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RESOLUTION NO. 3251
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF AUBURN,
WASHINGTON, AUTHORIZING THE MAYOR TO EXECUTE AN INTERLOCAL
AGREEMENT BETWEEN THE CITY OF AUBURN AND THE STATE OF
WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES, DIVISION
OF DEVELOPMENTAL DISABILITIES, TO PROVIDE SERVICES TO ELIGIBLE
PARTICIPANTS AND THEIR FAMILIES FOR ACCESS TO NEEDED FACILITIES
AND RECREATION PROGRAMS.
THE CITY COUNCIL OF THE CITY OF AUBURN, WASHINGTON, IN A
REGULAR MEETING DULY ASSEMBLED, HEREWITH RESOL VES THAT:
Section 1.
The Mayor of the City of Auburn is herewith authorized to execute
an Interlocal Agreement between the City of Auburn and the State of Washington
Department of Social and Health Services, Division of Developmental Disabilities, to
provide services to eligible participants and their families to have access to needed
facilities and recreation programs. A copy of said Agreement is attached hereto and
denominated as Exhibit "A", and made a part hereof as though set forth in full herein.
Section 2.
The Mayor is hereby authorized to implement such administrative
procedures as may be necessary to carry out the directives of this legislation.
DATED AND SIGNED this _~ay of September, 2000.
CITY OF AUBURN
CHARLES A. BOOTH
MAYOR
Resolution No. 3251
August 10,2000
Page 1 0[2
~
ATTEST:
f~~~
Danielle Daskam,
City Clerk
APPROVED AS TO FORM:
l:ç' . \ .
.', . f "
·,lt~(f~
Michael J. Reynolds
City Attorney
Resolution No. 3251
August 10, 2000
Page 2 0[2
6~- INTERLOCAL AGREEMENT DSHS CONTRACT #:
DEPA ENT OF
SOClAL&~LTH
SERVl
This Agreement is by and between the State of Washington Program Contract Number
Department of Social and Health Services (DSHS) and the -
Contractor identified below, and is issued pursuant to the Interlocal Contractor Contract Number
Cooperation Act, chapter 39.34 RCW.
CONTRACTOR NAME CONTRACTOR DBA
CITY OF AUBURN PARKS AND RECREATION DEPARTMENT
CONTRACTOR ADDRESS CONTRACTOR SOCIAL SECURITY NUMBER OR FEDERAL EMPLOYER
25 WEST MAIN IDENTIFICATION NUMBER (mandatory. for tax purposes)
AUBURN, WA 98001 916001228
CONTRACTOR CONTACT TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
253-931-3007
DSHS ADMINISTRATION I DSHS DIVISION I DSHS CONTRACT CODE
HRSA ODD
DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS
LINDA SHEEHAN 1700 E CHERRY ST
SEATTLE, WA 98122
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS
206-568-5685
nHE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBERS
Yes IZI No
CONTRACT START DATE CONTRACT END DATE I $AXIMUM CONTRACT AMOUNT
09-01-00 08-31-03
ATTACHMENTS. When the boxes below are marked with a check (.f) oran X, the following Exhibits are attached to and
incorporated into this Interlocal Agreement by reference:
IZI Exhibit A. Statement of Work (Required for new contracts unless included in text of Agreement).
0 Additionai Exhibits (specify).
Thi~ Jht~miqÇ~!·¡¡,~r~mE!ht,.in(;IY9ip~åJl¡~~hibit~anº othérdocUhlehÌ$attachadorinco\þþ\atE!d ibyreferehce, i contains all of
thE!te.IJ1')~.i3nc!,¡;().nditi().ll~a!: reed¡µp()'IlPY ·th.eparties.. N o other undel1jti3lldings ..orreprese"tations, oral'.or otherwise,
regarding the. subject matter9f.t~¡er1ocaIAgreement shall be deemed to exist orbindthe· parties,
CO~r:~~NQ~ß(c+~ PRINTED NAME AND TITLE DATE SIGNED
Ch~rlo~ ~ , M"".....r 1- to -{JÒ
DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
Michael J. Reynol s,
City Attorney
DSHS Central Contract Services
Inter10cal Agreement (2-26-99) Rev 5-9-00
Page 1
~; ,
INTERLOCAL AGREEMENT (CONTINUED)
1. Definitions
· "Agreement" means this Interlocal Agreement, including all documents attached or
incorporated by reference.
