HomeMy WebLinkAboutPSA between KC and AtWork!Kittitas County Public Health
Contract/Agreement Review Form
Today's Date: 07/22/2026 Legal Request #: 1 12623
Fund/Department: 116-Public Health Agenda Date:
Contract/Agreement Information
Contract/Agreement Agency: AtWork!
Contract/Agreement Title: AFS between Kittitas County and AtWork!
Begin Date: 07/01/2026 1 1 End Date: 06/30/2027
Total $ Amount: Fee for Service
Contract/Agreement Summary:
Public Health
Contract/Agreement #: PHMH26-021
The purpose of this Agreement is as follows: To provide a coordinated and comprehensive state
and local program of services for persons with developmental disabilities in accordance with
Revised Code of Washington chapter 71A.14.
Kittitas County Prosecutor an Auditor Review and Comment:
APPROVED AS TO FO
re of r ecutor's Office
Signature of Auditor's
Budget Information
Revenue Code(s): 105-568.334.04.68 —
Expense Code(s): HS1000-101/4122
❑ Agency is not suspended/disbarred
Pass Through Information
Agency to Pass Through
Amount to Pass Through
Sub -Contract Approved Date:
❑ Not Checked (reason)
Expense Code:
_Z/
Date
_ Xr Z /o
ADMIN I Version: 0 1 Supersedes: 0 Date Adopted: 12/01/2024 Modified By: Katie Odiaga Approval By: Chelsey Loeffers
7/28/26, 10:07 AM
SAM.gov
Entity information
TVV O Active Registration
0
Unique Entity ID CAGE/NCAGE
YZYWSMJX2EY9 1 MUX9
Physical Address
1935 152ND PL NE
Bellevue, Washington
98007-4209, United States
Purpose of Registration
All Awards
Version
Current Record
BUSINESS INFORMATION
Doing Business As URL
ATWORK!
www.atworkwa.org
Division Name
Division Number
(blank)
(blank)
Congressional
State/Country of
District
Incorporation
Washington 01
Washington, United
States
Owner CAGE Legal Business
Name
Immediate (blank)(blank)
Owner
Highest Level (blank)(blank)
Owner
Expiration Date
Mailing Address
1935 152ND PL NE
Bellevue, Washington
98007-4293, United States
Registration Dates
Activation Date
Nov 20, 2025
Submission
Date
Nov 18, 2025
Initial Registration
Date
Aug 1, 2001
Entity Dates
Nov 18, 2026
https://sam.gov/entities/view/YZYWSMJX2EY9/coreData?status=Active&emrKeyValue=1551592-1763399404446864®ld=16672901 113
7/28/26. 10:07 AM SAM.gov
Entity Start
Date
Mar 1, 1977
Fiscal Year End
Close Date
Sep 30
Executive Compensation
Registrants in the System for Award Management (SAM) respond to the Executive Compensation
questions in accordance with Section 6202 of P.L. 110-252, amending the Federal Funding
Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is
sent to USAspending.gov for display in association with an eligible award. Maintaining an active
registration in SAM demonstrates the registrant responded to the questions.
SAM SEARCH AUTHORIZATION
authorize my entity's non -sensitive information to be displayed in SAM public search results:
Yes
ENTITY TYPES
Business Types
Entity Structure Corporate Entity (Tax
Exem pt)
Entity Type Business or
Organization
Profit Structure Non -Profit
Organization
Organization (blank)
Factors
Socio-Economic Types
AbilityOne Non Profit Agency
Check the registrant's Reps & Certs, if
present, under FAR 52.212-3 or FAR 52.219-1
to determine if the entity is an SBA -certified
HUBZone small business concern. Additional
small business information may be found in
the SBA's Dynamic Small Business Search if
the entity completed the SBA supplemental
pages during registration.
https://sam.gov/entities/viewlYZYWSMJX2EY9/coreData?status=Active&emrKeyVaIue=1551592-1763399404446864®ld=16672901 2/3
7/28/26, 10:07 AM
SAM.gov
https://sam.gov/entities/viewlYZYWSMJX2EY9/coreData?status=Active&emrKeyValue=1551592-1763399404446864®ld=16672901 3/3
~'Xki KITTITAS COUNTY
AGREEMENT FOR SERVICES
PHMH26-021
KITTiT: r f)CNTti - -
This Agreement for Services (hereinafter Agreement) is entered into by and between Kittitas County
(hereinafter "County"), a political subdivision of the State of Washington, and AtWork! (hereinafter "Contractor").
The purpose of this Agreement is as follows: To provide a coordinated and comprehensive state and local
program of services for persons with developmental disabilities in accordance with Revised Code of Washington
chapter 71A.14.
The term of this Agreement shall be from July 15t, 2026, through June 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
Kittitas County Public Health
507 N. Nanum, Suite 102
Ellensburg, WA 98926
Project Contact:
Laurie Holt
Developmental Disabilities Administrative
Specialist
Human Services
Lau rie. holt@co. kittitas.wa.us
509-962-7515
CONTRACTOR
AtWork!
1935 152nd PI NE
Bellevue, WA 98007-4209
Project Contact:
Daniel Harting, Director
danielhl@atworkwa.org
This Agreement includes the following, which are attached hereto and hereby incorporated by this
reference:
Attachment "A":
Scope of Work
Attachment "B":
Compensation
Attachment "C":
Insurance Requirements
Attachment "D":
General Terms and Conditions
Attachment "E":
Program agreement between DSHS and the county for DDCS services
Attachment "F":
DSHS/DRW Agreement
Attachment "G":
W-9 (Contractor must complete and return to the County for payment)
Kittitas County Agreement for Services (rev. 5/14/25)
Page 1 of 21
IN WITNESS WHEREOF, this Agreement has been executed by and on behalf of the parties through their
authorized representatives, effective as of the latest date written below.
KITTITAS COUNTY
BOARD OF COUNTY COMMISSIONERS
Chair
Vice -Chair
Commissioner
Date:
Attest:
Clerk of the Board
Kittitas County Agreement for Services (rev. 5/14/25)
Page 2 of 21
CONTRACTOR
Signature
Printed Name
Title
Date: X
ATTACHMENT "A"
SCOPE OF WORK
Provide community inclusion (CI) Services in accordance with DDCS Policy 4.11
Provide supported employment services through individual employment (IE) services or group supported
services (GSE), if applicable, in accordance with DDCS Policy 4.11
® Provide any other direct services in compliance with attachment "E" and "I"'
■ Ensure clients have a current IE, Cl, or GSE plan in place that includes the following:
o Person Centered assessment
o Clearly states the client's goal, who is responsible for what action steps.
o Based on the client's strengths and builds on their skills.
o The plan advances the client toward their goals and tracks their progress.
o Measurable outcomes that can be identified.
o Updated every 6 months to assess and revise as needed.
Contact clients according to their plan and provide case notes that center on the client's skills, gifts, interests,
desires and preferences for activities or work.
® Submit data and reports as requested by the county.
• Follow billable requirements per DDCS.
• Submit billing to county, monthly.
Participate in biennial county evaluation (monitoring) to meet the standards set forth on the DDCS County
Best Practices site.
® Comply with all applicable requirements in the contract between DDCS and Kit
titas County (Attachment Q.
o Comply with referenced RCW, WAC, DDCS policies, confidential information, data security, and
referenced materials.
® Comply with referenced documents found at DDCS internet site Count Best Practices ❑SH5 wa. ov .
Any service provider offering transportation must ensure that drivers hold valid driver's licenses and
have a background screening completed to include a driving abstract in order to safely perform the
services.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 3 of 21
ATTACHMENT "B"
COMPENSATION
THE COUNTY WILL NOT PROCESS PAYMENT FOR SERVICES RENDERED UNDER THIS AGREEMENT UNTIL
CONTRACTOR SUBMITS A COMPLETED W-9 (SEE ATTACHMENT "G").
As full compensation for satisfactory performance of the work described in Attachment "A", and within
thirty (30) days of receiving Contractor's itemized invoice, the County shall pay Contractor the following amount(s)
plus any applicable taxes as detailed in Contractor's invoice:
Individual Employment (IE) $108.80 per service hour
Group Supported Employment (GSE) $93.80 per service hour
Community Inclusion (CI) $66.08 per service hour
Unless otherwise provided herein, the Contractor shall be solely responsible for Contractor's travel and
related expenses.
Any uses of these funds outside of the listed allowable uses must be approved by Kittitas County in advance of the
expenditure, in writing.
All funds must be spent by June 30, 2027. No extension of the funding period will be granted.
Reimbursement Procedures
A. The Contractor will receive a billing template(s) each month from the Human Services Department of
Kittitas County Public Health.
B. The Contractor shall complete the billing templates each month and send to Laurie Holt
laurie.holt co.kittitas.wa.us by the 25th of the month following the calendar month in which services
were delivered.
C. The Contractor must provide an invoice for approval prior to the end of each month. Invoices may not
be processed for payment until after the end of the month
D. All invoices must include an invoice date and an invoice number.
E. Kittitas County Health Department will verify all invoices through AWA prior to processing payment.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 4 of 21
ATTACHMENT "C"
INSURANCE RE UIREMENTS
Contractor shall secure and maintain in effect at all times during performance of work under this
Agreement such insurance as will protect Contractor, its employees, and agents from all claims, losses, harm,
costs, liabilities, damages and expenses arising out of Contractor's performance under this Agreement, including
but not limited to personal injury (including death) or property damage.
All insurance shall be issued by companies admitted to do business in the State of Washington and have
a rating of A-, Class VII or better in the most recently published edition of Best's Reports unless otherwise approved
by the County. If an insurer is not admitted, all insurance policies and procedures for issuing the insurance policies
must comply with Chapter 48.15 RCW and 284-15 WAC.
At a minimum, Contractor shall maintain and provide proof of the following selected options:
® Commercial General Liability Insurance
■ Coverage limits are not less than:
• $1,000,000 per occurrence, for all covered losses
■ $2,000,000 general aggregate
■ $1,000,000 products & completed operations aggregate
$1,000,000 personal and advertising injury, each offense
The policy must be endorsed to include the County and its officials, employees and agents
as additional insureds.
® Commercial Automobile Liability Insurance
■ Automobile Liability for owned, non -owned, hired, and leased vehicles, with an MCS 90
endorsement and a CA 9948 endorsement attached if 'pollutants' are to be transported.
a Coverage limits are not less than:
$1,000,000 combined single limit
❑ Excess or Umbrella Liabilit
■ The Contractor shall provide Excess or Umbrella Liability coverage of $5,000,000. This
Excess or Umbrella Liability coverage shall apply, at a minimum, to both the Commercial
General and Automobile Insurance policy coverages. If used to meet limit requirements,
coverage must be at least as broad as specified for underlying coverages and must cover
those insured in the underlying policies.
■ This requirement may alternatively be satisfied through Contractor's primary Commercial
General and Automobile Liability coverage, or any combination thereof.
■ The policy must be endorsed to include the County and its officials, employees and agents
as additional insureds.
Coverage shall be "pay on behalf", with defense costs payable in addition to policy limits.
There shall be no cross -liability exclusion precluding coverage for claims or suits by one
insured against another.
® Workers' Com ensation & Em to ers Liability
■ The Contractor shall provide Workers Compensation and Employer's Liability insurance
on a state -approved policy form providing benefits as required by law with employer's
liability limits no less than $1,000,000 per accident or disease.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 5 of 21
❑ Professional Liability/ Errors and Omissions Liabilit
■ Coverage limits not less than:
7 $1,000,000 each claim
Contractor must provide evidence of this coverage on a policy form appropriate to
Contractor's profession.
Contractor shall furnish to the County a Certificate of Insurance, with endorsement where required above,
as evidence that policies providing insurance required by this Agreement are in full force and effect. Contractor's
insurance policies required above must apply on a primary non-contributing basis in relation to any other
insurance or self-insurance available to the County.
Contractor agrees to provide notice to the County at least thirty (30) days prior to cancellation, or any
material alteration or non -renewal, of any of the above -required insurance coverages.
Contractor shall assume full responsibility for all loss or damage from any cause whatsoever to any tools,
machinery, equipment, or motor vehicles owned or utilized by Contractor, or Contractor's agents, employees,
suppliers or contractors, as well as to any temporary structures, scaffolding and/or protective fences.
Contractor shall have sole responsibility for ensuring the insurance coverage and limits required herein
are also obtained by any subcontractors.
NOTE: Notwithstanding any other provision(s) of this Agreement, no contract shall form under this Agreement
until and unless the following are provided to the County: (1) a copy of the Certificate(s) of Insurance with all
required endorsements, properly completed and in the amounts required, and (2) where requested by the County,
a copy of the required insurance policies, including all required endorsements.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 6 of 21
ATTACHMENT "D"
GEIVERALTERMS AND CONDITIONS
1. Scope of Contractor's Services: Contractor agrees to provide to the County services as set forth in
Attachment "A". No materials, labor, or facilities will be furnished by the County, unless otherwise provided
herein. All work performed under this Agreement shall comply with applicable laws and regulations.
2. Accounting and Payment: Compensation to Contractor for services rendered under this Agreement
shall be as set forth in Attachment "B". Where Attachment "B" requires payment(s) by the County, payment shall
be based upon billings, supported unless provided otherwise in Attachment "B", by documentation of units of
work actually performed and amounts earned, including, where appropriate, the total number of hours for the
month and the total dollar payment requested. Unless specifically stated in Attachment "B", the County will not
reimburse 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 "B". In the event Contractor fails to perform any of its obligations under this Agreement within the
time specified herein, then the County may withhold all monies due and payable to Contractor until such failure
to perform is cured a otherwise adjudicated. The County will not process payment for services rendered under
this Agreement until Contractor submits a completed W-9 (See Attachment "G").
3. Taxes: Contractor understands and acknowledges that the County will not withhold Federal or State
income taxes from payments made to Contractor. Where required by State or Federal law, Contractor authorizes
the County to make withholding for anytaxes otherthan income taxes (e.g., Medicare). All compensation received
by Contractor will be reported to the Internal Revenue Service at the end of the calendar year in accordance with
applicable IRS regulations. It is the responsibility of Contractor to make its necessary estimated tax payments
throughout the year, if any, and Contractor is solely liable for any tax obligation arising from Contractor's
performance of this Agreement.
The County will pay sales and use taxes imposed on goods or services acquired here under as required by
law. Contractor must pay all other taxes, including but not limited to: business and occupation tax; or taxes based
on (1) Contractor's gross or net income, or (2) personal property to which the County does not hold title. The
County is exempt from federal excise tax.
4. Independent Contractor: Contractor's services shall be furnished by Contractor as an independent
contractor, and nothing stated herein shall be construed to create a relationship of employer -employee or a
guarantee of future employment. Contractor acknowledges that its entire compensation under this Agreement
is specified in Attachment B , and that Contractor is not entitled to any County benefits, including but not limited
to: vacation pay, holiday pay, sick leave pay, medical, dental, or other insurance benefits, or any other rights or
privileges afforded to Kittitas County employees.
S. Assignment and Subcontractin : No portion of this Agreement may be assigned or subcontracted to
any other individual, firm or entity without the express and prior written approval of the County. The Contractor
may only subcontract work contemplated under this agreement if it obtains the prior written approval of the
County. If the County approves subcontracting, the Contractor shall maintain written procedures related to
subcontracting, as well as copies of all subcontracts and records related to subcontracts. For cause, the County in
writing may require the Contractor to amend its subcontracting procedures as they relate to this agreement,
prohibit the Contractorfrom subcontracting with a particular person orentity, or require the Contractorto 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 comply with any applicable
Kittitas County Agreement for Services (rev. 5/14/25)
Page 7 of 21
term or condition of this agreement. The Contractors ha I I appropriately monitor the activities of the Subcontractor
to assure fiscal conditions of this agreement. In no event shall the existence of a subcontract operate to release
or reduce the liability of the Contractor to the County for any breach in the performance of the Subcontractor's
duties.
Every subcontract shall include a term that County is not liable for claims or damages arising from a
Subcontractor's performance of the subcontract.
6. Riizht to Review.• Maintenance of Records: This Agreement is subject to review by any Federal or State
auditor. The County or its designee shall have the right to review and monitor the financial and service
components of the work performed under this Agreement by whatever means are deemed expedient by the
County. Such review may occur with or without notice, and may include, without limitation, on -site inspection,
inspection of all records or other materials which the County deems pertinent, and any and all communications
with or evaluation by service recipients under this Agreement. Contractor shall preserve and maintain all records
relating to this Agreement for six (6) years after termination or expiration of the Agreement, and upon request
shall make them available for review by any Federal or State auditor, the County, and/or any persons authorized
by the County.
7. Modification
7.1. This Agreement may be amended by mutual agreement of the parties. Any such amendment
shall be in writing and signed by both parties.
7.2 The County may unilaterally amend this Agreement at any time by written notice ("Change
Notice") to Contractor, to modify the work to be performed under this Agreement, within the general scope of
the Agreement. Such changes may include, but are not limited to, changes in the exact scope of work to be
performed (including modification, substitution, addition, or deletion of required tasks) and changes to the
schedule of performance. If any such Change Notice causes an increase or decrease to Contractor's cost of, or the
time required for, performance of the work, an equitable adjustment in the compensation to Contractor and/or
in the schedule for the performance of the work shall be made by the County to reflect such an increase or
decrease. Notwithstanding any dispute or delay in arriving at a mutually acceptable equitable adjustment,
Contractor shall proceed in accordance with all Change Notices. Within thirty (30) days after receipt of any Change
Notice which, in Contractor's opinion, lacks adequate adjustment, Contractor must submit to the County a written
statement requesting a modified adjustment; otherwise, Contractor will forfeit its right to any such modified
adjustment. The County retains the final right to determine adjustments hereunder.
8. Termination
8.1 This Agreement may be terminated at any time by mutual written agreement of the parties.
8.2 The County, by giving written notice, may terminate this Agreement at any time without cause
and without further obligation to Contractor except for payment due for deliverables provided and/or services
performed prior to the effective date of termination. An equitable adjustment in the contracted price for partially
completed tasks will be made by the County, but such an adjustment shall not include compensation for loss of
anticipated profit on uncompleted work.
8.3 If Contractor defaults by failing to perform any of its obligations under this Agreement, or
becomes insolvent, is declared bankrupt or commits any act of bankruptcy or insolvency, or makes an assignment
for the benefit of creditors, the County may, by written notice to Contractor, terminate the Agreement, and at
the County's option, obtain performance of the work elsewhere. If the Agreement is terminated under this
paragraph, Contractor shall not be entitled to receive any further payments under this Agreement until all its
obligations hereunder have been fully performed, and any extra cost or damage to the County shall be deducted
Kittitas County Agreement for Services (rev. 5/14/25)
Page 8 of 21
from any money due or coming due to Contractor. Furthermore, in the event of termination under this paragraph,
Contractor shall bear the costs of any extra expenses incurred by the County in completing the work, and all
damages sustained, or which may be sustained, by the County.
8.4 Termination of this Agreement by any means provided herein shall not excuse any party's
performance of its obligations hereunder through the effective date of termination, except that the County shall
not be obligated to pay for services that have not been performed or deliverables that have not been provided.
