluurdsk
. Protecl !*our S,$N"
. EflsurE yolir emloyer b pmrmthg 1@'t r SSN, and
. Be caretul wh€n ctlo€irq a tax retrtn tr€parcr,
lf lour tar recor& are affected hy idenlity lllreft and yott necei're a
notice ftorn the tRS, respcnd ri$lf auraylo th,e narne and phone nurnber
printed on llle llRS notiae or lelter-
]f your tar re€ords are rEt cunrean$ ffiected by identit'. tlEfi but ltou
lhinli ]rou are al risk due to a lost qn $dbn prrrse or wallet, questionable
snedit card rclisity, or a cpestionalile *reeft report [ofllacl lhe IRS
ldentily Tlrefl Fbfrine at gtttFgtls-{4go on slt{dil Fonn l4O:}9"
For more info*rmtion, s€e Ftib" flI?I. ldlerrtity Theft lnformation for
Taxpayers.
Fm 9{-s iFe{.3-2024}Pqe6
\lictirns ol identity lheft who are experiencing emnomic harm or a
systernlc probtem, br are seeking help in resolving tax probl€ms lhat
teale not been resalved througfi normal chanlreb, may be eligible for
TaxpqrerArfuocate Seruice [AS] assisrance. You can reach TAS by
cd[ing t]re TA,S toll-free case intak€ line at 817-777-4118 orTTYJll-DD
su}-8z$-!t059.
Protect yoursell ltom suspicious €mails or phishing schen*s.
Phishing is lhe sreafion and use ofernail and websites designed to
rrirnic legitimate business emails snd website,s. The most common act
is sendng an email io a userlalsely claiming to be an established
legitimate enteryrise in an attempt to scam the user into sunenderirq
priraate inlormation that qrill be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the
hffi does nol request personal detailed information lhrcugh email or ask
taxpsy€rs for tfte PIN numben, passwords, or similar secret accws
inlonnatirn lor lheir credit card, bank, or other financial accounts,
lf lfslr receive qn unsolicited emeil claiming to be {rom the lFlS,
fon'rard thb messag€ to p"isfting@its.gov. You may also re.port misuse
of tile IFS name, logo, or other lFlS property to the Treasury lnspector
Gereral fiorTax Adminisiration fltGTA) at 800-386-4484. You can
fon'rard suspicious emails lo the Federal Trade Commission at
rym6uce.gou or report them al www.flc.gov/complarnL Yotl can
cqntact lhe FTC at www.ftc.gavlidtheft or 877-IDTHEFT {87?-438-4:x}8}.
lf yonr haue been the uicrim ol identity theft, see wwuldenfitylbeft"got'
ard Pub. 5027"
Go to rvlvw.{.s.grovlldentityTheft lo lgam more abcul identity tleft and
howr to reduce !rcur risk,
Kittitas County Agreement for Services (rev.5/14/25l,
Page 19 of 22
Privacy Act Notice
Se€-thn 610S df SE liql€rnal ReiJerue Gode requires yu,u to prov*de your
corrcot Tlll'l le Fssons fnctrtdiing fied'eral agrvrckl wtn are requirsd lo
filb hfu{rEliffx relurm ui{h lhe IRS to ,eport iaiersst. dividends, oe
certain odrer iiqoorne paid to yttl; mo,rtgage i*lerest you paid; the
acguisitio,n orMonnnnt of secwed poperty; tte cancellalion ol
debt s conUfornbns yfiJ {rlde to an llRA. Argh€r IiSA, or l{SA The
psson cnilecting thb lonn use the iniourrration on the furnr to file
infurnn*ion rutrurns with the HR$. repodirq tiie aboe hfornnaticn.
Routihe uses odfis inrfqnndion in6'lude qit irlg ir to.$re @arbnent of
Jrl.etice forciqil *d criminal liligation and to oitis. siales" the t$shictof
CdirLxritfa. aed l.i"S, conunonnedtfp and tenitotis lor we in
adm,ir*sterirng tfi€ir hws The iniormaion rnay ako be disched to olher
cornrilrbs urfr€. a besry. ta fudetd and state agencbs to enlorce ciuil
and rris[*nd la'.'rs. or to federd lalu er:forcernent ard intelligence
qe,neins t* rxrmhat tennrisrn. Yrur mrst p*n lide ynrtr TIN l+trcfh*r nr not
you are neqdred lo fife a tax tettnrr Unds sectioo 34t15. pal/ds must
lvrerafy uiit**old a percentage oltaxat*e interest" diviCends, and
cer-tain other p,agments lo a payee {rtrc does nst gir,,e a TtN to lhe pa}'ar.
Gedainr penaltiee may aho apply for providirrg false orhaudulent
infiorunalicn-
Attachment "F"
DSHS Agreement Number
2663-70974COUNTY PROGRAM AGREEMENT
School-to-Work Direct Service Pilot
Contract
Jlrt
frf,r
Transforming lives
Washinglon State
Department of Social
& Health Services
Administration or Division
Agreement Number
County Agreement Number
This Program Agreement is by and between the State of Washington
Department of Social and Health Services (DSHS) and the County identified
below, and is issued in conjunction with a County and DSHS Agreement On
GeneralTerms and Conditions, which is incorporated by reference
DSHS INDEX NUMBER
1225
IJSHS riUN tRAU I COlJt
8500cc-63
DSI{S DIVISION
Division of Vocational
Rehabilitation
D3H3 ADMINISTRATION
Division of Vocational
Rehabilitation
DSHS CONTACTADDRESS
4565 7th Ave SE
Lacev, WA 98503
DSHS CONTACT NAME AND TITLE
Austin Diaz-Munoz
Contracts Specialist
DSHS CONTACT E-MAIL
Austin. DiazMunoz@dshs.wa.qov
DSHS CONTACT FAX
elick here to enter text.
DSHS CONTACT TELEPHONE
$64\ 200-2812
COUNry ADDRESS
Kittitas County Court House
205 W Fifth St Room 211
Ellensburo. WA 98926
COUNTY NAME
Kiftitas County
COUNTY CONTACT NAME
Kasey Knutson
COUNTY FEDEML EMPLOYER IDENTIFICATION
NUMBER
COUNTY CONTACT E-MAIL
kasev. knutson@co. kittitas.wa. us
COUNW CONTACT FAX
(509) 962-5883
COUNTY CONTACT TELEPHONE
(509) 962-7090
ASSISTANCE LISTING NUMBERSIS THE COUNry A SUBRECIPIENT FOR PURPOSES OF THIS PROGRAM
AGREEMENT?