· "Contracting Officer" means the Contracts Administrator, or successor, of Central
Contract Services or successor section or Office.
· "Contractor" means the entity performing services pursuant to this Interlocal
Agreement and includes the Contractor's officers, directors, trustees, employees
and/or agents unless otherwise stated in this Interlocal Agreement. For purposes of
this Interlocal Agreement, the Contractor shall not be considered an employee or
agent of DSHS.
2. Statement of Work
The Contractor shall perform the services described below or as set forth in the
attached Statement of Work (Exhibit A): AN 0 B
3. Billing Procedure
SEE EXHIBIT A AND B
4. Payment
DSHS shall pay the Contractor an amount not to exceed the maximum consideration
specified on page 1 of this Agreement for the satisfactory performance of all work set
forth in the Statement of Work. The Contractor shall request payment using forms as
designated by DSHS. DSHS shall pay the Contractor upon acceptance by D~HS of
properly-completed invoices or vouchers.
If this Interlocal Agreement is terminated, DSHS shall only pay for performance
rendered or costs incurred in accordance with the terms of this Interlocal Agreement
prior to the effective date of termination.
5. Governance
a. The provisions of this Interlocal Agreement are severable. If any provision of this
Interlocal Agreement is held invalid by any court, that invalidity shall not affect the
other provisions of this Interlocal Agreement and the invalid provision shall be
considered modified to conform to existing law.
DSHS Central Contract Services
Interlocal Agreement (2-26-99) Rev. 5-9-00
Page 2
INTERLOCAL AGREEMENT (CONTINUED)
b. In the event of an inconsistency in the terms of this Interlocal Agreement, or between
its terms and any applicable statute or rule, the inconsistençy shall be resolved by
giving precedence, in the following order to:
· Applicable federal and state law, regulations, and rules;
· Exhibit A (if any);
· Any other provision of this Interlocal Agreement; and
· Any document incorporated by reference.
c. In the event of a lawsuit involving this Interlocal Agreement, venue shall be proper
only in Thurston County, Washington.
d. The Contractor shall comply with all applicable non-discrimination and other local, state
and federal laws, regulations and rules.
6. Indemnification
The Contractor shall be responsible for and shall indemnify and hold DSHS harmless
from all claims resulting from the acts or omissions of the Contractor and any
Subcontractor. DSHS shall be responsible and shall indemnify and hold the Contractor
harmless from all claims resulting from the acts or omissions of DSHS.
7. Inspection: Maintenance of Records
a. During the term of this Interlocal Agreement and for one year following termination or
expiration of this Interlocal Agreement, the Contractor shall give reasonable access
to the Contractor's place of business and client and Contractor records to DSHS and
to any other employee or agent of the State of Washington or the United States of
America for the purpose of inspecting the Contractor's place of business aDd its
records, and monitoring, auditing, and evaluating Contractor performance and
compliance with applicable laws, regulations, rules, and this Interlocal Agreement.
b. During the term of this Interlocal Agreement and for six years following termination or
expiration of this Interlocal Agreement, the Contractor shall maintain records
sufficient to:
(1) Document performance of all acts required by statute, regulation, rule, or this
Interlocal Agreement;
(2) Substantiate the Contractor's statement of its organization's structure, tax status,
capabilities, and performance; and
DSHS Central Contract Services
Interlocal Agreement (2-26-99) Rev. 5-9-00
Page 3
INTERLOCAL AGREEMENT (CONTINUED)
(3) Demonstrate accounting procedures, practices, and records which sufficiently
and properly document the Contractor's invoices to DSHS and all expenditures
made by the Contractor to perform as required by this Interlocal Agreement.