9. Indemnification
9.1 To the fullest extent permitted by law, Contractor agrees to indemnify, defend and hold the
County and its departments, elected and appointed officials, employees, agents and volunteers, harmless from
and against any and all claims, damages, losses and expenses, including but not limited to court costs, attorney's
fees and alternative dispute resolution costs, for any personal or bodily injury, sickness, disease or death, for any
damage to or destruction of any property (including the loss of use resulting therefrom), and for any other claims,
damages, losses, and expenses sustained by the County, which (1) are caused in whole or in part by any act or
omission, negligent or otherwise, of Contractor, its employees, agents or volunteers, or Contractor's
subcontractors, their employees, agents or volunteers; or (2) are directly or indirectly arising out of, resulting
from, or otherwise connected with the performance of this Agreement; or (3) are based upon Contractor's or its
subcontractors' use of, presence upon or proximity to the property of the County. This indemnification obligation
of Contractor shall not apply in the limited circumstance where the claim, damage, loss or expense is caused by
the sole negligence of the County. This indemnification obligation of Contractor shall not be limited in any way by
the Washington State Industrial Insurance Act, RCW Title 51, or by application of any other workmen's
compensation act, disability benefit act or other employee benefit act, and Contractor hereby expressly waives
any immunity afforded by such acts. The foregoing indemnification obligations of Contractor are a material
inducement to the County to enter into this Agreement, are reflected in Contractor's compensation, and have
been mutually negotiated by the parties.
9.2 The County reserves the right, but not the obligation, to participate in the defense of any claim
for damages, losses or expenses, and such participation shall not constitute a waiver of Contractor's indemnity
obligations contained in any section of this Agreement.
9.3 In the event Contractor enters into subcontracts to the extent allowed under this Agreement,
each such subcontractor shall indemnify the County on a basis equal to or exceeding Contractor's indemnity
obligations to the County.
10. Venue and Choice of Law: In the event that any litigation should arise concerning this Agreement,
the venue for such action shall be in the Superior Court of the State of Washington in and forthe County of Kittitas.
This Agreement shall be governed by the laws of the State of Washington.
11. Non-Appropriationof Funds: If the County does not appropriate sufficient funding for this Agreement
for any future fiscal period, the County will not be obligated to make payments for services performed after the
end of the last fiscal period for which sufficient funding was appropriated. No penalty or expense shall accrue to
the County in the event this provision applies.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 9 of 21
12. Contractor Cammitments Warranties and Representations: Contractor represents and warrants as
follows:
12.1 Contractor is duly incorporated, validly existing and in good standing under the laws of the State
of Washington and has ail requisite corporate power and authority to enter into and to perform its obligations
under this Agreement.
12.2 Contractor has the authority to execute this Agreement, to make the representations and
warranties set forth herein, and to perform its obligations hereunder.
12.3 This Agreement has been validly executed by an authorized representative of Contractor and
constitutes a valid and legally binding and enforceable obligation of Contractor.
12.4 Contractor holds, or wi(i obtain prior to commencing work under this Agreement, such licenses,
permits and other authorizations from federal, state and local governmental authorities, or from any applicable
industrial or professional certification or licensing bodies, as are necessary for the lawful performance of its
obligations under this Agreement, and will maintain such throughout the term of this Agreement.
12.5 Contractor is not in violation of any applicable law, ordinance or regulation the consequence of
which will or may materially affect Contractor's ability to perform its obligations under this Agreement. Contractor
is not subject to any order or judgment of any court, tribunal or governmental agency which materially and
adversely affects its operations or assets in the State of Washington, or its ability to perform its obligations under
this Agreement.
12.6 Contractor is not presently debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded from covered transactions by any Federal or State department or agency.
12.7 None of the representations or warranties in this Agreement, and none of the docLIments,
statements, certificates or schedules furnished by Contractor in connection with the performance of the
obligations contemplated under this Agreement, contains or will contain any untrue statement of a material fact
or omits or will omit a material fact necessary to make the statements of fact contained therein not misleading.
13. Ownership of Items Produced: All writings, programs, data, reports, films, recordings, or other
materials prepared by Contractor and/or its consultants or subcontractors, in connection with the performance
of this Agreement, shall be the sole and absolute property of the County. The County will have all rights of
ownership therein, including but not limited to the right to use, copyright, trademark, and/or patent, and the
ability to transfer any or all ownership rights.
14. Intellectual Property Infrin ement: Contractor will defend and indemnify the County from any
claimed action, cause or demand brought against the County, to the extent such action is based on the claim that
information and/or materials supplied by Contractor infringe any intellectual property rights of any third
party(ies). Contractor will pay all costs and damages attributable to any such claims finally awarded against the
County in any action. Such defense and payments are conditioned upon the following: (1) Contractor shall be
notified promptly in writing by the County of any notice of such claim; and (2) Contractor shall have the right
hereunder, at its option and expense, to obtain for the County the right to continue using the information and/or
materials that are the subject of such claim, provided no reduction in performance or loss results to the County.
15. Use of County Name and Logo: Contractor may not use the County's name, logo(s), trademark(s), or
other identifying information, or identify the County as a current or former client, on its website or in any
marketing or promotional materials without the prior written consent of the County.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 10 of 21
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
by a dispute board ("Dispute Board") in the following manner: Each party shall appoint one memberto the Dispute
Board, the members so appointed shall jointly appoint an additional member to the Dispute Board, and the
Dispute Board will evaluate the facts, Agreement terms, and all applicable statutes and rules, and make a
determination as to the proper resolution of the dispute. Such determination shall be final and binding on both
parties. The cost of resolution will be borne as allocated by the Dispute Board. Alternatively, if agreed to in writing
by both parties, the parties may forego the option of establishing a Dispute Board to adjudicate the dispute, and
instead pursue arbitration, jointly selecting an arbitrator acceptable to both parties. In the event the parties
choose to pursue arbitration, the parties agree that: (1) the fees and expenses of the arbitrator shall be shared
equally by both parties to this Agreement, (2) each party shall bear its own costs and attorney fees, (3) arbitration
shall be conducted according to the commercial arbitration procedures of the American Arbitration Association,
and (4) the arbitrator's decision or award shall be final and binding on both parties.
17. Confidentiality: Contractor, its employees, agents and volunteers, and any of Contractor's
subcontractors and their employees, agents and volunteers, shall maintain the confidentiality of all information
provided by the County or acquired by Contractor in performance of this Agreement, except upon the prior
written consent of the Kittitas County Prosecuting Attorney or an order entered by a court after having acquired
jurisdiction over the County. Contractor shall immediately provide the County notice of any judicial proceedings
seeking disclosure of such information. Contractor agrees to indemnify, defend and hold harmless the County
and its departments, elected and appointed officials, employees, agents and volunteers from all loss or expense,
including but not limited to settlements, judgments, setoffs, attorneys' fees and costs resulting from Contractor's
breach of this provision. Notwithstanding the foregoing, and to the extent that any information obtained by the
Contractor hereunder is required to be shared with others by the explicit terms of the Scope of Work, this
provision shall not be construed as prohibiting such sharing, provided there are no applicable laws or regulations
prohibiting same.
18. Notices: Written notices required or permitted to be provided by one party to the other party under
this Agreement may be provided by personal delivery, legal courier service, or certified mail, postage prepaid and
return receipt requested. Notice may be provided by regular first class mail if simultaneous notice is provided by
email. Notices given by Contractor shall be provided to the County's point of contact listed on page 1 of this
Agreement, at the address there listed, and to the department head of the county department for which services
under this Agreement are rendered. Notices given by the County shall be provided to Contractor at Contractor's
address listed on page 1 of this Agreement.
19. Prevailing Wage: Where labor to be performed under this Agreement is considered "public work" as
defined in RCW 39.04.010, Contractor shall pay the prevailing rate of wages to all workers, laborers, or mechanics
employed in the performance of work under this Agreement in accordance with RCW 39.12 and the rules and
regulations of the Washington State Department of Labor and Industries. The schedule of prevailing wage rates
for the applicable locality or localities is determined by the Industrial Statistician of the Department of Labor and
Industries. It is Contractor's responsibility to verify the applicable prevailing wage rate. It is understood that
Contractor is responsible for obtaining and completing all required government forms relating to prevailing wage
and submitting same to the proper authorities. Disputes regarding prevailing wage rates shall be referred for
arbitration to the Director of the Department of Labor and Industries. The arbitration decision shall be final and
conclusive and binding on all parties involved in the dispute as provided for in RCW 39.12.060.
20. Standard of Care: Contractor shall perform its duties hereunder in a manner consistent with that
degree of care and skill ordinarily exercised by members of the same profession or industry as Contractor currently
Kittitas County Agreement for Services (rev. 5/14/25)
Page 11 of 21
practicing or working under similar circumstances. Contractor shall, without additional compensation, correct any
of its services not meeting such a standard.
21. Nondiscrimination
21.1 In the performance of this Agreement, Contractor will not discriminate against any employee or
applicant for employment on the grounds of age, race, creed, color, national origin, citizenship or immigration
status, sex, sexual orientation, marital status, honorably discharged veteran or military status, or the presence of
any sensory, mental or physical disability or the use of a trained dog guide or service animal by a person with a
disability; provided that the prohibition against discrimination because of such disability shall not apply if the
particular disability prevents the proper performance of the particular worker involved. Contractor shall ensure
that applicants are employed, and that employees are treated during employment, without discrimination
because of their age, race, creed, color, national origin, citizenship or immigration status, sex, sexual orientation,
marital status, honorably discharged veteran or militarystatus, orthe presence of any sensory, mental or physical
disability or the use of a trained dog guide or service animal by a person with a disability. Such requirements
apply, without limitation, to the following: employment, promotion, demotion, transfer, recruitment or
recruitment advertising, layoff or termination, rates of pay or other forms of compensation, and programs for
training, including apprenticeships. Contractor shall take such action with respect to this Agreement as may be
required to ensure full compliance with local, state and federal laws prohibiting discrimination in employment.
21.2 Contractor will not discriminate against any recipient of any services or benefits provided for
under this Agreement on the grounds of age, race, creed, color, national origin, citizenship or immigration status,
sex, sexual orientation, marital status, honorably discharged veteran or military status, or the presence of any
sensory, mental or physical disability or the use of a trained dog guide or service animal by a person with a
disability.
21.3 If any assignment and/or subcontracting has been authorized by the County, said assignment or
subcontract shall include appropriate safeguards against discrimination.
22. Waiver: The waiver of any default or breach of this Agreement, or the failure of a party to enforce
any provision hereof or to exercise any right or privilege hereunder, shall not be deemed to waive any prior or
subsequent default or breach, the enforcement of any provision hereof, or the exercise of any right or privilege
hereunder, unless otherwise stated in a writing, signed by the parties hereto.
23. Headiness: The headings of sections and paragraphs of this Agreement are for convenience of
reference only and are not intended to restrict, affect, or be of any weight in the interpretation or construction of
the provisions of such sections or paragraphs.
24. Survival: The provisions of paragraphs 2, 3, 4, 6, 8, 9, 10, 13, 14, 15, 16, 17, 19, 20, 22, 24, and 28 of
these General Terms and Conditions shall survive the completion, expiration, termination or cancellation of this
Agreement for any reason.
25. Complete Agreement: This Agreement constitutes the entire agreement between the parties and
supersedes any and all other agreements, understandings, negotiations and discussions, oral or written, express
or implied, regarding the work to be performed hereunder. The parties agree that no other representations,
inducements, promises, agreements, 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.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 12 of 21
26. 5everabilit If any term or condition of this Agreement or the application thereof to any person(s)
or circumstances is held invalid, such invalidity shall not affect other terms, conditions or applications which can
be given effect without the invalid term, condition or application. To this end, the terms and conditions of this
Agreement are declared to be severable.
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. 5/14/25)
Page 13 of 21
Attachment E
COUNTY
DSHS W TSHINGTON STATE PROGRAM AGREEMENT
Depanment or Soclal
and Health Services
DDCS County Services
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 General Terms and Conditions,
which is incorporated by reference.
DSHS ADMINISTRATION DSHS DIVISION DSHS INDEX NUMBER
Developmental Disabilities
Admin
DSHS CONTACT NAME AND TITLE
Seanna Woodard
Operations Manager
DSHS CONTACT TELEPHONE
509 329-2952
COUNTY NAME
Division of Developmental 1225
Disabilities i -
DSHS CONTACT ADDRESS
1611 W Indiana Ave
Spokane, WA 99205
CONTACT FAX
COUNTY ADDRESS
DSHS Agreement Number
2663-71228
Administration or Division
Agreement Number
County Agreement Number
DSHS CONTRACT CODE
1769CS-63
DSHS CONTACT E-MAIL
woodas0dshs.wa.gc
Kittitas County 507 North Nanum Street Suite 102
Kittitas County DDA County Services Ellensburg, WA 98926-2886
COUNTY FEDERAL EMPLOYER IDENTIFICATION COUNTY CONTACT NAME
NUMBER
Kasey Knutson
COUNTY CONTACT TELEPHONE COUNTY CONTACT FAX COUNTY CONTACT E-MAIL
509 962-7090 509 962-5883 kasel.knutson@co.kittitas.wa.us
IS THE COUNTY A SUBRECIPIENT FOR PURPOSES OF THIS PROGRAM ASSISTANCE LISTING NUMBERS
AGREEMENT?
No
PROGRAM AGREEMENT START DATE PROGRAM AGREEMENT END DATE MAXIMUM PROGRAM AGREEMENT AMOUNT
07/01 /2026 06/30/2027 $1, 021,440.00
EXHIBITS. The following Exhibits are attached: Exhibit A — Data Security Requirements; Exhibit B — Budget and
Spending Plan
By their signatures below. the parties agree to the terms and conditions of this County Program Agreement and all
documents incorporated by reference. No other understandings or representations, oral or otherwise, regarding the
subject matter of this Program Agreement shall be deemed to exist or bind the parties. The parties signing below certify
that the are authorized t0 51 n this Pra ram A feement. DATE(S) SIGNED
COUNTY SIGNATURE(S) PRINTED NAME(S) AND TITLE(S)
DSHS SIGNATURE
DSHS Central Contract Services
1769CS County Agreement (12-26-2025)
PRINTED NAME AND TITLE
SIGNED
Page 1
Special Terms and Conditions
Definitions Specific to Program Agreement: The words and phrases listed below, as used in this
Program Agreement, shall each have the following definitions:
a. "Acuity Level" means the level of a Client's abilities and needs as determined through the DDCS
assessment.
b. "ALTSA Web Access (AWA)" means a web -based portal to the Developmental Disabilities
Community Services CARE system designed to support county services for DDCS clients.
c. "Additional Consumer Services" refers to indirect Client service types as follows:
(1) "Community Information and Education": Activities to inform and/or educate the general public
about developmental disabilities and related services. These may include information and
referral services; activities aimed at promoting public awareness and involvement; and
community consultation, capacity building and organization activities.
(2) "Training": To increase the job related skills and knowledge of staff, providers, volunteers, or
interning students in the provision of services to people with developmental disabilities. Also to
enhance program related skills of board or advisory board members.
(3) "Other Activities" reserved for special projects and demonstrations categorized into the following
types:
(a) Infrastructure projects: Projects in support of Clients (services not easily tracked back to a
specific working age Client) or that directly benefit a Client(s) but the Client is not of working
age. Examples include planning services like generic job development e.g. "Project
Search".
(b) Start-up projects: Projects that support an agency or directly benefit the agency. Examples
include equipment purchases and agency administrative support.
(c) Partnership Project: Collaborative partnerships with school districts, employment providers,
DVR, families, employers and other community collaborators needed to provide the
employment supports and services young adults with developmental disabilities require to
become employed during the school year they turn twenty-one (21).
d. "Budget and Accounting Reporting System (BARS)" means a master classification of balance
sheet, revenue and expenditure/expense accounts.
e. "Client" means a person with a developmental disability as defined in chapter 388-823 WAC who is
currently eligible and active with the Developmental Disabilities Community Services or is an
identified PASRR Client.
f. "Competitive Integrated Employment" means work performed by a Client on a part-time or full-time
basis. within an integrated setting within the community that meets HCBS settings requirements.
The Client must be compensated at minimum wage or higher, using the higher of the Federal,
State, or local rate, and at a rate comparable to the wage paid to non -disabled workers performing
the same tasks, including receiving the same benefits and opportunities for advancement.
g. "Consumer Support" refers to direct Client service types as follows:
(1) "Community Inclusion" or "Cl": means individualized services provided in integrated community
settings with other individuals without disabilities. The activities are based on Client interests
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Special Terms and Conditions
and provide opportunities typically experienced by the general public of similar age in their local
community, accessible by public transit or a reasonable commute from their home. The goal of
the service is to support clients to participate, contribute, and develop relationships with
community members who are not paid staff. These services may be authorized for individuals
age 62 and older. These services may be authorized in addition to or instead of employment
support (Individual Employment or Group Supported Employment) for working age individuals
who have received nine months of employment support.
(2) "Child Development Services" or "CDS": Birth to three services are designed to meet the
developmental needs of each eligible child and the needs of the family related to enhancing the
child's development. Service may include assistive technology, audiology, family training/home
visits, health services, medical services, nursing services, nutrition services, occupational
therapy, physical therapy, psychological services, sign language, social work, special
instruction, speech -language pathology, vision, and transportation. Services are provided in
natural environments to the maximum extent appropriate.
(3) "Individual Supported Employment" or °IE": services are a part of a Client's pathway to
employment and are tailored to individual needs, interests, and abilities, and promote career
development. These are individualized services necessary to help persons with developmental
disabilities obtain and continue integrated employment at or above the state's minimum wage in
the general workforce. These services may include intake, discovery, assessment, job
preparation, job marketing, job supports, record keeping and support to maintain a job.
(4) "Individualized Technical Assistance' or "ITA": services are a part of a Client's pathway to
individual employment or community inclusion. This service provides assessment and
consultation to the provider to identify and address existing barriers to employment or
community inclusion. This is in addition to supports received through supported employment or
community inclusion services for Clients who have not yet achieved their goal.
(5) "Group Supported Employment' or "GSE": services are a part of a Client's pathway to integrated
jobs in typical community employment. These services are intended to be short term and offer
ongoing supervised employment for groups of no more than eight (8) workers with disabilities in
the same setting. The service outcome is sustained paid employment leading to further career
development in integrated employment at or above minimum wage. Examples include
enclaves, mobile crews, and other business models employing small groups of workers with
disabilities in integrated employment in community settings.
h. "County" is the political subdivision of the state of Washington and the county or counties entering
into this Program Agreement.
i. "DDCS Case Resource Manager (CRM)" means a case manager for DDCS Clients.
j. "County Service Authorization (CSA)" means an authorization for county services.
k. "Developmental disabilities (DD)" means a disability attributable to intellectual disability, cerebral
palsy, epilepsy, autism, or another neurological or other condition of an individual found by the
secretary to be closely related to an intellectual disability or to require treatment similar to that
required for individuals with intellectual disabilities, which disability originates before the individual
attains age eighteen, which has continued or can be expected to continue indefinitely, and which
constitutes a substantial limitation to the individual.
I. "Developmental Disabilities Community Services "DDCS" means a division within the Department of
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Special Terms and Conditions
Social and Health Services.
m. "DDCS Regional office (DDCS Region)" means the regional DDCS office that supports DDCS
clients.
n. "Division of Vocational Rehabilitation (DVR)" means a division within the Department of Social and
Health Services
o. "Employment Outcome Payment" means a payment to providers for transition students born
between specific dates; have high acuity; are authorized for Individual employment; and student
obtains a competitive integrated job within a specific timeframes. If the job is a minimum of ten
hours of work per week an additional amount will be include in the payment.
p. "General Terms and Conditions" means the contractual provisions contained within that agreement,
which govern the contractual relationship betrveen DSHS and the county.
q. "High Acuity Client" means a DDCS Client who requires significant and intensive support in the
community, often due to complex needs, as determined through the DDCS assessment.
r. "Medicaid Home and Community Based Services (HCBS)" means services that occur in a Client's
home or community rather than institutions or other isolated settings. These programs serve a
variety of targeted populations groups, such as people with intellectual or developmental
disabilities, physical disabilities, and/or mental illnesses
s. "Job Foundation Report' is a document derived from em to ment readiness activities performed by
students who are between ages 19 through 20 that identifies actionable next step for employment.
