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AG 15-105 I I RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: CD/CS 2. ORIGINATING STAFF PERSON:_DEE DEE CATALANO EXT: _2651 3. DATE REQ.BY: 4. TYPE OF DOCUMENT(CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT(E.G.,RFB,RFP,RFQ) ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT X HUMAN SERVICES/CDBG ❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT(E.G.BOND RELATED DOCUMENTS) ❑ ORDINANCE ❑ RESOLUTION ❑ CONTRACT AMENDMENT(AG#): ❑ INTERLOCAL ❑ OTHER 5. PROJECT NAME: SOUTH KING COUNTY MOBILE MEDICAL PROGRAM 6. NAME OF CONTRACTOR: PUBLIC HEALTH OF SEATTLE-KING COUNTY ADDRESS: 401 FIFTH AVENUE,SEATTLE,WA 98104 TELEPHONE E-MAIL: FAX: SIGNATURE NAME: TITLE 7. EXHIBITS AND ATTACHMENTS:X SCOPE,WORK OR SERVICES X COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE X ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: 01/01/2015 COMPLETION DATE: 12/31/2016 9. TOTAL COMPENSATION $20,000 (INCLUDE EXPENSES AND SALES TAX,IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE-ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE:❑YES ❑NO IF YES,MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑YES ❑NO IF YES,$ PAID BY:❑CONTRACTOR❑ CITY ❑ PURCHASING: PLEASE CHARGE TO: 001-7300-083-562-10-410 10. DOCUMENT/CONTRACT REVIEW L/ D ATE ' IEWED INITIAL/DATE APPROVED ❑ PROJECT MANAGER �rACAT®M ❑ DIRECTOR / •1S ❑ RISK MANAGEMENT (IF APPLICABLE) / ❑ LAW 14/01/1 f 11. COUNCIL APPROVAL(IF APPLICABLE) COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING 0 TO VENDOR/CONTRACTOR DATE SENT: � DATE E REC'D: 11- / I�/s _ ATT ACH. SIGNATURE AUTHORITY, INSURANCE CERTI I ATE IICENSES EXHIBITS I TIAL/DA SIGNED [FLAW DEPARTMENT ''5((?// ❑ CJF OF STAFF NoSIGNATORY WAYOR eTO) A WEI ❑ CITY CLERK ❑ ASSIGNED AG# AG# — 1' ❑ SIGNED COPY RETURNED DATE SENT: lEE COMMENTS: *APP vr-IPS 11/9 • C 4518?'1 ` CITY OF CITY HALL Federal Way 33325 8th Avenue South Federal Way,WA 98003-6325 (253)835-7000 www cit yoffedera!way.corn HUMAN SERVICES AGREEMENT FOR SOUTH KING COUNTY MOBILE MEDICAL PROGRAM This Human Services Agreement("Agreement")is made between the City of Federal Way,a Washington municipal corporation("City"),and Public Health Seattle-King County,a local government("County").The City and County (together"Parties")are located and do business at the below addresses which shall be valid for any notice required under this Agreement: PUBLIC HEALTH SEATTLE-KING COUNTY: CITY OF FEDERAL WAY: John Gilvar Denise Catalano 401 5th Avenue, Suite 1000 33325 8th Ave. S. Seattle, WA 98104 Federal Way, WA 98003-6325 (253) 835-2651 (telephone) (206) 369-3489 (telephone) (253) 835-2609 (facsimile) john.gilvargakingcounty.gov Denise.catalano@cityoffederalway.com The Parties agree as follows: 1. TERM. The term of this Agreement shall be for a period of two (2) years commencing on January 1, 2015 and terminating on December 31,2016("Term"). Funding for the second year of the Agreement is contingent upon satisfactory Agreement performance during the first year of the Agreement term and upon funding availability. This Agreement may be extended for additional periods of time upon the mutual written agreement of the City and the County. 2. SERVICES. The County shall perform the services more specifically described in Exhibit"A",attached hereto and incorporated by this reference("Services"), in a manner consistent with the accepted professional practices for other similar services within the Puget Sound region in effect at the time those services are performed in a satisfactory manner,within the time period prescribed by the City. The County warrants that it has the requisite training, skill, and experience necessary to provide the Services and is appropriately accredited and licensed by all applicable agencies and governmental entities.Services shall begin immediately upon the effective date of this Agreement. Services shall be subject,at all times,to inspection by and approval of the City, but the making(or failure or delay in making) such inspection or approval shall not relieve County of responsibility for performance of the Services in accordance with this Agreement, notwithstanding the City's knowledge of defective or non-complying performance, its substantiality or the ease of its discovery. 3. TERMINATION. Either party may terminate this Agreement,with or without cause,upon providing the other party thirty(30)days'written notice at its address set forth above.The City may terminate this Agreement immediately if the County fails to maintain required insurance, breaches confidentiality, or materially violates Section 12, and such may result in ineligibility for further City agreements. 