Grant Number: Washington State Department of Health (DOH) 1. Grantee 2. Grantee Doing Business As (optional) Name Mailing address City, State, Zip Code 3. Grantee Representative 4. Department of Health Representative (Name) (Phone number) (Name) (Phone number) (Title) (Email address) (Program Manager Title) (Email address) (Mailing address) (Mailing address) (City, State, Zip Code) (City, State, Zip Code) 5. Grant Amount 6. Funding Source 7. Start Date 8. End Date Federal: State: Other: Date of 18 months after FFATA Form Required: Yes No Execution Date of Execution 9. Federal Funds (as applicable) CFDA Number Federal Agency 66.468 Environmental Protection Agency 10. Tax ID # 11. SWV # 12. UBI # 13. DUNS # 14. Grant Purpose The outcome of this performance-based agreement is to ____________________________as referenced in Attachment I - Project Scope of Work. DOH, defined as the Department of Health or its successor agency, and the Grantee, as defined above, acknowledge and accept the terms of this Grant and attachments and have executed this Grant on the date below to start as of the date and year referenced above. The rights and obligations of both parties to this Grant are governed by this Grant and the following other documents incorporated by reference: Grant Terms and Conditions, Attachment I - Project Scope of Work, Attachment II - Estimated Project Costs, and Attachment III - Federal Compliance and Standard Federal Certifications and Assurances. FOR THE GRANTEE FOR THE DEPARTMENT OF HEALTH Authorized Signature Department of Health Contracting Officer Signature Print Name Print Name Title Date Date as to “Approved Form: Sandra Adix, Assistant Attorney General, March 25, 2014”
Grant Number: Washington State Department of Health (DOH) 1. Grantee 2. Grantee Doing Business As (optional) Name Mailing address City, State, Zip Code 3. Grantee Representative 4. Department of Health Representative (Name) (Title) (Mailing address) (City, State, Zip Code) (Phone number) (Email address) (Name) (Program Manager Title) (Mailing address) (City, State, Zip Code) (Phone number) (Email address) 5. Grant Amount 6. Funding Source 7. Start Date 8. End Date Federal: State: Other: FFATA Form Required: Yes No Date of Execution 18 months after Date of Execution 9. Federal Funds (as applicable) Federal Agency Environmental Protection Agency CFDA Number 66.468 10. Tax ID # 11. SWV # 12. UBI # 13. DUNS # 14. Grant Purpose The outcome of this performance-based agreement is to ____________________________as referenced in Attachment I - Project Scope of Work. DOH, defined as the Department of Health or its successor agency, and the Grantee, as defined above, acknowledge and accept the terms of this Grant and attachments and have executed this Grant on the date below to start as of the date and year referenced above. The rights and obligations of both parties to this Grant are governed by this Grant and the following other documents incorporated by reference: Grant Terms and Conditions, Attachment I - Project Scope of Work, Attachment II - Estimated Project Costs, and Attachment III - Federal Compliance and Standard Federal Certifications and Assurances. FOR THE GRANTEE FOR THE DEPARTMENT OF HEALTH Authorized Signature Print Name Title Date Department of Health Contracting Officer Signature Print Name Date “Approved as to Form: Sandra Adix, Assistant Attorney General, March 25, 2014”
GrantRFATemplate.docx