The employment service providers developing the Job Foundation report will be supporting
students with employment activities on average of 35 hours.
t. "Preadmission Screening and Resident Review (PASRR)" means individuals with intellectual
disabilities or related conditions (ID/RC) who have been referred for nursing facility (NF) care.
u. Person Centered Service Plan or PCSP" means a document that authorizes and identifies the
DDCS paid services to meet a Client's assessed needs. Formerly referred to as the Individual
Support Plan.
v. "Quality Assurance means an adherence to all Program Agreement requirements, including DDCS
Policy 6.13, Provider Qualifications for Employment and Day Program Services, County Guidelines
and the Criteria for Evaluation, as well as a focus on reasonably expected levels of performance,
quality, and practice.
w. "Quality Improvement" means a focus on activities to improve performance above minimum
standards and reasonably expected levels of performance, quality and practice.
x. "Service Provider" is a qualified Client service vendor who is contracted to provide Employment and
Day Program services.
y. "Subcontractor" is the service provider contracted by the County to provide services.
2. Purpose: This Program Agreement is entered into between the Developmental Disabilities Community
Services and the County in accordance with chapter 71 A.14 RCW. Its purpose is to advance the state
legislative policy to provide a coordinated and comprehensive state and local program of services for
persons with developmental disabilities.
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Special Terms and Conditions
3. Client Eligibility: Client eligibility and service referral are the responsibility of DDCS under chapter
388-823 WAC (Eligibility) and chapter 388-825 WAG (Service Rules). Only persons referred by DDCS
shall be eligible for direct Client services under this Program Agreement. It is DDCS's responsibility to
determine and authorize the appropriate direct service(s) type. Direct Client services provided without
a current County Service Authorization are not reimbursable under this Program Agreement.
4. Credentials and Minimum Requirements:
a. Administration of the developmental disabilities County program cannot be subcontracted.
b, Qualified DD Program Coordinator: A qualified DD program coordinator has a minimum of five
years training and experience in the administration and/or the delivery of developmental disabilities
services to a community. For a county where the coordinator administers more than one program
area (e.g. Chemical Dependency, Mental Health, Developmental Disabilities), training and
experience in administration and/or a related Human or Social service may be considered.
c. Administration Responsibility: The County must demonstrate the ability to administer the program
agreement including contract oversight and monitoring, community outreach and education
activities, and regular communication with the DDCS Regional Office (DDCS region) and contracted
providers.
d. Fiscal Responsibility: The County must demonstrate the ability to safeguard public funds including
maintaining books, records, documents and other materials relevant to the provision of goods and
services.
e. Sufficient Policies and Procedures for establishment and maintenance of adequate internal control
systems: The County will maintain written policy procedural manuals for information systems,
personnel, and accounting/finance in sufficient detail such that operations can continue should
staffing change or absences occur. Policies shall be dated and include dates when updated.
f. Background/Criminal History Check: A background/criminal history clearance is required every
three years for all employees (including D❑ program County staff), subcontractors, and/or
volunteers who may have unsupervised access to vulnerable DSHS Clients, in accordance with
RCW 43.43.830-845, RCW 74.15.030. and chapter 388 WAC. If the entity reviewing the application
elects to hire or retain an individual after receiving notice that the applicant has a conviction for an
offense that would disqualify the applicant from having unsupervised access to vulnerable adults as
defined in chapter 74.34 RCW, then DDCS shall deny payment for any subsequent services
rendered by the disqualified individual provider. The DSHS Background Check Central Unit (BCCU)
must be utilized to obtain background clearance.
g. Qualified Advisory Board Members: A Developmental Disabilities advisory board shall include
members knowledgeable about developmental disabilities. No board member shall have a contract
with the County to provide Training, Community Information Activities, and Consumer Support as
defined in this Program Agreement, and shall not be a board member, officer, or employee of an
agency subcontracting with the County to provide such services.
h. Qualified Service Providers: The County assures that all service providers meet qualifications as
outlined in the DDCS Policy 6.13, Program Qualifications for Employment and Day Program
Providers.
Home and Community Based Waiver Services Assignment of Medicaid Billing Rights: The County
assures that each subcontractor has agreed to assign to DDCS its Medicaid billing rights for
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Special Terms and Conditions
services to DDCS Clients eligible under Title XIX programs in this Program Agreement. Written
documentation shall be available to DSHS on request.
j. Reporting Abuse and Neglect: The County staff and its subcontractors who are mandated reporters
under RCW 74.34.020(13) must comply with reporting requirements described in RCW 74.34.035,
.040 and chapter 26.44 RCW. If the County is notified by DSHS that a subcontractor staff member
is cited or on the registry for a substantiated finding, then that associated staff will be prohibited
from providing services under this Program Agreement.
k. Counties who provide Child Development Services (birth to three early intervention services), must
provide those services under the regulations implementing the Individuals
with
Disabilities
and Tiddler
Education Act (IDEA), Part C, and Washington State's Early Support
Federally Approved Plan.
I. The County staff who perform evaluations of subcontractor work sites will promptly report to DSHS
per DDCS Policy 6-08, Incident Management and Reporting Requirements for County and County -
Contracted Providers, if:
(1) They have reasonable cause to believe that abandonment, abuse, financial exploitation or
neglect (as defined in RCW 74,34.020) of a person who has a developmental disability (as
defined in RCW 71A.10.020) has occurred, and,
(2) If they have reason to suspect that sexual or physical assault of such a person has occurred,
they shall also immediately report to the appropriate law enforcement agency.
m. Counties are specifically authorized to have data storage on portable devices or media in
accordance with the Data Security Requirements.
n. Order of Precedence: In the event of any inconsistency in this Program Agreement and any
attached exhibits, unless otherwise provided herein, the inconsistency shall be resolved by giving
precedence, in the following order, to:
(1) County Program Agreement; and
(2) Attached Exhibits.
5. Duty to Disclose: Under 42 CFR §455.104, the Administration must obtain certain disclosures and
complete required screenings to ensure the State does not pay federal funds to excluded person or
entities. The County is required to provide disclosures from managing employees, specifically the
persons in the positions of Developmental Disabilities Director and Fiscal/Budget Director, i.e. the
person who authorizes expenditures. A completed Medicaid Provider Disclosure Statement, DSHS
Form 27-094, should be submitted to the Administration to complete the required screenings.
Disclosures must be provided at contract renewal and within thirty-five (35) days whenever there is a
change in the staff holding these management positions [42 CFR 455.104 (c)(1)].
6. Statement of Work: The County shall provide the services and staff, and otherwise do all things
necessary for or incidental to the performance of work, as set forth below. Working collaboratively and
sharing information as needed for service coordination, the parties shall administer DID services within
the county as set forth below:
a. The DDCS region shall:
(1) Review subcontractors and shall immediately notify the County of any concerns with the Page 6
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1769CS County Agreement (12-26-2025)
Special Terms and Conditions
subcontractors identified by the County;
(2) Inform and include the County in the discharge planning of Client's leaving institutions and
returning to the community who will need program funding;
(3) Inform the County of Client's who have had their waiver status changed;
(4) Work with the County when referring Client's for services and will withdraw referrals when
authorization is not issued;
(5) Authorize new service within 5 working days and will extend existing service authorization
before expiration date;
(6) Inform Clients of service changes through Planned Action Notice(s);
(7) Work with the County to document planned services in the Client's Person Centered Service
Plan including notification of assessment dates;
(8) Work with the County when terminating services;
(9) Work with DDCS Head Quarters and the County on Spending Plan adjustments; and
(10) Work with the County in participating in evaluation of direct service providers.
b. The County shall:
(1) Work with the DDCS Region when Clients are referred for services, authorized services, and/or
for support modifications;
(2) Work with the DDCS Region to document planned services in the Client's Person Centered
Service Plan;
(3) Assist with informing the DDCS Region of any potential service level changes not documented
in the Client's DID Assessment prior to any changes;
(4) Work with the DDCS Region regarding service termination;
(5) Work with the DDCS Head Quarters on Spending Plan adjustments;
(6) Inform the DDCS Region of new providers to be included on the ALTSA Web Access (AWA)
system;
(7) Notify the DDCS Region of any intent to terminate a subcontractor who is serving a DDCS
referral;
(8) Provide a copy of each subcontractor's contract upon written request from DDCS; and
(9) Notify and work with the DDCS Regional Employment Specialist when performing evaluations of
direct service providers.
c. Compliance with Budget and Accounting Reporting System Policies: The County shall take any
necessary and reasonable steps to comply with BARS Policies.
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d. The County shall comply with the following referenced documents:
(1) DDCS Policy 4.11, County Services for Working Age Adults;
(2) Chapter WAC 388-850, chapter 388-828 WAC, WAC 388-845-0001, 0030, 0210, 0215, 0220,
0600-0610, 1030-1040, 2100, 2110;
(3) Criteria for Evaluation;
(4) ❑DA Guiding Values•
(5) Counv Guide to Achieve ❑DA's Guiding Values;
(6) ❑DA Guidelines for Community Assessments within Employment and Vocational Pro rams and
(7) Disability Rights Washington former) Wash in ton Protection and Advocac System) Access
Agreement.
e. The County shall develop and submit a comprehensive plan for the County DD Services as
required by WAC 388-850-020.
f. Conveyance of The Estimated Number of People to be Served and Targeted Outcomes: The
County shall submit the Service Information Forms (SIF's) (provided by DDCS at Internet site
https:tiwww.dshs.wa.gov/dda/counly-best-practices) to indicate the estimated number of people to
be served, targeted outcomes, and identified goal(s) that focus on quality improvement within the
categories of Training, Community Information, Direct Client Services, and Other Activities within 30
days of execution of the Program Agreement. Once approved, the SIF outcomes may be modified
only by mutual agreement of the County and the DDCS Region.
g. Solicitation for Qualified Employment and Day Program Service Providers: Requests for
Applications (RFAs), Requests for Information (BFI's) and/or Requests for Proposals (RFPs),
Requests for Qualifications (RFQ's) for direct services, excluding Child Development, will be open
continuous enrollment.
h. Qualified Providers: A qualified provider must be a county or an individual or agency contracted
with a county or DDCS.
L Technical Assistance: DDCS contracts with Technical Assistance providers that may be utilized by
Counties with prior written approval.
}. Subcontractors: The County will pass on all applicable contractual requirements that are between
DDCS and the County to the subcontractor. The County shall immediately notify the DDCS Region
of the County's intent to terminate a subcontractor who is serving a DDCS referral. Individuals or
agencies contracted with a county or DDCS may not subcontract for Employment or Community
Inclusion services.
k. The County shall provide or contract with qualified Employment and Day Program Service
Providers for consumer support services that include the following program outcomes:
(1) Monthly Community Inclusion (CI) service support hours will be based on the Client's Cl service
level per WAC 388-828-9310 for all Clients who began receiving Cl services July 1, 2011 and
forward.
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(a) To ensure health and safety, promote positive image and relationships in the community,
increase competence and individualized skill -building, and achieve other expected benefits
of Cl, services will occur individually or in a group of no more than two (2) or three (3)
Client's with similar interests and needs.
(b) Cl services will focus on activities that are typically experienced by the general public.
Support to participate in segregated activities and/or specialized activities will not be
reimbursed.
(2) Clients in an employment program will be supported to work towards a living wage. A living
wage is the amount needed to enable a Client to meet or exceed living expenses. Clients
should be supported to average twenty (20) hours of community work per week or eighty-six
(86) hours per month; however, each person's preferred hours of employment should be taken
into consideration. The amount of service a Client receives will be based on his/her
demonstrated need, acuity level and work history per WAC 388-828.
(3) The Client's DDCS PCSP is the driver for service. The AWA County Service Authorization
(CSA) and updated Planned Rates information will not exceed the Client's DDCS PCSP.
Service changes will not occur until the Client has received proper notification from DDCS.
(4) All Clients will have an Individualized Employment and/or Community Inclusion plan to identify
Client's preferences. Minimum plan elements are outlined in the reference document "Criteria
for an Evaluation." A copy of the Client's individualized plan will be provided to the Client, their
DDCS Case Resource Manager (CRM), guardian and others as appropriate.
(5) Six-month progress reports describing the progress made towards achieving Client's goal will
be provided by the service provider to the CRM, Client, and/or guardian, if any, within 30 days
following the six-month period. The report will summarize activities and outcomes made towards
the Client's individualized goal(s).AII Clients will be contacted by their service provider according
to Client need and at least once per month.
(6) All Clients will be contacted by their service provider according to Client need and at least once
per month.
(7) If Clients in Individual Employment or Group Supported Employment, have not obtained paid
employment at minimum wage or higher within six (6) months, the County will assure the
following steps are taken:
(a) Review the progress toward employment goals;
(b) Provide evidence of consultation with the Client/guardian; and
(c) Develop additional strategies with the Client/guardian, county staff, employment support
staff, case manager, and others identified by the Client. Strategies may include providing
technical assistance, changing to a new provider, and/or providing additional resources as
needed to support the Client's pursuit of employment. The additional strategies will be
documented for each Client and kept in the Client's file(s).
(8) If after twelve (12) months the Client remains unemployed, an additional review will be
conducted. The provider will address steps outlined in the previous six month progress report in
the next six month progress report. When requesting to participate in Cl, the Client shall
communicate directly with his or her DDCS Case Manager. The DDCS Case Manager is
responsible for authorizing Cl services.
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(9) For Individual Employment where the service provider is also the Client's employer, long term
funding will remain available to the service provider employer for six months after the employee
DDCS Client's date of hire. At the end of the six-month period, if the DDCS Client continues to
need support on the job, another service provider who is not the employer of record must
provide the support unless the County or DDCS issues prior written approval for the service
provider to continue to provide long-term supports if needed_ If the County or DDCS approves
the continuation of long-term supports where the service provider is also the Client's employer,
the County or DDCS will regularly monitor these positions to assure fading efforts occur when
appropriate and any potential conflict of interest is addressed.
(10) Individual Employment staff hours must be attributed to the "Individual Em to meat and Billable
Activity Phase(
(11) For Group Supported Employment (GSE), Clients must have paid work. The total number of
direct service staff hours provided to the group should be equal to or greater than the group's
collective amount of individual support monthly base hours. If the direct service staff hours are
less than the collective amount, then the provider will be reimbursed only for the number of hours
staff actually provided.
(a) The collective group's individual hours should be the minimum staff hours delivered to
support the group.
(b) A GSE Client must be on-site/at work at least their base individual hours as a minimum per
month. If a Client is not on-site/at work for all of their base hours, the county should verify
that the provider delivered the collective group's individual hours to the group (what was the
number of staff hours provided to the group during the month? If it was less than the
collective group's total the provider can only bill for the staff hours that were provided).
(c) A GSE agency may not bill for a GSE Client who does not receive services during an entire
service month.
(d) A GSE agency must have a record of which staff is supporting which Clients on any given
day.
(e) A GSE agency must have supportive documentation that provides clear evidence of support
helping with specific activities as identified in the Client plan to move a Client on their
pathway towards their employment goal(s).
(f) Running a GSE service is a part of the business operation and not billable to Clients
(contract procurement, contract maintenance, or administration functions associated with
GSE).
(g) Individual time in the community working towards the individual employment goal, separate
from the group time, must include phase information (refer to Employment Phases and
Billable Activities - see Phases 1 — 4 for element I activity description).
(12) Employment and day services must adhere to the Home and Community Based settings
(HCBS) requirements of42 C.F.R. Section 441.301(c)(4), including that:
(a) The setting is integrated in the greater community and supports Client's to have full access
to the greater community;
(b) Ensures the Client receives services in the community to the same degree of access as
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individuals not receiving Medicaid HCBS;
(c) The setting provides opportunities to seek employment and work in competitive integrated
settings; and
(d) The setting facilitates individual choice regarding services and supports, and who provides
them.
Quality Assurance and Service Evaluation: The County shall develop and have available an
evaluation system to review services. The evaluation system must have both a Quality Assurance
and a Quality Improvement component, and both must include objective measures. The objective
measures at a minimum will include performance indicators, by acuity, that include the number of
new jobs; job loss and reasons for job loss; the percentage employed earning minimum wage or
better; and the average number of hours worked. The County's service evaluation system shall
serve as the method by which current providers demonstrate that they continue to be qualified
providers. A copy of description of such evaluation system shall be provided upon request to DDCS
for review.
m. Evaluation: The County shall evaluate and review services delivered to reasonably assure
compliance and quality. The County shall conduct at least one visit to each subcontractor every two
(2) years excluding Child Development Services subcontractors. The County shall conduct at least
one visit to Child Development Services providers every three (3) years. The County shall maintain
written documentation of all evaluations, recommendations and corrective action plans for each
subcontractor. Copies of such documentation will be provided to the DDCS upon request.
n. The County shall work with local developmental disability advisory groups to plan for and coordinate
services.
o. The County shall participate in regularly scheduled meetings between County DID staff and DDCS
staff to remain updated and current including ACHS and Regional Meetings.
p. AWA Data System: In compliance with the AWA Training Manua, the County shall use the AWA
data system for all:
(1) Billing requests;
(2) Service provider address and phone number maintenance;
(3) Evaluation dates;
(4) Employment outcome information; and
(5) Monthly provide all data described in the Billing Instructions and in the Employment Outcomes
Instructions, which is hereby incorporated by reference.
q. Assure the integrity of data submitted to the State. When data is submitted and rejected due to
errors or an error is later identified, the County will correct and resubmit the data within thirty (30)
days.
r. Review and respond the AWA "Work List" items within 5 working days including Referrals and
pending Authorization.
s. Review the AWA "Ticklers" Planned Rate tab and update the planned rate within 5 working days
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after the Planned Rate start date.
t. Partnership Project.
(1) A Job Foundation document will be completed per guidelines for eligible students. Eligible
students are DDCS clients who were born between:
(a) For fiscal year 2026 9/1/05 through 8/31/06
(b) For fiscal year 2027 9/1/06 through 8/31/07
These students currently attending school and have completed an application to participate in
this Value Based Payment (VPB) project. The VBP project application will include the following
minimum criteria identified in the sample application found at:
htt s://www.dshs.wa, ovisites/default/files/DDA/dda/do -,uments/Job%20FDundation%2OApplica
tion 040720%20%28002%29.docx
(2) Qualified providers will collaborate with School District staff to complete the Job Foundation
document and then provide a copy to the County. To be a qualified provider for the Partnership
Project the Counties must require the provider to have a current contract with the Division of
Vocational Rehabilitation; a contract in good standing with the County and cannot be in
provisional status; a minimum of two years' experience providing Individual Employment with
demonstrated job placement skills. The Job Foundation recommendation will only have
actionable next steps towards integrated competitive employment.
(3) County participating in the Partnership Project must have the ability to work collaboratively with
School Districts to identify DDCS students in high school, collect and track information, be
proficient in electronic spreadsheets, and ability to evaluate if completed Job Foundation
document(s) meet quality standards.
u. Outcome Payment.
Providers, with transition students born between:
(a) For fiscal year 2026 9/1/03 through 8/31/04
(b) For fiscal year 2027 9/1/04 through 8/31/05
(2) High acuity transition students who are authorized for individual employment, the provider may
receive one outcome payment if transition student obtains a competitive integrated job approved
by the County within timeframes described in the chart in the Billin Instructions. If the County
is also the service provider DDCS will provide the job approval. If the job is at a minimum of ten
hours of work per week an additional amount will be include in the payment.
(3) High acuity Clients who are authorized for Individual employment, provider may receive one
outcome payment if client obtains a new competitive integrated job at a minimum of ten hours of
work per week for a minimum of 4 out of each 6 months during the fiscal year.
(4) Client who are authorized for Community Inclusion who have an acuity of F which equals 18
support hours per month or G which equals 20 support hours per month as based on the
Support Intensity Scale (SIS), provider may receive on outcome payment per month if provider
delivers a minimum of 80% of the authorized hours.