No
MAXIMUM PROGMM AGREEMENT AMOUNT
Fee For Service
PROGRAM AGREEMENT END DATE
09t30t2027
PROGRAM AGREEMENT START DATE
05t01t2026
EXHIBITS. When the box below is marked with an X, the following Exhibits are attached and are in
County Program Agreement by reference:
I exniOits (specify): Exhibit A - Data Security Requirements Exhibit B - Student Guide Instructions, Exhibit C -
Student Guide, Exhibit D - School-to-Work Student Data, Exhibit E - School-to-Work Billing Checklist
corporated into this
n No Exhibits.
aentire exclusivendandtheofandtermsofconditionststhareContractanTherepresentationntegration
an d oralandallcommunications,thebetween writings,superseding mergrng previous agreementspartiesunderstanding
that readhave andTheContract.belowotherwiseorsuthematterthis represent theyofslgnpartiesngregardingbject
HContractThisbeshallbiDS S ononhandtheavetothisexecuteContract.lythisunderstandndingContract,authority
DSHS.
DATE(S) SIGNEDPRINTED NAME(S) AND TITLE(S)COUNTY SIGNATURE(S)
DATE SIGNEDPRINTED NAME AND TITLEDSHS SIGNATURE
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017)Page 1
Special Terms and Conditions
1. Definitions
a. "Authorization for Purchase (AFP)' means the formal DVR fiscal document that officially identifies
and authorizes a DVR Contractor to deliver a specific service.
b. "CRP' or "Community Rehabilitation Program", means a provider which provides vocational
rehabilitation service to individuals with disabilities to enable those individuals to maximize their
opportunities for em ployment.
c. "Contractor" means Kittitas County.
d. "County" means the political subdivision of the State of Washington, named above, performing
services pursuant to this Program Agreement and includes the County's officers, employees, and
authorized agents.
e. "County Coordinator" means the official developmental disabilities program coordinator or their
designee.
f. "DDCS" means the Developmental Disabilities Community Services, formerly known as the
Developmental Disabilities Administration (DDA)
g. 'DVR" means Department of Social and Health Services, Division of Vocational Rehabilitation.
h. "DVR Counselor(s)" means the Vocational Rehabilitation Counselor(s) assigned to the School-to-
Work Student through the DVR eligibility process.
i. "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.
j. "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 onthe-job performance, with job supports;
(2) Meet the employer's expected level of work productivity; and
(3) Transition to Long-Term Services when stabilization is achieved.
k. "Job Foundation" - The Job Foundation process is intended to engage students earlier in targeted
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employment planning and connection; increase partnerships with school staff to complete student's
Job Foundation report with actionable next steps; and increase the number of students completing
transition programs with a job or secondary education connection.
(1) The Job Foundation report and process may be a source of information for the
Assessment in determining an employment goal for the Student'
l. "Job Placement" means locating, securing, and placing a Student into competitive integrated
employment that is mutually agreed upon by the DVR Counselor, the Contractor, and the Student
or the Student's Team.
m. "Job Stabilization" means the Student, the employer, the DVR Counselor and the Contractor
mutually agree that a Student placed in a Supported Employment position has demonstrated and
maintained satisfactory onthe-job performance and has the quantity and type of long-term
employment supports available to 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 Student obtains employment and exits DVR School-to-Work services.
o. "Monthly Progress Report" means progress reports that are to be filled out on a monthly basis and
shared with the Student's Team to demonstrate progress towards employment and summarize
monthly work being done with and on behalf of the Student.
p. "Assessment" means
(1) 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.
"school-to-Work" means a program that supports a seamless transition for students with
intellectual/developmentaldisabilities from schoolto adulthood through employment services and
connecting students to the necessary resources for success.
"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.
"Student" means an individual with an intellectual/developmental disability age 20 to 22 who is in
their high school transition program.
"student Guide" means a guide designed for a Student and/or parent(s)/guardians to house School-
to-Work related documentation, information, assessments, activity logs, and notes. This guide is a
Student's'roadmap'to ensure key activities and milestones are completed and organized.
"student's Team" means any combination of people, including, but not limited to; educators, CRPs,
the Student's Legal Representative or Guardian, County Staff, DVR Counselor(s) who support a
Student as they move towards Job Placement and Job Stabilization.
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v. "subcontractor" means a Community Rehabilitation Program that the Contractor has separately
chosen to perform all or a portion of the duties and obligations that the Contractor is obligated to
perform pursuant to this Contract.
w. "Youth Extended Services" means ongoing support services and other appropriate services
provided to support a Student with a most significant disability in employment as a means to bridge
employment support between stabilization and longterm 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
needed, to provide disability-related access per the Americans with Disabilities Act (ADA) unless
the cost involved would cause an undue hardship (significant difficulty or expense) for the
Contractor. Determination of what constitutes an undue hardship will be made on a case-by-case
basis, relative to the Contractor's overall resources.
(1) lf an undue hardship does exist, the DVR Schoolto-Worl</Transition Program Manager
or their designated representative may authorize paying for interpreter services and/or
translation services apart from the contracted fee for service.
(2) Provide and be responsible for the cost of providing services through alternative
formats, methods, and languages, as needed, for Students who have Limited English
Proficiency (LEP) as per the Civil Rights Act of 1964.
c. Contractor is responsible for addressing cultural, language, and technological accessibility for all
Students to the best of their abilities when performing the services under this Contract.
d. Eligibility: Students must meet the following criteria:
(1) DDCS-eligible.
(2) DVR-eligible.
(3) Enrolled in a school district educational program that may include, but is not limited to
(a) High school;
(b) Home school;
(c) Technical college, by exception approved by the DVR Transition Program Manager or
desig nated representative;
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(4) Higher Education, by exception approved by the DVR Transition Program Manager or
designated representative. Student starts School-to-Work services as of May 1,2026 or
later, as determined by the Student.
(a) School-to-Work is a wrap-around service that's only available one (1) time per Student.
i. Students who choose to participate in this cohort may not participate again under a
different contract covering a different cohort. Should the Student change their mind on
the cohort they choose to participate in, the Contractor is responsible for communicating
with DVR to ensure there are no duplicate payments.
ii. Should a Student move from one Schoolto-Work County to another, or pause services,
due to individual circumstances, it is determined by the DVR Transition Program
Manager or designated representative, whether Schoolto-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 Schoolto-Work Transition Program Manager or their
designated representative.
