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State of North Carolina <br />Division of Social Services <br />Contract Application <br />Page 3 of 7 <br />II. Fiscal Provisions <br />A. Amount of Reimbursement: <br />Reimbursement under the terms of this agreement will be Limited to a maximum of <br />$ 25,000 TOTAL = $ SSBG + $ IV-B + $ RAP + <br />$ State +$ County + $ Other (identify): TANF Block Grant <br />(Optional : County funds consist of $ for <br />(funding source) <br />and$ <br />for <br />B. Method of Reimbursement: <br />1. For Purchase Contract (DSS-2497) Total and Unit Cost: <br />(X) a. Reimbursement will be made in accordance with the current budget approved by <br />the Department and on file with both parties. The amount of reimbursement will be <br />based on allowable expenditures made in behalf of eligible clients, determined in a <br />accordance with acceptable cost allocation methods. The Provider will report all <br />expenditures made under the terms of the contract. <br />() b. Reimbursement will be made at a unit cost rate of $ per unit of <br />reimbursement delivered to eligible clients for an estimated number of <br />units. The Provider will document total expenditures made under the terms of the <br />contract to the Department within thirty days after the termination of this contract, <br />or as instructed by the Department. Reimbursement which exceeds actual allowable <br />cost will be adjusted to actual allowable cost. <br />2. For Vendor Agreements (DSS-2252) Fixed Rate <br />Reimbursement will be based on: <br />() a. a standard fixed rate or <br />() b. an individual fixed rate. . <br />c. Reimbursement will be made at a fixed rate of $ per unit of <br />(define) for as estimated number of units. <br />Reimbursement will be based on the actual number of units delivered whether over <br />or under the estimated number. If multiple components are being purchased, <br />additional rates and units can be identified as follows: <br />9 <br />