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410—
DSHS CONTRACT NUMBER:
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COUNTY PROGRAM Or INTERLOCAL
1963-56851
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Department of Social
&Health Services
Amendment No. 01
LONG-TERM PAYABLE AGREEMENT
AMENDMENT
Transforming lives
This Amendment is between the State of Washington Department of Social and
Program Contract Number
Health Services (DSHS) and the Contractor identified below.
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ract Number
Contractor Contract
CONTRACTOR NAME
CONTRACTOR doing business as (DBA)
Grant Count
CONTRACTOR ADDRESS
WASHINGTON UNIFORM BUSINESS
DSHS INDEX NUMBER
IDENTIFIER (UBI)
840 E Plum St
136-000-784
1221
Moses Lake, WA 98837-1874
CONTRACTOR CONTACT
CONTRACTOR TELEPHONE
CONTRACTOR FAX
CONTRACTOR E-MAIL ADDRESS
Veronica Perez
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DSHS ADMINISTRATION
DSHS DIVISION
DSHS CONTRACT CODE
Facilities, Finance and Analytics
Financial Services
8030CS-63
Administration
DSHS CONTACT NAME AND TITLE
DSHS CONTACT ADDRESS
Mariann Schols
PO Box 45842
Manager, Finance
Olympia, WA 98504-5842
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS
360 902 8170 (360664_5775 scholm' dshs.wa. ov
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT?
CFDA NUMBERS
No
AMENDMENT START DATE
CONTRACT END DATE
07/01/2020
06/30/2021
PRIOR MAXIMUM CONTRACT AMOUNT
AMOUNT OF INCREASE OR DECREASE
TOTAL MAXIMUM CONTRACT AMOUNT
$0.00
N/A
Based on Annual Review
REASON FOR AMENDMENT;
CHANGE OR CORRECT PERIOD OF PERFORMANCE
ATTACHMENTS. When the box below is marked with an X, the following Exhibits are attached and are incorporated into
this Amendment by reference:
❑ Additional Exhibits (specify):
This 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 County Program Agreement or Interlocal Agreement. No
other understandings or representations, oral or otherwise, regarding the subject matter of this Amendment shall be
deemed to exist or bind the parties. All other terms and conditions of the original County Program Agreement or Interlocal
Agreement remain in full force and effect. The parties signing below warrant that they have read and understand this
Amep,dment,and hag authority to enter into this Amendment.
CR4CT0 SIGNAT!
NAME AND TITLE
DATE SIGNED
Irl
PRINTED
C t N D `i CJVA--E` Q I -j J c t Cl fh !L
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DSHS SIGNATOAE
PRINTED NAME AND TITLE
DATE SIGNED
Clarissa Brechwald, Contracts Consultant
DSHS Central Contracts and Legal Services
DSHS Central Contracts and Legal Services R E C IV Page 1
6046 LF Long -Term Payable Amendment (5-5-20)
JUN 17 2020
GRANT COUNTY COMMISSIONERS
This Agreement between the State of Washington Department of Social and Health Services (DSHS) and the
Contractor is hereby amended as follows:
DSHS extends the Agreement End Date twelve months from June 30, 2020, to June 30, 2021, as
stated on Page One of this Amendment.
DSHS revises the Contractor Contact Name to Veronica Perez as stated on Page One of this
Amendment.
All other terms and conditions of this Agreement remain in full force and effect.
DSHS Central Contracts and Legal services Page 2
6046 LF Long -Term Payable Amendment (5-5-20)