(5) Between ages 20-22. Students who have been identified to start services at age 19
may do so with prior written approvalfrom the DVR School-to-Work Transition Program
Manager or designated representative.
(6) Have an lndividualized Education Plan (lEP).
(7) Establish a DVR lndividual 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
and Assessment Phase per section 5, Statement of Work.
e. 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.
f. Contractor must keep all Students enrolled in School-to-Work through the duration of this Contract,
regardless of outcome and/or Stabilization, unless Student chooses to exit the program of their own
volition or due to unforeseeable circumstances.
(1) Should a Student exit early for any reason, Contractor must document the departure in
Exhibit D - School-to-Work Student Data. See Section 6, Deliverables for further
instruction.
g. Service Delivery Agreement: The Contractor's delivery of VR services specified in this agreement
will begin upon the completion and signing of the agreed upon SDOP.
h. Service Delivery Payment: The Contractor will be paid upon completion and submission of the
required documentation demonstrating completion of each of the three phases for each Student as
outlined in Section 5, Statement of Work.
i. Service Delivery Method: This Contract utilizes Exhibit C - Student Guide as a reporting tool and all
associated activities outlined in Section 5, Statement of Work shall be carried out using the Student
Guide. Exhibit B - Student Guide lnstructions offers instruction on how the Contractor may use the
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vi. Potentialjob safety concerns;
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Student Guide.
Statement of Work. The Contractor shall provide a program to provide the services, staff, resources,
and otherwise do all things necessary for, or incidental to the performance of work, as set forth below
Services shall be sorted into the following three phases:
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, and build an individualized roadmap of the Student's transition from
their education to meaningful community employment. This shall be accomplished through the
following objectives:
(1) lntake
(a) At a minimum, the Contractor shall work with the Student, the Student's legal representative
or guardian (unless they are their own), the CRP, and the DVR Counselor to:
i. Complete intake forms as needed, including the SDOP.
ii. Outline how assessment will occur, including additional meeting time.
(b) The employment goal is established and documented.
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
strengths, skills, and supports needed for success on the job. This information will be based
on the Student's school, home, and community work-related activities, interviews with the
Student, family, school personnel, and others who are familiar with the Student. This
information may be obtained from Job Foundation report, work-based learning, school
assessments, etc.
(b) At a minimum, the following criteria must be addressed:
i. History of school attendance and reliability;
ii. Behavior support or potential strategies;
iii. Student Communication skills;
iv. Student learning preferences;
v. Student's personal hygiene;
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Special Terms and Conditions
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 gual(s) [rat aligrt witlt t]te Studettt's:
i. Skills and interests;
ii. Desired work environment;
iii. Desired schedule;
iv. Ability to travel to/from work within a reasonable length of time; and
v. Accommodations and supports necessary to achieve identified goals.
b. Job Placement Phase. The intent of this phase is to provide the Student with the tools they will
need to find and secure meaningful community employment based on their employment goal. The
Contractor shall provide all services necessary to locate, secure, and place a Student into
competitive integrated employment that is mutually agreed upon by the Student's Team. Specific
placement expectations shall be outlined on the DVR SDOP for Job Placement and 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 employment 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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iv. Job Duties;
v. Expected Weekly Hours;
vi. Starting Wage;
vii. Location;
viii. Transportation Consideration;
ix. Benefits Package; and
x. Potential Training Services and Date/Additional lnfo.
(b) lf the Student rejected the job offer, Contractor must provide the reason(s) why the Student
rejected the job offer. Details must include how the job did not meet their individualized
employment goal, as well as the criteria in (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 hours per week, the Contractor shall request approvalfrom the DVR Counselor in
consultation with the Student's Team should the Student want to accept the offer.
c. Employment Phase. The intent of this phase is to verify, stabilize, and maintain meaningful
community employment.
(1) Employment Verification
(a) Contractor shall submit the following method of verification of employment after Student's
first day of employment:
i. The Employment Verification page of the Student Guide.
(2) lntensive Training Services
(a) lntensive job training expectations shall be outlined by the Student's Team. The Contractor
shall provide individualized, one-on-one job skills training and support at the supported
employment job site that will enable a Student to:
i. Achieve job stabilization in 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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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{he-job employment and meets
employer expectations.
iii. The supports available are adequate for the Student to maintain stable employment and
meet the employer's expected level of work productivity.
iv. The Student has long-term employment supports available or in process and is able to
transition to these services to maintain job stability.
(c) Once achieved, a Stabilization Report and supports on the job the Student may need, must
be completed for the Student as outlined in the SDOP and must include:
i. Detail and summary of how the placement hours were met (or if the job represents
suitable employment); and
ii. Detail, descriptions, and summary of how the DVR Counselor, CRP, and the employer
agrees that the employer's expectation have been met; and
iii. Detail and summary of how long-term supports have been set up and will occur; and
iv. The strengths the Student brings to the job; and
v. The Student's fading plan, including how they will remain stable on the job; and
vi. Additional training, services, and supports the Student may need.
(4) Stabilization needs to be achieved by September 30,2027. However, exceptions may
be made on a case-by-case basis through the end of the calendar year (December 31,
2027) with approval from the DVR Transition Program Manager or their designated
representative. Youth Extended Services.
(a) DVR shall provide Youth Extended Services needed by the Student until DDCS funds are
available, in accordance with WAC 388-891A-1060.
i. Should Youth Extended Services reach six (6) months, the Contractor and DVR shall
collaborate to determine next steps which may include additional Youth Extended
Services or other options as needed.
(b) Youth Extended Services funded by DVR shall be outlined on the DVR Youth Extended
Services SDOP.
Maximum 26 hours per month at the hourly rate of $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-Work Transition Program Manager or designated representative.
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Deliverables. The Contractor shall demonstrate completion of activities for payment through the
following reporting methods. Submissions should be written in language that directly addresses the
Student and shall continue for 90 days beyond the Student's stabilization, or until DVR case closure.
The Contractor shall submit the required Monthly Progress Report to the assigned DVR Vocational
Rehabilitation Counselor for each Student who is served by this Contract.
a. Student Guide
(1) The Contractor shall submit a copy of the Student Guide to the Student's Team at the
end of each month demonstrating the progress of the Student's transition year via
completion of the Monthly Progress Reports section located on the front page and the
back of the Student Guide.