8. Ownership of Material
Material created by the Contractor and paid for by DSHS as a part of this Interfocal
Agreement shall be owned by DSHS and shall be "works for hire" as defined by the
U.S. Copyright Act of 1976. This material includes, but is not limited to: books;
computer programs; documents; films; pamphlets; reports; sound reproductions;
studies; surveys; tapes; and/or training materials. Material which the Contractor uses to
perform this Interlocal Agreement but which is not created for or paid for by DSHS is
owned by the Contractor; however, DSHS shall have a perpetual license to use this
material for DSHS internal purposes at no charge to DSHS.
9. Confidentiality
The Contractor shall not use or disclose any information concerning any DSHS client for
any purpose not directly connected with the administration of the Contractors
responsibilities under this Interlocal Agreement except by prior written consent of the
DSHS client.
10. Insurance
DSHS certifies it is self-insured under the State's self-insurance liability program, as
provided by RCW 4.92.130, and shall pay for losses for which it is found liable. For
purposes of this Agreement, the Contractor shall maintain insurance as required in the
Statement of Work, unless the Contractor is self-insured or insured through a risk pool.
11. Alteration. Amendment. and Waiver
This Agreement may be amended only by a written amendment signed by both parties.
Only the DSHS Contracting Officer may waive any provision of this Agreement on
behalf of DSHS.
12. Disputes
Disputes shall be determined by a Dispute Board. Each party to this Agreement shall
appoint one member to the Dispute Board. The members so appointed shall jointly
appoint an additional member to the Dispute Board. The Dispute Board shall review the
facts, contract terms, and applicable statutes and rules and make a determination of the
dispute. As an alternative to this process, either party may request intervention by the
DSHS Central Contract Services
Interlocal Agreement (2-26-99) Rev. 5-g..()Q
Page 4
INTERLOCAL AGREEMENT (CONTINUED)
Governor, as provided by RCW 43.17.330, in which event the Governor's process shall
control. Participation in either dispute process shall precede any judicial or quasi-
judicial action and shall be the final administrative remedy available to the parties.
13. Termination
a. If the funds DSHS relied upon to establish this Interlocal Agreement are withdrawn,
reduced or limited, or if additional or modified conditions are placed on such funding,
DSHS may immediately terminate this Interlocal Agreement by providing written
notice to the Contractor. The termination shall be effective on the date specified in
the notice of termination.
b. Either party may terminate this Interlocal Agreement for any other reason by
providing 30 calendar days' written notice to the other party.
14. Assiç¡nment
The Contractor shall not assign all or any portion of this Interlocal Agreement to a third
party.
15. Waiver of Default
If DSHS waives any breach of this Agreement by the Contractor on any occasion, such
waiver shall not be deemed to be a waiver of any subsequent breach of this Interlocal
Agreement by the Contractor.
16. Subcontracting
Except as otherwise provided in this Agreement, the Contractor may subcontract for any of the
contracted services with the prior, written approval of DSHS. The Contractor shall be
responsible for the acts and omissions of any subcontractor.
17. Single Audit Act Compliance
If the Contractor is a subrecipient of federal awards as defined by Office of Management and
Budget (OMB) Circular 133-A, the Contractor shall maintain records that identify all federal
funds received and expended. Such funds shall be identified by the appropriate OMB Catalog
of Federal Domestic Assistance numbers. The Contractor shall make the Contractor's records
available for review or audit by officials of the federal awarding agency, the General
Accounting Office, DSHS, and the Washington State Auditor's Office. The Contractor shall
incorporate OMB Circular A-133 audit requirements into all contracts between the Contractor
and its subcontractors who are subrecipients. The Contractor shall comply with any future
amendments to OMB Circular A-133 and any successor or replacement Circular or regulation.
DSHS Central Contract Services
Inte~ocal Agreement (2-26-99) Rev. 5-9-00
Page 5
INTERLOCAL AGREEMENT (CONTINUED)
If the Contractor expends $300,000 or more in federal awards from any and/or all sources in
any fiscal year beginning after June 30, 1996, the Contractor shall procure and pay for a single
or program-specific audit for that year. Upon completion of each audit, the Contractor shall
submit to the DSHS Contact named in this Contract the data collection form and reporting
package specified in OMB Circular A-133, reports required by the program-specific audit guide
(if applicable), and a copy of any management letters issued by the auditor.
