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State of North Carolina <br />Division of Social Services <br />Contract Application <br />Page 6 of 7 <br />() 2. The provider certifies through the contract budget attached to this contract that <br />the matching share in available. Further, it is agreed that the provider will <br />report all program costs incurred each month relating to this contract on the <br />DSS-1571. However, reimbursement will be limited to the federal/state <br />financial participation rate. <br />(X) 3. The county department of social services is providing the match. <br />G. Provider Fees (For Purchase Contracts Only) <br />(N/A) 1. The Provider agrees to pay the Department/Division up to <br />$ Administrative Fee as payment in full for the <br />administration of the contract. The amount of the fee is five percent of the <br />matching share contributed by the Provider. <br />(N/A) 2. The Provider agrees to pay the Department up to $ Certification Fee <br />as payment in full for the determination and certification of client <br />eligibility. The amount of the fee is five percent of the matching share <br />contributed by the Provider. <br />Monitoring and Certification Fees, when applicable, will be deducted from the <br />amount to be reimbursed. <br />12 <br />