(2) The Contractor shall submit Exhibit E - School-to-Work Billing Checklist to the DVR
Counselor upon completion of payment points for each Student as demonstrated in the
Student Guide.
(3) Contractor shall submit a minimum of three (3) Schoolto-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) Stabilization - Stabilization Report.as stated in Section 5 - Statement of Work.
b. Data Sharing and Reporting - DVR is tracking the progress and success of the School-to-Work
program to ensure the program is available to all Students who meet eligibility requirements across
the state. ln order to accomplish this, the Contractor must submit Exhibit D - School-to-Work
Student Data.
(a) Exhibit D incorporates the following required data elements:
i. Number of Students identified as eligible for School-to-Work in county or counties
served. lf the Contractor coordinates 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 School-to-Work early.
v. Reason for Student exiting early.
vi. Number of Students who exited Schoolto-WoTUDVR employed and transferred into
Long-Tertrt Services witlt 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 Schoolto-Work Transition
Program Manager or their designated representative throughout the course of the 2027
transition cohort following the below schedule and with the appropriate tab completed:
i. The "Aug 31 , 2026" tab shall be submitted on August 31, 2026, or upon execution of the
Contract, whichever is later.
ii. The "March 31,2027" tab shall be submitted on March 31,2027.
iii. The "Sept 30, 2027" tab shall be submitted on September 30, 2027, or at the conclusion
of the Contractor's program, whichever is sooner.
(c) 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
with the terms, conditions, and specifications of their Contracts. DVR manages and monitors its
contracts through conducted risk assessments and monitoring plans. Authority to conduct such
reviews is provided by Title 2 of the Code of Federal Regulations (CFR), 34 CFR 80.36, OFM
SAAM Policy 16.20.55, DSHS Administrative Policies No. 13.11 and 19.50.30.
b. Progress Meetings: DVR Schoolto-Work Transition Program Manager shallwork with Contractors
to plan meetings which allow discussion of program progress and support methods to ensure
Students are receiving adequate services to obtain employment. ln addition, Contractor may invite
DVR partners to attend local County-initiated service provider meetings. DVR partners may include
local DVR Counselors, supervisors, and School-to-Work staff.
8. Subcontractors.
a. All Subcontractors utilized by the Contractor in delivery of direct services described in this Contract
shall hold a current DVR Community Rehabilitation Program (CRP) contract in which they provide
the following services:
(1 ) Community-Based Assessments; and
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(2) CRP Job Placement; and
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(3) CRP lntensive Training Services
b. Subcontracts
(1) Copies of proposed subcontracts between the Contractor and subcontracted CRPs
shall be provided to DVR Schoolto-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 requtrements.
Consideration. Total consideration payable to Contractor for satisfactory performance of the work
under this Contract is up to a maximum of $14,000 per Student. This is a comprehensive rate for each
service and takes into account the administrative costs associated with operating the program as well
as the actual costs of each service, and shall be based on the following:
a. 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 Student Guide. The total billable amount for this activity is $2,000 per
Student.
(2) Assessment: Paid upon receipt of a School{o-Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $3,000 per
Student.
b. Job Placement Phase - A total payment of $3,000 per Student shall be paid to the Contractor when
the individualstudent has completed the following activities:
(1) Job Seeker Tools: Paid upon receipt of a School{o-Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $1,000 per
Student.
(2) Job Offer: Paid upon receipt of a 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 week, an exception for payment may be granted with
approval of the appropriate DVR Supervisor. This approval shall be in consultation with
the team including the Student, Student's Family (as applicable), DVR Counselor, CRP,
and County staff.
c. Employment Phase - A total payment of $6,000 per Student shall be paid to the Contractor when
the individual Student has completed the following activities:
(1) Employment Verification: Paid upon receipt of a School-to-Work Billing Checklist and a
written report in the Student Guide. The total billable amount for this activity is $1,000
per Student.
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(2) Job Stabilization: Paid upon receipt of a School-to-Work Billing Checklist and a written
report in the Student Guide. The total billable amount for this activity is $5,000 per
Student.
Billing and Payment
a. The Contractor shall submit no less than three (3) separate original Schoolto-Work Billing
Checklists to the assigned DVR Vocational Rehabilitation Counselor for each Student who is
successfully served by this Contract.
(1) At a minimum, one School-to-Work Billing Checklist per phase as outlined in Section 5,
statement of work.
(2) School-to-Work Billing Checklists may only be submitted to DVR upon the successful
completion of an activity outlined in the SDOP.
(3) School-to-Work Billing Checklists must be submitted within sixty (60) days of service(s)
having occurred or within sixty (60) days of the completion of each phase.
b. Payment shall be considered timely if made by DSHS within thirty (30) days after receipt and
acceptance by the designated DVR Counselor of the properly completed Schoolto-Work Billing
Checklist. Payment shall be sent to the address designated by the Contractor on page one (1) of
this Contract.
c. DSHS may at its sole discretion, withhold payment claimed by the Contractor for services rendered
if the Contractor fails to satisfactory comply with any term or condition of this Contract.
11. 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) f] 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
shall, prior to the execution of this Agreement by DSHS, provide certificates of
insurance to that effect to the DSHS contact on page one of this Agreement.
Commercial General Liabilitv lnsurance (CGL) - to include coverage for bodily injury, property
damage, and contractual liability, with the following minimum limits: Each Occurrence - $1,000,000;
GeneralAggregate - $2,000,000. The policy shall include liability arising out of premises,
operations, independent contractors, products-completed operations, personal injury, advertising
injury, and liability assumed under an insured contract. The State of Washington, DSHS, its elected
and appointed officials, agents, and employees shall be named as additional insureds.
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
{0.
12.
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or volunteer of the Contractor or a subcontractor, is investigated by DSHS or a local, county, state
or federal agency regarding any matter that, if ultimately established, could either:
(1) Result in a conviction for violating a local, state or federal law.
(2) 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, Lrntil the investigation is concluded and a final
determination made by the investigating agency if inconclusive or unsubstantiated.
13. 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 individual from providing direct services to DSHS Students. Failure to
do so may result in a Corrective Action Plan.
14. Compliance with Corrective Action Plan
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.
15. 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, or particular than those contained in this contract shall not
be construed as being inconsistent or in conflict.