18. Year 2000 Readiness
The Contractor acknowledges and understands that the so-called "Year 2000 problem" may
impact computer systems that the Contractor relies upon to perform the Contract. The
Contractor shall take all reasonable actions to ensure that the Contractor will be able to
perform all duties required by the Contract despite any computer system malfunction due to
the Year 2000 problem.
APPROVED AS TO FORM BY THE OFFICE OF THE ATTORNEY GENERAL
DSHS Central Contract Services
Interlocal Agreement (2-26-99) Rev. 5-9-00
Page 6
Exhibit A
SPECIAL TERMS AND CONDITIONS
Client Support Services: The Contractor shall provide needed support or
supplemental services such as community, educational, household, nutrition,
recreation, and budgeting activities/classes to ensure client well-being or Î!"proved
function in the least restrictive setting.
CONSIDERATION
102 Negotiated, as follows: Fees for services shall be the actual cost of the service
described above and as authorized by DDD.
105 Travel expenses, not to exceed current State of Washington rates as published by the Office of Financial
Management.
199 Other. as follows:
"Statem~nt of Work".
PAYMENT AND BILLING:
200 Social Service Payment System (SSPS): The Contractor shall receive invoices
generated by SSPS. The Contractor shall verify that services stated on the
invoices were delivered by indicating in the total units block offonm DSHS 08-141,
or equivalent, that services were delivered, and shall return the invoices as
directed by SSPS. DSHS shall use the verified SSPS invoice to generate payment
to the Contractor. In case of any problem with an SSPS invoice, the Contractor
shall contact the service worker who authorized services to the client.
209 Duplication of work: The contractor ensures that work to be performed does not duplicate work to be
charged to the State of Washington under any other contractor agreement with the contractor. _
210 Complete Payment: The contractor agrees to accept this payment as total and complete remuneration for
services provided to DSHS clients. This does not preclude the contractor from seeking other funding
sources, except federal matching funds.
EVALUATION:
306 Progress/Implementation Reports: The contractor shall provide to the Department reports, at regular
intervals, using agreed-upon criteria, of progress in implementing purchased services, or progress toward
purchased outcomes.
399 Other, as follows:
The contractor shall cooperate with the department in the evaluation of hislher performance under the
terms of this contract including the following:
1. Follow-up contact with clients, their families, guardians or primary care givers, regarding their
satisfaction with the services provided;
2. Investigation and documentation of all complaints about the service provided;
3. feriodic monitoring of service documentation records and of billing and payment data on SSPS.
EXHIBIT .ß
STATEMENT OF WORK
SUPPORT SERVICES
DEFINITIONS OF SUPPORT SERVICES
1. CCKMUNITY ACTIVITIES - Respite care out ot the home provided
Dr agencies or licensed personnel to give primory care
q vers a rest trom care tasks to relieve .tr.... Community
activities may be u.ed for respite euch as $pecial Olympic.,
pool tee., Y'S, Scouts, day camp., Camp Fir., Youth Club.,
day care and community acc.... Siblings and friend. of the
individual with developmental disabilities may De included
in the community activity.
2. EDUCATIONAL SUVlCES - Includes par.nting cla...., .upport
groups, conter.nces, work.shops, educationa,l material, and
care training. -
3. EQUI1'JŒN'r SUPPLIES - equipment and euppUe. per.onal to the
person not covereä DY any oth.r re.ource. Kay include
chairs, walkers, water bed., communication devic.., special
toys, intercoms, monitors, air purifiers, diapers, car seats
nece..ary for ~rav.l, bicycle adaptations such as adaptive
¡eats and carryalls, or other items to car. tor or provide
stimulation, entertainment, or recreation tor the person.
4. HOUSEHOLD SZRvtCES- Housecl.aning eervicea, home repairs,
and modification. to the home.
5 . INDIVIDtJAL COUNSZLIHG/'l'HERAPI!:UTIC SE1lVICES - Occupational
therapy (OT), phy.ical therapy (PT), communicatio~, b.havior
management or coun.eling for t~e individual dealing with
hi./her disability. -
6. MZDICAL/D~ SIKVIC!8 - Medical/dental services, including
medicine, not covered by any other resource and is beyond
the pr1mary c:areqiver'. ability to cover. This may include
insurAnce premiums and deductibles. -
7 . Nt1'l'!.I'1'ION SERVICES - special tormulaa or specially prepared
foods beyond what would be need.d tor an individual of the
.ame age who cUd not have a medical or other di.abili ty.
