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0 1 ! North Carolina <br /> Department of Human Resources <br /> Division of Social Services <br /> Long Term Care <br /> . -Grant Application <br /> Contact Person: Ms. Ann Gent Title: Social Worker II <br /> Agency:- Orange County Dept. Social Services Telephone: 732-9361 <br /> Address: 300 W. Tryon Street County: Orange - <br /> I <br /> City: Hillsborough Zip Code: 27278 <br /> Budget Summary <br /> Check Functions <br /> Agencies to Receive Amount Staffing for Services to LTC Screening <br /> Grant Funds Screening and LTC Clients Program Admin-- <br /> • Case Management istration <br /> 1.0range County Dept }$25,000 I $22 000 I 0 I 3 1'' <br /> • ocia Services <br /> 2 <br /> • <br /> 3. <br /> 4. <br /> 5. <br /> Total $25,1100 "$22,000 0 $3,000 <br /> This application has been endorsed by the Board of Commissioners and is <br /> being submitted for the purpose of implementing a tong Term Care Screening <br /> Program under the provisions of HB 405. The Board of Commissioners understands <br /> it is a local responsibility to continue the screening program after the <br /> start-up grant period is over. <br /> Chairman, Board of County Commissioners <br /> Date <br />