AG 17-073RETURN TO: Sarah Bridge ford
EXT: 2651
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
1. ORIGINATING DEPT. /DIV: CD /CS
2. ORIGINATING STAFF PERSON: _SARAH BRIDGEFORD
4. TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.
❑ PUBLIC WORKS CONTRACT
❑ PROFESSIONAL SERVICE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT
❑ REAL ESTATE DOCUMENT
❑ ORDINANCE
❑ CONTRACT AMENDMENT (AG #):
❑ OTHER
EXT: 2651 3. DATE REQ. BY:
G, RFB, RFP, RFQ)
❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
❑ MAINTENANCE AGREEMENT
x HUMAN SERVICES / CDBG
❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
❑ RESOLUTION
❑ INTERLOCAL
5. PROJECT NAME: SOUTH KING COUNTY MOBILE MEDICAL PROGRAM
6. NAME OF CONTRACTOR: _SEATTLE KING COUNTY DEPARTMENT OF PUBLIC HEALTH
ADDRESS: .461 Q hap NAld-ix
. IM TELEPHONE 2d(o - 4q) - g34g3422. E -MAIL: ai %Gici 6Pri$% V FAX: NIA-
SIGNATURE NAME: TITLE
7. EXHIBITS AND ATTACHMENTS: E SCOPE, WORK OR SERVICES ® COMPENSATION ❑ INSURANCE REQUIREMENTS /CERTIFICATE )( ALL
OTHER REFERENCED EXHIBITS X PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT /AMENDMENTS
8. TERM: COMMENCEMENT DATE: 01/01/2017 COMPLETION DATE: 12/31/2018
9. TOTAL COMPENSATION $_19,200.00 (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
RETAINAGE: RETAINAGE AMOUNT: ❑ RETAINAGE BY (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED
❑ PURCHASING: PLEASE CHARGE TO: 001- 7300 - 083 - 562 -10 -410
10. DOCUMENT /CONTRACT REVIEW INITIAL / DATE REVIEWED INITIAL/ DATE APPROVED
❑ PROJECT MANAGER
LfDIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
❑ LAW
11. COUNCIL APPROVAL (IF APPLICABLE)
12. CONTRACT SIGNATURE ROUTING
SENT TO VENDOR/CONTRACTOR
❑ ATTACH: SIGNATURE AUTHORITY,
❑ LAW DEPARTMENT
g.091GNATORY (MAYOR OR DIRECTOR)
❑ CITY CLERK
❑ ASSIGNED AG#
❑ SIGNED COPY RETURNED
Ch 2L i `(e1'la-
COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE:
DATE SENT: I /jtr /j- DATE REC'D:
INSURANCE CERTIFICATE, LICENSES, EXHIBITS
INITIAL / DATE S GNED
•
I I WAWA Er.
AG# i3'-b
DATE SENT: o4-i3 (}-
4_ Vecleral Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www cityoffederalway com
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 of Seattle -King County, a Washington county ( "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 OF SEATTLE -KING
COUNTY:
Alicia Benish
401 Fifth Avenue
Seattle, WA 98104
(206) 450 -8922 (telephone)
alicia.benish@kingcounty.gov
CITY OF FEDERAL WAY:
Sarah Bridgeford
33325 8th Ave. S.
Federal Way, WA 98003 -6325
(253) 835 -2651 (telephone)
(253) 835 -2609 (facsimile)
Sarah.Bridgeford@cityoffederalway.com
The Parties agree as follows:
1. TERM. The term of this Agreement shall be for a period commencing on January 1, 2017 and terminating on
December 31, 2018 ( "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 the 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.
HUMAN SERVICES AGREEMENT 1 4/2015
Federal Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www.cilyoffederaiway.com
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
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, defend, and hold the City, its elected officials, officers, employees, agents, and volunteers harmless from any and all
claims, demands, actions, losses 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 in connection with this 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 on 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 City Indemnification. The City agrees to release, indemnify, defend and hold the County, its officers, directors,
shareholders, partners, employees, agents, representatives, and subcontractors harmless from any and all claims, demands,
actions, suits, causes of action, arbitrations, mediations, proceedings, judgments, awards, injuries, damages, liabilities, losses,
fines, fees, penalties expenses, attorney's fees, costs, and/or litigation expenses 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 this
Agreement to the extent solely caused by the negligent acts, errors, or omissions of the City.
