HomeMy WebLinkAbout*Other - RenewGRANT COUNTY
COMMISSIONERS AGENDA MEETING REQUEST FORM
(Must be submitted to the Clerk of the Board by 12:00pm on Thursday)
REQUESTING DEPARTMENT: Renew
REQUEST SUBMITTED BY:Reyna Gonzales
CONTACT PERSON ATTENDING ROUNDTABLE:
—DelLAnderson
CONFIDENTIAL INFORMATION: ®YES ❑ NO
onre:04/11/2024
PHONE: 509 764-2660
If necessary, was this document reviewed by accounting? F-1 YES ❑ NO
If necessary, was this document reviewed by legal? ❑ YES ❑ NO
DATE OF ACTION: , t
APPROVE: DENIED ABSTAIN
D1:
D2:
D3:
4/8/24
DEFERRED OR CONTINUED TO:
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JA
A in
Agreement /Contract
❑Appointment /Reappointment
❑ARPA Related
El Bids /RFPs /Quotes Award
[]Bid Opening Scheduled
F1 Boards /Committees
El Budget
El Computer Related
❑County Code
❑Emergency Purchase
❑Employee Rel.
❑Facilities Related
1:1 Financial
1:1 Funds
❑Hearing
1:1 Invoices /Purchase Orders
❑Grants —Fed/State/County
❑Leases
E] MOA / MOU
❑Minutes
F1 Ordinances
El Out of State Travel
El Petty Cash
❑Policies
❑Proclamations
El Request for Purchase
11 Resolution
❑Recommendation
❑Professional Sery/Consultant
El Support Letter
❑Surplus Req.
❑Tax Levies
❑Thank You's
❑Tax Title Property
❑WSLCB
man
•
This is our yearly Cost Report for Developmental Disabilities.
Please print schedule A,
sign and return back to me as I need to send the orignial to our
anaylist at the State of Washington
If necessary, was this document reviewed by accounting? F-1 YES ❑ NO
If necessary, was this document reviewed by legal? ❑ YES ❑ NO
DATE OF ACTION: , t
APPROVE: DENIED ABSTAIN
D1:
D2:
D3:
4/8/24
DEFERRED OR CONTINUED TO:
IN - Grant County Developmental Disabilities (DCL)
3. PROVIDER MAILING ADDRESS 4. CITY, STATE, ZIP
1103 Lowry St. Moses Lake WA 98837
6. ADMINISTRATOR NAME 7. ADMINISTRATOR E-MAIL
200012501
S. PROVIDER PHONE NUMBER
509 762-1161
8. ADMINISTRATOR PHONE NUMBER
Missy Lopez mlopez0grantcountywa gov 1509 762-1161
9. HOME OFFICE/CORPORATE NAME (please indicate if NONE or SAMEAS ABOVE
)
Same as above
10. HOME OFFICE MAILING ADDRESS 11. CITY, STATE, ZIP 112. HOME
OFFICE PHONE NUMBER
13. COST REPORT PREPARER 114. FIRM NAME
Reyna Gonzales Grant County dba Renew
15. REPORT CONTACT INDIVIDUAL(S) 16. CONTACT PHONE NUMBER 17. CONTACT EMAIL
Reyna Gonzales 509 764-2660
rgonzales cC�grantcou
18. COST REPORT PERIOD 19. FEDERAL ID NUMBER(S)
1/1/2023
FROM:
12/31/2023
TO:
PART B. - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE
PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW
CERTIFICATION
� I HEREBY CERTIFY under penalty of penury that I have read the above statement and have examined
' the accompanyingcost report and supporting schedules prepared for:
Grant County Developmental Disabilities
(Provider Name)
and I attest, it is a true, correct and complete representation of actual co .related to client supports prepared in
accordance with applicable instructions providedb xce
`1 t as n ed.
ii
;f
PER
SOP
Cindy Cater�uT GRIT TO BIND THE PROVIDER LISTED
f
Chair DATE
DSHS/DDA Schedule A (Rev. 12/2022)
4/11/2024 2023 Cost Report - Template- Reyna Schedule B-3 A -
General Info &Cert, Page 1 of 1