16. Disputes
When a dispute arises over an issue concerning the terms of this Contract, the following process is
used to address the dispute:
a. The Contractor and DVR shall attempt to resolve the dispute through informal means between the
Contractor and the assigned DVR Counselor. For those contracts where a DVR Counselor is not
assigned, the Contractor shall attempt to resolve the dispute with the contact person identified on
the first page of the contract.
b. 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:
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017)Page 14
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 email
(3) Contract number.
(4) Description of the issue in dispute.
(5) A statement describing the requester's position on the issue in dispute, including any
documentation that supports this position.
(6) Steps already taken to resolve the dispute.
e. The reviewer may request additional supporting documentation from either party to assist in
reaching a fair resolution.
f. The Director shall issue a written decision to the Contractor within thirty (30) business days of
receipt of all information relevant to the issue.
g. The dispute resolution process described above is the sole administrative remedy available under
this Contract.
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601 7CF County Program Agreement (10-3'l-2017)Page 15
,l
Special Terms and Conditions
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 and Technology (https://nvlpubs.nist.gov/nistpubs/FIPS/NlST.FlPS.197-upd1.pdf).
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 under the 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 information (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
regulations that require especially strict protection of the data and from which especially serious
consequences may arise in the event of any compromise of such data. Data classified as Category
4 includes but is not limited to data protected by: the Health lnsurance Portability and Accountability
Act (HIPAA), Pub. L. 104-191 as amended by the Health lnformation Technology for Economic and
Clinical Health Act of 2009 (HITECH), 45 CFR Parts '160 and 164; the Family Educational Rights
and Privacy Act (FERPA), 20 U.S.C. $12329; 34 CFR Part 99; lnternal Revenue Service
Publication 1075 (https://www.irs.gov/pub/irs-pdf/p1075.pdfl; Substance Abuse and Mental Health
Services Administration regulations on Confidentiality of Alcohol and Drug Abuse Patient Records,
42 CFR Part2; and/or Criminal Justice lnformation Services, 28 CFR Parl20.
e. "Cloud" means data storage on servers hosted by an entity other than the Contractor and on a
network outside the control of the Contractor. Physical storage of data in the cloud typically spans
multiple servers and often multiple locations. Cloud storage can be divided between consumer
grade storage for personal files and enterprise grade for companies and governmental entities.
Examples of consumer grade storage would include iTunes, Dropbox, Box.com, and many other
entities. Enterprise cloud vendors include Microsoft Azure, Amazon Web Services, and Rackspace.
f. "Encrypt" means to encode Confidential 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.
"FedRAMP" means the Federal Risk and Authorization Management Program (see
www.fedramp.gov), which is an assessment and authorization process that federal government
agencies have been directed to use to ensure security is in place when accessing Cloud computing
products and services.
"Hardened Password" means a string of at least eight characters containing at least three of the
following four character classes: Uppercase alphabetic, lowercase alphabetic, numeral, and special
characters such as an asterisk, ampersand, or exclamation point.
g
h
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601 7CF County Program Agreement (10-31-2017)Page 16
2
Special Terms and Conditions
"Mobile Device" means a computing device, typically smaller than a notebook, which runs a mobile
operating system, such as iOS, Android, or Windows Phone. Mobile Devices include smart phones,
most tablets, and other form factors.
"Multi-factor Authentication" means controlling access to computers and other lT resources by
requiring two or more pieces of evidence that the user is who they claim to be. These pieces of
evidence consist of something the user knows, such as a password or PIN; something the user has
such as a key card, smart card, or physical token; and something the user is, a biometric identifier
such as a fingerprint, facial scan, or retinal scan. "PlN" means a personal identification number, a
series of numbers which act as a password 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
tingerprint.
k. "Portable Device" means any computing device with a small form factor, designed to be transported
from place to place. Portable devices are primarily battery powered devices with base computing
resources in the form of a processor, memory, storage, and network access. Examples include, but
are not limited to, mobile phones, tablets, and laptops. Mobile Device is a subset of Portable
Device.
l. "Portable Media" means any machine readable media that may routinely be stored or moved
independently of computing devices. Examples include magnetic tapes, optical discs (CDs or
DVDs), flash memory (thumb drive) devices, external hard drives, and internal hard drives that have
been removed from a computing device.
m. "secure Area" means an area to which only authorized representatives of the entity possessing the
Confidential lnformation have access, and access is controlled through use of a key, card key,
combination lock, or comparable mechanism. Secure Areas may include buildings, rooms or
locked storage containers (such as a filing cabinet or desk drawer) within a room, as long as access
to the Confidential lnformation is not available to unauthorized personnel. ln othenvise Secure
Areas, such as an office with restricted access, the Data must be secured in such a way as to
prevent access by non-authorized staff such as janitorial or facility security staff, when authorized
Contractor staff are not present to ensure that non-authorized staff cannot access it.
n. "Trusted Network" means a network operated and maintained by the Contractor, which includes
security controls sufficient to protect DSHS Data on that network. Controls would include a firewall
between any other networks, access control lists on networking devices such as routers and
switches, and other such mechanisms which protect the confidentiality, integrity, and availability of
the Data.
o. "Unique User lD" means a string of characters that identifies a specific user and which, in
conjunction with a password, passphrase or other mechanism, authenticates a user to an
information system.
Authority. The security requirements described in this document reflect the applicable requirements of
policies and standards of the Washington Technology Services Agency
(https://watech.wa.qov/policies?combine=&field cateqories tarqet id=8O&field tvpe tarqet id=All),
and of the DSHS lnformation Security Policy and Standards Manual. Reference material related to
these requirements can be found here: https://www.dshs.wa.qov/ffalkeepinq-dshs-client-information-
private-and-secure, which is a site developed by the DSHS lnformation Security Office and hosted by
DSHS CentralContracts and Legal Services.
Administrative Controls. The Contractor must have the following controls in place:3
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601 7CF County Program Agreement (10-31-2017)Page 17
4.
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 Dala.
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 always 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 alltimes), 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:
DSHS Central Contract Services
6017CF County Program Agreement (10-31-2017)Page 18
Special Terms and Conditions
(1) Ensuring mitigations applied to the system don't allow end-user modification.
(2) Not allowing the use of dial-up connections.
(3) Using industry standard protocols and solutions for remote access. Examples would include
RADIUS and Citrix.