HUMAN SERVICES AGREEMENT 2 4/2015
4CITY OF
., Federal Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www catyoffederalway. com
5.4 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:
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 agrees, at its own expense, to maintain, through its self - funded program, coverage for all of its liability 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 PRODUCT. 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 shall 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 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 AND 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
HUMAN SERVICES AGREEMENT - 3 -
4/2015
Vecleral Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www cityoffederalway com
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
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. EQUAL 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
HUMAN SERVICES AGREEMENT - 4 - 4/2015
Federal Way
CITY HALL
33325 8th Avenue South
Federal Way. WA 98003 -6325
(253) 835 -7000
www.cityoffederalway.com
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
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
an inconvenient forum. If either Party brings any claim or lawsuit arising from this Agreement, each Party shall pay all its legal
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 executed in 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 4/2015
Federal Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www. cityoffederalway.. corn
IN WITNESS, the Parties execute this Agreement below, effective the last date written below.
CITY OF FEDERAL WAY:
DATE:
PUBLIC HEALTH OF SEATTLE -KING COUNTY:
By:
Printed Name:TJ Cosgrove, Director
Community Health Services Division
Public Heafth - Seattle & ling County
Title:
DATE:
A(//r/t7
STATE OF WASHINGTON )
) ss.
COUNTY OF KING )
ATTEST:
C % C erk, Stephanie Court D, , CMC
APPROVED AS TO FORM:
Aster City Attorney, J. Ryan Call
• C)
Cs' • F„
• 0
•
On this day personally appeared before me 7711o.srfrvve , to me known to be the
jikic$r of 4?/397ic i' /re' /7/4 , /vi e /S that executed the foregoing
instrument, and acknowledged the said instru cent to 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.
GIVEN my hand and official seal this /9 day of /2P-/ / , 20/1
Notary's signature
Notary's printed name — 5 /4coha, i - "7a��.
Notary Public in and for the State of Washington.
My commission expires 2- to / 5
HUMAN SERVICES AGREEMENT - 6 - 4/2015
4A&.* Federal Way
EXHIBIT A
SERVICES
Project Summary
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www.cityoffederalway.com
The County shall provide dentistry services to people experiencing homelessness in the City of Federal Way.
The County shall ensure that services provided with funding under this Agreement are made available to
Federal Way residents.
Performance Measures
A. Number Served
The County agrees to serve, at minimum, the following unduplicated number of Federal Way residents with
Human Services funds:
B. Units of Service
The County agrees to provide, at minimum, the following units of service by quarter:
1st
Quarter
JAN. -
MARCH
2nd
Quarter
APRIL -
JUNE
2nd
Quarter
APRIL -
JUNE
4th
Quarter
OCT. -
DEC.
3rd
Quarter
JULY -
SEPT.
4th
Quarter
OCT. -
DEC.
Total
No. of unduplicated Federal
Way persons assisted in 2017
11
11
10
12
10
42
No. of unduplicated Federal
Way persons assisted in 2018
2018
11
11
10
10
42
B. Units of Service
The County agrees to provide, at minimum, the following units of service by quarter:
C. Definition of Services
1. Dental Care: Dental care visits on the mobile van.
HUMAN SERVICES AGREEMENT 1
HSA Exh 1/2017
1st Quarter
JAN. -
MARCH
2nd
Quarter
APRIL -
JUNE
3rd
Quarter
JULY -
SEPT.
4th
Quarter
OCT. -
DEC.
