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NAME AND ADDRESS Home and Community Care Block Grant for Older Adults <br />COMMUNITY SERVICE PROVIDER DOA-732 (Rev. 2/03) <br />Joint Oran a Chatham Communi Action, Inc. County Funding Plan County_Orange <br />PO Box 27 July 1, 2003 through June 30, 2004 <br />Pittsboro, NC 27312 Provider Services Summary <br /> A B. C D E F G H I <br /> Sec Delivery <br />(Check one BiockGrantFundin <br />Required <br />Net* <br />USDA <br />Total Projected <br />HCCBG Projected <br />Reimburse Projected <br />HCCBG Projected <br />Total <br />Services Duect Purch Access In-Home Other Total Local Match Serv Cost Subsid Fundin Units Rate Clients Units <br />Other (Congregate <br />Nutrition <br />X <br />103716 <br />11524 <br />115240 <br />15535 <br />130775 <br />26000 <br />4.43 <br />400 <br />29629 <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 0 103716 103716 11524 115240 15535 130775 26000 400 29629 <br />*Adult Day Caze & Adult Day Health Care Net Service Cost <br />ADC ADHC <br />Daily Caze Certification of required minimum local match availability. Executive Director ~3 ~9 _ <br />Transportation Required local match will be expended simultaneously Sig Dat <br />Administrative with Block Grant Funding. Community S er <br />Net Ser. Cost Total <br />Signature, County Finance Officer Date Signature, Chairman, Boazd of Commissioners Date <br />r <br />~o <br />