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H <br /> It <br /> 4.) DSHS Contract Number: <br /> hair4LET1T T0564-71263 <br /> � INTERLOCAL AGREEMENT <br /> Agency Respite Care <br /> ❑ Out of Home in Licensed Facility _ <br /> ❑ Staffed Residential licensed by Children's Administration <br /> ❑ Home Care Agency in Client's Home <br /> ® Community Settings <br /> Check the box that applies <br /> This Contract is between the State of Washington Department of Social and Health Program Contract Number: <br /> Services (DSHS) and the Contractor identified below, and is issued pursuant to the Contractor Contract Number. <br /> Interlocal Cooperation Act, chapter 39.34 RCW. 157229 <br /> CONTRACTOR NAME CONTRACTOR doing business as(DBA) i <br /> City of Everett Camp Patterson <br /> CONTRACTOR ADDRESS CONTRACTOR UNIFORM CONTRACTOR DSHS INDEX <br /> BUSINESS IDENTIFIER(UBI) NUMBER <br /> 802 East Mukilteo Blvd <br /> 1428 <br /> Everett WA 98203 <br /> CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS <br /> Jane Lewis (425) 257-8369 Ext: (425)257-8374 jlewis@ci.everett.wa.us <br /> DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE <br /> Aging and Disability Services Division of Developmental Disabilities 1735LP <br /> Administration <br /> DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS <br /> Jan Hickman-Moran 840 North Broadway <br /> Case/Resource Manager Ste 100 <br /> Everett WA 98201-1296 <br /> DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS <br /> (425) 339-5090 (425) 339-4856 hickmja@dshs.wa.gov <br /> IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT? CFDA NUMBER(S) <br /> No <br /> CONTRACT START DATE CONTRACT END DATE CONTRACT MAXIMUM <br /> AMOUNT <br /> 06/20/2005 06/19/2008 <br /> $0.00 <br /> ,,,77:,,,...° T ;The following Exhibit is attachedand hereby incorporated"into this Contract by refe epee F V'' <br /> ,„� , 5 dTi( , „' �R-t�-,�. <br /> -a r `�+ •�� o t -1 Qt tent are an integration and representation of the final,entire �c t1 ive understanding between the parties <br /> :•t :n- t. • :,,,,410e. ments,writings,and communications,orator otherwisser-• rxi • ttie subject matter of this Agreement, <br /> 12:400:44t40404)140 'i• ' `s6 low represent that they have read and un a •'t t ` and have the authority to execute this <br /> . t 2 ". ` ia - ."_: <br /> t ` •t rig onOSHS:onlyrpon signature,by DSk5 .. 1F" _: ri . <br /> CONTRACTOR SIGNATURE PRINTED NAME AND TITLE DATE SIGNED <br /> DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED <br /> 13 <br /> DSHS Central Contract Services <br /> 1735LP Agency Respite Care Interlocal(6-09-05) Page 1 <br />