HomeMy WebLinkAboutGrant Related - BOCCDocuSign Envelope ID: 9E988662-BFCA-40BF-BEF2-A309D5D5C9EF K
19-064
Washington StateHCA
CONTRACT NUMBER:
Health Care Ut�
CONTRACT AMENDMENT
1763-94250
Prevention Services
Amendment No. 04
This Contract Amendment is between the State of Washington Health Care
Program Contract Number
Authority (HCA) and the Contractor identified below.
Click here to enter text.
Contractor Contract Number
CONTRACTOR NAME
CONTRACTOR doing business as (DBA)
Grant County
CONTRACTOR ADDRESS
WASHINGTON UNIFORM BUSINESS
ACD INDEX NUMBER
840 E Plum St
IDENTIFIER (UBI)
1221
136-000-784
Moses Lake, WA 98837-1874
CONTRACTOR CONTACT
CONTRACTOR TELEPHONE
CONTRACTOR FAX
CONTRACTOR E-MAIL ADDRESS
Gail Goodwin
509 764-2644
I 509 765-4124
ggoodwin@grantcountywa.gov
HCA PROGRAM AREA
HCA CONTRACT CODE
Division of Behavioral Health and Recover
1644CS-63
HCA CONTACT NAME AND TITLE
HCA CONTACT ADDRESS
Ray Horodowicz
PO Box 45330
Project Manager
Olympia, WA 985045330
HCA CONTACT TELEPHONE
HCA CONTACT FAX
HCA CONTACT E-MAIL ADDRESS
(360)725-1528
(360)725-2280 1
horodr@dshs.wa.gov
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT?
CFDA NUMBERS
No
AMENDMENT START DATE
CONTRACT END DATE
04/26/2019
06/30/2019
PRIOR MAXIMUM CONTRACT AMOUNT
AMOUNT OF INCREASE OR DECREASE
TOTAL MAXIMUM CONTRACT AMOUNT
$295,827.00
$2,300.00
$298,127.00
REASON FOR AMENDMENT;
CHANGE OR CORRECT CHOOSE ONE:
ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into
this Contract Amendment by reference:
❑ Additional Exhibits (specify):
This Contract Amendment, including all Exhibits and other documents incorporated by reference, contains all of the terms
and conditions agreed upon by the parties as changes to the original Contract. No other understandings or
representations, oral or otherwise, regarding the subject matter of this Contract Amendment shall be deemed to exist or
bind the parties. All other terms and conditions of the original Contract remain in full force and effect. The parties signing
below warrant that they have read and understand this Contract Amendment, and have authority to enter into this Contract
Am m
CO IG
PRINTED NAME AND TITLE
DATE SIGNED
Cindy Carter, Vice -Chair
Richard Stevens, Member
'5 1(0119
Q�RE
PRINTED NAME AND TITLE
DATE SIGNED
M(,S {D10,
James W. Gayton Contracts Admi ni stra
JIB/2019
1
`- 780E8771 E443429...
HCA Contract Services Page 1
7024PF HCA Custom Contract Amendment (5-2-2018)
This Contract between the State of Washington Health Care Authority (HCA) and the Contractor is hereby
amended as follows:
1. The Contract end date is extended to September 30, 2019.
2. The maximum Contract amount is increase from $295,827 to $298,127.
3. The additional $2,300 funds are to be used for implementation of the following programs as described
in the Contractor submitted action plan:
• PAX GBG Summit
• Strengthening Families Program
All other terms and conditions of this Contract remain in full force and effect.
HCA Contract Services Page 2
7024PF HCA Custom Contract Amendment (5-2-2018)