(4) Encrypting all remote access traffic from the external workstation to Trusted Network or to a
component within the Trusted Network. The traffic must be encrypted at all times while
traversing any network, including the lnternet, which is not a Trusted Network.
(5) Ensuring that the remote access system prompts for re-authentication or performs automated
session termination after no more than 30 minutes of inactivity.
(6) Ensuring use of Multi-factor Authentication to connect from the external end point to the internal
end point.
Passwords or PIN codes may meet a lesser standard if used in conjunction with another
authentication mechanism, such as a biometric (fingerprint, face recognition, iris scan) or token
(software, hardware, smart card, etc.) in that case:
(1) The PIN or password must be at least 5 lefters 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)
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
S. 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 seryer disks. For.Data stored on hard disks mounted on network servers and made
available through shared folders, access to the Data will be restricted to Authorized Users through
the use of access control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User lD and Hardened Password or other
DSHS Central Contract Services
6O17CF 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
paragraph. Destruction of the Data, as outlined below in Section 8 Data Disposition, may be
deferred until the disks are retired, replaced, or otherwise taken out of the Secure Area.
c. Optical discs (CDs or DVDs) in localworkstation optical disc drives. Data provided by DSHS
on optical discs which will be used rn 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
DSHS on optical discs which will be attached to network servers and which will not be transported
out of a Secure Area. Access to Data on these discs will be restricted to Authorized Users through
the use of access control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User 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 accessible to authorized personnel. When not in use, such records must be stored in
a Secure Area.
Remote Access. Access to and use of the Data over the State Governmental Network (SGN) or
Secure Access Washington (SAW will be controlled by DSHS staff who will issue authentication
credentials (e.g. a Unique User 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.
Data storage on portable devices or media.
(1) Except where otherwise specified herein, DSHS Data shall not be stored by the Contractor on
portable devices or media unless specifically authorized within the terms and conditions of the
Contract. 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.
t
g
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6017CF County Program Agreement (10-31-2017\Page 20
Special Terms and Conditions
(d) Apply administrative and physical security controls to Portable Devices and Portable Media
by:
i. Keeping them in a Secure Area when not in use,
ii. Using check-in/check-out procedures when they are shared, and
iii. Taking frequent inventories
(2) When being transported outside of a Secure Area, Portable Devices and Portable Media with
DSHS Confidential lnformation must be under the physical control of Contractor staff with
authorization to access the Data, even lf the Data ls encrypted.
h. 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 until such time as that media would 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.9. Storage Area Network drives, virtual media,
etc.) as part of a Contractor's existing, documented backup process for business continuity or
disaster recovery purposes. lf so, such media will be protected as otherwise described in this
exhibit. lf 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.
i. Cloud storage. DSHS Confidential lnformation requires protections equalto or greater than those
specified elsewhere within this exhibit. Cloud storage of Data is problematic as neither DSHS nor
the Contractor has control of the environment in which the Data is stored. For this reason:
(1) DSHS Data will not be stored in any consumer grade Cloud solution, unless all of the following
conditions are met:
(a) Contractor has written procedures in place governing use of the Cloud storage and
Contractor attests in writing that all such procedures will be uniformly followed.
(b) The Data will be Encrypted while within the Contractor network.
(c) The Data will remain Encrypted during transmission to the Cloud.
(d) The Data will remain Encrypted at all times while residing within the Cloud storage solution
(e) The Contractor will possess a decryption key for the Data, and the decryption key will be
possessed only by the Contractor and/or DSHS.
(f; The Data will not be downloaded to non-authorized systems, meaning systems that are not
on either the DSHS or Contractor networks.
(g) The Data will not be decrypted until downloaded onto a computer within the control of an
Authorized User and within either the DSHS or Contractor's network.
DSHS Central Contracl Services
6017CF County Program Agreement (10-31-2017)Page 21
6
Special Terms and Conditions
(2) Data will not be stored on an Enterprise Cloud storage solution unless either:
(a) The Cloud storage provider is treated as any other Sub-Contractor, and agrees in writing to
all of the requirements within this exhibit; or,
(b) The Cloud storage solution used is FedRAMP certified.
(3) lf the Data includes protected health information covered by the Health lnsurance Portability and
Accountability Act (HIPAA), the Cloud provider must sign a Business Associate Agreement prior
to Data being stored in their Cloud solution.
System Protectton. To prevent compromlse of systems whlch contaln DSHS Data or through whlch
that Data passes:
a. Systems containing DSHS Data must have all security patches or hotfixes applied within 3 months
of being made available.
b. The Contractor will have a method of ensuring that the requisite patches and hotfixes have been
applied within the required timeframes.
c. Systems containing DSHS Data shall have an Anti-Malware application, if available, installed.
d. Anti-Malware software shall be kept up to date. The product, its anti-virus engine, and any malware
database the system uses, will be no more than one update behind current.
Data Segregation.
a. DSHS Data must be segregated or otherwise distinguishable from non-DSHS data. This is to
ensure that when no longer needed by the Contractor, all DSHS Data can be identified for return or
destruction. lt also aids in determining whether DSHS Data has or may have been compromised in
the event of a security breach. As such, one or more of the following methods will be used for data
segregation.
(1) DSHS Data will be kept on media (e.9. hard disk, optical disc, tape, etc.) which will contain no
non-DSHS Data. And/or,
(2) DSHS Data will be stored in a logical container on electronic media, such as a partition or folder
dedicated to DSHS Data. And/or,
(3) DSHS Data will be stored in a database which will contain no non-DSHS data. And/or,
(4) DSHS Data will be stored within a database and will be distinguishable from non-DSHS data by
the value of a specific field or fields within database records.
(5) When stored as physical paper documents, DSHS Data will be physically segregated from non-
DSHS data in a drawer, folder, or other container.
b. When it is not feasible or practical to segregate DSHS Data from non-DSHS data, then both the
DSHS Data and the non-DSHS data with which it is commingled must be protected as described in
this exhibit.
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
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 will overwrite the Data at
least three (3) times using either random or single
character data, or
Degaussing sufficiently to ensure that the Data
cannot be reconstructed, or
Phvsicallv destrovinq the disk
Paper documents with sensitive or Confidential
lnformation
Recycling through a contracted firm, provided the
contract with the recycler assures that the
confidentiality of Data will be protected
Paper documents containing Confidential lnformation
requiring special handling (e.9. protected health
information)
On-site shredding, pulping, or incineration
Optical discs (e.9. CDs or DVDs)lncineration, shredding, or completely defacing the
readable surface with a coarse abrasive
Maonetic taoe Deoaussinq, incineratinq or crosscut shredding
9.