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(5) A new Community Inclusion referral is defined as a Client who has a new County Service
Authorization (CSA). Incentive/outcome payments to accept and support overall increased
CSAs billed over the year may be requested from DDCS if funds are available.
(6) Community Inclusion case notes and 6-month progress report summary review that scores 16
points or more with the "Community Inclusion Case Note Review Tool' when used in
conjunction with a Community Inclusion plan that has scored 20+ points with the Community
Inclusion plan Quality review tool, provider may receive an outcome payment.
(7) All outcome payments are described in the chart in the Biflin Instructions.
Consideration:
a. Fees:
(1) Approval of fees is the responsibility of the DDCS. The DDCS HQ Employment and Day Unit
Manager reserves the right to approve fees/rates for the services being provided. The County
will submit a fee/rate schedule with the initial Program Agreement. The County will submit
updated fee/rate schedules to the HQ Employment and Day Unit Manager for approval as
changes occur. The rate schedule will include the following information:
(a) County(s) name;
(b) Time period for which the schedule is applicable; and
(c) Each contracted direct service (IE, GSE, Cl, ITA, CDS) and its associated rate.
(2) Fee Limitations: The Biding Instructions found on the County Best Practices site provides
limitations on the Hourly Rate for each direct service. Hourly rates must be divisible by four.
b. Budget and Spending Plan, attached as Exhibit B:
(1) Budget amount listed in Exhibit B: The County may not exceed the state only revenue dollar
amount or the total revenue dollar amount indicated on the Program Budget Agreement
included in Exhibit B. The waiver revenue dollar amount may be exceeded to accommodate
Clients moving from state -only employment and day services to waiver employment and day
services.
(2) Spending Plan: DDCS will provide the initial spending plan / Program Agreement Budget /
Exhibit B. Funding shall be distributed under State and Medicaid in the revenue section. The
planned expenditures for Consumer Support are based on authorized Clients, their acuity level
and work history for a given point in time. To determine the Additional Consumer Support
amount, the Consumer Support amount is multiplied by a percentage. The spending plan may
only be modified by mutual agreement of the parties in writing and shall not require a program
agreement amendment.
(a) Funds Designated for Additional Consumer Services: If a County provides Community
Information and Education services under additional consumer services, then activities must
include outreach efforts to federally recognized local tribes.
(b) Funds Designated for Adult Day Care Consumers: Funds designated for Adult Day Care
Consumers are available to Clients who were served between December 1996 and
December 2003 in Adult Day Health agencies and were subsequently determined ineligible
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for Level II or III services (Adult Day Health). Level II and III services are licensed
rehabilitation and skilled nursing services along with socialization. Level I services (Adult
Day Care) are supervised day programs where frail and disabled adults can participate in
social, educational, and recreational programs without the need for skilled nursing. These
Clients may be referred to services defined in the statement of work, or to an Adult Day Care
service other than Level II or III. If a Client no longer needs and wants services, the funds
are available for other Clients who are not part of the group of original Clients identified
between December 1996 and 2003. An Adult Day Care service shall only be provided by
Adult Day Care agencies certified by the local Area Agency on Aging. Adult Day Care
service is not a waiver approved service.
c. Program Agreement Amendments: A County can request an amendment at any time. An
amendment for additional Client(s) may be supported when clients exceed the number used to
develop the contract. An amendment for additional service hours authorized may be supported
when county provides evidence. An amendment request for expenditures exceeding contract total
due to hourly rates paid to service provider may not be supported as the county is responsible to
manage contract and rates paid to their providers.
d. Exemptions: The DDCS Assistant Secretary may approve in writing an exemption to a specific
program agreement requirement.
8. Billing and Payment:
a. Program Agreement Budget: DSHS shall pay the County all allowable costs, which are defined by
DDCS as cost incurred by the program for:
(1) Administration: Costs of the County Human Services Department or similar county office,
responsible for administration of the Developmental Disabilities Program. Allowable costs
include personnel and overhead costs directly related to the administration and coordination of
the program, including such activities as program planning, budgeting, contracting, monitoring,
and evaluation. Also included are departmental and county indirect and/or direct administrative
costs, to the extent that such costs are appropriately allocated to the program using an
established methodology consistent with grants management guidelines. For a County whose
designated coordinator manages multiple programs, the County must be able to provide
evidence of the time the coordinator spent working on the Developmental Disabilities program.
(2) Additional Consumer Services:
(a) Training:
i. Staff Training: Costs incurred by the program for planned, structured activities for the
purpose of providing, or improving, or enhancing job -related knowledge and skills of
staff, providers, volunteers, or interning students in the provision of developmental
disabilities services.
ii. Board Training: Costs incurred by the program for planned, structured activities
designed to provide, improve, or enhance program -related skills of board and advisory
committee members.
(b) Community Information and Education: to inform and/or educate the general public about
developmental disabilities and related services. These may include information and referral
services; activities aimed at promoting public awareness and involvement; and community
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consultation, capacity building and organization activities.
(c) Other Activities.
i. Infrastructure projects: Projects in support of Clients (services not easily tracked back to
a specific working age Client) or that directly benefit a Client(s) but the Client is not of
working age. Examples include planning services like generic job development e.g.
"Project Search."
J. Start-up projects: Projects that support an agency or directly benefit the agency.
Examples include equipment purchases and agency administrative support.
iii. Partnership project: Collaborative partnerships with school districts, employment
providers, Division of Vocational Rehabilitation (DVR), families, employers and other
community collaborators needed to provide the employment supports and services
young adults with developmental disabilities require to become employed during the
school year they turn twenty-one (21). Supports provided should complement and not
replace what the student(s) receive through the Individualized Education Program (IEP).
(3) Consumer Support.
(a) Adult Day Care services are available to Clients who were served between December 1996
and December 2003 in Adult Day Health agencies and were subsequently determined
ineligible for Level II or III services (Adult Day Health). Level it and III services are licensed
rehabilitation and skilled nursing services along with socialization. Level I services (Adult
Day Care) are supervised day programs where frail and disabled adults can participate in
social, educational, and recreational programs without the need for skilled nursing.
(b) Community Inclusion Services are individualized and provided in integrated community
settings with other individuals without disabilities. The activities are based on Client
interests and provide opportunities typically experienced by the general public of similar age
in their local community, accessible by public transit or a reasonable commute from their
home. The goal of the service is to support Clients to participate, contribute, and develop
relationships with community members who are not paid staff. These services may be
authorized for individuals age 62 and older. These services may be authorized in addition to
or instead of employment support (Individual Employment or Group Supported Employment)
for working age individuals who have received nine months of employment support.
(c) Child Development Services are designed to meet the developmental needs of each eligible
child and the needs of the family related to enhancing the child's development. Service may
include: assistive technology, audiology, family trainingthome visits, health services,
medical services, nursing services, nutrition services, occupational therapy, physical
therapy, psychological services, sign language, social work, special instruction, speech -
language pathology, vision, and transportation. Services are provided in natural
environments to the maximum extent appropriate.
(d) Individual Supported Employment services are a part of a Client's pathway to employment
and are tailored to individual needs, interests, and abilities to promote career development.
These are individualized services necessary to help persons with developmental disabilities
obtain and continue integrated employment at or above the state's minimum wage in the
general workforce. These services may include intake, discovery, assessment, job
preparation, job marketing, job supports, record keeping and support to maintain a job (per
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the Individual Employment Phases & Billable Activities
(e) Individualized Technical Assistance services are a part of a Client's pathway to employment
or community inclusion. This service provides assessment and consultation to the provider
to identify and address existing barriers to employment or community inclusion. This is in
addition to supports received through supported employment or community inclusion
services for individuals who have not yet achieved their goal.
(f) Group Supported Employment services are a part of a Client's pathway to integrated jobs in
typical community employment. These services are intended to be short term and offer
ongoing supervised employment for groups of no more than eight (8) workers with
disabilities in the same setting. The service outcome is sustained paid employment leading
to further career development in integrated employment at or above minimum wage.
Examples include enclaves, mobile crews, and other business models employing small
groups of workers with disabilities in integrated employment community settings.
b. Reimbursement for the state Fiscal Year shall not exceed the total amount listed in Exhibit B to this
Program Agreement. However, with a Program Agreement amendment, the parties may increase
or decrease the Program Agreement amount. Counties will work with DDCS HQ on amendments to
the Program Agreement.
c. Monthly Invoice with Signed Documentation: All requests for reimbursement amounts must be
entered and posted into the AWA system. The County may post a combined claim of all
programs/services covered by this Program Agreement. DSHS shall make all payments due to the
County for all invoices submitted pursuant to this section within forty five (45) days following posting
of required information.
d. Clients will be assisted in accessing DVR services per the DDCS/DVR MOU. Client services shall
not be reimbursed under this Program Agreement when the same services are paid for under the
Rehabilitation Act of 1973 by DVR, Public Law 94-142 or any other source of public or private
funding.
e. Reimbursement of Client Services: A claim for each Client is made on the AWA system by
indicating the number of service units delivered to each Client listed and the fee per unit. Units are
defined as:
(1) An "Hour' is at least fifty (50) minutes of direct service. Partial hour to the quarter may be
recorded.
(2) A "Day" is at least four (4) hours of direct service and will only be used in connection with Adult
Day Care reimbursement.
(3) A "Month" represents a minimum of at least fifty (50) minutes of direct service for CDS
reimbursement.
f. Program Administration: The County will provide program administration and coordination including
such activities as planning, budgeting, contracting, monitoring, and evaluation. Monthly claims for
administration can be 1/12 of the maximum amount identified in Exhibit B under Administration or
for the actual costs incurred in the given month but the total Administration billed will be the lesser
of the two. Administration cost reimbursement will not exceed 10% unless the Assistant Secretary
of DDCS approves a request for an exception under chapter 388-850 WAC.
g. The Individual Employment Phases & Billable Activities document defines the individual Client
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services that DDCS reimburses. That document is located on the DSHS DDCS County Best
Practices Web site at https*://www.dshs.wa,gov/dda/countV-best-I)ractices.
h. The Community Inclusion Billable Activities document defines the individual Client services
DDCS reimburses. That document is located on the DSHS DDCS County Best Practices Web site
at https://www-dshs-wa.gov/ddalcounty-best-
practices.
i. Timeliness of and Modification to Billings: All initial invoices with signed documentation must be
received by the DDCS Region within forty-five (45) calendar days following the last day of the
month in which the service is provided. Corrected invoices and documentation including re -posted
billing information will be accepted throughout the fiscal year as long as they are received within
sixty (60) calendar days of the associated fiscal year unless an extension is approved by the DDCS
Regional Administrator or designee. Payment will not be made on any invoice submitted past sixty
(60) calendar days after the Program Agreement fiscal year.
j. Recovery of Fees: if the County bills and is paid fees for services that DSHS later finds were (a) not
delivered or (b) not delivered in accordance with Program Agreement standards, DSHS shall
recover the fees for those services and the County shall fully cooperate during the recovery.
k. Preadmission Screening and Resident Review (PASRR) Administration: The County may bill for
administration costs as identified in Exhibit B. Monthly claims for administration cost will be based
on the actual PASRR expenditures multiplied by 10%.
I. Reimbursement for Partnership project: A claim of $3,000 per student for each completed Job
Foundation document that is at a satisfactory or above rating will be requested through the AWA
system as other monthly cost.
m. Job Foundation report line item 95 as identified in the ADSA Web Access (AWA) billing system. A
copy of the completed Job Foundation document will be sent electronically to the shared mailbox
located at: DDAJobFoundationRe arts dshs_wa. ❑v
n. Job placement verification for transition students: The AWA Employment Output for Individual
Employment will be completed and submitted with payment request to verify employer, job start
date, job type, etc.
o. Job Foundation Administration: The County may bill for administration costs as identified in Exhibit
B. Monthly claims for administration cost will be based on the actual expenditures multiplied by
10%. Participating counties will use line item 13.
9. Intermediate Care Facilities for Intellectual Disabilities (ICF/ID) Agreement. If applicable per 42
CFR 483.410, the County shall assure that all county -operated or subcontracted programs serving
persons living in ICF/ID facilities develop a plan and coordinate their services with the facility on behalf
of the ICF/ID resident.
10. Single State Medicaid Agency —Health Care Authority (HCA): HCA, as the single state Medicaid
Agency, has administrative authority for Title XIX coverage per 42 CFR 431.10. DSHS is the operating
agency for the Home and Community Based Waivers for services for people with developmental
disabilities. The County only has responsibility for services covered in this agreement.
11. DSHS/DRW Access Agreement: The DRW February 27, 2001 Access Agreement with DDCS is
incorporated by reference. The County assures that it and its subcontractors have reviewed the
Access Agreement. The agreement covers DRW's access to individuals with developmental
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disabilities, Clients, programs and records, outreach activities, authority to investigate allegations of
abuse and neglect, and other miscellaneous matters and is binding for all providers of DDCS
contracted services.
12. Confidential Information. All Counties and their subcontractors must:
a. Ensure the security of Confidential Information, and
b. When transporting client records containing Confidential Information outside a Secure Area, one or
more of the following as appropriate:
(1) Using a Trusted Network; or
(2) Encrypting the Confidential Information, including:
(a) Email and/or email attachments
(b) Confidential Information when it is stored on portable devices or media including but not
limited to laptop computers and flash memory devices.
13. Data Security Requirements. Exhibit A shall only apply to the County if the County possesses 150 or
more DSHS records across all programs or services throughout their organization, or transmits more
than 5 records at one time.
14. Supersession of Prior Data Security Agreement. If the Parties hereto have previously entered into a
Standalone Data Security Requirements Agreement, both Parties hereby agree that upon mutual
execution said Agreement shall take precedence as the sole Data security Agreement between the
Parties.
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Exhibit A — Data Security Requirements
Definitions. The words and phrases listed below, as used in this Exhibit, shall each have the following
definitions:
a. "AES' means the Advanced Encryption Standard, a specification of Federal Information Processing
Standards Publications for the encryption of electronic data issued by the National Institute of
Standards and Technology (https://nvlpubs.nist.gov/nistpubs/FIPS/NIST.FIPS.197-upol.pdf).
b. "Authorized Users(s)" means an individual or individuals with a business need to access DSHS
Confidential Information, and who has or have been authorized to do so.
c. "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. For purposes of this
contract, data classified as Category 4 refers to data protected by: the Health Insurance Portability
and Accountability Act (HIPAA).
d. "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 iCloud, Dropbox, Box.com, and many other
entities. Enterprise cloud vendors include Microsoft Azure, Amazon Web Services, 0365, and
Rackspace.
e. "Encrypt" means to encode Confidential Information into a format that can only be read by those
possessing a "key"; a password, digital certificate or other mechanism available only to authorized
users. Encryption must use a key length of at least 128 bits (256 preferred) 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.
f. "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. "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.
h. "Multi -factor Authentication" means controlling access to computers and other IT resources by
requiring two or more pieces of evidence that the user is who they claim to be. These pieces of
evidence consist of something the user knows, such as a password or PIN; something the user has
such as a key card, smart card, or physical token; and something the user is, a biometric identifier
such as a fingerprint, facial scan, or retinal scan. "PIN" means a personal identification number, a
series of numbers which act as a password for a device. Since PINs are typically only four to six
characters, PI Ns are usually used in conjunction with another factor of authentication, such as a
fingerprint.
i. "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
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are not limited to, mobile phones, tablets, and laptops. Mobile Device is a subset of Portable
Device.
j. "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.
k. "Secure Area" means an area to which only authorized representatives of the entity possessing the
Confidential Information have access, and access is controlled through use of a key, card key,
combination lock, or comparable mechanism. Secure Areas may include buildings, rooms or
locked storage containers (such as a filing cabinet or desk drawer) within a room, as long as access
to the Confidential Information is not available to unauthorized personnel. In otherwise Secure
Areas, such as an office with restricted access, the Data must be secured in such a way as to
prevent access by non -authorized staff such as janitorial or facility security staff, when authorized
Contractor staff are not present to ensure that non -authorized staff cannot access it.
I. '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.
m. "Unique User ID" means a string of characters that identifies a specific user and which, in
conjunction with a password, passphrase or other mechanism, authenticates a user to an
information system.
2. Authority. The security requirements described in this document reflect the applicable requirements of
policies and standards of the Washington Technology Services Agency
(https:/Iwatecti.wa.gov/policies?combine=&field categories tar et id=80&field type tar et id=Ally,
and of the DSHS Information Security Policy and Standards Manual. Reference material related to
these requirements can be found here: htt s://www.dshs.wa. ovtffa/kee in -dshs-client-information-
private-and-secure, which is a site developed by the DSHS Information Security Office and hosted by
DSHS Central Contracts and Legal Services.
3. Administrative Controls. The Contractor must have the following controls in place:
a. A documented security policy governing the secure use of its computer network and systems, and
which defines sanctions that may be applied to Contractor staff for violating that policy.
b. If the Data shared under this agreement is classified as Category 4 data, the Contractor must be
aware of and compliant with the applicable legal or regulatory requirements for that Category 4
Data.
c. If Confidential Information shared under this agreement is classified as Category 4 data, the
Contractor must have a documented risk assessment for the system(s) housing the Category 4
Data.
4. Authorization, Authentication, and Access. In order to ensure that access to the Data is limited to
authorized staff, the Contractor must:
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a. Have documented policies and procedures governing access to systems with the shared Data
b. Restrict access through administrative, physical, and technical controls to authorized staff.
c. Ensure that user accounts are unique and that any given user account logon ID and password
combination is known only to the one employee to whom that account is assigned. For purposes of
non -repudiation, it must always be possible to determine which employee performed a given action
on a system housing the Data based solely on the logon ID used to perform the action
d. Ensure that only authorized users are capable of accessing the Data.
e. Ensure that an employee's access to the Data is removed immediately:
(1) Upon suspected compromise of the user credentials.
(2) When their employment, or the contract under which the Data is made available to them, is
terminated.
(3) When they no longer need access to the Data to fulfill the requirements of the contract.
f. Have a process to periodically review and verify that only authorized users have access to systems
containing DSHS Confidential Information
g. When accessing the Data from within the Contractor's network (the Data stays within the
Contractor's network at all times), enforce password and logon requirements for users within the
Contractor's network, including:
(1) A minimum length of 8 characters, and containing at least three of the following character
classes: uppercase letters, lowercase letters, numerals, and special characters such as an
asterisk, ampersand, or exclamation point.
(2) That a password does not contain a user's name, logon ID, or any form of their full name.
(3) That a password does not consist of a single dictionary word. A password may be formed as a
passphrase which consists of multiple dictionary words.
(4) That passwords are significantly different from the previous four passwords. Passwords that
increment by simply adding a number are not considered significantly different.
h. When accessing Confidential Information from an external location (the Data will traverse the
Internet or otherwise travel outside the Contractor's network), mitigate risk and enforce password
and logon requirements for users by employing measures including:
(1) Ensuring mitigations applied to the system don't allow end -user modification.
(2) Not allowing the use of dial -up connections.
(3) Using industry standard protocols and solutions for remote access. Examples would include
RADIUS and Citrix.
(4) Encrypting all remote access traffic from the external workstation to Trusted Network or to a
component within the Trusted Network. The traffic must be encrypted at all times while
traversing any network, including the Internet, which is not a Trusted Network.
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(5) Ensuring that the remote access system prompts for re -authentication or performs automated
session termination after no more than 30 minutes of inactivity.
(6) Ensuring use of Multi -factor Authentication to connect from the external end point to the internal
end point.