4. COMPENSATION. 4.1 Amount. In return for the Services,the City shall pay the County an amount not to exceed a maximum amount and according to a rate or method as delineated in Exhibit"B",attached hereto and incorporated by this reference. The City shall reimburse the County only for the approved activities and in accordance with the procedures as specified in Exhibit`B". The County shall be solely responsible for the payment of any taxes imposed by any lawful jurisdiction resulting from this Agreement. 4.2 Method of Payment. On a quarterly basis,the County shall submit to the City an invoice for payment on a form provided by the City along with supporting documentation for costs claimed in the invoice and all reports as required by this HUMAN SERVICES AGREEMENT - 1 - 1/2015 CITY OF CITY HALL 4ra` 33325 8th Avenue South Federal Way u Federal Way, nu 98003-6325 (253) 835-7000 wvw.cityoffederaiway.com Agreement. Payment shall be made on a quarterly basis by the City only after the Services have been performed and within forty-five (45) days after the City's receipt and approval of a complete and correct invoice, supporting documentation and reports. The City will use the quantity of Services actually delivered, as reported on the County's reports, as a measure of satisfactory performance under this Agreement. The City shall review the County's reports to monitor compliance with the performance measures set forth in Exhibit"A." Should the County fail to meet the performance measures for each quarter,the City reserves the right to adjust payments on a pro rata basis at any time during the term of this Agreement. Exceptions may be made at the discretion of the City's Human Services Manager in cases where circumstances beyond the County's control impact its ability to meet its service unit goals and the County has shown reasonable efforts to overcome these circumstances to meet its goals. If the City objects to all or any portion of the invoice,it shall notify the County and reserves the option to pay only that portion of the invoice not in dispute. In that event,the Parties will immediately make every effort to settle the disputed portion. 4.3 Final Invoice. The County shall submit its final invoice by the date indicated on Exhibit`B". If the County's final invoice,supporting documentation,and reports are not submitted by the last date specified in Exhibit`B",the City shall be relieved of all liability for payment to the County of the amounts set forth in said invoice or any subsequent invoice;provided, however,that the City may elect to pay any invoice that is not submitted in a timely manner. 4.4 Budget. The County shall apply the funds received from the City under this Agreement in accordance with the line item budget set forth in Exhibit`B". The County shall request in writing prior approval from the City to revise the line item budget when the cumulative amount of transfers from a line item in any Project/Program Exhibit is expected to exceed ten percent(10%)of that line item. Supporting documents are necessary to fully explain the nature and purpose of the revision,and must accompany each request for prior approval. All budget revision requests in excess of 10%of a line item amount shall be reviewed and approved or denied by the City in writing. 4.5 Non-Appropriation of Funds. If sufficient funds are not appropriated or allocated for payment under this Agreement for any future fiscal period,the City will not be obligated to make payments for Services or amounts incurred after the end of the current fiscal period,and this Agreement will terminate upon the completion of all remaining Services for which funds are allocated. No penalty or expense shall accrue to the City in the event this provision applies. 5. INDEMNIFICATION. 5.1 County Indemnification. The County represents to the City that the County has competent,trained staff and where necessary, professional staff to render the services to be performed under this Agreement. The County agrees to indemnify,hold harmless and defend the City,its elected officials,officers,employees,agents,and volunteers from any and all claims,demands,losses,actions and liabilities(including costs,expenses and all reasonable attorneys'fees)to or by any and all persons or entities, including without limitation,their respective agents, licensees, or representatives,arising from,resulting from,or connected with the Agreement to the extent caused by the negligent acts,errors or omissions of the County,its partners, shareholders,agents,employees, or by the County's breach of this Agreement. 