10.
Special Terms and Conditions
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 to the DSHS Privacy Officer at dshsprivacyofficer@dshs.wa.gov. Contractor must also
take actions to mitigate the risk of loss and comply with any notification or other requirements imposed
by law or DSHS.
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
6017CF County Program Agreement (10-31-2017)Page 23
Exhibit B: School-to-Work Student Guide Instructions
Thefottowing 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 wi[[ use Exhibit E: STW Bitting
Checktist for Student Guide, provided to the Contractor by DVR'
Theseinstructionswittsupportguidanceto Schoot-to-Work (STW)contractors as theyworkwith students
whoare participatinginSTW.Tobegintheprocessof STWandtoreviewtheSTWStudentGuide,schedutea
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 fina[ year of Transition.
Bilting lnstructions:
1. Bitt $2,OOO for the STW lntake Meeting once the fottowing pages are complete:
o Team Buil,ding and lnformation
r Team Contacts, Rotes, and Responsibitities
2. Bilt $3,OOO for Assessment once the fottowing pages are complete:
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 emptoyment goat. The student and the student's team wi[[ work together to determine this.
The main goat for this section is to get to an emptoyment goat and the next steps for the student.
o STWAssessment
o Job Goa[
o Next Steps and Team Actions
3. Bitt $1,OOO f or the Job Seeker Tools once the fotlowing pages are complete:
o Job Seeker Toots (determined bythe student's team and have been compteted and shared with the
student and DVR)
4. Bitt $2,000 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. Bitt $1,OOO for Emptoyment Verification once the following page is comptete:
o Form is compteted on the page titted "Congratutations, you are emptoyed!"
6. Bilt $5,OOO for Stabitization once the fottowing pages are comptete:
o Your Supports on the Job
o 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-:-m
Division of Vocational Rehabilitation (DVR)
Exhibit E:
School-to-Work Billing Ghecklist
Contractor Month and Year
Signature Date of Signature
AFP Number Student lnitials
Activity Billed Amount
Billed
To be filled out by DVR Staff Only;
DVR staff slgn and date below to confirm
items received and to authorize payment
I lntake Meeting $ 2,000
I Assessment $ 3,000
! .loO Seeker Tools $1 000
I .loo offer $ 2,000
J Employment Verification $ 1,000
tr Stabilization $ 5,000
Total Billing $
lnstructions:
1. The Student Guide is sent monthly to the Student's Team, including the DVR Counselor.
2. The Contractor checks the appropriate box(es) as the corresponding activities are completed in
the Student Guide (one form per student).
3. The Contractor submits this completed form to the assigned DVR Counselor.
4. The DVR Counselor confirms information from monthly submissions of the Student Guide,
verifies activities were completed, then signs and dates the checklist.
5. The DVR Counselor submits for payment.
Notables:
. The Student Guide serves as documentation for proof of completion for the payment / activity
point.
. The Contractor submits no less than three (3) separate checklists to the assigned DVR
Counselor for each student (submitting all payment points separately is also an option).
Any questions, please contact the School-to-Work Team at
DVRSchoolToWork@dshs.wa. gov.
Exhibit E: Schoolto-Work Billing Checklist
DSHS 11-195A (O4t2026)
Attachment "G"
DIVISION Of: VOCA, I i'J\J AI R r i-l /\ tj I L i rAT i i-r i\i
School-to-Work
STUDENT GUIDE
Job Seeker:
Month/Year:
sHs
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. Onlythe Monthly Summary above
to share the progress being made towards supporting you in being employed!
Phase One
Team Contacts, Roles, and ResponsibilitiesTeam Building and lnformation
Assessment I nformation I JoO Goal Established [ rue*t Steps and Team Actions
Phase Two
Job Seeker Tools I loU offer Details
Phase Three
Em ployment Verifi cation Supports on the Job Job Stabilization Report
DtvlstoN oF vocATloNAL REHABtLTTATION ISCHOOL-TO-WORK IPAGE 2
Welcome!
Sch oo I -to-Wo rk Ove rview
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 directly with a job coach who will collaborate with you, your parent(s)/guardian(s),
school district staff, County Developmental Disabilities programs, the Division of Vocational Rehabilitation, and
Developmental Disabilities Administration.
This School-to-Work Student Guide
This guide will be updated regularly and is designed to house your School-to-Work related information,
assessments, activity logs, notes, and much more. 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
employment verification information, completion of the first day of work, and much more!
DtvtstoN oF vocATtoNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 3
Next Steps and Team Actions
You and your team will work together to decide what next steps are needed to support you.
Everyone should agree on tasks and actions.
Task 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)
\g/Tip: Tasks may be added throughout your School-to-Work year,
or removed if they are no longer something you want to explore.
DtvtstoN oF vocATtoNAL REHABtLtTATION I SCHOOL-TO-WORK I PAGE 4
Phase 1 Starts: Intake and Assessment
This phase includes bringing your team together that will support and guide you through the
program, Key intake and assessment activities will take place to ensure a positive experience for you.
Team Building and lnformation
Team Building Date
To-Do-List
1. lntroductions / Overview of Services / Strengths and Challenges
2. Assessment Needs
3. Job Goal is Established
Name Role/Agency
DtvtstoN oF vocATtoNAL REHABtLtTATION ISCHOOL-TO-WORK IPAGE s
Show Up, Speak Up, and
Share! You are the driver of
your services and without
your voice, tlre team is not
able to support you with
your goals. Work with your
team to get a job. services
are person-centered and
individualized.
You, the Student
(most important
person on the team)Email:
Name:
Phone:
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.
Employment
Provider:Your Job
Coach
Name:
Email
Phone
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.)
DtvlsloN oF vocATloNAL REHABILITATION I SCHOOL-TO-WORK PAGE 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.
Your School Teacher
and/or School Staff
Name:
Email
Phone:
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
Other Person on Your
Team
Name:
Email:
Phone:
Team Member
Role
Team Member
Contact tnformation
Team Member
Responsibility to You
Team Contacts, Roles, Responsibilities
(Continued)
DtvtstoN oF vocATtoNAL 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, skills, and supports needed for success on the job. This information will be gathered through school,
you, your family and friends, and community activities, as well as conversations and observations with those
supporting you.