Passwords or PIN codes may meet a lesser standard if used in conjunction with another
authentication mechanism, such as a biometric (fingerprint, face recognition, iris scan) or token
(software, hardware, smart card, etc.) in that case:
(1) The PIN or password must be at least 5 letters or numbers when used in conjunction with at
least one other authentication factor
(2) Must not be comprised of all the same letter or number (11111, 22222, aaaaa, would not be
acceptable)
(3) Must not contain a "run" of three or more consecutive numbers (12398, 98743 would not be
acceptable)
If the contract specifically allows for the storage of Confidential Information on a Mobile Device,
passcodes used on the device must:
(1) Be a minimum of six alphanumeric characters.
(2) Contain at least three unique character classes (upper case, lower case, letter, number).
(3) Not contain more than a three consecutive character run. Passcodes consisting of 12345, or
abcd12 would not be acceptable.
k. Render the device unusable after a maximum of 10 failed logon attempts.
5. Protection of Data. The Contractor agrees to store Data on one or more of the following media and
protect the Data as described:
a. Hard disk drives. For Data stored on local workstation hard disks, access to the Data will be
restricted to Authorized User(s) by requiring logon to the local workstation using a Unique User ID
and Hardened Password or other authentication mechanisms, which provide equal or greater
security, such as biometrics or smart cards.
b. Network server disks. For Data stored on hard disks mounted on network servers and made
available through shared folders, access to the Data will be restricted to Authorized Users through
the use of access control lists which will grant access only after the Authorized User has
authenticated to the network using a Unique User ID and Hardened Password or other
authentication mechanisms which provide equal or greater security, such as biometrics or smart
cards. Data on disks mounted to such servers must be located in an area, which is accessible only
to authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism.
For DSHS Confidential Information stored on these disks, deleting unneeded Data is sufficient as
long as the disks remain in a Secure Area and otherwise meet the requirements listed in the above
paragraph. Destruction of the Data, as outlined below in Section 8 Data Disposition, may be
deferred until the disks are retired, replaced, or otherwise taken out of the Secure Area.
Page 22
DSHS Central Contract Services
1769CS County Agreement (12-26-2025)
Special Terms and Conditions
c. Optical discs (CDs or DVDs) in local workstation optical disc drives. Data provided by DSHS
on optical discs which will be used in local workstation optical disc drives and which will not be
transported out of a Secure Area. When not in use for the contracted purpose, such discs must be
Stored in a Secure Area. Workstations which access DSHS Data on optical discs must be located
in an area which is accessible only to authorized personnel, with access controlled through use of a
key, card key, combination lock, or comparable mechanism
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 ID and Hardened Password or other
authentication mechanisms which provide equal or greater security, such as biometrics or smart
cards. Data on discs attached to such servers must be located in an area, which is accessible only
to authorized personnel, with access controlled through use of a key, card key, combination lock, or
comparable mechanism.
e. Paper documents. Any paper records must be protected by storing the records in a Secure Area,
which is only accessible to authorized personnel. When not in use, such records must be stored in
a Secure Area..
Remote Access. Access to and use of the Data over the State Governmental Network (SGN) or
Secure Access Washington (SAW) will be controlled by DSHS staff` who will issue authentication
credentials (e.g. a Unique User ID and Hardened Password) to Authorized Users on Contractor's
staff. Contractor will notify DSHS staff immediately whenever an Authorized User in possession of
such credentials is terminated or otherwise leaves the employ of the Contractor, and whenever an
Authorized User's duties change such that the Authorized User no longer requires access to
perform work for this Contract.
g. Data storage on portable devices or media.
(1) Except where otherwise specified herein, DSHS Data shall not be stored by the Contractor on
portable devices or media unless specifically authorized within the terms and conditions of the
Contract. If so authorized, the Data shall be given the following protections::
(a) Encrypt the Data.
(b) Control access to devices with a Unique User ID and Hardened Password or stronger
authentication method such as a physical token or biometrics.
(c) Manually lock devices whenever they are left unattended and set devices to lock
automatically after a period of inactivity, if this feature is available. Maximum period of
inactivity is 20 minutes.
(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.
Page 23
DSHS Central Contract Services
1769CS County Agreement (12-26-2025)
Special Terms and Conditions
(2) When being transported outside of a Secure Area, Portable Devices and Portable Media with
DSHS Confidential Information must be undff the physical control of Contractor staff with
authorization to access the Data, even if the Data is encrypted.
h. Data stored for backup purposes.
(1) DSHS Confidential Information may be stored on Portable Media as part of a Contractor's
existing, documented backup process for business continuity or disaster recovery purposes.
Such storage is authorized until such time as that media would be reused during the course of
normal backup operations. If backup media is retired while DSHS Confidential Information still
exists upon it, such media will be destroyed at that time in accordance with the disposition
requirements below in Section 8 Data Disposition.
(2) Data may be stored on non -portable media (e,g. Storage Area Network drives, virtual media.
etc.) as part of a Contractor's existing, documented backup process for business continuity or
disaster recovery purposes. If so, such media will be protected as otherwise described in this
exhibit. If this media is retired while DSHS Confidential Information still exists upon it, the data
will be destroyed at that time in accordance with the disposition requirements below in Section 8
Data Disposition
i. Cloud storage. DSHS Confidential Information requires protections equal to or greater than those
specified elsewhere within this exhibit. Cloud storage of Data is problematic as neither DSHS nor
the Contractor has control of the environment in which the Data is stored. For this reason:
(1) DSHS Data will not be stored in any consumer grade Cloud solution, unless all of the following
conditions are met:
(a) Contractor has written procedures in place governing use of the Cloud storage and
Contractor attest to the contact listed in the contract and keep a copy of that attestation for
your records 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.
(f) The Data will not be downloaded to non -authorized systems, meaning systems that are not
on the contractor network
(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.
(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 HIPAA compliant.
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DSHS Central Contract Services
1769CS County Agreement (12-26-2025)
Special Terms and Conditions
(3) If the Data includes protected health information covered by the Health Insurance Portability and
Accountability Act (HIPAA), the Cloud provider must sign a Business Associate Agreement prior
to Data being stored in their Cloud solution.
6. System Protection. To prevent compromise of systems which contain DSHS Data or through which
that Data passes:
a. Systems containing DSHS Data must have all security patches or hotfixes applied within 3 months
of being made available.
b. The Contractor will have a method of ensuring that the requisite patches and hotfixes have been
applied within the required timeframes.
c. Systems containing DSHS Data shall have an Anti-Malware application, if available, installed.
d. Anti-Malware software shall be kept up to date. The product, its anti -virus engine, and any malware
database the system uses, will be no more than one update behind current.
7. Data Segregation.
a. DSHS category 4 data must be segregated or otherwise distinguishable from non-DSHS data. This
is to ensure that when no longer needed by the Contractor, all DSHS Data can be identified for
return or destruction. It also aids in determining whether DSHS Data has or may have been
compromised in the event of a security breach. As such, one or more of the following methods will
be used for data segregation
(1) DSHS Data will be kept on media (e.g. hard disk, optical disc, tape, etc.) which will contain no
non-DSHS Data.
(2) DSHS Data will be stored in a logical container on electronic media, such as a partition or folder
dedicated to DSHS Data.
(3) DSHS Data will be stored in a database which will contain no non-DSHS data. And/or,
(4) DSHS Data will be stored within a database and will be distinguishable from non-DSHS data by
the value of a specific field or fields within database records.
(5) When stored as physical paper documents, DSHS Data will be physically segregated from non-
DSHS data in a drawer, folder, or other container.
b. When it is not feasible or practical to segregate DSHS Data from non-DSHS data, then both the
DSHS Data and the non-DSHS data with which it is commingled must be protected as described in
this exhibit.
8. Data Disposition. When the contracted work has been completed or when the Data is no longer
needed, except as noted above in Section 5.b, Data shall be returned to DSHS or destroyed. Media on
which Data may be stored and associated acceptable methods of destruction are as follows:
Data stored on: Will be destroyed by:
Server or workstation hard disks, or Using a "wipe" utility which will overwrite the Data at
least three (3) times using either random or single
character data, or
Page 25
DSHS Central Contract Services
1769CS County Agreement (12-26-2025)
Special Terms and Conditions
Removable media (e.g, floppies, USB flash drives,
portable hard disks) excluding optical discs
Paper documents with sensitive or Confidential
Information
Paper documents containing Confidential Information
requiring special handling (e.g. protected health
information)
Optical discs (e.g. CDs or DVDs)
Degaussing sufficiently to ensure that the Data
cannot be reconstructed, or
Physically destro in -the disk
I
Recycling through a contracted firm, provided the
contract with the recycler assures that the
confidentiality of Data will be protected.
On -site shredding, pulping, or incineration
Incineration, shredding, or completely defacing the
readable surface with a coarse abrasive
jMagnetic tape De aussin iicinerating or crosscut shredding
9. Notification of Compromise or Potential Compromise. The compromise or potential compromise of
DSHS shared Data must be reported to the DSHS Contact designated in the Contract within one (1)
business day of discovery. If no DSHS Contact is designated in the Contract, then the notification must
be reported to the DSHS Privacy Officer at dshsprivacyofficer@dshs.wa.gov. Contractor must also
take actions to mitigate the risk of loss and comply with any notification or other requirements imposed
by law or DSHS.
10. Data shared with Subcontractors. If DSHS Data provided under this Contract is to be shared with a
subcontractor, the Contract with the subcontractor must include all of the data security provisions within
this Contract and within any amendments, attachments, or exhibits within this Contract_ if the
Contractor cannot protect the Data as articulated within this Contract, then the contract with the sub -
Contractor must be submitted to the DSHS Contact specified for this contract for review and approval.
Page 26
DSHS Central Contract Services
1769CS County Agreement (12-26-2025)
Exhibit B
Program Agreement Budget
X Original Budget Budget Revision
REVENUES
Fiscal Year Fund Source Ori final Is' Revision 2"d Revision 3rd Revision
2026 State onl 567,912 576,712
Medicaid 555,171 562,371
___r :r7���
Total Rev. $1,123,083 $1,139,083 $ $
Fiscal Year
Fund Source
Original
1 st Revision
2"d Revision
3rd Revision
2027
State only
Medicaid
Total Rev.
$
$
$
$
Job
Foundation PASRR Funds
Medicaid
Funds
State Funds
Funds
TOTAL
_
ADMINISTRATION (11,
51072
41786
92,858
12, 13, 14)
OTHER CONSUMER
SUPPORTS
(31, 32, 41, 92, 93, 94,
33411
27337
60,748
97) _
CONSUMER
SUPPORT
STATE -ONLY
(62, 64, 65, 67, 69
Child Development 61
MEDICAID CLIENTS
433917
433917
867,834
64, 67, 69, 95, 96
,
ROADS to
COMMUNITY LIVING
(62, 64, 65, 67, 69)
TOTAL
518,400
503,040
1 1.021,440
Page 27
DSHS Central Contract Services
1769CS County Agreement (12-26-2025)
Attachment F
ACCESS AGREEMENT BETWEEN
WASHINGTON FROTECTIONAN D ADVOCACY SYSTEM, INC.,
THE DIVISION OF DEVELOPMENTAL DISABILITIES,
DEPARTMENT OF SOCIAL AND IIEALTH SERVICES•
This agreement is entered into by the Washington Protection and Advocacy System, Inc.
(hereinafter WPAS), the protection and advocacy system authorized pursuant to the Developmental
Disabilities Assistance and Bill of Rights Act of 1975, 42 U.S.C. see. 6000, et seg. to investigate
alleged incidents of abuse, neglect, and rights violations of persons with developmental disabilities,
and the Division of Developmental Disabilities (hereinafter DDD) of the Department of Social and
Health Services, for the purpose of clarifying the rights and responsibilities of WPAS with respect
to its access to individuals with developmental disabilities, clients, programs, and records.
The Department of Social and Health Services, specifically DDD, is responsible for
providing services to individuals with developmental disabilities, to the extent hording is available.
In providing those services, DDD must protect the confidentiality of records and information
regarding those individuals pursuant to the state and federal confidentiality laws.
WPAS is charged by federal law to protect the legal and human rights of individuals with
developmental disabilities. WPAS provides legal and related advocacy services to meet that
obligation. WPAS is also required to maintain the confidentiality of records and information
regarding individuals with developmental disabilities consistent with 42 U.S.C. § 6000, et seg.
This agreement governs the access of Washington Protection and Advocacy System to DDD
employees who do not work in Residential Habilitation Centers (RHCs) and ,records maintained by
DDD which are associated with individuals with developmental disabilities living outside of RHCs.
Federal laws and regulations also provide NVPAS with access to community programs and
individuals with developmental disabilities served by DDD contracted providers. DDD will work
with community providers and WPAS to arrive at an agreement governing access to DDD
contracted programs and the people served by them.
General.
A. That all terms used in this agreement which arc defined in the Developmental
Disabilities Assistance and Bill of Rights Act of 1975, 42 U.S.C. § 6000, et seg., will have
the meaning given to them in the Act, unless otherwise stated in this agreement.
B. This agreement is intended to carry out the provisions of the Developmental
Disabilities Assistance and Bill of Rights Act of 1975, 42 U.S.C. § 6000, et. se ., and
therefore, if this agreement is or becomes inconsistent with the Act or the implementing
regulations promulgated thereto. the terms of the Act and its implementing regulations will
control.
C. If any provision of the agreement is held invalid, the parties intend that the
remainder of the agreement not be affected.
COMMUNITY ACCESS AGREEMENT
II. Definitions.
A. Active! Aggressive: means that the individual with developmental disabilities is
assaulting others or is threatening to do so, or the individual with developmental disabilities
is actively harming him or her self.
B. Client Services: means legal representation. The term does not include monitoring
and observation.
C. Compl as defined in 45 CFR 1386, or hereinafter amended, includes, but is not
limited to, any report or communication, whether formal or informal, written or oral,
received by WPAS including media accounts, newspaper articles, telephone calls (including
anonymous calls), from any source alleging abuse or neglect of an individual with a
developmental disability.
D. DDD Consumer: means an individual with a developmental disability receiving
support from a program funded by DDD. The term includes DDD consumers who have
died orwhose whereabouts are unknown. See 45 CFR 1386.22(a)(2).
E. DDD Employees: includes those individuals who are employed by DDD or who
volunteer for DDD to provide services to individuals with developmental disabilities.
F. Emergencies: means actions, omissions, or conditions that immediately threaten an
individual with a developmental disability's health, life or well being.
G. Individual with a Develo mental Disabili : means individuals with developmental
disabilities in the process of applying for or who have been found eligible for services from
DDD.
H. Monitor: means unaccompanied access to all residents of a program at
reasonable times, which at a minimum shall include normal working and visiting hours to
ensure program compliance with respect to the rights and safety of DDD consumers. See 45
C.F.R. § 1386.22(g).
I. Probable Cause: as defined in 45 cFK 13K6, or hereinafter amended, means a
reasonable ground for belief that an individual with developmental disabilities has been, or
may be, subject to abuse or neglect. The individual making such determination may base
the dmision ou rcasaimbic infcremcs di-awu fi'oni €tie or her cxpericacc or b,aining regarding
similar incidents, conditions or problems that are usually associated with abuse and neglect.
J. Pro am: consistent with the definition of "facility" in 45 CFR 1386.19 includes any
setting that provides care, treatment services and habilitation, ever: if only "as needed" or
under a contractual arrangement. Programs include, but are not limited to, community
living arrangements (e.g., group homes, adult family homes, congregate care facilities,
boarding homes, individual residences and apartments), day programs, Juvenile detention
centers, nursing homes, homeless shelters, jails and prisons.
K. Provider: means those individuals/corporations with whom DDD contracts to
provide services to DDD consumers, including but not limited to behavioral management
services, family support services, vocational support services, sheltered employment, tenant
support, intensive tenant support, alternative living, supported living, group home, adult
family home, and congregate care facilities, chore services, medicaid personal care and
other personal assistance services.
COMMUNITY ACCESS AGREEMENT
L. Provider Ern to ee: includes those individuals who are employed by a provider or
who volunteer for a provider to provide services to individuals with developmental
disabilities.
M. Records: as defined in 42 U.S.C. § 6042 and 45 CFR 1:86(2.2)(b), or hereinafter
amended, reports prepared by any state staff or reports prepared by an agency charged with
investigating reports of incidents of abuse, neglect, injury, or death that describe incidents of
abuse, neglect, injury, or death occurring at a facility, investigative documents and discharge
planning records. The term records also includes DDD consumer abuse and neglect
committee reports but does not include peer review death reports, attorney work product,
and records which are otherwise privileged under state or federal law.
N. RgegHlar Pro am Activity: includes work assignments, education programs, therapy,
health services, and daily living activities.
O. SOLA: means the DDD consumer support program, State Operated Living
Alternative.
P. WPAS Clients :
(1) Individuals with developmental disabilities who do not have a guardian or
legal representative and who indicate either orally or in writing to a WAS
employee that they want WPAS to represent them.
(2) Individuals with developmental disabilities without guardians who are
unable to communicate their wishes regarding protection and advocacy services
when WAS has received a complaint of abuse and/or neglect about the individual
with a disability, or WPAS dctcrmincs that there is probable cause to believe that the
individual with a developmental disability has been abused or neglected.
(3) Individuals with developmental disabilities who have a guardian or legal
representative where the guardian or legal representative has consented to the
representation in -writing.
(4) Individuals with developmental disabilities whose guardian or legal
representative fails or refuses to act on behalf of the individual with a developmental
disability, despite being contacted by WPAS, after a court has detemmined that the
guardian has failed or refuses to act.
(5) A WAS client does not include those instances where WPAS represents the
guardian. WPAS shall notify the DDD Regional. Administrator or designee in
writing that it represents the individual with developmental disabilities and forward a
copy of that notice to either the guardian or the individual with developmental
disabilities.
Q. WPAS 1rm to ees: includes paid employees and volunteer employees as identified
by WPAS. Each employee shall carry WAS identification.
III. Access to Programs.
A. DDD will not obstruct WPAS access to programs when consistent with the law and
will ensure that SOLA and other programs staffed by DDD employees will comply with this
agreement. For programs which contract with DDD to provide services, DDD will not
COMMUNITY ACCESS AGREEMENT
obstruct WPAS access to programs when consistent with the law, but WPAS will assume
primary responsibility for enforcing its access rights. WAS will attempt to resolve access
issues at the lowest level possible. In cases where there is danger of imminent or continuing
harm to an individual with developmental disabilities WPAS will report the occurrence to
DDD, consistent with the Washington State Bar Association Rules of Professional
Responsibility and other applicable state law. in those cases and where there is a pattern of
failure to provide access for WPAS to a program or DDD consumers, WPAS will report this
failure to DDD, and DDD will respond by investigating the allegation of failure to provide
access and will take appropriate actions.
B. WPAS staff will identify themselves to any staff present when they arrive at a
program by showing a WPAS photo identification badge. WPAS shall provide the DDD
director with a fist of employees and their pictures by July 1, 1997, and WPAS shall update
this list as necessary.
C. WPAS shall have access to SOLAs and other programs staffed by DDD employees
as specified in this section. This agreement does not affect the right of an individual with a
developmental disability served by such a program who owns or rents his or her own home
to deny access to WPAS to his or her home. However, DDD employees do not have the
right to deny WPAS access to programs or the residences of individuals who are served by
programs.
D. WPAS staff shall have access to all programs when WPAS has received a complaint
or has probable cause to believe than an incident of abuse, neglect, or other rights violation
has occurred;
E. WPAS staff shall have access to all living areas of SOLAs and other programs
staffed by DDD employees during regular business hours for the purpose of providing
information on legal rights and self advocacy to the individuals with disabilities who
participate in the program. During the course of such access, WPAS staffshall be allowed
to engage in informal discussions with the individuals with disabilities, out of the presence
of DDD employees or others, in an area that affords privacy.