8. OTHER SERVICES - Services approved by the director of ~he
Division of Developmental ~isabilities, DSHS, in conjunction
with the recommenåation. of the regional advisory committ.e.
9. PARENT/FAMILY COUNSELING - Counseling dealing with a
diagnosis, grief and loss issues, decision. making, genetic
counseling, and behavior management.
.~
CONTRACTOR INTAKE
This form is NQI a confract but must be completed by the Contractor in order to receive a cô-ntract~
from DSHS.
1. CONTRACTOR INFORMATION.
CONTRACTOR NAME CONTRACTOR DBA (IF ANY)
I~,l¡ ó'¡:AIJ!w/,.I'?d 1-2~~kc..v
CONTRACTOR CONTACT PERSON CONTACT PERSON PHONE
- t./ (./'>Jq- y)- 1';¡¡-3dY3
J C-"""'J~~
CONTRACTOR ADDRESS CONTRACTOR PHONE
,;l~ 1-'. .11"1 e:- ';./ ,)s:;¡- 9JI·-j(Wj
..4 v¿v,~r' j./,¿ qpOð/ CONTRACTOR FAX
.2.fJ - 2fF-::;.JI..ï.2.
' -'
- - - ,-.---- CON I HAC I OK E-MAIU'>;DDRI::SS ~
j (.J>.ft!/;Jtt:.rec.-,'. C<.V~V/'N.· t,;...., v.s
FACILITY ADDRESS (If Applicable) 'BILLING ADDRESS (If Applicable)
~::)~-<-- ..s-"~~<-
-
What is your business Employer Identification Number (EIN)? If Is your fiscal year the s~ the calendar year (January
you do not have an EIN, what is your Social Security Number? through December)? Yes No
(mandatory, for tax purposes)
If not, what is your fiscal year?
q;-(POO /;L;;....~ Start: End: -
What is your Washington State Uniform Business Identifier (UBI) If you do not have a UBi Number, state why you are exempt from
Number? (Please attach a CODV of vour Washinoton State registering your business with the State of Washington.
business license.)
/7/ ,
-¿JcJC) -¿¡/O ,
Have you had any contract to provide services terminated for defauit? If so, please attach a list of each terminated contract with an
explanation of the situation inv<>lved. Nil,
-
2. How Is your business organized? (see instruction page for explanation of terms). --¡:¡'¡:c.--¡¡::- 0 f ::ec.o r,d p OJ €J.
o Sole Proprietor o Corporation, for profit o Corporation, non-profit (attach ~ Govemmental Entity
copy of 501 (c) status)
o General Partnership o Limited Partnership o Limited Liability Partnership o Limited Liability Company
3. Do any of the following descriptions apply to your business? If so, please check those that apply.
0 Certified, for profit Minority-Owned Business Enterprise 0 Certified, for profit Woman-Owned Business
(MBE) Certification Number: Enterprise (WBE) Certification Number:
0 Non-certified, for profit Minority-Owned Business Enterprise 0 Non-certified, for profit Woman·Owned Business
(MBE) Enterprise (WBE)
D Community-Based Organization (CBO) (25% of the Board of D Owned by person(s) with disabilities
Directors of the CBO aoo minorities oopresenting the ¡gJ
population whom the CBO serves) None of the above apply
DSHS Central Contract Services
Contractor Intake (1-21-00)
Page 1
ETHICS CERTIFICATION FOR CURRE~EMPLOYEES
CONTRACTOR NAME. SERVICES THE CONTRACTOR WILL PROVIDE
CURRENT STATE OFFICER/EMPLOYEE NAME
CURRENT STATE EMPLOYER.,________
TITLE OF YOUR STATE JOB
I hereby certify that the following statements are true:
~_.._-_._--_._- - -.-.-----.-..-- ---
I am a current employee, member, manager, officer, director, and/or partner of the above-named contractor;
My role with the above-named contractor is not in conflict with the proper discharge of my official duties as a
state officer or employee.
