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2 <br /> DSHS Contract Number. <br /> INTERLOCAL AGREEMENT 1164-26141 <br /> waster on state <br /> II7c <br /> oEPAK,i`E►,TOF AGENCY RESPITE CARE <br /> OCIAL GHEA,, <br /> SERVICES Check the box that applies: <br /> • <br /> ❑ Out of Home in Licensed Residence or Facility <br /> 0 Home Care Agency in Client's Home <br /> Z Community Settings(excluding IFS Program Participants) <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. SSPS#157229 <br /> CONTRACTOR NAME CONTRACTOR doing business as(DBA) <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.everettwa.us <br /> DSHS'ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE <br /> Aging and Disability Services Division of Developmental Disabilities 1735LP-64 <br /> Administration <br /> DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS <br /> Jerrye Ralston 840 N Broadway Bldg A Ste 100 <br /> Contracts Manager <br /> Everett WA 98201 <br /> DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS <br /> (425) 339-4840 (425) 339-4856 ralstja@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 /> 7/1/2011 6/30/2014 <br /> Fee For Service <br /> EXHIBITS. The following Exhibit is attached and hereby incorporated into this Contract by reference: <br /> Exhibit A—Rate Schedule <br /> The terms and conditions of this Agreement are an integration and representation of the final,entire and exclusive understanding between the parties <br /> superseding and merging all previous agreements,writings,and communications,oral or otherwise,regarding the subject matter of this Agreement, <br /> between the parties. The parties signing below represent that they have read and understand this Contract,and have the authority to execute this <br /> Agreement. This Agreement shall be binding on DSHS only upon signature by DSHS. <br /> CONTRACTOR SIGNATURE PRINTED NAME AND TITLE DATE SIGNED <br /> DSHS SIGNATURE PRINTED NAME AND TITLE DATE SIGNED <br /> DSHS Central Contract Services <br /> 1735LP Agency Respite Care Interlocal(9-23-10) Page 1 <br /> 17 <br />