F. WPAS staff may visit any location where residents are served by DDD employees,
where the purpose is observation or monitoring compliance with respect to the rights and
safety of service recipients (CFR 1386.22(g)(2)), Such observation and monitoring
activities need not be limited to clients of VVPAS, and WPAS staff shall not be required to
sultGl ult: ul givG 1]l'il7l, 11oticc 41f su0i visits to DDD caiiploy=5, P"ovided that WPAS b" dic
permission of a DDD consumer. WPAS staff shall be permitted to monitor the program
without an accompanying DDD employee. WPAS staff shall conduct all monitoring
activities in a manner which is respectful of the privacy of the individuals with disabilities
who reside in the monitored program.
IV. Access to Individuals with Developmental Disabilities.
A. WAS staff will be provided access to their clients in the same manner as such
access is provided to privately retained and/or court appointed attorneys. DDD shall assist
and support the professional relationship between WPAS and its clients. Written consent
for such access is not required.
B. WAS recognizes that all individuals with developmental disabilities have the right
to refuse to talk with WPAS, to have a third party present during the interview, or to
reschedule the appointment for a more convenient time. WPAS shall advise their clients
and other individuals with developmental disabilities with whom they have contact of these
COMMUNITY ACCESS AGREEMENT
rights before each meeting. A person who does not wish to talk with WPAS staff shall be
allowed to communicate this directly and privately to WPAS staff unless he or she overtly
manifests fear of being alone with the WPAS staff. When the individual with a
developmental disability overtly manifests such fear by words or behavior, WPAS shall
respect that person's desires and not meet alone with that person.
C. WPAS will encourage its clients and other individuals with developmental
disabilities to notify DDD and/or providers of complaints regarding DDD services and to
resolve those complaints through any existing dispute resolution process.
D. WPAS staff shall comply with all safety and security requirements of DDD. DDD
will communicate these requirements to WPAS staff.
E. DDD employees shall not interfere with WPAS staff in obtaining a private space for
meetings between WPAS staff and individuals with developmental disabilities. Private
space does not mean a corner of a common area room or other location which would afford
other residents and DDD employees open access to WPAS employees in living areas or on
the graund-,. Di7T? empinyees shall respect the confidentiality needs of the individual with a
developmental disability and WPAS. Where an individual with a developmental disability
indicates that he or she does not want to meet in a private space, WPAS staff will respect
this request.
F. WPAS staff will not be required to schedule visits with DDD employees in advance
of their visits. However, WPAS staff may contact DDD employees to do so if access to a
WPAS client or other individual with a developmental disability will be facilitated due to
the individual's daily activities.
G. WPAS staff shall have the right to unaccompanied access to any SOLA or program
staffed by DDD employees, and access to any 'individual WPAS client or DD consumer they
are authorized to serve, subject to the following limitations:
(1) While WPAS need not notify the DDD employees prior to meeting with its
client or DDD consumer, WPAS agrees not to disturb a client or DDD consumer if
the WPAS employee arrives at the residence or other building in which the client or
DDD consumer is served and the client or DDD consumer is engaged in regularly
scheduled program activity. In such case, WPAS staff will be permitted to observe
or otherwise verify the programming without disturbing it. if WPAS staff presence
disturbs or is objected to by the WPAS client or any other DDD consumer who is
present, WPAS staff shall make arrangements to meet with the WPAS client or
DDD consumer at a later time. Where consulted prior to making an appointment,
DDD employees will cooperate with WPAS staff in making scheduling
arrangements. The WPAS employee shall not disturb nor interrupt the activity. If
the activity is confidential, WPAS shall obtain the client or DDD consumer's
permission to observe the activity or shall respect the client or DDD consumer's
right to privacy. WPAS staff" will then either wait until the activity is completed or
reschedule the visit at a time that is mutually agreeable to WPAS staff and its
individual client or DDD consumer, no later than 48 hours later.
(2) If the WPAS employee arrives For a meeting with a client or DDD consumer
and the individual is actively aggressive, in programming to address this behavior, or
receiving "one -"to -one" supervision, in such a situation, WPAS staff will be
permitted to observe the individual from a safe distance or otherwise verify that the
individual is actively aggressive. WPAS staff will then either:
COMMUNITY ACCESS AGREEMENT
(a) wait until the individual's aggressive behavior has stopped and be
permitted to meet with the individual privately while DDD employees
remain in viewing distance; unless such distance would place the individual
with developmental disabilities at serious risk of harm based on that
individual's documented behavioral issues; if the individual would be at
serious risk of harm, WAS and DDD shall work cooperatively to address
WAS need for confidentiality with the individual's need for safety;
provided that any such interview floes not interfere with the individual's
Behavior Support Program, Individual Program Plan, Individual Service
Plan, or other program plan, nor interfere with staffing needs for other
individuals with developmental disabilities; or
(b) reschedule the visit at a time mutually agreeable to WAS and DDD
employees, but no later than forty-eight (48) hours;
(c) if the WAS staff is notified that an individual is either actively
aggressive or receiving one-to-one supervision and if knowing this the staff
chooses to meet with the individual, WAS agrees to release, indemnify, and
hold DDD, DSHS, the State and its employees, agents, officers, and servants
harmless for any injuries that occur from any claims or cause of action
asserted by any WPAS employee or agent who is injured as a result of any
act committed by an individual with developmental disabilities except that
those circumstances where DDD employees' willful misconduct is the
proximate cause of the injury to WPAS' employee or agent. WAS agrees
that its staff shall sign a statemenr to this effect prior to requesting to meet
with any such individual. If the WAS staff' refuses to sign such an
agreement, DDD employees may deny the WPAS staff access to the
individual until such time as DDD employees deternnine that safety to the
WAS staff is no longer an issue. When a WPAS staff member elects to
meet with an individual who is actively aggressive, it is neither negligent nor
willful misconduct for a state employee to allow the meeting to take place.
H. All individuals with developmental disabilities who wish to contact WPAS staff
shall be provided uncensored access to writing materials, WPAS' address and toll -free
telephone number, a stamped envelope, and/or access to a telephone for private
conversations without monitoring by or permission from DDD employees.
I. SDLAs and programs staffed by DUD Gmployccs shall pcnnit individuals with
developmental disabilities to set appointments with WAS staff at times agreeable to both
the individual with a developmental disability and WAS staff. If the DDD employees
know that a meeting with a DDD consumer will be disruptive of the DDD consumer's
regular program activity, WAS staff shall be informed of this and allowed to reschedule
the appointment in order to meet with the DDD consumer so that the appointment does not
disrupt his or her regular activity.
V. Access to Records of Individuals with Developmental Disabilities.
A. %VPAS has access to records as provided in 42 U.S.C. § 6042, etetseg. WPAS has
legal authority to review an individual with developmental disabilities' records only when
there is consent or, if a DDD consumer is unable to consent, there is a complaint or probable
cause to believe a DD15 consumer has suffered abuse or neglect. WAS has no general
right to review records except in these circumstances.
COMMUNITY ACCESS AGREEMENT
B. Upon receiving a valid, written consent, DDD will have 48 hours in which to
schedule an appointment with WPASso that it may come to the record location to review
specified records. DDD will verify that WPAS has received consent to view such records,
or if the DDD consumer is unable to consent and there is no guardian to consent, that there
is a complaint or probable cause to believe the DDD consumer hav suffered abuse or
neglect. DDD shall make the requested records within its possession available within five
working days from the date the request is made.
C. WAS may access records of:
(1) any DDD consumer if he, or she consents, or if he or she has a legal guardian
with the power to consent for the DDD consumer and that guardian consents;
a) the DDD consumer or guardian shall give written authorization for access
on a form approved by WPAS and DDD jointly.
(2) any DDD consumer:
a) who by reason of his or her mental or physical condition is unable to
authorize WAS to have access to their records;
b) who does not have a legal guardian, conservator, or other legal
representative, or for whom the legal guardian is the state; and
c) with resPcL:t to w110111 a t;ufnplaillt lldti LW=1 Let;t:ivzd by WPAS.ur with
respect to whom, as a result of monitoring or other activities there is
probable cause to believe that such individual has been subject to abuse or
neglect.
d) If records are requested pursuant to this section, the request shall be in
writing and will state that the resident, by reason of his or her mental or
physical condition is unable to authorize WAS to have access to his or her
records, does not have a legal representative, and that a complaint has been
received by WAS with respect to the DDD consumer or that there is
probable cause to believe the resident has been subjected to abuse or neglect.
The DDD case manager will make a determination regarding whether a
DDD consumer is able to consent to access within 3 working days, except in
case of an emergency.
(3) In the case of a resident who has a legal guardian, and upon request by
WPAS, DDD will provide WAS with the name, address and telephone number of
the legal guardian by 5 p.m. the next business day so that WAS can contact such
representative and offer its assistance. If the guardian has been contacted by WAS
and failed or refused to act on behalf of the individual WPAS has received a
complaint sufficiently that sufficiently identifies the individual or WAS has
probable cause to believe that the health or safety of the individual is in serious and
immediate jeopardy, WPAS shall obtain court approval for such access.
a) If a guardian refuses to consent to allow WPAS access to records, and
WAS stilt wants access, WPAS wiiI file a lawsuit to access the records and
allow a court to determine whether the guardian has failed or refused to act
on behalf of the DDD consumer. WAS agrees to provide legal notice to
DDD of any such proceeding. If the .guardian refuses to provide written
COMMUNITY ACCESS AGREEMENT
consent for WAS to access the records, DDD shall not make the records
available absent a court order.
b) WAS shall attempt to contact the guardian to obtain consent. Unless an
emergency exists, then WPAS shall contact the standby guardian if one has
been designated. If no standby guardian is appointed and the guardian is
unavailable, and WPAS determines that the DDD consumer is at risk of
serious injury or death. DDD shall make the records available to WAS to
review.
D. WAS staff may review the requested records within normal business hours in the
building or room in which such records are provided. A DDD employee may remain in the
room while the records are viewed. Under no circumstances tray WAS staff remove the
original records, or any part thereof, from the room where they are viewed.
E. WPAS agrees to reimburse DDD for the costs of copies at the same rate charged for
public disclosure requests, currently $.15 per page. When feasible, copies will be provided
on the day the copies are regnecterl. If that is not pncsihle, DDD will make the copies
available within 10 days of the request.
P. WAS shall request guardian information or access to DDD consumer records of the
DDD Regional Administrator of the region in which the DDD consumer resides.
Thereafter, their contact regarding that DDD consumer shall be the regional administrator,
or his or her designee. DDD shall provide WAS a list with contact information for
purposes of access to records. DDD agrees to update that list at least annually.
G. In order to access DDD records, WAS will send a written request directly to the
DDD Regional Administrator or designee in custody of the records. In the request, WPAS
will identify the individual whose records it seeks. WPAS need not identify the individual
by name, but must sufficiently identify the individual so that the person reviewing the
request can determine whose records are being sought. WPAS will specify which records it
wants and for which time periods. WAS will also indicate that it has received a complaint
concerning the individual so that it has probable cause to believe the individual has suffered
abuse or neglect. WAS need not ftirther specify the nature of the complaint nor who made
the complaint.
H. In the event DDD denies access to records pursuant to a request, WAS staff may
request that the.deriial be in writing and include the reason for the denial.
1. WAS will limit its request to records it considers necessary to accomplish its
investigation. DDD may request that WAS specifically identify the records that it is
seeking if the request is too broad or voluminous.
VI. Outreach.
A. All individuals with developmental disabilities shall have access to WAS staff for
the purpose of obtaining information about their legal rights and self -advocacy. WAS staff
shall be allowed to engage in infurrual discussiurts witli DDD consurrrers wlio wish to speak
to them out of the presence of DDD employees in an area that affords privacy.
B. WAS may have regularly scheduled information/training sessions for DDD
consumers and parents/guardians/family members regarding WPAS' services and individual
rights. DDD employees may attend outreach and scheduled information sessions only with
advance written permission of WAS staff.
COMMUNITY ACCESS AGREEMENT
C. DDD agrees to give WAS a list of all current DDD consumers and their addresses.
DDD will provide WAS an updated list annually-
D. DDD agrees to provide DDD consumers with notice of WAS services at the time
of application for DDD services. WAS will provide DDD with copies of their brochure
and/or any other information they want DDD to distribute at that time.
E. DDD agrees to require contractors to comply with 42 U.S.C. §6000 et. seo. and 45
C.F.R. Parts 1385-86 by including the requirement in contracts. Current contracts will be
amended to include this requirement when they are renewed.
VII. Authority to Investigate Allegations of Abuse and Neglect.
A. WAS shall have unaccompanied reasonable access to DDD consumers and
facilities when necessary to conduct a full investigation of an incident of abuse or neglect.
This access shall include the opportunity to interview any individual with a developmental
disahility, any DDD or provider employee, or any other person who might be reasonably
believed by WAS to have knowledge of the incident under investigation; and to review
what WAS is entitled to review pursuant to this agreement. WPAS shall be permitted to
do its own investigation of allegations of abuse or neglect regardless of any pending action
or investigation by the State or any other individual or entity.
B. WAS' investigations shall not interfere with any other ongoing investigation.
WAS employees shall not visit areas at times that would violate any person's right to
privacy.
C. DDD shall allow and encourage all employees and providers to talk openly with
WAS employees. WAS will not ask staff to disrupt their work schedules or
responsibilities to talk with WPAS. Except in cases of emergency, WAS will schedule
appointments with staff in advance.
D. While DDD and provider employees shall be encouraged to cooperate with WPAS,
employees have the right to refuse to talk with WPAS. WAS shall notify employees of
that right prior to any attempt to interview them.
E. Any complaint concerning WPAS staff shall be immediately brought to the attention
of the WAS Executive Director or his or her designee. Upon receipt of a complaint, the
WAS Executive Director or his or her designee shall conduct an investigation and submit a
written response to the State within fourteen (14) days in an effort to resolve any complaints
as expediently as possible. DDD reserves the right to file formal charges if the behavior
places a DDD consumer's health or safety at risk.
F. WAS shall inform DDD and providers, in writing, of its findings and concerns
upon completion of any investigation activity undertaken pursuant to its autt€onty under 42
U.S.C. § 6000 et. seg., and the access rights granted to WAS in this agreement, in an effort
to resolve DDD consumer complaints or concerns prior to commencing litigation, unless
WPAS believe that such delay would result in serious injury or harm to the DDD consumer.
VIII. Implementation of the Agreement.
A. The DDD Director shall ensure that each supervisor will conduct an annual meeting
with his or her staff to provide information regarding the parties' rights and responsibilities
under this agreement. The DDD director shall ensure that each employee of DDD has read
COMMUNITY ACCESS AGREEMENT
and signed a copy of a form indicating that they have read this agreement at the time of hire
and at the time of his/her annual evaluation. DDD and WAS shall develop a mutually
agreed to summary of this agreement for use in informing DDD employees of the parties'
rights and responsibilities. When DDD and WAS develop and agree regarding the content
of this summary, DDD employees shall be required to read the sur nramy, rather than reading
this agreement, and acknowledge that they head and understood the summary with a
signature.
B. The agreement is effective as of the date it is signed.
C. DDD agrees that having an agreement in place that would govern WAS and DDD
provider relationships is appropriate. This agreement will affect contractual relationships, so
it will be negotiated with providers prior to implementation. This negotiation will take place
during the 1997-1998 provider contract negotiations. DDD will request WAS review the
proposed contract language prior to contract signing by DDD_ The goal of this negotiation
process will be to arrive at an agreement which implements the federal statutory and
regulatory requirements in a manner consistent with the provision of quality, individualized
service.-, and supports to people with developmental disabilities living in the community.
D. The DDD director will make changes as necessary to implement this agreement by
September 1, 1997, and prior to implementing changes will confer with WPAS.
E. WAS and DDD agree to work together to assist providers in becoming familiar
with WAS access to programs. DDD agrees to host a forum in each region to familiarize
providers with the access provisions. WAS agrees to make staff available as presenters at
regional forums, and otherwise as mutually agreed to with providers. DDD will distribute to
providers a summary of the access provisions. This summary will be prepared by WPAS,
and will be subject to the review and approval of DDD prior to distribution.
IX. Miscellaneous.
A. WAS agrees that its staff shall not give medical advice and shall not engage in the
practice of medicine. it is WPAS' intent and purpose to give legal advice_ For example,
WAS will not tell DDD consumers not to take medication or that medications are wrong
for them.. WPAS will not discourage individuals with developmental disabilities from
participating in programs or activities. WPAS may explain DDD consumer legal rights
including the right to informed consent, their right to be told of the risks and benefits of
medication or medical procedures, their right to refuse to take medications and the
procedure to follow if the DDD consumer does not wish to take medications, and their right
to refuse to participate in experimental programs or research, all as guaranteed under state
and federal law.
B. WAS agrees that there are some DDD consumers who are identified as medically
fragile or to have behavioral concerns that require constant monitoring. If WAS requests a
meeting with such a DDD consumer and DDD determines that the I)t)L) consumer cannot
be left unsupervised with a WPAS employee, a DDD or provider employee shall be present
during any meetings. If DDD consumers are hospitalized due to medical conditions, DDD
or pruvidc� employees may remain within viewing distance if necessary for the DDD
consumer's health and safety. The employees will not interfere with the meeting except for
medical reasons and will respect the DDD consumer's privacy to the extent possible given
his or her medical needs.
COMMUNITY ACCESS AGREEMENT 10
C. This agreement delineates the usual process by which WPAS and DDD will work
together. In some situations, it may be necessary to amend these procedures. WPAS and
DDD may agree to modify these procedures as necessary for any particular situation.
X. Dispute Resolution.
A. WPAS and DDD agree that informal resolution of dispates is preferred. If WPAS
staff and the DDD Regional Administrator or designee are unable to agree about an issue
regarding interpretation or application of this agreement, they will request the WPAS
Executive Director and the DDD Director review the situation and attempt to resolve the
disagreement.
B. The Directors Meeting and Mediation process are mandatory for both parties.
The only exception to this term of the agreement is where WPAS, in good faith, has
probable cause to believe that there are exigent circumstances warranting immediate
access. Such circumstances are defined as "emergencies" as defined in the access
agreements. In such cases, the WPAS Executive Director or his or her designee shall
contact the Director of the Division of Developmental Disabilities or his or her designee;
and/or Office of the Attorney General to attempt to resolve the dispute. If the exigent
access dispute is not resolved by the end of the following business day, WPAS may
immediately take any necessary legal action, including seeking a temporary restraining
order and preliminary injunction or an order to show cause in order to secure the
necessary access without going through the ADR process discussed herein. When NVPAS
does take such action, it shall give the Office of the Attorney General advance notice of
such action by telephone and facsimile.
C. In the event that there is an access dispute regarding any aspect of the Acccss
Agreements between WPAS and DDD (Community), the aggrieved party shall send written
notice to the director of the other party (e.g. WPAS Executive Director, the Director of
nnD, or their designees) of the dispute and the desire to meet to attempt to resolve the
dispute. The DDD director (or hislher designee) shall meet with the WPAS Executive
Director (or hislher designee) within ten days after receiving written notice form the
aggrieved party. The date of receipt of notice shall be in accordance with Civil Rule 6 of the
Washington Court Mules. The meeting may take place in person or telephonically. The
parties have the right to bring their counsel to the directors meeting, however it is the
preference of the parties not to have their counsel present. In the event a party intends to
havu his or her counsel present, that patty will advise the other party of this intent in advance
of the meeting. However, when either director (or his or her designee) is an attorney, it will
be understood and expected that the other director may have his or her attorney present
without prior nntic.e.
D. In the event, that the access issues are not resolved by a meeting between the
Director/CEO and Executive Director of WPAS or their designees, the parties agree to
attempt to resolve the dispute through mediation absent exigent circumstances as described
in paragraph 1. An available mediator from the mutually agreed upon Mediator Panel list as
described below will be used to conduct the mediation.