5.2 Industrial Insurance Act Waiver. The County waives any immunity that may be granted to it under the Washington State Industrial Insurance Act,Title 51 RCW.The County's indemnification shall not be limited in any way by any limitation of the amount of damages,compensation or benefits payable to or by any third party under workers'compensation acts,disability benefit acts or any other benefits acts or programs. 5.3 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement with respect to any event occurring prior to such expiration or termination. 6. INSURANCE. The County agrees to carry insurance for liability which may arise from or in connection with the performance of the services or work by the County,their agents,representatives,employees or subcontractors for the duration of the Agreement and thereafter with respect to any event occurring prior to such expiration or termination as follows: HUMAN SERVICES AGREEMENT - 2 - 1/2015 Alibi CITY OF CITY HALL 33325 8th Avenue South ,,. ,„t,, Federal Way Federal Way,WA 98003-6325 (253) 835-7000 www.cityoffederatway.corn 6.1. Self-Insurance Program. King County, a charter county government under the constitution of the State of Washington,hereinafter referred to as"County",maintains a fully funded Self-Insurance program as defined in King County Code 4.12 for the protection and handling of the County's liabilities including injuries to persons and damage to property. The City acknowledges, agrees and understands that the County is self-funded for all of its liability exposures. The County ty agrees,at its own expense,to maintain,through its self-funded program,coverage for all of its liability ty exposures for this Agreement.The County agrees to provide the City with at least 30 days'prior written notice of any material change in the County's self-funded program and will provide the City with a certificate of self-insurance as adequate proof of coverage.The City further acknowledges,agrees and understands that the County does not purchase Commercial General Liability insurance and is a self-insured governmental entity;therefore the County does not have the ability to add the City as an additional insured. 6.2. No Limit of Liability. City's acknowledgement of County's fully funded self-insurance program shall not be construed to limit the liability of the County to the coverage provided by such program,or otherwise limit the City's recourse to any remedy available at law or in equity. The County's self-insurance program shall be primary insurance as respect the City. Any insurance, self-insurance,or insurance pool coverage maintained by the City shall be excess of the County's insurance and shall not contribute with it. 6.3 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement. 7. CONFIDENTIALITY.All information regarding the City obtained by County in performance of this Agreement shall be considered confidential subject to applicable laws. Breach of confidentiality by the County may be grounds for immediate termination. All records submitted by the City to the County will be safeguarded by the County. The County will fully cooperate with the City in identifying,assembling, and providing records in case of any public records disclosure request. 8. WORK PRQDUCT. All originals and copies of work product, including plans, sketches, layouts,designs, design specifications,records,files,computer disks,magnetic media or material which may be produced or modified by County while performing the Services shall belong to the City upon delivery. The County make such data,documents,and files available to the City and shall deliver all needed or contracted for work product upon the City's request. At the expiration or termination of h' p P tY q this Agreement all originals and copies of any such work product remaining in the possession of County shall be delivered to the City. 9. BOOKS 3ND RECORDS. The County agrees to maintain books,records, and documents which sufficiently and properly reflect all direct and indirect costs related to the performance of the Services and maintain such accounting procedures and practices as may be deemed necessary by the City to assure proper accounting of all funds paid pursuant to this Agreement. These records shall be maintained for a period of six(6)years after the termination of this Agreement and may be subject,at all reasonable times, to inspection, review or audit by the City, its authorized representative, the State Auditor, or other governmental officials authorized by law to monitor this Agreement. 