Universal Agreement Agreement Number: Purchase Order Number: 1. Purpose: The purpose of this Agreement is to document the mutual understanding and respective obligations of the parties to facilitate the successful completion of the identified project or objective. This Agreement is by and between the Spokane Regional Health District, hereinafter referred to as SRHD, and the community partner identified in section 3 below, hereinafter referred to as Other Party. 2. SRHD Program Information: Originator (SRHD Employee): Program: BAC Code(s): Email Address: Phone: Web Address: www.SRHD.org Federal Tax ID #: 91-1527532 3. Other Party Information: Name: Phone: Contact Person: Email Address: Physical Address: City: State: Zip: Mailing Address: City: State: Zip: Web Address: Social Security #: Federal Tax ID #: DUNS #: CFDA #: Title: For Federal Awards Only: Award Name: Federal Agency: If an independent contractor or personal service contractor, did you retire from the Washington Yes No N/A State Retirement System using the 2008 Early Retirement Factor? 4. Attachments Applicable to this Agreement: Attachment A Statement of Work Attachment E Federal Certifications – – Attachment B Compensation Attachment F Circular A-133 Requirements (Subrecipient Only) – – Attachment C Standard Provisions Attachment G Terms and Definitions: – – Attachment D Special Provisions Other: – 5. Agreement Period and Amount: This Agreement commence on the start date indicated below and will continue in effect until the end date, unless terminated prior to that date in accordance with paragraphs 11 or 12 of Attachment C Provisions. If applicable, the Agreement Amount set forth below represents the estimated –Standard proportional financial contribution of the Other Party, with Estimate as the Condition. In the event there is actual monetary exchange, the true value will appear in Amount, with the appropriate Condition selected, and be set forth on Attachment B-Compensation. Start: End: Condition: Amount: $ By their signatures below, the parties agree to the terms of this Agreement: Other Party Signature SRHD Signature (including legible name, title, and date)
Agreement Number: Purchase Order Number: Universal Agreement 1. Purpose: The purpose of this Agreement is to document the mutual understanding and respective obligations of the parties to facilitate the successful completion of the identified project or objective. This Agreement is by and between the Spokane Regional Health District, hereinafter referred to as SRHD, and the community partner identified in section 3 below, hereinafter referred to as Other Party. 2. SRHD Program Information: Originator (SRHD Employee): Program: BAC Code(s): Email Address: Phone: Web Address: www.SRHD.org Federal Tax ID #: 91-1527532 3. Other Party Information: Name: Phone: Contact Person: Email Address: Physical Address: City: State: Zip: Mailing Address: City: State: Zip: Web Address: Social Security #: Federal Tax ID #: DUNS #: For Federal Awards Only: CFDA #: Title: Award Name: Federal Agency: If an independent contractor or personal service contractor, did you retire from the Washington State Retirement System using the 2008 Early Retirement Factor? Yes No N/A 4. Attachments Applicable to this Agreement: Attachment A – Statement of Work Attachment E – Federal Certifications Attachment B – Compensation Attachment F – Circular A-133 Requirements (Subrecipient Only) Attachment C – Standard Provisions Attachment G – Terms and Definitions: Attachment D – Special Provisions Other: 5. Agreement Period and Amount: This Agreement commence on the start date indicated below and will continue in effect until the end date, unless terminated prior to that date in accordance with paragraphs 11 or 12 of Attachment C –Standard Provisions. If applicable, the Agreement Amount set forth below represents the estimated proportional financial contribution of the Other Party, with Estimate as the Condition. In the event there is actual monetary exchange, the true value will appear in Amount, with the appropriate Condition selected, and be set forth on Attachment B-Compensation. Start: End: Condition: Amount: $ By their signatures below, the parties agree to the terms of this Agreement: Other Party Signature (including legible name, title, and date) SRHD Signature