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NAME AND ADDRESS Home and Community Care Block Grant for Older Adults <br />COMMUNITY SERVICE PROVIDER DOA-732 (Rev. 2/OS) <br />Orange County Social Serv ices County Fund'Ing Plan County: Orange <br />300 West Tryon Street July 1, 2005 through June 30, 2006 <br />Hillsborou h, NC 27278 Provider Services Summary REVISION # ,DATE <br /> A B C D E F G H I <br /> Ser. Delivery <br />(check one) Block Grant Funding <br />Required <br />Net* <br />USDA <br />Total Projected <br />HCCBG Projected <br />eimburse Projected <br />HCCBG Projected <br />Total <br />Services Direct torch. Access In-Home Other Total Local Matc Serv Cost Subsidy Funding Units Rate Clients Units <br />In-Home Aide X 32869 \\\\\\\\\\\\\\\\\\ 3652 36521 36521 2811 12.99 10 2811 <br /> \\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br /> \\\\\\\\\\\\\\\\\\ 0 0 0 <br />Total \\\\\\ \\\\\\\ 0 32869 0 32869 3652 36521 0 36521 2811 \\\\\\\\\\\\\\ 10 2811 <br />*Adult Day Care & Adult Day Health Care Net Service Cost <br />ADC ADHC t <br />Daily Care Certification of required minimum local match availability. + J ~ ~ <br />Transportation Required local match will be expended simultaneously Authorize Sign e, Title Date <br />Administrative with Block rant Fu/n/d~ing. ,,.. Community Service Provider <br />Net Sec Cost Total ~~~~-~ ~ ~ ~ ~~ <br />Signature, County Finance Officer Date Signature, Chairman, Board of Commissioners Date <br />f% <br />