10. INDEPENDENT CONTRACTOR. The Parties intend that the County shall be an independent contractor and that the County has the ability to control and direct the performance and details of its work,the City being interested only in the results obtained under this Agreement. The City shall be neither liable nor obligated to pay County sick leave,vacation pay or. any other benefit of employment, nor to pay any social security or other tax which may arise as an incident of employment. County shall take all necessary precautions and shall be responsible for the safety of its employees,agents,and subcontractors in the performance of the Services and work and shall utilize all protection necessary for that purpose. All work shall be done at County's own risk,and County shall be responsible for any loss of or damage to materials,tools,or other articles used or held for use in connection with the work. The County shall pay all income and other taxes due except as specifically provided in Section 4. Industrial or any other insurance that is purchased for the benefit of the City,regardless of whether such may provide a secondary or incidental benefit to the County, shall not be deemed to convert this Agreement to an employment contract. 11. CONFLICT OF INTEREST. It is recognized that County may or will be performing services during the Term for other parties;however,such performance of other services shall not conflict with or interfere with County's ability to perform the Services. County agrees to resolve any such conflicts of interest in favor of the City.County confirms that County does not HUMAN SERVICES AGREEMENT - 3 - 1/2015 ` CITY OF CITY HALL 33325 8th Avenue South Federal Way Federal Way,WA 98003-6325 (253)835-7000 www cityoffederalway con) have a business interest or a close family relationship with any City officer or employee who was,is,or will be involved in the County's selection,negotiation,drafting, signing,administration, or evaluating the County's performance. 12. EOUAL OPPORTUNITY EMPLOYER. In all services,programs,activities,hiring,and employment made possible by or resulting from this Agreement or any subcontract,there shall be no discrimination by County or its subcontractors of any level,or any of those entities'employees,agents,sub-agencies,or representatives against any person because of sex,age(except minimum age and retirement provisions), race, color, religion, creed, national origin, marital status, or the presence of any disability, including sensory, mental or physical handicaps, unless based upon a bona fide occupational qualification in relationship to hiring and employment. This requirement shall apply to, but not be limited to,the following: employment, advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training, including apprenticeship. County shall comply with and shall not violate any of the terms of Chapter 49.60 RCW,Title VI of the Civil Rights Act of 1964,the Americans With Disabilities Act,Section 504 of the Rehabilitation Act of 1973,49 CFR Part 21,21.5 and 26, or any other applicable federal,state,or local law or regulation regarding non-discrimination. 13. GENERAL PROVISIONS. 13.1 Interpretation and Modification. This Agreement, together with any attached Exhibits, contains all of the agreements of the Parties with respect to any matter covered or mentioned in this Agreement and no prior statements or agreements,whether oral or written,shall be effective for any purpose.Should any language in any Exhibits to this Agreement conflict with any language in this Agreement,the terms of this Agreement shall prevail.The respective captions of the Sections of this Agreement are inserted for convenience of reference only and shall not be deemed to modify or otherwise affect any of the provisions of this Agreement.Any provision of this Agreement that is declared invalid,inoperative,null and void,or illegal shall in no way affect or invalidate any other provision hereof and such other provisions shall remain in full force and effect. Any act done by either Party prior to the effective date of the Agreement that is consistent with the authority of the Agreement and compliant with the terms of the Agreement,is hereby ratified as having been performed under the Agreement. No provision of this Agreement,including this provision,may be amended,waived,or modified except by written agreement signed by duly authorized representatives of the Parties. 