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DocuSign Envelope ID: 31 D6625C-0058-4E4A-8FOC-FB93F3CFOD72 K21-0 / FCC)li LT
Washin tan State HCA Contract No.
y.-K391-9—'ate:
No.: 3
AMENDMENT
TRACT
Health Care.uthority,
I THIS AMENDMENT TO THE CONTRACT is between the Wash I ington State Health Care Authority and
the party whose name appears below, and is effective as of the date set forth below.
CONTRACTOR NAME CONTRACTOR doing business as (DBA)
Grant County
CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS IDENTIFIER
840 E Plum Street (UBI)
Moses Lake, WA 98837
AMENDMENT START DATE: AMENDMENT END DATE: CONT RACT END DATE:
April 15, 2021 June 30, 2021 September 29, 2022
PRIOR MAXIMUM CONTRACT AMOUNT-- AMOUNT OF INCREASE TOTAL MAXIMUM. CONTRACT AMOUNT
$631)354 $9,837 $6417191
WHEREAS, HCA and Contractor previously entered into a Contract •for CPWI Prevention Services
and;
WHEREAS, HCA and Contractor wish to amend the Contractpursuant to Section 17 to increase
federal State Opioid Response (SOR) No Cost Extension(NCE) funding;
NOW THEREFORE, the parties agree the Contract is amended as follows:
1. Section 8, Compensation and Billing, Subsection 8.1 Consideration and Source of Funds is
amended to increase maximum consideration by $9, 837 from $631,354 to $641,191.
2. Attachment 8, Federal Award Identification for Subrecipients, •SOR Grant table is replaced, and
incorporated herein.
3. Attachment 9, Award and Revenue for the Quincy coalition, is •replaced, and incorporated
herein.
4. This Amendment will be effective April 15, 2021("Effective Date").
5. All capitalized terms not otherwise defined herein have the meaning ascribed to them in the
Contract.
6. All other terms and conditions of the Contract remain unchanged and in full force and effect.
The parties signing below warrant that they have read and understand this Amendment and have
authority to execute the Amendment. This Amendment will be binding on HCA only upon signature by
both parties.
Tqj�CTMS-IGNA'
HCA SIGNATURE
DocuSigned by:
W, 1-1
Washin fA S a e N1711 ?A1
Health Care Authority
PRINTED NAME AND TITLE
Cindy Carter, BOCC Chair
PRINTED NAME AND TITLE
Zachelle Amerine
Contracts Administrator
Page 1 of 3
DATE SIGNED
DATE SIGNED
5/10/2021
CPWI Prevention Services
HCA Contract No. K3943-3
l6
DocuSign Envelope ID: 31 D6625G-0058-4E4A-8FOC-FB93F3CFOD72
ATTACHMENT 8 - Federal Award Identification for Subrecipients (reference 2 CFR 200.331)
Washington State Opioid Response (SOR) Grant, No Cost Extension
(i)
Subrecipient name (which must match the name
Grant County
associated with its unique entity identifier);
010202562
H79TIO81705
09/03/2018
(ii) Subrecipient's unique entity identifier; (DUNS)
(iii) Federal Award Identification Number (FAIN);
(iv) Federal Award Date (see §200.39 Federal award date);
(v)
Subaward Period of Performance Start and End Date;
7/1/2019 through 9/29/2020
(vi)
Amount of Federal Funds Obligated by this action;
n -7
$9,83 t
(vii)
Total Amount of Federal Funds Obligated to the
$100)358
subrecipient;
(viii) Total Amount of the Federal Award;
$21,573,093
(ix)
Federal award project description, as required to be
Washington State Opioid Response (SOR)
responsive to the Federal Funding Accountability and
Grant
Transparency Act (FFATA);
(x)
Name of Federal awarding agency, pass-through entity,
SAIVIHSA
and contact information for awarding official,
WA State Health Care Authority
Keri Waterland, Assistant Director DBHR
626 8th Ave SE; Olympia, WA 98504-5330
Keri.wateriand(@,hca.wa.gov
(xi)
CFDA Number and Name; the pass-through entity must
93.788
identify the dollar amount made available under each
Federal award and the CFDA number at time of
disbursement;
(xii)
Identification of whether the award is R&D; and
El Yes ® No
(xiii)
Indirect cost rate for the Federal award (including if the
de minimus (10%)
de minimis rate is charged per §200.414 Indirect (F&A)
costs).
Page 2 of 3
Washington State HCA CPWI Prevention Services
Health Care Authority HCA Contract No. K3943-3
DocuSign Envelope ID: 31 D6625C-0058-4E4A-8FOC-FB93F3CFOD72
ATTACHMENT 9 - Award and Revenues
CONTRACTOR: Grant County CONTRACT NUMBER: K3919, Amendment 3
COUNTY: Grant COMMUNITY/COALITION: Quincy
The above named Contractor is hereby awarded the following amounts for the purposes listed.
REVENUE
TYPE OF SERVICE
AWARD AMOUNTS
SOURCE CODE:
SF_Y2_0 S_
Total 19-21
SFY 22
SFY23
Total 22-23
333.37.88
SOR No Cost Extension (FFY2020) - Admin
$ $787
$78
333.37.88
SOR No Cost Extension (FFY2020) — Direct
$
$9,050
$ 9 05
$
costs
, .
$0
$C
Total Federal Funds
$116,_--1 0
-.
$139,887
$255, 991
00,
$27 500
_
1 37; 500
Total State Funds
$
$p
$
0
$0
TOTAL ALL AWARDS
137,50.0
;$116,10
$139,887
$255,991
$11Q,00
$27 50
Federal CFDA:
*All timelines include any associated admin.
State Opioid Response (SOR), CFDA 93.788, Substance Abuse and Mental Health Services Administration (SAMHSA)
• Year 1 funding period: 7.1.19-9.29.19; Year 2 funding period: 9.30.19-9.29.20;
• Funds must be used in the FFY in which they are awarded, as indicated above.
• Beginning 9.30.19, funds in year 2 may be used in SFY 20 or SFY 21, until 9.29.20.
• Final invoice due: 45 days after fund source end date on 11.13.2019 and 11.13.2020.
State Opioid Response (SOR) II, CFDA 93.788, Substance Abuse and Mental Health Services Administration (SAMHSA)
• Year 1 funding period: 9.30.20-9.29.21; Year 2 funding period: 9.30.21-9.29.22.
• Funds must be used only in the FFY in which they are awarded as indicated above.
• Beginning 9.30.20, funds in year 2 may be used in SFY 21 or 22, until 9.29.21. Beginning 9.30.21, funds in year 3 may be used in
SFY 22 or 23, until 9.29.22.
• Final invoice due: 45 days after fund source end date on 11 .13.2021 or 11.13.2022.
State Opioid Response (SOR) Supplemental, CFDA 93.788, Substance Abuse and Mental Health Services Administration (SAMHSA
• Year 1 funding period: 7.1.19-9.29.19; Year 2 funding period: 9.30.19-9.29.20; )
• Funds must be used in the FFY in which they are awarded, as indicated above. Beginning 9.30.19, funds in year 2 may be used
in SFY 20 or SFY 21, until 9.29.20.
• Final invoice due: 45 days after fund source end date on 11. 13.20219 and 11.13.2020.
Page 3 of 3
Washington State HCA CPWI Prevention Services
Health Care Authority HCA Contract
No. K3943-3
Attachment 9: Award and Revenue