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DSHS Central Contract Services Page 1
6024PF Contract Amendment (1-26-2018)
DSHS CONTRACT NUMBER:
5""
CONTRACT AMENDMENT
1963-58857
OrW
Department
Department of Social
& Health Services
Amendment No. 01
Transforming lives
This Contract Amendment is between the State of Washington Department of
Program Contract Number
Social and Health Services (DSHS) and the Contractor identified below.
Click here to enter text.
Contractor Contract Number
CONTRACTOR NAME
CONTRACTOR doing business as (DBA)
Grant County
Grant County DDA County Services
CONTRACTOR ADDRESS
WASHINGTON UNIFORM BUSINESS DSHS INDEX NUMBER
PO BOX 1057
IDENTIFIER (UEI) 1221
Moses Lake, WA 98837-0160
136-000-784
CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
Nicole Davidson 509 764-6329 1 Click here to enter text. Click here to enter text.
DSHS ADMINISTRATION
DSHS DIVISION
DSHS CONTRACT CODE
Developmental Disabilities Admin
Division of Developmental
1769CS-63
Disabilities
DSHS CONTACT NAME AND TITLE
DSHS CONTACT ADDRESS
Seanna Woodard
1611 W Indiana Ave
Operations Manager
Spokane, WA 99205
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS
(509)329-2952 (509)568-3037 woodas dshs.wa. ov
IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS
No
AMENDMENT START DATE
CONTRACT END DATE
05/01/2020
06/30/2020
PRIOR MAXIMUM CONTRACT AMOUNT
AMOUNT OF INCREASE OR DECREASE
TOTAL MAXIMUM CONTRACT AMOUNT
$809,724.00
$14,263.00
$823,987.00
REASON FOR AMENDMENT;
CHANGE OR CORRECT MAXIMUM CONTRACT AMOUNT
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 : Exhibit B
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
Amendment.
COTOR IGNATU
PRINTED NAME AND TITLE _
DATE SIGNED
�
Cindy Carter, Chair
DSHS SIGNAT
PRINTED NAME AND TITLE
DATE SIGNED
DSHS Central Contract Services Page 1
6024PF Contract Amendment (1-26-2018)
This Contract between the State of Washington Department of Social and Health Services (DSHS) and the
Contractor is hereby amended as follows:
1. The Total Maximum Contract Amount is hereby increased in the amount of $14,263 for a new Contract
Amount of $823,987. The additional amount is reflected in the attached amended Spend Plan.
EXHIBIT B
Program Agreement Budget
❑ Original Budget ® Budget Revision
REVENUES
Fiscal
Year
Fund Source
Original
15' Revision
2nd Revision
2020
State Only
411,066
418,288
53906
OTHER CONSUMER SUPPORTS
(CMIS/AWA Code 31, 32, 41, 92,
93,94)
Waiver
27708
22671
50379
CONSUMER SUPPORT
STATE -ONLY
Local
Medicaid Match to
Local
Child Development
Total Rev.
$809,724
$823,987
All other terms and conditions of this Contract remain in full force and effect.
DSHS Central Contract Services Page 2
6024PF Contract Amendment (1-26-2018)
PASRR
Funds
State
Funds
Medicaid
Funds
TOTAL
ADMINISTRATION (CMIS/AWA
BARS 11)
29648
24258
53906
OTHER CONSUMER SUPPORTS
(CMIS/AWA Code 31, 32, 41, 92,
93,94)
27708
22671
50379
CONSUMER SUPPORT
STATE -ONLY
Child Development
2160
2160
MEDICAID CLIENTS
358771
358771
717542
ROADS to COMMUNITY LIVING
TOTAL
418,287
405,699
823,987
All other terms and conditions of this Contract remain in full force and effect.
DSHS Central Contract Services Page 2
6024PF Contract Amendment (1-26-2018)