13.2 Assignment and Beneficiaries. Neither the County nor the City shall have the right to transfer or assign, in whole or in part,any or all of its obligations and rights hereunder without the prior written consent of the other Party.If the non- assigning party gives its consent to any assignment,the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent.Subject to the foregoing,the rights and obligations of the Parties shall inure to the benefit of and be binding upon their respective successors in interest, heirs and assigns. This Agreement is made and entered into for the sole protection and benefit of the Parties hereto. No other person or entity shall have any right of action or interest in this Agreement based on any provision set forth herein. 13.3 Compliance with Laws. The County shall comply with and perform the Services in accordance with all applicable federal,state,local,and city laws including,without limitation,all City codes,ordinances,resolutions,regulations, rules, standards and policies, as now existing or hereafter amended, adopted, or made effective. If a violation of the City's Ethics Resolution No.91-54,as amended,occurs as a result of the formation or performance of this Agreement,this Agreement may be rendered null and void,at the City's option. 13.4 Enforcement. Time is of the essence of this Agreement and each and all of its provisions in which performance is a factor. Adherence to completion dates set forth in the description of the Services is essential to the County's performance of this Agreement.Any notices required to be given by the Parties shall be delivered at the addresses set forth at the beginning of this Agreement. Any notices may be delivered personally to the addressee of the notice or may be deposited in the United States mail,postage prepaid,to the address set forth above. Any notice so posted in the United States mail shall be deemed received three(3)days after the date of mailing. Any remedies provided for under the terms of this Agreement are not intended to be exclusive,but shall be cumulative with all other remedies available to the City at law,in equity or by statute.The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement,or to exercise any option conferred by this Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. Failure or delay of the City to HUMAN SERVICES AGREEMENT -4 - 1/2015 CITY OF CITY HALL 33325 8th Avenue South Federal Way Federal Way,WA 98003-6325 (253)835-7000 www cityoffederaMay.corn declare any breach or default immediately upon occurrence shall not waive such breach or default. Failure of the City to declare one breach or default does not act as a waiver of the City's right to declare another breach or default.This Agreement shall be made in,governed by,and interpreted in accordance with the laws of the State of Washington.If the Parties are unable to settle any dispute,difference or claim arising from this Agreement,the exclusive means of resolving that dispute,difference,or claim, shall be by filing suit under the venue,rules and jurisdiction of the King County Superior Court,King County,Washington, unless the parties agree in writing to an alternative process. If the King County Superior Court does not have jurisdiction over such a suit, then suit may be filed in any other appropriate court in King County, Washington. Each party consents to the personal jurisdiction of the state and federal courts in King County,Washington and waives any objection that such courts are Agreement,each Party shall pay all its legal an inconvenient forum.If either Party brings any claim or lawsuit arising from this Agr arty p y g costs and attorney's fees and expenses incurred in defending or bringing such claim or lawsuit,including all appeals,in addition to any other recovery or award provided by law;provided,however,however nothing in this paragraph shall be construed to limit the Parties' rights to indemnification under Section 5 of this Agreement. 13.5 Execution. Each individual executing this Agreement on behalf of the City and County represents and warrants that such individual is duly authorized to execute and deliver this Agreement.This Agreement may be executedin any number of counterparts,each of which shall be deemed an original and with the same effect as if all Parties hereto had signed the same document. All such counterparts shall be construed together and shall constitute one instrument,but in making proof hereof it shall only be necessary to produce one such counterpart.The signature and acknowledgment pages from such counterparts may be assembled together to form a single instrument comprised of all pages of this Agreement and a complete set of all signature and acknowledgment