2004/03/10 Council Agenda Packet

1.4 w` `KSlcadr D " nr"d¢ CONTRACT NUMBER: N12437 Health SHORT FORM AGREEMENT BETWEEN STATE OF WASHINGTON AND CONTRACTOR NAME MAILING ADDRESS Everett Fire Department 2811 Oakes Avenue Everett, WA 98201 BUSINESS TELEPHONE NUMBER: FAX NUMBER: 425.257.8123 UBI NUMBER: N/A. PURPOSE: Distribute and install smoke alarms in targeted households. TERM Subject to its other provisions, the Period of Performance under this contract shall be from the Date of Execution through September 30, 2004, unless sooner terminated as provided herein. STATEMENT OF WORK: The Contractor shall distribute and install smoke alarms, provide education and outreach to targeted households and perform the protocol as established by the Department of Health and as more fully described in EXHIBIT A, Statement of Work, and submit monthly reports as described in EXHIBIT B, Monthly Report, each attached hereto and incorporated herein. PAYMENT The total payment for services provided under this agreement shall not exceed a maximum fee of $1,500 and is inclusive of all costs (i.e., hourly fee, travel and office expenses, etc.). SOURCE OF FUNDS: (FED) $1,500; (ST).N; (OTHER)I0; TOTAL $1,500. Federal funds disbursed through this contract were received by DOH through OMB Catalogue of Federal Domestic Assistance Number 93.136. Contractor agrees to comply with applicable rules and regulations associated with these federal funds. INVOICING DOH will reimburse the Contractor within 30 days upon receipt of properly executed invoice vouchers. (Note: Failure to submit a properly completed IRS form W-9 may result in delayed payments.) Upon expiration of the contract, any claims for payment for costs due and payable under this contract that are incurred prior to the expiration date must be submitted by the Contractor to DOH within 60 days after the contract expiration date. Belated claims shall be paid at the discretion of the Department and are contingent upon the availability of funds. DOH N12437 1 1/2/2004 1"17