Mediation will be scheduled to occur as soon as possible following the directors
meeting, but will occur no later than 30 days from the time mediation is agreed upon by the
parties, absent written agreement by both parties to extend this timeline. The mediation may
rake place telephonically or in any manner the mediator believes will be efficient and
conducive to a productive mediation. IF, at any time during the mediation, either party
declares an impasse, the mediation will end. The parties are then encouraged, but not
COMMUNITY ACCESS AGREEMENT l I
required, to arbitrate the dispute. The costs of mediation shall be borne equally by the
parties_ if no litigation results within 90 days of the completion of mediation, WPAS shall
withdraw its access request. Nothing, however, prevents WPAS from renewing its request
in the fixture should that become necessary. In such event WPAS renews the request, and
that request is denied by the State, the ADR process will begin again.
E. Within 90 days of the execution of this agreement, the parties shall select a panel of
at least 4 mntually agreeable mediators. There will be twn sepsrate lists' one for WPAS and
DDD and one for WPAS and the MHD. The parties agree that any one of the selected panel
members will mediate all disputes related to the Access Agreement. However, the parties
will rotate the order of contacting the panel members for each mediation in a nonst ategical
manner.
In order to select this panel, within 60 days of execution of this agreement, the
parties will each propose at least 4 mediators. The parties will exchange, via fax, their list of
proposed mediators and the mediators' curriculum vitae and any other necessary facts such
as cost, mediation rules, etc. If the parties cannot agree upon at least 4 mediators .from the
first exchange of lists, the parties will exchange additional lists of mediators until an
agreement can be reached. However, a final agreement must be reached no later than 90
days from the date of the settlement agreement of this case absent written agreement for an
extension of specific amount aftirne.
Any party may strike a mediator from the list except that a party may not strike a
mediator from the panel once the mediation process has been initiated to resolve a dispute.
If a party strikes a mediator from the panel, that mediator will be replaced by another
mediator using the same mediator selection process as described above.
F. In the event that the access issues are not resolved through mediation, the parties
may agree to attempt to resolve the dispute through arbitration. Written agreement to
proceed to arbitration must be made within five working days of the completion of
mediation described in Section Ei. An available arbitrator From the motiuMly agreed upon
Arbitrator Panel list, as described below, will be used to conduct the arbitration of the
dispute. Arbitration will be scheduled to occur as soon as possible, but will occur no later
than 45 days from the time arbitration is agreed upon by the parties, absent written
agreement by both parties to extend this timeline. Prior to the time of final agreement to
arbitrate the dispute, the parties shall agree in writing whether the arbitration decision will
be binding or advisory, and if advisory, whether that opinion is admissible in court. If no
litigation results within 90 days of the completion of this arbitrdtiOn, WPAS shall withdraw
its access request. Nothing, however, prevents WPAS from renewing its request in the
future should that become necessary. In such event that WPAS renews its request, and that
request is denied by the State, the ADR process will begin again.
G. Within 120 days of the execution of this agreement, the parties shall select a panel
of at least 4 mutually agreeable arbitrators. The parties agree that any one oC the selected
panel members will arbitrate all disputes related to the Access Agreement. However, the
parties will rotate the order of contacting the panel members for each arbitration in a
nonstrategical manner.
In order to select this panel, within 60 days of the execution of this agreement, the
parties will each propose at Ieast 4 arbitrators. The parties will exchange. via fax, their list
of proposed arbitrators and the arbitrators' curriculum vitae and any other necessary facts
such as cost, etc. If the parties cannot agree upon at least 4 arbitrators from the first
exchange of lists, the parties. will exchange additional Iists of arbitrators until an agreement
can, be reached- However, a final agreement must be reached no later than 120 days from
COMMUNITY ACCESS AGREEMENT 12
the date of the settlement agreement of this case absent written agreement for an extension
of a specific amount of time.
Any party may strike an arbitrator from the list except that a party may not strike an
inbiticatui. fluor flit pailol olm:c dir, il1t3jUdL1V11 E71U[:eJti llaa broil. hiiLiuLud LU LCJUIVG a C ibPULC.
If a party stripes an arbitrator from the panel, that arbitrator will be replaced by another
arbitrator using the same arbitrator selection process as described above.
H. The timeframes for dispute resolution shall be as detailed above. Any timeframes
not described in this proposal will be those set out in the current relevant access agreements.
Any firrlefxame may be extended by written agreement of the parties.
L The parties agree they will abide by the timeframes contained in the Access
Agreement and this settlement agreement. The parties may mutually agree to extend any
tirnefrarne. If a party fails to act or respond within the allotted time, the other party may
request appropriate sanctions be imposed as provided by law or civil rule.
ROLFE Date
Acting Director
Division of Developmental Disabilities
MARK STROH Date
Executive Director
Washington Protection & Advocacy System
COMMUNITY ACCESS AGREEMENT 13
Force W09
IRev Warcn 2e24)
caoarMon; of Iho Treasury
Irtcmai Rcvenua Scrrice
FA=ttachment
Request for Taxpayer Give form to the
Identification Number and Certification requester. Do not
send to the IRS.
Go to www.irs.gov/FormW9 for instructions and the latest information.
Before you begin. Far gufdotnee related to ;he purpose o' Form W-9, see Purpose of Form, below.
1 Name of entty/individual. An entry is lacwred. (For a see proor etor or disregarded enter the omle� s -acre on ',ine 1, ❑rd enter -Le ous ncssidisregnrdsd
r'rc,%s rame on'ine 2 )
2 3LISMOS. name/drragarced entity name.:f dYoront'rcln above.
3a Cnerk :he appropnal. no. 'or ''ederel la. c:osS,fical'.or• of the anhtvta rl v:nunl ;,hose name 13 =.rterad ou 6ne 1 Check
anly one of the follo`.vrng seven Loxes.
❑ ndi.•'dualyso!c proorictcr ❑ G corpora:ion ❑ S corpo-ation ❑ oartrersnio ❑ TrUSTJe State
❑ LLC. Entry 'ha hart tlf+sifira!ian ;C - C ::nrponlrwr, S - S carffaaAl, P - P,• ,4, {h O -
Note: Check Ir* "LAC" pox above ard, in tneanlry sptlue, (C, S, et Pi tpr the tall
Grg"ificgtion ar llul V LC, WI —sit i s -, :1'sregerCrxl :YIHry. A d!dr pll,•1ri7nd'np!,:V siru.:ai irslr>q� CrlDClt rem i?flpfgflri0.:n
ocx'or :ho tax classification of is osvna?.
❑ O[her '�sCt? Ir`:ilrUCl,C/iSI
3b 'f on Im 3a you thecled Parre•shrp' or "Tst'ostate' x �recxed' LLB :.nd -crud 'P' as is tax classiicatioc,
ard yrt, are pro�lalnq his torn to is oa'ner,h,p, ;rus', 9r aslala .n ticicn y'oo n&ve ed ar nerscip nleresr, check ElIaIs :lox 1f you have any 'lxolgn p=rtnyr;, owners. or :?erenclanas. See • nsln:�,:lons .
Adc-- (nurnbe , tilreet ard ap% or rude tie ). Sea irlslrur,:ions..
6 Crty, state. or.c Z:P :ode
7 sl -!sr-111 --A -r(sl ^ere 'ape e• a.'
Number
4-xornptions iccces apply cnly to
certain antitias, not individuals:
see irslnrchocs on page 3):
-xemot oayee coca (if any)
xorr•odcn from Foreign Account Tax
Gomp6a11co Ad !FATGA; rop.dwg
Coco (if any)
iA�Flic., rr. Lccc nf3 ravW.,.oed
cutslde :tie Uri' red States.l
' ere I.Sl of s hectic rrt; ai4dress fop'ion*
Enter your TIN in the acpropriate box. i he TiN p!Ovtdsd mst mztett the rarr,e given on line 1 to avoid
backup w. tnhole.ng. For individuals, -h`s s generally Mir 50rkil sr]carity number (SSM. flowe:`er, for a
resident alien, sole proprietor, or disrcyar ded no ty. see We irslructions for Part I, eater. For ri.,111
enb.lies, t is your employer Identification oumcer ON) If yoJ co not have a number, see How to yet a or
T.1N. later.
Note: If the account !s 11 more than one namo. sce the ulstrt_ct:ons for fine 1. See also V✓nat Nacre and r
Number To Gi*vc- In(,Pe;uester for quide. nee on whose numoer to enter, 11
number
num
Under penalties of penury. I Certify that:
1 1•te number snovvn or, th's fnim Is r-y correc'-axpayer clontficatior cumber (or I am :vading -or number to ce Issued to me); ard
2. I Itrrl not subJere to backup :v.lnhola:nq becat.3e':a) I err nxrrrpt from hackup vilhtc1ding, or;h) I -lave not beer noliflcr by --he ni;grtlal Revenue
Sery'ce IIRSi L'rlat I arr, sutilect to oackl-10 withholding as :a resent of n failure to report all interest or dividends, or (c) :he !RS has "olified :ne that I arc
ro onner sjo,ect to cat<uo v:ithnolding; and
3, 1 am a U S. c:h7en or other U S. oerson (defined pave:;: and
a, The FATCA ccde(s) en°ered or '.h:s form (if ary) indicatirg that I am exempt from FATCA reporting .s correct-
CeRification instructions.'%oc must cross out den? 2 lCove if you have been no.if;ed by Ine IRS ?hat you are currently subac W backLn wilhhcluny
because yeu nave a!ed to report all interest and eivid2rics cr yocy 'tax return. For real estate :r nsac:iors. tern2 does r•a apply. For mcrl.gage r,!eres; paid,
acquisi. ien or aba!idor:rent of secured croper /. cancellation of debt, rontnbUtiors -o an inci'viduai rebremer arrange!rer•.'IRAi. ard, generally, p : rnerrs
other than irterest and d:sidet1cM yw., are rot ropLimd -o sign Ina ood'Scation, 'out yor. - urt pro.vldo your corroc, TIN. See the nstructions for ?a i II, a cr.
Sign
Here
Signature of
11.S person
General Instructions
Section references are to the ln,emal Revenue Code unless other -vise
rolled.
Future developments. For the !82wy; irfcrrrtrtt:or about developments
re:ated .o Form':V-9 ard its irstrJG:ii 'qs. awn as legislation enacted
aver =,ey :vere publisned, go to wtvw.irs.goviFor r.019,
What's New
Lne 3a has beer moc.fied to clar^y hoe,, a d•sregarded entry completes
ch,s Itna. An 110 tart M a otsregatarrd entry Shoaled GhEGk Me
approp ante ocx for he :ax cla5sfflratlon of ;1,owner. Q.haralse, it
should ct ttck te'L box:ar•u ertrsr L; aparoprate lax chlssi`ication.
Cal Yo. Ifl�;31y,
Kittitas County Agreement for Services (rev. 5/14/25)
Page 16 of 21
Date
Nnej ill❑ $b has been adrald lo, to s ferna tlotiv-1i ml.gl ?r•lily u
required to corlp-ate tni$ fire tU ina.ca?e '"l I has ci.'ect or ir'L•ireci
IoMgvl partrer,, O%we s. or Oerefivaries,,het- I- provides .he Form VV-9
to anOs'.trr Jovv-tnret-tqt' -mi:y 'n Which it has ar: owrIOtarilp ill^-.r''St- jt'Is
enargr i, ntnrdrd to provide, a low•thmugh artily v,in nlnrmnlrnn
r^g; rc ig tho sl,-V s -Of is irdirocl °o,olgn aarlr•crs. osvrcr. or
^er3licrari8. so:i'fat it can satsty ary aophicable raDartl•tg
rL5Q:lirar`ents For exampltt. a pArnevsnip hat ties any Indl ec 'ore ggri
cFrfr rs nay ts'+:gwrno o cotrplate •cgnocules K-2 ard K, 3, See the
Dar rwr�t•ip Ir•ytru:l ers inns Srhrdulrm K 2 a K 3 ri=arnti 1^65).
Purpose of Form
An individual or e,iti:y (Fora W-9 mcuestcrj 'who s required :o file vul
nlornation relim w to t:ie Igs is gi`,iry you this lorm because they
Fcr•n W-9 r.e'a 3--0241
Fa m NJ-9 (Rev. 3-2024)
must obtain your c"red taxpayer identification number (TIN), which
may be your social security number f3SM). individual taxpayer
identifrcabori number kMt*. adoption taxpayer iderstif"tion number
(ATIM, of earp" Identification number PM. 10 report on an
information return the amount paid to ya1, or other amount reportable
on an information rohim. Examples of infprma5o!n returns include. but
are not limited to, the following.
• Form 1099-INT (interest eamed or paid;.
• Form 1099-DIVV (dividends, including those From stocks or mutuat
f1-dst.
- Form 1099-MiSC (various types of intame. prizes. awards. or gross
p-c eds).
- Form 1099-NEC (nonemployee cempensaWn).
• Form IM.1; (stock or mutual fund sales and certain other
transactions by brokers).
• Form 1099S (prooeeds from real estate transactions).
Form log" (merchant card and third -party network transactions).
- Form toga ¢tome mortgage interest), I0ge-E (student loan interest),
and 1098-T (tuition) .
• Form 1 o99-0 (canceled debt).
- Form I099-A (acquisition or abandonment of secured property).
Use Form W-9 only if you are a U.S. person (including a rssmdent
ahem), to provide your correct -nN.
Caution: If you don't retum Form W-9 to the regw..ter ivilh a TIN, you
might be subject to backup withholding. See Whal is backup
iviflhhofdrrig, later.
fay signing die filled -out form. you:
1. Certify that the T1N y)ou are gMT'g -s correct Ian you are waiting for a
number to be issuedl;
2. Certfy that you are not subject to backup'vithhokling: or
3. Claim exemption from backup withholding if you are a U.S, exempt
payee. and
4. Ciartify to your non-foreegn status for purposes of withholding under
chapter 3 or 4 of the Code (if applicable): and
3. Certify that FATCA codetsj entered on INS form (if any) indiaatina
that you. are exempt from the FATCA reporting is correct. See What Is
FATCA Reporting. later. for further information.
Note: if you are a U.S. person and a requester gives you a form other
than Form W-9 to r quest yout'WJ, you must use the requester's form if
it is substantially similar to this form W-B.
Definition of a U.S. person. For federal tax purposes. you are
considered a U.S. person rf you ate:
• An individual ","rho is a U.S. citizen or U.S. resident alien:
• A partnership, corpoWon, company. or association created or
organised in the United States or under the Iarws of the United States:
• An estate tother than a foreign estatel: or
• A domestic trust Ias defined in ". utatior* section 301.7701-71.
Establishing U.S. status for purposes of chapter 3 and chapter 4
wiW%olding. Payments made to foreign persons. including certain
distn%utions. allocations of income, or transfers Of sales proceeds, may
he subject to withhotding under chapter 3 or chapter 4 of the Coda
(sections 1 nil—i474). Under those rules, if a Farm W-9 or other
certification of non-foraign status has riot been recewed, a withholding
agent, erarisferee, or partnership 1payor) generally applies presumption
rules that may regwre the payor to withhold applicable tart from the
racipiertt, owner. transferor. or partner (payee). See Pub. 515.
Withhaldmg of Tax on Nonresident Aliens and Foreign FintitiM
The foilovring persons must provide Form W-9 to the payor for
purposes of establishing its none -foreign status.
In the case of a disragarded entity with a U.S. owner. the U.S, owner
of the disregarded entity and not the disc garded entity.
• In the case of a grantor trust with a U.S. grenlcr or other U.S. owner,
generaly. the U.S. grantor or other U.S. owner of the grantor trust and
not the grantor trust.
• In the case of a U.S. trust (other than a grantor trust). the U.S. trust
and not the beneficiaries of the trust.
See Pub. 51-3 for more information on providing a Form W-9 or a
certification of non4oreign status to avoid withholding,
Kittitas County Agreement for Services (rev. 5/14/25)
Page 17 of 21
Page 2
Foreign person. If you are a foreign person or the U.S. branch of a
f,x"n bank that has elected to be treated as a U.S. person (under
Reguiatioms section t .1441- IN12Hiv) or other aW-ble section for
chapter 3 or 4 purposes;, do riot use Form W-9. Instead, use the
appropriaY Form W-8 or Form 82M (see Pub. 515), If you ere a
qualified foreign pension fund (rider Regulations section 1 A�370)-1 (d), or
qualified a partnership that is wholly owned by foreign pension funds.
that is treated as a non foreign person for purposes of section 1445
withholding. do not use Form W-9. Instead. use Form W-8EXP (or other
certification of non -foreign status}.
Nonresiderd alien vrho becomes a resident alien. Generally. only a
nonresident afren individual may use the Mantis of a tax treaty to reduce
or, eliminate U.S. tax on certain types of income. However, most tax
treaters contain a provision known as a saving clause. Exceptions
specified in the saving clause may permit an exemption from tax to
continue for oert tin types of income even after the Mee has Otherwise
become a US, m6dent alien for tax purposes,
If you are a IS.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty 10 claim an exemption
from U.S. tax on certain types of income. you must attach a statement
to Form W-S that specifies the following five items.
1. The treaty country. Generally. this must be the same treaty under
which you chdivad exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of incerne that qualifies ford* exemptiorn
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Etampfe. Article 20 of dts U.S.-China income tax treat'/ allows an
exemption from tax for scholarship income received by a Chirtese
student temporarily present in the united States. Under U.S. favi, this
stud ant will become a resident alien for tax purposes if their stay in the
United States exceeds 5 calendar years. Howa).ar. paragraph 2 of the
first protocol to the U.S.-China treaty (dated April 30. le-Q-1) allows the
provisions of Mole 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for thin exception (under paragraph 2 of the first
Protocol) and is retying an this exception to claim an exemption from tax
cn their scholarship a fel owsh p mome would attach to Form W-9 a
statement that inciudes the information described above 10 support that
exemption.
It you are a nonresident alien or a foreign entity, give the requester the
appropriate rompteted Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons rnaWng cartain payments to you
must under cer4n condifiens withhold and pay to the IRS 24% of such
payments. This is called "backup %fthofding,' Payments that may be
srrbjecl to backup withholding include, but are not limited to. interest.
Iax-exempt interest. dividends. broker and barter exchange
transactions. rents, royalties. nonerrip?oyee pay. payments made in
settlement of payment card and third -party network transactions, and
certain payments from fishing boat Operators. Real estate transactions
are not subject to backup withholding.
You will not be subject to backup wahholdiug on payrnsrtts you receive
rf you give the requester your correct TIN. make the proper certifications.
and report all your taxable interest and dMdends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do riot furnish your TiN to the requester.
2. You do not certify your TiN when required (see the instructions for
Part Il for details):
3. The IFS talls the requaal+er that you fumrshad an incorrect TIN:
a, The IFS fella you that you are subject to backup wtthhoking
because you did not report all your interest and dividends- on your tax
return (lor reportable rnterest and dividends onIy): or
s. You do not certify to the requester that you are not subject to
backup viithhotding, as described in item 4 under "By srgr.vrg fuse frNed-
out forum' above Jor reportable interest and dividend accounts opened
after IM only).
Form W-9 Mev. 3-2024)
Certain payees and payments are exempt from backup wthhdc ing.
See Fxernpf payee code. Ialer. and the separate Instrsrctions for the
Requester of Form W-9 for more information.
See also 1=stabfishing U.S. status for purposes of chapter3 and
chapter 4 withholding. earlier.
What Is FATCA Reporting?
The Foreign Account Tax Comptiance Act iFATCAI regwres a
participating foreign financial institution to report all V.S. account
holders that are specified U.S. persons. Certain payees are exempt from
FATCA reporting. See Exarrtprmn Irom FATCA reporting code, later, and
the instructions for the Requester of Fom W-9 for more infomsation.