pages. The date upon which the last of all of the Parties have executed a counterpart of this Agreement shall be the"date of mutual execution"hereof. [Signature page follows] HUMAN SERVICES AGREEMENT - 5 - 1/2015 CITY OF CITY HALL 33325 8th Avenue South ;ice Federal Way Federal Way,WA 98003-6325 (253)835-7000 1 www cityoffederaiway.com IN WITNESS,the Parties execute this Agreement below, effective the last date written below. CITY OF FEDERAL WAY ATTEST: 41' Att./Alb .. LAIL... Jim F ill, Mayor 1C (Jerk, Stephanie Co ii, CMC APPROVED AS TO FORM: DATE: 5 f 5 % I � 'l/' .f✓ City Attorney,Amy Jo Pearsall PUBLIC HEALTH SE TTLE-KING COUNTY By: Printed Name:TJ Cosgrove interim Division Director Title: Public Health S fig DATE: ( ,7Setne&KlnCountY STATE OF WASHINGTON ) ) ss. COUNTY OF 677 ) On this day personally appeared before me ,J . 5, to me known to be the e/is ,406,01 64,e..sa c of az-i„-",-/" /hsv.r/ .. .eAce.s that executed the foregoing instrument,and acknowledged the said instrument fo be the free and voluntary act and deed of said corporation,for the uses and purposes therein mentioned,and on oath stated that he/she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. GA GIVEN my hand and official seal this 2 day of 41 / , 20/c I `��‘‘‘‘‘‘�;t i pq y�,i,,� Notary's signature �/ 0 �. .kN`E�o%ExPoi '',� Notary's printed name ,G�.S s, 4.4 Notary Public in and or the State of Washington. 4 4otPRT z My commission expires pus pp.'. iii nil it n0- HUMAN SERVICES AGREEMENT - 6 - 1/2015 ` CITY OF CITY HALL 33325 8th Avenue South Federal Way Federal Way,WA 98003-6325 (253)835-7000 www city .offederatway.corn EXHIBIT A SERVICES Project Summary The Agency shall provide dentistry services to people experiencing homelessness in the City of Federal Way. The Agency shall ensure that services provided with funding under this Agreement are made available to Federal Way residents. Performance Measures A.Number Served The Agency agrees to serve, at minimum, the following unduplicated number of Federal Way residents with Human Services funds: 1st 2nd rd 3 4 th Quarter Quarter Quarter Quarter Total JAN.— APRIL— JULY— OCT.— MARCH JUNE SEPT. DEC. No. of unduplicated Federal Way persons assisted in 2015 13 13 13 13 52 No. of unduplicated Federal Way persons assisted in 2016 13 13 13 13 52 B. Units of Service The Agency agrees to provide, at minimum,the following units of service by quarter: 1st Quarter 2nd 3rd 4th Total JAN.— Quarter Quarter Quarter MARCH APRIL— JULY— OCT.— JUNE SEPT. DEC. 2015 1. Dental Care 14 15 15 15 59 2016 1. Dental Care 14 15 15 15 59 HUMAN SERVICES AGREEMENT - 7 - 1/2015 Aih, CITY OF CITY HALL 33325 8th Avenue South Federal Way Federal Way,WA 98003-6325 (253)835-7000 www.cityoffederaiway.com C.Definition of Services 1. Dental Care: Dental visits on the mobile van. D. Performance Measure(s) Outcome(s)to be reported: 1. Individuals and/or families improve health(physical/dental/medical). Records A. Project Files The Agency shall maintain files for this project containing the following items: 1. Notice of Grant Award. 2. Motions, resolutions, or minutes documenting Board or Council actions. 3. A copy of this Agreement with the Scope of Services. 4. Correspondence regarding budget revision requests. 5. Copies of all invoices and reports submitted to the City for this project. 6. Bills for payment with supporting documentation. 7. Copies of approved invoices and warrants. 8. Records documenting that costs reimbursed with funding provided under this Scope are allowable. Such records include, but are not limited to: • for personnel costs,payroll for actual salary and fringe benefit costs. • for staff travel, documentation of mileage charges for private auto use must include: a) destination and starting location, and b)purpose of trip; and • for copy machine use,postage,telephone use, and office supplies when these costs are shared with other programs and no invoice is available, log sheets or annotated invoices. HUMAN SERVICES AGREEMENT - 8 - 1/2015 CITY OF CITY HALL ;.A6, Federal Way 33325 8th Avenue South Federal Way,WA 98003-6325 (253)835-7000 www cityoffederalway.corn 9. Documentation of client income. The Agency agrees to use the HUD Income Guidelines to report income of clients served under this Agreement. Income guidelines may be adjusted periodically by HUD. King County FY 2015 Income Limits Summary Median FY 2015 Income Income 1 2 3 4 5 6 7 8 King Limit Person Persons Persons Persons Persons Persons Persons Persons County Category Extremely Low (30%) $18,850 $21,550 $24,250 $26,900 $29,100 $32,570 $36,730 $40,890 Income Limits