Total
2017
1. Dental Care /Visits
12
12
12
12
48
2018
1. Dental Care
12
12
12
12
48
C. Definition of Services
1. Dental Care: Dental care visits on the mobile van.
HUMAN SERVICES AGREEMENT 1
HSA Exh 1/2017
CITY OF
Federal Way
D. Performance Measure(s)
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www cityoffederalway com
Outcome(s) to be reported:
1. Individuals and /or families will have improved health.
Records
A. Project Files
The County 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 2 HSA Exh 1/2017
V•cferal Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www cityoffederalway corn
9. Documentation of client income. The County agrees to use the HUD Income Guidelines to report
income of clients served under this Agreement. Income guidelines may be adjusted periodically by
HUD. The County agrees to use updated Income Guidelines which will be provided by the City.
King County FY 2016 Income Limits Summary
Median
FY 2016
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 %)
$19,000
$21,700
$24,400
$27,100
$29,300
$32,580
$36,730
$40,890
Income
Limits
Very Low
$90,300
(50 %)
$59,600
Income
$31,650
$36,150
$40,650
$45,150
$48,800
$52,400
$56,000
0
Limits
Low
(80 %)
$48,550
$55,450
$62,400
$69,300
$74,850
$80,400
$85,950
$91,500
Income
Limits
Reports and Reporting Schedule
The County shall collect and report client information to the City quarterly and annually on a Service Unit
Report to be provided by the City in the format requested by the City.
The County shall submit an Annual Demographic Data Report. The County 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 County 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 County 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 County will
include information identifying the source of funds as the City of Federal Way Human Services General Fund
Program.
HUMAN SERVICES AGREEMENT 3 - HSA Exh 1/2017
Federal Way
EXHIBIT B
COMPENSATION
Project Budget
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www cityoffederafway com
The County 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 Nineteen Thousand Two
Hundred and 00 /100 Dollars ($19,200.00).
A. City of Federal Way Funds
2017
2018
City of Federal Way General Fund:
$9,600.00
$9,600.00
Total City of Federal Way Funds:
$9,600.00
$9,600.00
B. Line Item Budget
2017
2018
Personnel Services (detail below)
Office or Operating Supplies
Rent & Utilities
Communications
Travel and Training
Other: Mobile Dental Clinic Expenses
$9,600.00
$9,600.00
Client Travel
Administration (Overhead)
Total City of Federal Way Funds:
$9,600.00
$9,600.00
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 County 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 4 HSA Exh 1/2017
CITY OF
Federal Way
Estimated Quarterly Payments:
2017
1st Qtr $2,400.00
2nd Qtr $2,400.00
3rd Qtr $2,400.00
4th Qtr $2,400.00
2018
1St Qtr $2,400.00
2nd Qtr $2,400.00
3rd Qtr $2,400.00
4th Qtr $2,400.00
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www cityoffederalway com
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 County agrees that it will meet the specific funding conditions identified for the County and acknowledges
that payment to the County will not be made unless the funding conditions are met.
HUMAN SERVICES AGREEMENT - 5 HSA Exh 1/2017
Federal Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003 -6325
(253) 835 -7000
www.cityoffederalway.com
City of Federal Way
Human Services Contract for 2017 -2018 General Fund
Authorized Signatures for Invoices
I authorize the following individuals to sign invoices and quarterly reports on behalf of:
Public Health of Seattle -King County (Contracting Agency), for
the following: South King County Mobile Medical Program
Authorizing
Signature:
(must be signed by
person who signs
the contract,
generally,
Executive Director)
TJ Cosgrove, Director
munity Health Services Drns�
(Printed Na is Health - Seattle & King Cour#tj ltle)
(Program Title).
Additional
Authorized
Signature:
Additional
Authorized
Signature:
(Printed Name
(
4/511`
(Tile)
(D te)
A- \■ C c1 13e 1W11 y /s/ I 1
(Printed Name) (Title)
(-}-/c /17
(Signature) (Date)
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.
L43
King County
Office of Risk Management
Department of Executive Services
500 Fourth Ave, #320
Seattle, WA 98104
(206) 263 -2250
April 6, 2016 •
To Whom it May Concern
RE: KING COUNTY CERTIFICATE OF SELF - INSURANCE - 2016
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,
maintains a fully funded Self- Insurance program 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,
Elizab ;1 yoshi, ARM -P
Insurance Analyst