AND ONE OF THE FOLLOWING IS ALSO TRUE:
1. I will not receive any thing of economic value under the contract as defined in RCW 42.52.010 (20);
-~----_.--....- -
OR
~._--~--_. .-
2. I have complied with RCW 42.52.030 (2);
OR
3. I meet all of the following conditions:
a. The contract is genuine and I will actually perform work under the contract.
b. Performance of the contract is not within the course of my actual duties or under my direct
supervision in my capacity as a state officer or employee.
c. Performance of the contract will not require me to reveal any confidential information or cause me to
. viQlate any state agency rules pertaining to outside employment.
d. The contract is neither performed for nor compensated by someone from whom I am prohibited from
accepting a gift (those prohibited gift givers include all persons who are regulated by DS1IS).
e. The contract is not one expressly created or authorized by me in my official capacity as a state officer
or employee.
,pro:vided:by¡.the)laws,of,tlì~Sta~o~WãshlhgtoíP"tlTat th'e;:;:-;'-" ~':' 7-:;
. ---.-;-;/..-,,";~::;t;-<"::1''':·i~_ _ :':~';:''¡')~"..-:~;h,.:,'.j._:.:~_';. <;:;.,.....,:."......'.\...,'.7_ .",*', :¡..~"·!"·.?'""'·'1:>,-jt'/f"1··~._·-·,,,... --, :. -. "--',,<>
"';':_'C,'" ',"::".',
Iflcatloware. true'and"corre¢ and:ttìattt'wtll"notlfY·DSHS"ofany<t·',;'
~P::S:_T'<;<,"__-;;~«' -'<":~¿;':;~-~'..~' ':' --~ '-:'.::',::_:~:LL;,~r:~;'-~ff: ,~<~:-.j'~-ii,t:-:~~:::L~,~ ,~;":.,,:_~: &è,::,:;)Je:i5F-/::"
State Officer/Employee Signature
Date
Printed Name
Title
DSHS Central Centrad Services
Contraclo<' Intake (1-21-00)
Page 3
State Business Records Detail
Page I of 1
Back to previous page.
Washington State Department of Revenue
State Business Records Database Detail
TRX REPORTING NUHBER:
LEGRL ENTITY NUHBER:
LEGRL ENTITY:
DOING BUSINESS RS:
HRILING RDORESS:
171B88818
171088018
CITY Of RUBURN
BUSINESS LOCRTION:
25 II HRIN ST
RUBURN. IIR 90881-4916
4512 R ST SE
RUBURN. IIR 90882-
OIlNER TYPE: HUNICIPRL SUBDIVISION
RCCOUNT OPENED: 81/81/1960
RCCOUNT CLOSED: OPEN
STRNDRRD INDUSTRIAL CODE: 4941
9n/2888 15:21
+
~~
FOR NON-COmmERCIAL USE ONLY
http://dor. wa.gov/prd/ getinfo.asp?colurnn= 171 0000 1 O&traId= 171 0000 1 O&xref=False
9/7/00
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Pl.':I¡,\ Ü~II:N\· (if
, ~4,:1i.1,\1 t;'J J A .J j-I
: . ~;¡:¡~V11. !os.
19~3:~~;~;;~ORK. '
------,-_._--~._.----~----------
. -,-,... .", ,q--.- .-.... --1
AMENDMENT NUMBER I
I
"..1
CLIENT SERVICE WORK ORDER AMENDMENT
'fhis Clienl Service Work Order Amendment and Incorporated attachments cannot be used for Personal or
Purchased Sarvices or Interagency Agreem"nts. See definitions on reverse side.