Very Low $89,600 (50%) $31,400 $35,850 $40,350 $44,800 $48,400 $52,000 $55,600 $59,150 Income Limits Low (800) $46,100 $52,650 $59,250 $65,800 $71,100 $76,350 $81,600 $86,900 Income Limits The Agency agrees to use updated Income Guidelines which will be provided by the City. Reports and Reporting Schedule The Agency shall collect and report client information to the City quarterly(on the dates outlined in Exhibit B) and annually on a Service Unit Report to be provided by the City in the format requested by the City. The Agency shall also submit a quarterly Narrative Report describing the program's accomplishments and explaining any variance in quarterly service units that is more than twenty-five percent over or under the quarterly goal. The Agency shall submit an Annual Demographic Data Report. The agency shall collect and retain the data requested on this form from the persons served through this contract. Data should be tracked in an ongoing manner and submitted annually no later than January 15 in the format requested by the City. The Agency shall implement and track at least one measurable outcome for the program as presented in the application. Changes to the outcome presented in the application must be approved by the City prior to implementation. The Agency shall report the results of its outcome measure(s) annually on the Annual Outcome Data Report to be submitted by January 15 in the format requested by the City. Public Information In all news releases and other public notices related to projects funded under this Agreement,the Agency will include information identifying the source of funds as the City of Federal Way Human Services General Fund Program. HUMAN SERVICES AGREEMENT - 9 - 1/2015 I CITY OF CITY HALL 41/4. 33325 8th Avenue South Federal Way Federal Way,WA 98003-6325 (253)835-7000 www cityoffederaiway.corn EXHIBIT B COMPENSATION Project Budget The Agency shall apply the following funds to the project in accordance with the Line Item Budget Summary. The total amount of reimbursement pursuant to this Agreement shall not exceed$20,000. A. City of Federal Way Funds 2015 2016 City of Federal Way General Fund: $10,000 $10,000 Total City of Federal Way Funds: $10,000 $10,000 B. Line Item Budget 2015 2016 Personnel Services(detail below) $ $ Office or Operating Supplies $ $ Rent&Utilities $ $ Communications $ $ Travel and Training $ $ Other: Mobile Dental Clinical Expenses $10,000 $10,000 Client Travel $ $ Administration(Overhead) $ $ Total City of Federal Way Funds: $10,000 _ $10,000 C. Personnel Detail Position Title Position Full Annual Salary HS Funds Time Equivalent and Benefits N/A N/A N/A N/A Total: $ $ Reimbursement Requests and Service Unit Report forms shall be submitted no less frequently than quarterly and are due on the following dates: 1st Quarter: April 15 or within 10 days of notice to proceed, whichever is later; 2nd Quarter: July 15; 3rd Quarter: October 15; and 4th Quarter: Final Reimbursement Request and Service Unit Report forms due January 8; Demographic Data Report and Annual Outcome Data Report with supporting documentation due January 15. The Agency shall submit Reimbursement Requests in the format requested by the City. Reimbursement Requests Invoices shall include a copy of the Service Unit Report and any supporting documents for the billing period. HUMAN SERVICES AGREEMENT - 10 - 1/2015 ` CITY OF CITY HALL �;. Federal Way 33325 8th Avenue South Federal Way,WA 98003-6325 (253)835-7000 www cityoffederaiway.corn Estimated Quarterly Payments: 2015 1st Qtr $2,500 2nd Qtr $2,500 3rd Qtr $2,500 4th Qtr $2,500 2016 1St Qtr $2,500 2nd Qtr $2,500 3rd Qtr $2,500 4th Qtr $2,500 Expenses must be incurred prior to submission of quarterly reimbursement requests. Proof of expenditures must be attached to the reimbursement request for invoice to be approved. Quarterly reimbursement requests shall not exceed the estimated payment without prior written approval from the City. Estimated quarterly payments are contingent upon meeting or exceeding the above performance measure(s) for the corresponding quarter. This requirement may be waived at the sole discretion of the City with satisfactory explanation of how the performance measure will be met by year-end on the Service Unit Report. Conditions of Funding The Agency agrees that it will meet any specific funding conditions identified for the Agency and acknowledges that payment to the Agency will not be made unless the funding conditions are met. HUMAN SERVICES AGREEMENT - 11 - 1/2015 EXN16if King County Office of Risk Management Division Department of Executive