Appendix 22.53   Local Agency Agreement Supplement
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The Local Agency requests to supplement the agreement entered into and executed on
All provisions In the basic agreement remain In effect except as modied by this supplement.
The change to the agreement are as follows:
Project Description
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Description of Work       ENo Change

Reason for Supplement
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Are you claiming indirect cost rate? [3 Yes E No        Project Agreement End Date  l 1- 3 i - / Q;
Does this change require additional Right of Way or Easements? 7:] Yes E5 No Advertisement Date:
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(1)                       (3)            (4)            (5)
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The Local Agency further stipulates that pursuant to said Title 23. regulations and policies and procedures. and as a
condition to payment of the Federal funds obligated. it accepts and will comply with the applicable provisions.
Agency Ofcial                            Washington State Department of Transportation
By                                 By
Tltle                                                  Director, Local Program
Dale Executed
DOT Form 140-041                                                                       Page t
Revised 05/2015


WSDOT LocalAgency Guidelines  M 36453.31                                 Page 22-13
April 2016