11'A~r;o~:;~~~ ~"1;/~,~~~~~:;~~~~~i~[~~jNQCBUSINESSAS(DBÄ)
CONlRAClOllS M)Onr::ss 6 DBA ADDRESS (IF DIFFERENT)
;).,C¿,) . \.A.') . AAQA/v0
.. A1A--J.r.J LA (' Y) .) . U)~9 ,~ººL._..~ ___..~u_______u ,,'.._.___.__
3, CLIENT SIRVICE WORK ORDER )RIGINATOR'S NAME PROGRAM
t... é~h e f,h (\¡{\ I ~~~~I~W¿:~~~:~=AL DISØIUTIØ
nÙ'PIIONI NUMBER 685 - rr 13&.~_NUMBEÁJ sOCi"ÜËCURITYNUMBER5.SERvice CODE {ATrACtl'
,(?- ~X:.,),~}20~) 5618-~_______l\1.Ll:_f~, ,º~ITÕ~W)1_L2_~_L.2~gWRI~~N PEFIN:TION) .l,
6. \IÊ,STR,,'CT1Q I< C.OOE (An. ACH 7. COMPETITIVELY PROCURED. THROUGH THE. B, MAXIMUM CONSIDERATION 9, IS CONTRACTOR SUBRECIPIENT?
. WI\ITTEN DIôFli'lITION), OFFICE OF CONTRACTS ANO ASSET
<8'. I.fo. .1 Ç> ...~A~A~EME~T(O~~:)_[~~~~~ ________=:IIYES {Lj-1<Io
q - I -- "0
-,._,-,-_._~._._._--~ .
MAIL 610P
10. AMI;NDMENT EFFECTIVE DATE:
11. FINANCIAL ASSESSMENT
R EOUESTEO?
[] YES œ-1'IÕ
12. NUMBER OF INconpORATED
PAGES ATTACHED
.. ~_..~ ,',." _.. .__ "0.__ ,,_ __ ___.~.__.u.._·,_~____~_'_ __". ,-___
.-,- '<-_'_"_'~
13. Check all applicable boxes below and, where Indicated, attach explanations.
U increas(> consideration by $ ,_ "" .,.., .._n , .. __. Utility Code 231.
ADDIT10NAL. DOLLARS
~lond Ihe period 01 performance from _9.__-nJ_~ _ O__D_ to _...0___=-.2:rl.::::.CXJ-Utili\Y Code 232,
DAlE DATI:
I J Am(1nJmcnl Adds Terms: Uliiity Code 226.
IJ Am¡)n<Jrnont Doletes Terms: Utility Code 227.
I I Amondmûot Changes Tern),,: Utility Code 228.
I] Explanation .'
_n_ _ ___ __ _______.. _ ... _ ______________ ,.. 'n" .___.._.__~___.._
______~._~ ____..m_.__._ ___._m._ ... .-,
L J Othm
------------ -,.. .~.__..--_.__._--.__.- '
--.- ----------
_..___ __._ _., . ._.__.______..__." .._ _. _.___ .n". _
------.--.... ~ -.---.-- .--.-.." _.__..._---~----
I 1 Unilatüml (it amendment is ¡¡ rate increase oniy, a Centractor signature is not required). Any claim for adjustment as a result of
this unilateral ch"nge must be asserted within 30 days to the undersigned Contracting Officer as provided In the Changes and
Modifìc<.,:tion-; ClaHse.
ALL OTHER TERMS AND CONDITIONS REMAIN THE SAME.
." -.. ....--------------..-.---"- --..-. -._- ----------.". ...------- --- ..
14. Sy their signatur~s below, the parties agree to this CI ient Service Work Order Amendment and certify
Qompliance with new 42.52, Ethics In Public Service. Both parties certify that the Contractor is not a DSHS
employee.
-" . -....
Ct~ ~:l'C~: (.~'¡~~R:~ ,{-f2
j m:;Hf', f.li~onl'{t,M $(GN.<\ TUn¡::.
--.--
OATE
..~.__._'"--------
-----.--. -_.------~_..-
.__.~---------
.. ..._-..'.- ....---- ... .....
TELËPHONE NUMBE:R (INCL.UDE
AREA CODE)
~53 ) 931-3041
·Ti:L.EPHO~E NÛMBH< (INCLUDE
AREA CODE)
PRINT NAME AND TITLE HERE
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DATE PRINT NAME AND TITI.E HERE
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[1$115-09 8IM{:<) (¡"tEV. ()!)I\JG)
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APPROVED AS TO FORM BV THE OFrlCE OF THE ATTORNEV GENERAL
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