Services Administration Building 500-4`h Avenue,Room 320 Seattle,-WA 98104 (206)263-2250 April 30,2015 City of Federal Way 33325 8th Ave South Federal Way,WA 98003 Att:Denise Catalano RE: KING COUNTY CERTIFICATE OF SELF-INSURANCE King County Mobile Medical Program—Dentistry Services for Federal Way Residents This letter is to certify that King County is fully self-funded for all its liability exposures. Should an incident occur involving the negligence of County employees acting in the scope of their employment,our self-funded program would respond. King County,charter county government under the constitution of the State of Washington, hereinafter referred to as"County",maintains a fully funded Self-Insurance program as defined in King County Code 2.12 for the protection and handling of the County's liabilities including injuries to persons and damage to property. If you have any questions,please do not hesitate to call me at(206)263-2242. Sincerely, -Elizabeth • Y o hi,':.' -P Insurance i alyst • L�ffii eaiftlieDfre�tor - ?`r: :. PlibliendAlth $saute mAlp. o4-lsi ;= ? ' i i;: Seat le &J g aunt *: - 206:29.6-46oa 'Fax Z0&-2 6-S1i.S6 inrvrtlzirigcot��tgav/healCki:'::: DELEGATION OF SIGNATURE AUTHORITY This order delegates to the Chief Administrative Officer(CAO) and others the authority to sign and administer Contracts,Agreements, Change Orders,Amendments, and Other Instruments. WHEREAS, Section 320.20 of the King County Charter authorizes the King County Executive t.• to "...sign, or cause to be signed, on behalf of the County all deeds, contracts and other instruments "; and WHEREAS, Section 850 of the Charter provides that powers and duties of a county officer may be delegated by that officer to another officer or employee of the County under the control and supervision of the delegating officer; and WHEREAS, Executive Order CON 7-3-2 (AEO) delegates authority related to signing and administering such contracts,and other instruments to Department Directors and authorizes them to further delegate such authority to qualified subordinates; and • NOW,THEREFORE, I, Patty Hayes, RN, MN, Interim Director of Public Health—Seattle& King County. hereby delegate the authority to negotiate sign, administer, and settle contracts, agreements, and other instruments, including, but not limited to, memoranda of understanding with other government agencies, permit documents, grant documents, amendments and change orders thereto to the Division Directors or Managers in charge of the Administration Division; Environmental Health Services Division, Prevention Division, Emergency Medical Services Division, Jail Health Services Division, Community Health Services Division, subject to the limitations outlined in Executive Order CON 7-3-2(AEO): FURTHER,the CAO has authority to sign and administer contracts and other instruments for • all divisions in the Department. FURTHER, the CAO may further delegate authority in writing to other staff under the CAO's control and supervision. FURTHER, 1 hereby ratify and confirm actions taken by the CAO and others identified herein with respect to signing contracts and agreements in accordance with Executive Order CON 7- 3-2 (AEO), to the extent such actions and delegations were consistent with the requirements set forth above in this delegation letter. NOW, THEREFORE, I, Patty Hayes, RN, MN, Interim Director do hereby order and direct. Dated this April 13, 2015 ,�L lir Patty Hayes, , MN, Interim Director, Public Health—Seattle & King County CITY OF CITY HALL CITY 33325 8th Avenue South Federal Way Federal Way,WA 98003-6325 (253)835-7000 www.atyoffederal way.com City of Federal Way Human Services Contract for 2015-2016 General Fund Authorized Signatures for Invoices I authorize the following individuals to sign invoices and quarterly reports on behalf of: f M)Ltc N-rk S OiTfle a- K146- Co,tiv (Contracting Agency), for the following: K / - Cov NTh MU I Lt M,&Dlci _ Pia i-Mftt-(Program Title). TJCosgrove Interim Division Dior Authorizing Community Heft Services Signature: Public H alth-Seams Ki n (must be signed by (Printed Name) g� eJ person who signs the contract, generally, / Executive Director) (Signature) (Date) Additional Authorized Signature: IuS410/4 Ccou� .L'e✓v�cer M��a fl (Printed Name) (Title) ior cm, - wta.-.( a 9' 2z 20/S gnature) (fn ate) Additional Authorized Signature: 7 i- r c iii}-/Z Mvelle Min« P446-020,0 nAG- (Print-- ame) (Title) AII 3 20/,s' = (Dat ) Note: It is the responsibility of the contractor to inform the City of Federal Way if they wish to add a name to or delete names from this list.