Updating Your Information
Yaw rnust provide updated informed on to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and an6cipale receiving reportable payments in the future from this
person, For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you are
no longer tax exempt_ In addition. you must furnish a new Form W-9 if
the name or 71M changes for the account. for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of 550 for each such failure
unless your failure is due to reasonable cause and not to willful neglect.
Civii penalty for false information with respect to withhold ing.lf you
make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a S500 penalty -
Criminal penalty for falsifying information. Wllfulty falsifying
certifications oraffirmaliarss may subject you to criminal penalties
including fines and/or imprisonment -
Misuse of TINS. If the requester discloses or uses TIN s in vkiamn of
federal taw. the requester may be subject to civil and criminal penalilas-
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W9 is for a joint account (other than an account
maintained by a foreign financial institution fFFI)), list first. and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. If you ara providing Farm W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
• individual. Generally. enter the name shown on your tax return. If y w
have changed your last name without informing the Social Security
Administration ISSA} of the name change. enter your first name, the last
name as shown on your social security card. and your new ast name.
Nate for MN applicant_ Enter, your individual name as it was entered
on your Form W-7 application, line i a. This should also be the same as
the name you entered on the Form 1040 you filed with your application.
• Sole proprietor. Enter your individual name as shown on your Form
1040 on line f. Fntar your business, trade. or adoing Business as- kOBA)
name on line 2.
• partnerah-rp. C corporation. S corporation, or LLC, otherthan a
I entity. Enter the entity's name as shown on the entity's fax
return on line 1 and any business. trade, or USA name on line 2.
• Other entities. Enter your name as shown on required US. federal tax
documents on line 1. This name should match the narne shown an the
charter or other Segal document creating tha entity. Enter any business.
trade, or USA name on line 2_
• Disregarded entity. in general. a business entity that has a single
owner, including an LLC, and is not a corporation, is disregarded as an
entity separate from its owner (a disregarded entity). See F49utetiorrs
section 301,7791-2(cH2). A disregarded entity should chock the
appropriate box for the tax classification of its owner. Enter the ovvner's
name on line 1. The name of the owner entered on line 1 should never
be a disregarded entity- The name on line 1 should be the name. shown
on the income tax return on which the income should be reported. For
Kittitas County Agreement for Services (rev. 5/14/25)
Page 18 of 21
page 3
example, 6 a form LLC that is treated as a disregarded entity for U3.
federal tax purposes has a single o rser that is a U.S pemm the U.S.
owner's name is required to be prouid'ed on line t. It the direct owner of
the entity is also a disregarded entity. enter the first owner Ural is not
disregarded for federal tax Wposes. Enter time disregarded sr»it}i s
name on line 2. If the ativnee of the dsregarded entity is a foreign person
the_ o7,,mer must complete an appropriate Form W-8 instead of a Form
W-9. This is the case even if the foreign person has a U-S. TIN.
Line 2
IF you have a business name. trade name. DBA name, or disregarded
entity name, enter it on line 2_
Line 3a
Check the appropriate box on line 3a for the U.S. federal tax
classification of time person whose name is enler on log 1. Check ordy
one box on line 3a-
IF the entityfindividual on line 1
THEN check the box for ...
is a(n) ...
Corparaliiort
Gon_
• Individual or
Individual/sole proprietor.
• Sole proprietorship
• LLC classified as a partnership
Limited liability company and
for U.S. federal tax purposes of
enter the appropriate tax
• LLC that has filed Form 8= or
classification:
2553 electing to be taxed as a
P = Partnership.
corporation
C = C corporation, or
S = S corporation.
• Partnership
Partnership.
• Trustlestate
I Tnist`estate.
Line 3b
Check this box if you are a pait-- sh p including an LLC classified as a
paftership for U.S. federal tax purposes,. trust or estate that has any
tomtgn partners, owners. or benefician and you are providing this
form to a partnership. trust. or estate. in which you have an ciATtership
interest. You must check the box an line 3b if you recenve a Form W-8
(or documentary evidence![ from any partner. owner, or berwftcfarf
establishing foreign stahrs or if yw reoFave a Form W-9 from any
Danner, owner. or beneficiary that has checked the box an Ilse 3b.
Note: A partnership that provides a Form W-9 and chscks box 3b may
be regtured to complete Schedules K-2 and K-3 (Form 1O65}. For, more
information. see the Partnership Instiructions for Schedules K-2 and K-3
(Form 1065).
If you are required to complete fine 3b but fail to do so. kvu may not
receive the information re-cssany to file a correct information mttim with
the IRS or furnish a correct payee statenel`it to Your partners or
benefiaadM See, for exampip sections 6698. 8722, and 6724 for
penaly Vs that may apply.
Line 4 Exemptions
If you are exempt irom backup vrrthlrolding anWor FATCA reporting.
eater I the ap;;F rprretµ space u+r ling 4 any cude(s) If rat rrsay apply to
You.
Exempt payee code.
• Generally, indNiduafs (including sale proprietors) are not exempt from
backup withholding.
• Except as provided b51ax. corporations are exempt from backup
withholding for certain paymsnts. including interest and dividends.
• Corporations are not exempt from teckup withhotdirx} for payments
made in settlement of payment card or third -party network harrarctrans.
• Corporations are not exempt from backup •rwrthhotding vrilh respect to
attomeys' fens or gross proceeds pad to attnm=ys- and corpQratsons
that pro:•ids medical or health cafe serlres are not exempt with respect
to payments reportable on Form TOW-MW.
The f0ovang codes identify payees that are exempt from backup
withholding. Enter the apWopr a -Code in the Waco on tine 4.
f —An organization exempt franc tax under section 5O1(aj. any IRA, or
a custedef account under semen 403(bX7-j d the account satiAes the
requirements of section 401(f)(2).
page 4
Form W-9 (Rev. 3-2024)
2—The United States or any of its agencies or instrumentalities.
3—A state, the District of Columbia, a U.S. commonwealth or territory,
or any of their political subdivisions or instrumentalities.
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities.
5—A corporation.
6 —A dealer rn securities or commodities required to register in the
United States, the District of Columbia. or a U.S. commonweatth or
territory.
7—A futures commission merchant registered with the Commodity
Futures Trading Commission-
B—A real estate investment trust.
9—An entittyy registered at all times during the tax year under the
Invesiment%ompany Act of 1940.
10—A common trust fund operated by a bank under section 584(a)-
11—A financial institution as defined under section 581.
12—A middleman known in the investment community as a nominee or
custodian.
13—A trust exernpt from tax under section 664 or described in section
4947.
The following chart shoves types of payments that may be exempt
from backup withholding_ The chart applies to the exempt payees listed
above. 1 through 13. _
IF the payment is for...
THEN the payment is exempt
for...
• Interest and dividend payments
All exempt payees except
for 7.
• Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations-
3 corwaticm must rat enter an
exempt payee code because they
are exempt only for sales of
nonowered sacurittesacquired
prior to 2012.
• Barter exchan&? transactions
Exempt payees 1 through 4.
and patronage dividends
• Payments Over S600 required to
Generally, exempt payees
be reported and direct sales over
1 through 5.2
55.000'
• Payments made in settlement of
F=xempt payees 1 through 4-
payment card or fft3fd-party
nemovk transactions
1 See Form 1099-MISC. Miscellaneous Information. and its instructions.
However, the following paymares made to a corporation and
reportable on Form 1099=tvt1SC are not exempt from backup
withholding: medical and health care payments, attorneys' fees. gross
proceeds paid to an attorney reportable under section 6043(f). and
payments for services paid by a federal executive agency -
Exemption from FATCA reporting code. The following codas identify
payees that are exempt from reporting under FATCA. These codes
apply to persons submitting this form for accounts maintained outside
of the United States by certain foreign financial institutions. Therefore, if
you are only submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain it the financial institution is
subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with "Not Applicable' (or
any similar indication) entered an the line for a FATCA exemption code.
A— An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(aK37).
B—The United States or any of its agencies or instrumentalities.
C—A state, the District of Columbia, a U.S. commonwealth or
territory. or any of their political subdivisions or instrumentalities.
D—A corporation the stock of which is regularly traded on one or
morn established sacurities markets, as described in Regulations
section 1.1472-1(c)(1)().
E—A corporation that is a member of the same expanded affiliated
group as a corporation described in Regulations section 1.1.172-1(cXIhi),
Kittitas County Agreement for Services (rev. 5/14/25)
Page 19 of 21
F—Adealer in securities. corrrinodities. or derivaliv8 financial
insi umartLa fincluding national principal contracts. fuitres, forvva'ds,
and options) that is registered as such undef the taws of the United
States a any state.
C—A real estate cwestment ftst-
H—A regulated rrnrestment eamparry as defined in section 851 or an
entity registered at all times during the tax year under the ImLestment
Company Ar_t of 1440,
1—A common [nisi fu id as defined in sections 58-11af.
J—A bank as defined in section let.
K—A broker.
L—A Rust exempt from tax under section W or described in section
4947(a)(1)-
fd—A tax-exempt trust under a section 4tb) Phr or section :.57(91
plan.
Note: You may wish to coirsult witty the financial institution requesting
this form to determine whather the FATCA code arrdlar exempt payee
code should be completed.
dine a
Enter your address (number. street, and aparbr nt a suite number).
This is where the requester of this Form W-9 will mail your information
returns. if this address differs from the one the requester already has on
file. enter 'NEW" at the top. If a now address is provided, there is still a
chance the old address vvifl be used until the payorchaitg s your
address in their records.
Line 6
Enter vow city, state. and ZIP coda.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate boot. It you are a resident alien and
you do not have. and are not elirgble to get. an SSN. your nN is your
IRS ITIN. Enter it in the entry space for the Social security nurnber. If you
do not have an [TIN, see Flory to get a 77N below.
if you are a sole proprietor and you have an EIN, you may -nter either
your SSN or FIN.
it you area single- member LLC that rs disregarded as an entity
separate from its owner. enter the o 'rer's SSN [or Ella. if the anvner has
ante=- if the LLC is classed as a oorporaiian or partnership. enter the
entity's EIP1
Note: So-- What Name 4Ftd Nunoer To Give lire Aequestar, later. for
further clarification of name and TIN =T&riatiorrs.
Flaw to get a TIN, if you do not have a TTN. apply tar one nmMediataly.
To apply for an SSW. gat Form SS-5. Application for a Social Security
Card. from your local SSA office or get this form onruis at
trnrx.SSA gov. You may al -so get this form by calftrg a00-7-72-1213. Use
Form W-7. Application for IRS IndMdLW Taxpayer Identification
Number. to apply for an ITIN, or Form SS-1. Application for Employer
Identification f itxni>?r. to apply for an EiN. You can apply for an EIN
or>Cne by aco.�ssing tits IRS vrebsite at -"w.ira9ov.'0N. Go to
LriYiY.i15-govlForms to vi?w, download, or pylon Farm ►`1-7 a-id:'or Form
SS-4. Or, yriu can yu, tv www.ivs.9uv!0idWRxerW ter pgace etc wd ar W'd
have Form W-7 and gr Form S-S-4 mailed to you'cvithci 15 business
days.
If you are asked to complete Form W-9 but do rat have a TIN, apply
for a TIN and enter -Applied Poo'' in the space for the TIN, sign and date
the firm. and gn�e it to dmie requester. Far irtlerest and &vfdend
payments. a-4 certain payments made siith respect to readily tradable
instruments. you xi$ generally have 60 days to get a TIN and give a to
the requester befog you are subject to backup v:rthhafdrng on
Yogi will be subject to backup idirule does ot apply to 09Wt on all such Payments untils
you provide your TIN to the requester.
Note: Entering 'Applled For' means that you have already applied for a
TIN or that you intend to apply for one soon. See also fis`Nnu US.
status for purposes of chapter and dhafrfer 4 wifftf,^aiayrig. earlier. for
when you may instead be subject to Mth o4diN :order chapter 3 or 4 of
the Code.
Caution: A disregarded U -S. amity that has a'ofeign owner must use
The appropr.ate Form W-8.
Forth W-9 (Rev. 3-2024)
Part II. Certification
To estatliish to the withholding agent that you are a U.S. person. or
resident a#ien, sign Form W-9. You may be requested to sign by the
withholding agent erFn if item t, 4. or 5 below indicates atherbvise.
For a joint account. only the person whale TIN is shown in part I
should sign (when required). In the case of a disregarded entity. the
person identified on line I must sign. Exempt payees, sae ExempI AaYee
code, earlier.
Signature requirements. Complete the certification as indicated in
items 1 through 5 below.
1. Interest, dividend, and barter exchange accounts Opened
before 1984 and broker accounts considered active during M&
You must give your correct TIN. but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 11983 and broker accounts considered inactive during
f M. You must sign the certification or backup wAholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in Fite
certification before signing the farm.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
4. Other payments. You must give your correct TIN. but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect 11N. "Other payments" include
payments made in the course of the requester's trade or business for
rents, royafties. goods (other than bills for merchandise), medical and
health care services (including payments to corporations). payments to
a nonemployee for services. payments made in settlement of payment
card and third -party network transactions. payments to certain fishing
boat craw members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
S. Mortgage interest pasd by you, acquisition or abandonment of
Secured property. cancellation of debt, qualified tuition program
payments (under seetion SM. AB LE accounts (under section 529A),
IRA, GoverdeiI ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TiN, but you do nut have to sign the certification.
What Name and Number To Give the Requester
For this type of account:
Give name and SSN of:
1. Inds, ideal
The individuA
2. Two or mart ir4jv duals ijoirm 104ot o
The actual owner of the account or.
other 1F>Sn an account rruinttineo by
if combined funds, the first individual
an FFI
on the 3ccourt1
3. Two or more US Pem0ns
Each holder of the account
6oint account maintainad by an FFI)
4. CuutodiA account of a minor
The minor'
I73nftim Gift to MkKx:r Act)
5. a. Tkc usual ce.ocable savrngs tnrSt
The grantor-trusts-e-
(grantor is afro
b. So-called trust account that * not
The actual owner'
a legal or valid tnni ,eider state law
c. Sole propd4tomlvp or d!sregarded
The ovmers
entity owned by an ind-idual
r, Grantor trust frying -,TK4r Optional
The grantor"
Filing method t Sset ReguWiors
SeUion 1,671
Kittitas County Agreement for Services (rev. 5/14/25)
Page 20 of 21
Page 5
For this type of account
Give name and EIN of-
S. Disregarded Mtity Nt owned by an
The owner
indivi&ml
9. A valid trust, estate, OF pehsuo-n trust
Le:o emit.'
10. Corporation or LLC electing corpO,ate
The coryoratron
status on Form SK2 or Form 2553
11. Associatirn, dub. religion.:. chasiiaL4--.
Tfie rrgaramtiOn
educational, or othx taxaAempt
organi=tian
12. Partnership or multi-merniser 1L:
The pares^. ershp
13. A broke, or registered nominee
Tre broker or nominee
14. Acwta-ft hith the Department of
The public entity
Agriculture it the runx of s PuWic
entity f%zch as a state or iccel
g r.wrviterit. whool ?istrm or on-,on't
that receives agricdtural program
payments
15, Grantor trust filing Form 1041 ar
Tile trust
wider the Optional Filing A Hind 2.
re[luirng Farr+ 1098 tsecP49UL tocs
section 1.fs71-41.bi(2Ajlft;ij"
'List first and circle the name of the person whose number you furnish.
If only one person on a joint account has an SSN. that person's number
must be furnished.
2Circle the minors narne and furnish t.'te rmnor's SSN.
3Yore must shovr your individual name on line 1, and enttr yyo�ur business
air06A name. if any, on fine 2. You may use a thar your SSN or EIN ',d
you have one). but the IRS r"urages you to use your SSN.
' List first and circle the name of the trust. estate. or mansion trust. Mo
not furnish the TIN of the personal repma ntattve or trustee unless the
leg at entity itself is not designatEd in the account title.)
Note: The grantor must also provide a Form W-9 to the trustee of the
trust.
--For morn information on optorral thing mathods for grantor trusts s?a
the Instructions for Form 1041.
Note_ If no name rs carded htten more than one name is listed. the
number will be com &red to 4e tat of the fir=-t nafn- list.
Secure Your Tax Records From Identity Theft
Identity thatt accurs when someone uses your personal information.
such as your name. SSN. or otter idett6iog infarmation. vrittwut your
pecmisslon to commit fraud ar other cremes. An identty thief may use
your SSN to get a tab or may file a tax return using your SSN to receive
a refund.
To reduce your risk
• Protect your SSN.
• E um your employer is protec509 your SSN. and
• Be careful when ctwosing a tax return prvloamr.
If your tax records are affected by kkritity theft and VW receive a
notice from the IRS. resgoryJ right aaay to the name and phone nwnber
printed on the IRS notice or letter.
If your tax records are hat currently affected by identity theft but you
think you are at risk due to a lest or stolen p'os' or wallet, questionable
credit card activity, or a quiestionahJe credit report- contact She IRS
Identity Theft Hotline at 2t)u-9N -449D or submd Form W39.
For more information. sea Pub- 302" tderttily Theft Information for
Taxpayers.
Form W-9 (Rev. 3-2024)
Victims of identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in rasohnng tax problems that
have not been resolved through normal channels. may be eligiwe For
Taxpayer Advocate Service (TAS) assistance. You can reach TA5 by
calling the TAS toll-frea case intake line at 877-77-7-4778 or TTW701)
800-829-4059.
Protect yourself from suspicious entails or phishing schemes.
Phishing is the creation and use of email and website5 designed to
mimic legitimate business emavls and vrehsites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into sunandering
private information that will be used for identity theft.
The IRS does not initiate contacts vMh taxpayers via emails. Also. the
IRS does not request personal detailed information through email a ask
taxpayers for the PIN numbers. passriords. or similar secret access
information for their credit card, bank. or other financial accounts.
It you receive an unsolicited email claiming to be from the IRS.
forward this message to phishinglirs.gay. You may also report misuse
of the IRS name, Togo, or other IRS property to the Treasury Inspector
General For Tax Administration (TIG A) at SM-366-4-1 - You can
forward suspicious ernads to the Federal Trade Commission at
sparrreuce_gov or report them at rvmv.ffc,govlcompWnf. You can
contact the FrO at wvrcv_ftc govhdrheft of 877•IDTHEFT (877-438-4338Y.
If you have been the victim of identity theft, see wwrv.IdeniityTheh gov
and Pub. 5027.
Go to www.irs.gov/ldentityTheff to learn more about identity theft and
how to reduce your risk.
Kittitas County Agreement for Services (rev. 5/14/25)
Page 21 of 21
p.je 6
Privacy Act Notice
Section 6109 of the Intenjal Rev nn-�s Cade mquires you to provide your
correct TlN to Persons 6rctuding i_deral agencies) who are required to
file infomwtion returns w1h the 1RS to report interest. dividends. or
certain other income paid -o you: mortgage interest you paid: the
acquisition or abandonmernt of secured property: file canrallatian of
debt: or coMiibutions you made- to an tRA- Archer M-SA or HSA. The
person caileciirrg tie s corm uses the information on the farm i0 file
iniumrabon retrmrs with the IRS. reportiN tha above information.
rRoufin3 uses of this information include givin ii to the De-partrmnt of
Justice for civil and criminal fitrgation and to cifiss, states. thO igiWct at
Cdtmbia, and U.& cornrnorrcveaiths and territories for use in
administering thew laws. The information may also be disclosed to other
countries under a treaty. to federal and state agerK�s to enforce cstd
and criminal is m or to federal Iaw entafcement and intelligence
agencies to combat terrorism. You must provide your TNV whether or n4A
you are required to file a tax relum. Under se0on 3406. payors must
gen"yvnthhold a peroerL-Kge of taxable irrterest. dividends. and
certain other payments to a payee who does not give a Tl# to the Payer.
Certain penallies may also apply for providing False or fraudulant
information.