History of school attendance and reliability:
Behavior support or strategies likely to be needed:
Communication skills:
Learning preferences:
Personal hygiene:
Potential job safety issues:
Summary of Assessment Areas
DtvtstoN oF vocATloNAL REHABILITATtON ISCHOOL-TO-WORK IPAGE 8
Summary of Assessment Are?s (continued)
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:
Nota ble Accom modations and N ecessa ry Su pports:
Your job goal a
a
\Q/' Congratulations!You are on your way to being employed!
tgr
DtvtstoN oF vocATtoNAL REHABtLITATION ISCHOOL-TO-WORK IPAGE 9
Phase 2 Starts: Job Placement
This phase includes conducting and capturing important job placement activities like employment
goals, site visits,iob interviews, and more.
Job Seeker Tools
Job seeker tools will be developed to support you as you look for a job. You will work with your
team to figure out what you need, which may include the following: online portfolios, cover
letters, video resumes, letters of recommendation, Linkedln pages, and more.
Resume or Media Resume
(Video, PowerPoint, Portfolio, etc.)
Cover Letter (as determined if needed by you and your team)
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
Sent to Student: Yes
Sent to DVR Counselor: Yes
No
No
No
No
No
No
No
No
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Employer Letter of Recommendation (optional)
Linkedln Page (optional)
DlvtstoN oF vocATtoNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 10
You were Offered the Job! Way to Go!
Did you accept this job offer? Yes
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 originalgoalon your DVR plan? Yes
r.ro ! l
No:
\I
t
\
DtvtstoN oF vocATtoNAL REHABILTTATION ISCHOOL-TO-WORK IPAGE 11
Job Offer Details
Job Goal:
Employer:
Job Title:
Start Date:
Job Duties:
Expected Weekly Hours:
Starting Wage:
Location:
Transportation Considerations:
Benefits Package:
Potential Training Services and Date/Additional lnformation:
DtvtstoN oF vocATtoNAL REHABtLITATION 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 moret
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:
Monthly Annually
Daily Weekly Every Two Weeks Two Times a Month
-' I r=l
Monthly []
Tips:
Bonuses:No
Overtime:No
No Yes; if yes, how often and how much?
Commissions:No Yes; if yes, how often and how much?
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
ls health insurance available:No Yes
Saturday Sunday
1.lf yes, did the employee enroll in the health plan?:
a. lf yes, when does the coverage begin?
No Yes
b. lf yes, what is the employee's portion of the premiums? 5
Name and Title of Person Who Completed This Page:
Date:
DtvlstoN oF vocATtoNAL REHABtLITATION 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.
DtvlstoN oF vocATtoNAL REHABILTTATTON I SCHOOL-TO-WORK I PAGE '.t4
Job Stabilization Report
You are considered stable on the job when the following things happen:
1. Your desired work hours are met (unless you and your team agree the job represents suitable
employment).
2. Your DVR Counselor, your job coach, and your employer agree that you meet your employer's
expectations (this is verified by your job coach).
3. You are ready for long-term support.
But first...
Did you meet your expected job goal? Yes
Was your starting wage what you wanted? Ves I No
Does the job location meet your expected needs? Yes No
Anything else you want to add about your job?
No
DtvtstoN oF vocATtoNAL REHABILtTATIoN I ScHooL-To-woRK I PAGE 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:
DtvtstoN oF vocATtoNAL REHABILITATION ISCHOOL-TO-WORK IPAGE 16
Helpful Resources
Developmental Disabilities Administration
. Website: www.dshs.wa.govldda
. DDA Eligibility lnformation:www.dshs.wa.qov/dd a/consu mers-a n d -fa m i I ies/el iq i b i I ity
Division of Vocational Rehabilitation, or DVR
. Website: www.dshs.wa.gov/dvr
. Phone: 1-800-637 -5627
Social Security Administration, or SSA
. Website: www.ssa.gov
. Phone: 1-800-772.1213
Benefit U
. Website: www.benefitu.org
. Benefit U lnformation: support@be nefitu.orq
Other Resources and/or Additional Contacts:
Name:
Phone:
Email:
Other:
Name:
Phone:
Email:
Other:
DtvtStoN oF vocATloNAL REHABILITATlON ISCHOOL-TO-WORK IPAGE 17
Optional Documents
Copy of Food Worker Card
Sent to Student: Yes
Sent to DVR Counselor: Yes No
Copy of Current CPR and/or First Aid Certification
No
No
No
No
No
No
No
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
Date sent:
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
* ldeas of other items to include could be a person-centered plan, other certifications, and other
job-related documents.
DtvtstoN oF vocATtoNAL REHABtLITATION ISCHOOL-TO-WORK IPAGE 18
Monthly Progress Reports
Below is your story of finding a job! As your Job Coach works with you, they will be adding in
their monthly reports that are on the first page of this Student Guide. You will be able to read the
progress made for you. . .the story of your journey to a job!
May
Year
June
Year
July
Year
DtVlstoN oF VocATtoNAL REHABtLITATIoN I SCHooL-To-WoRK I PAGE't9
August
Year
September
Year
October
Year
DtvtStoN oF vocATtoNAL REHABtLITATION I SCHOOL-TO-WORK I PAGE 20
November
Year
December
Year
January
1
Year
DtvtstoN oF vocATtoNAL REHABtLtTATtoN I scHooL-To-woRK I PAGE 21
February
1
Year
March
1
Year
April
1
Year
DtvtstoN oF vocATtoNAL REHABtLtTATtoN I scHooL-To-woRK I PAGE 22
May
1
Year
June
1
Year
July
1
Year
DtvtstoN oF vocATtoNAL REHABILITATION I SCHOOL-TO-WORK I PAGE 23
August
1
Year
September
1
Year
DtvtstoN oF vocATtoNAL REHABtLITATION ISCHOOL-TO-WORK IPAGE 24
Additional Comments
DtvtStoN oF vocATtoNAL REHABtLtTATIoN I scHooL-To-woRK I PAGE 2s
Legacy Pilot
f of Students
enrolled in
School to Work
# of Students in
SDOP for
Assessment
# of Students in
SDOP for Job
Placement
il of Students in
SDOP
# of Students
Employed
Asotin
Benton
Chelan
Clark
Columbia
Cowlitz
Douglas
Ferry
Franklin
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 o o 0 0
Attachment "H"
Schoolto Work 202512027: Graduation Year 2027 or 2028
*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